FIRST STEPS ACP. April 30 May 2, 2012 Onalaska, WI. An advance care planning system that works. ORGANIZATION AND COMMUNITY COURSE

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1 Non-Profit Organization U.S. Postage PAID La Crosse, WI Permit #395 An advance care planning system that works. FIRST STEPS ACP erts p x e m the planning o r f Learnance care v in ad 1900 South Avenue La Crosse, WI ORGANIZATION AND COMMUNITY COURSE April 30 May 2, 2012 Onalaska, WI Become certified in First Steps ACP facilitation Learn the key elements in designing an effective ACP program Become certified to teach First Steps ACP Facilitator Certification

2 First Steps Advance Care Planning (ACP) is the foundation for weaving ACP discussions into the routine of good patient care and preventive healthcare for all adults. When integrated in the outpatient or community setting, and early in the course of healthcare, First Steps discussions help to normalize the concept of planning, and orient individuals to the importance of regular review and update of written plans. Course Content First Steps ACP Facilitator Certification Design and Implementation First Steps ACP Instructor Certification Organizations interested in replicating the First Steps ACP model will find it valuable to send representatives to all three days; however participants are welcome to attend First Steps ACP Facilitator Certification or Design and Implementation independently, based on their objectives. First Steps ACP Facilitator Certification First Steps ACP Facilitator Certification is intended for healthcare providers (nurses, all levels of social workers and physicians), clergy, and others involved in providing ACP facilitation. Purpose The purpose of this program is to assist participants in learning effective communication and interview skills for patient-centered ACP facilitation. Objectives 1. Identify interview skills for First Steps ACP discussions. 2. Identify interview skills for First Steps ACP for adults with chronic illness. 3. Describe strategies for creating a clear, thorough and accurate advance directive document. 4. Identify strategies for community engagement. 5. Examine three key systems for building an effective ACP program. 6. Demonstrate beginning competency in facilitating First Steps ACP discussions through role-play activities. Prerequisite Respecting Choices Online Facilitator Course (included in registration fee). Access instructions will be provided via three to four weeks prior to the classroom training. AGENDA 7:30 a.m. Sign in and continental breakfast 8:00 Introductions Welcome Introduction of faculty and participants Overview of course Program description, objectives and agenda Competency evaluation expectations 8:30 Review of First Steps ACP facilitation skills (online modules 1 & 2) 1. General interview: For any advance care planning discussion (purple card) 2. Interview: Introduction to First Steps ACP (green card) 3. Video role-play: First Steps ACP introduction 4. Group evaluation of observed skills 5. First Steps ACP interview skills: 2nd meeting with adult and healthcare agent (yellow card) 9:30 Break 9:45 Review of First Steps ACP facilitation skills (online modules 4 & 5) 1. Interview: First Steps ACP for adults with chronic illness (blue card) 2. Video role-play: Facilitating ACP for adults with chronic illness (20 minutes) 3. Group evaluation of observed skills 10:45 Practice role-play exercises (Work in groups of 4) 1. Introduction to First Steps ACP 2. Introduction to First Steps ACP: 2nd meeting with adult and healthcare agent 3. First Steps ACP for adults with chronic illness 4. Introduction to First Steps ACP 11:45 Debriefing Noon Lunch 12:45 p.m. The personal connection What did you learn while initiating a conversation about ACP with someone you love? Why is this an important exercise? 1:15 2:00 Creating an advance directive (online module 3) Review of the legal issues and requirements for completing a written advance directive in your community. Discuss common issues and concerns. 2:00 2:30 Community engagement Community engagement strategies 1. Delivering consistent, common and receptive messages (examples of written information) 2. Use of narrative ( Making Choices video presentation with discussion) 3. Presentation Tool Kit a. Making Choices PowerPoint CD

