Table 3.

Barriers and facilitators to ACP in general and implementing Jumpstart AN/AI.

SCF Employees (n = 16)
Perceived Barriers	Perceived Facilitators
• Not enough time, i.e. short appointments with high demands • Staff shortages and turnover • Change fatigue • Hard to integrate electronic health record and patient portal • Documents sent home with customer- owners may not be returned • Employee discomfort talking about ACP • Customer-owner distrust in health care system • Low use of patient portal, especially among Elders • Customer-owners may not engage with ACP (e.g., overwhelmed, do not want)	• Primary care staff are familiar with process for ACP • Primary care providers are generally comfortable with having ACP conversations • High staff buy-in for ACP • Existing ACP fields in the EHR • Using technology to deliver services (e.g., EHR automation of Jumpstart) could create efficiency in health system • Staff can notarize ADs immediately • Integrated palliative care specialist available in primary care • Same-day appointments available • Community resource and behavioral health specialists can support ACP • Aligns with Existing Aging Well initiative • Customer-owners trust in health care system • Customer-owners are used to completing screeners and questionnaires
Customer-Owners (n = 14)
Perceived Barriers	Perceived Facilitators
• Providers do not bring up ACP • Difficult to navigate between primary care and specialty care providers • Many customer-owners do not use patient portal • Some customer-owners may be reluctant to discuss ACP in groups • Customer-owners do not know about ACP • Lack of Alaska Native language interpreters in health system	• High trust in health care system • Strong relationships with primary care team • Some customer-owners use the patient portal • Customer-owners are comfortable with ACP conversations • Customer-owners are used to completing screeners and questionnaires • Support system for ACP • Support from AN/AI community