3 2:30 p.m. Break 2:45 3:15 Making ACP work: Building systems (online module 6) 1. Creating ACP/AD written policies/guidelines that highlight the following key systems. a. The role of the ACP facilitator (sample position description) b. Definition of roles/responsibilities of other ACP team members c. Making ACP referrals d. Documentation expectations e. Review, entry and transfer of AD documents 2. Developing strategies to educate a. Healthcare professionals b. The community 3. Developing ongoing quality improvement practices 3:15 Competency validation role-play exercise (groups of four) Introduction to First Steps ACP interview skills with competency evaluation completion by observer 4:15 Summary/evaluation What comes next? 4:30 Adjourn Design and Implementation Design and Implementation is intended for healthcare and community leaders (administrators, managers, program directors and others) and intermediate to advanced level social work practitioners who are interested in implementing an effective ACP program within their organization or community. Purpose The purpose of this program is to describe the key elements in designing an effective ACP program within an organization or community. Objectives 1. Discuss the cultural issues in changing the practice of advance care planning. 2. Describe the four key elements and related strategies in designing an effective ACP program. 3. Identify strategies to address the ACP needs of diverse communities. 4. Participate in dialogue to begin to design an ACP pilot implementation plan. AGENDA 7:30 a.m. Sign in and continental breakfast 8:00 Overview: Achieving successful ACP outcomes The La Crosse experience (PBS Now segment) Creating conditions for change Video presentation: Escape Fire Institute for Healthcare Improvement National Forum, December, 1999, Don Berwick (ihi.org) 9:45 Break 10:00 Making advance care planning work: Four key elements in designing an effective ACP system Key element #1: Systems design 11:15 Break 11:30 Making advance care planning work: Four key elements in designing an effective ACP system (cont.) Key element #2: ACP facilitation skills education and training 12:30 p.m. Lunch Key element #3: Community education and engagement Challenges and strategies in addressing the ACP needs of diverse communities: The impact of culture, religion and personal beliefs 1:15 Strategies to design an effective ACP pilot project Key Element #4: Continuous quality improvement 2:30 Break 2:45 Small group breakout session: Begin to design an implementation plan 4:00 Report from small groups: Questions and concerns 4:30 Adjourn First Steps ACP Instructor Certification** First Steps ACP Instructor Certification is intended for healthcare educators, community leaders and intermediate to advanced level social work practitioners who are interested in becoming certified to replicate the First Steps ACP Facilitator Certification course in their own organization or community. Purpose The purpose of this program is to assist participants in becoming certified as Respecting Choices First Steps ACP Instructors.

4 Objectives 1. Define common strategies for teaching the Respecting Choices First Steps ACP Facilitator Certification Course. 2. Facilitate a brief discussion on a selected advance care planning topic. 3. Demonstrate ACP facilitation skills through a selected role-play. 4. Complete the First Steps ACP Instructor certification exam. Prerequisite Participants must complete the Respecting Choices Online Facilitator Course (included in registration fee), the First Steps Facilitator Certification course, and the Design and Implementation course. AGENDA 7:30 a.m. Sign in and continental breakfast 8:00 Instructor responsibilities and strategies for teaching the First Steps ACP Facilitator Certification course 9:45 Break 10:00 Instructor-led discussions 11:45 Certification exam 12:15 p.m. Lunch 12:45 Role-play demonstration with faculty group observation and feedback 4:00 Adjourn **Registration requirements To attend First Steps ACP Instructor Certification, the healthcare or community organization that the instructor candidate represents (or instructors themselves if attending independently) must commit through a written agreement to replicate the standardized Respecting Choices First Steps curriculum. Please contact Matthew Isbell at (608) ; (800) , ext ; or mrisbell@gundluth.org for more information. Continuing Education Nursing Contact Hours Gundersen Lutheran Health System, Inc., is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Facilitator Certification provides 7.0 contact hours. Design & Implementation provides 7.0 contact hours. Instructor Certification provides 7.0 contact hours. Online Facilitator Course provides 9.4 contact hours. California Provider (Gundersen Lutheran Bereavement and Advance Care Planning Services) approved by the California Board of Registered Nursing, provider #12245, for 7.0 contact hours for Facilitator Certification, 7.0 for Design & Implementation, 7.0 contact hours for Instructor Certification, and 9.4 contact hours for online course. Social Work Credits Gundersen Lutheran, provider #1089, is approved as a provider for continuing education by the Association of Social Work Boards. ASWB Approval Period: November 15, 2009 November 15, Gundersen Lutheran maintains responsibility for the program. Licensed social workers should contact their individual state jurisdiction to review current continuing education requirements for licensure renewal. Social workers will receive 9.4 continuing education clock hours for the online course, 7.0 continuing education clock hours for Facilitator Certification, 7.0 continuing education clock hours for Design & Implementation, and 7.0 continuing education clock hours for Instructor Certification for participating in this course. California Course meets the qualifications for 7.0 hours of continuing education credit for Facilitator Certification, 7.0 for Design & Implementation, 7.0 for Instructor Certification, and 9.4 contact hours for online course for Licensed Clinical Social Workers as required by the California Board of Behavioral Sciences. Gundersen Lutheran Bereavement and Advance Care Planning Services is an approved provider, #934. Other disciplines will receive a certificate of attendance. To receive continuing education credit, nurses and social workers must complete the online course and be present for the entire onsite program for which they register. No partial credit will be given. Completed evaluation is required for contact or clock hours. Continuing education certificates will be given on-site. Note: After completing the online course, you will receive a continuing education certificate for 9.4 contact or clock hours. The Respecting Choices office can verify your completion electronically. You do not need to bring your certificate to the on-site workshop.

5 Additional information on speakers available from If you have questions or concerns regarding this course, require special assistance or accommodations, or have food allergies, please contact Planning committee: Bernard J. Hammes, PhD; Linda Briggs, MS, MA, RN; Rana Limbo, PhD, RN, PMHCNS-BC; Waneeta Everson, BSN, RN; Irene Sundboom, MSW Presenters and planning committee claim no conflict of interest. Program planners and presenters do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters outside of their recognized place of employment. These presentations do not involve the unlabeled use of a product or products under investigational use. Course location Stoney Creek Inn 3060 South Kinney Coulee Road, Onalaska, WI Date/Time April 30 8 a.m. 4:30 p.m May 1 8 a.m. 4:30 p.m. May 2 8 a.m. 4 p.m. (Sign in and continental breakfast begins at 7:30 a.m. each day.) Registration fees Early Bird (through March 26) After March 26 First Steps ACP Facilitator Certification (Day 1) $337 $375 Design and Implementation (Day 2) $275 $304 First Steps ACP Instructor Certification (Day 3) $405 $450 Late fee A $75 late fee will apply to registrations received after April 16. Payment Pay by Visa, MasterCard, American Express, Discover or check. Full payment must be received by April 16. Registrations received after April 16 are payable by Visa, MasterCard, American Express, Discover only and will incur a $75 late fee. Payment type Total Amount $ o Check enclosed (payable to Gundersen Lutheran Medical Foundation, Inc.) o MasterCard o Visa o American Express o Discover Account # Exp. Date Signature Substitution and transfers You can transfer your registration to a colleague in your organization up to two weeks prior to the conference for a $25 administrative fee. Cancellation policy We offer a full refund, minus a $25 cancellation fee, if you cancel by April 18. We do not offer refunds if you fail to notify us that you cannot attend. Hotel Stoney Creek Inn 3060 S. Kinney Coulee Rd., Onalaska, WI (608) or (800) $70 single or double Please reserve your room by April 20 and mention Respecting Choices to receive the special rate. Fees include online facilitator course, classroom instruction, course materials, continuing education credit, continental breakfast, lunch and refreshments.

6 How to register respectingchoices.org Call (608) or (800) , ext Fax (608) Mail to: Respecting Choices, 1900 South Ave., Mailstop ALEX, La Crosse, WI Registrant Information Full name (type or print) Job title Faculty/Instructors Bernard J. Hammes, PhD Director, Medical Humanities, Director, Respecting Choices, Ethics Consultant, Gundersen Lutheran Medical Foundation National POLST Paradigm Executive Committee Chair Chair of the National POLST Paradigm Task Force Linda Briggs, MS, MA, RN Associate Director, Respecting Choices Ethics Consultant, Gundersen Lutheran Medical Foundation Employed by Work address (including department or mail stop) City State/province Zip/postal code Work phone What others are saying about this course Amazing & Inspiring these 3 days are exquisitely designed. I do a lot of teaching and the content, pace and competence of faculty are superb. Great programs. Loved the dynamics and role-playing. Thank you for allowing conversations. Well balanced videos, presentations, practice sessions. Excellent, rich program. Applicable to real life situations. Very good program really makes me hopeful that we can have the conversation. It was an excellent day. I m excited about the possibilities for implementing change in practice. Home address City State/province Zip/postal code Home phone Preferred address (by including your , you agree to be added to our communication list) Please note: We do not share your contact information with any individual or organization. An advance care planning system that works. # EOL 1900 South Avenue, ALEX La Crosse, WI (608) Respecting Choices and First Steps are registered trademarks of Gundersen Lutheran Medical Foundation, Inc.