Five Questions for HCM Advance Care Planning Programs. Question 1. What is your target population for advance care planning?

Transcription

1 Five Questions for HCM Advance Care Planning Programs Question 1. What is your target population for advance care planning? Allina: Age 50 and over Fairview: One of our strategic plans is to address ACP with all of our patients/clients/residents beginning at age 18. We currently target those ages 55 and older in our clinics. All other service areas (inpatient, homecare/hospice, senior housing) are targeting 18 and older. HealthEast: Our HCM program originally focused on a predetermined group of patients with a chronic and progressive illness who were receiving care at a specific clinic. We soon learned of the need to also provide HCM services to family members of those patients. While this expanded our scope, we were able to handle the workload so as to not adversely impact our delivery of HCM services to the initial core population. Our second effort included adding other clinics and those physicians to champion this outreach to other patients, regardless of diagnosis, who had achieved a milestone birthday usually 60 years or older. Once again, our scope was impacted by younger spouses and, in some cases, adult children. Additionally, our scope included inquiries from the public (not referred by a clinic). Here, again, our Facilitators were assigned so as to not adversely impact our HCM service to physician referrals. We are beginning our third stage of the HCM program where, in addition to physician referrals and public walk-ins, HealthEast is broadening the HCM contact population to include hospice, cancer care, and patients who are in contact with social workers and spiritual care. Park Nicollet: We have different targets depending on location. We strive to provide ACP services to adults of all ages. However, due to limited resources, our two pilots in primary care are targeted to those over 60 and over 65 years. Light the Legacy: Light the Legacy s target population is anyone over 18 years of age. Because we are a community-based organization, we not only target the medical community, but colleges/universities, places of worship, civic organizations, estate planners, etc. Light the Legacy/St. Cloud State University: Students in health-related majors at St. Cloud State University through an elective course in advance care planning. 1

2 Thrivent: Our corporate employee population of about 3,000 people in Appleton, WI; Minneapolis, MN; and in remote roles nationally. We also reach participating employees health care agents through the ACP process. Entira Family Clinics: o Starting with Health Care Home enrolled patients when completing the care plan o Some providers are also offering to their patients when seen for a physical o Our goal once implementation / workflow/ more patient volunteers are hired is to offer to all patients 18 years and over o Patients can also request interest in using facilitator services at any time and we will assist them Ridgeview Hospital: Ideally anyone over age 18. Presbyterian Homes: Our residents in independent living, assisted living and care centers as well as families of residents. Lakeview: Anyone 18 years and older HealthPartners: Everyone, really. Certainly anyone who requests information and willing to have conversation. Higher priority for patients with conditions and diagnoses suggesting life limiting illness. Question 2. How do you track ACP data? Allina: Electronic EMR Fairview: MEASURING DATA: EPIC reports these measures: % of patients with ACP on the problem list (documentation); % of patients with scanned ACP documents for hospitals, clinics, expired patients and systems o #/type of scanned ACP documents for hospitals and clinics o # of referral orders for hospitals and clinics o Manual reports measure: Facilitation satisfaction (5 pt scale)-1:1, group, and employee sessions; Impact/Satisfaction with facilitator training STORING DATA: o Access all ACP information by clicking on code status in the patient header bar (report pop-up) o Documentation in the Problem List using SmartPhrase o Documentation in the Demographics tab-clinical-permanent comments of designated decision maker using a SmartPhrase 2

3 HealthEast: We report HCM activity via a spreadsheet workbook which lists Help Line requests and tracks facilitator activity on those requests. Information for each patient includes: o Initial callback o Providing additional information either by phone discussion, /internet or by US mail o Meetings scheduled with the patient o Results of HCM discussions such as document completed/signed/notarized HealthEast has visited clinics to do a random review of patient records to determine if the patient has completed the final step of the ACP process submitting a copy to their physician. Park Nicollet: Our earliest measure has been the % of patients who die at Methodist Hospital with a retrievable AD in their medical record. We also track the % of patients with an AD based on care team of assigned PCP in three age ranges 18+, 50+, and 65+. We track population specific percentages (ACO) as well as #contacts/#completed documents associated with our pilots, % of inpatients with an ACP status (meaningful use), number of inpatient consults, number of HCD/POLST scanned into EMR, number of ACP and POLST facilitators trained, number of ACP group classes/attendance monthly, and number of community presentations/attendance. Light the Legacy: Because we are fairly new yet, tracking ACP data is in the development stages. Currently, we have a student intern from the gerontology graduate program at SCSU that is helping in the development tracking more effective stats. Light the Legacy/St. Cloud State University: We will track data through service-learning projects, student evaluations, and yearly follow-ups with students who have completed the course. Thrivent: We use an Excel spreadsheet to track first and second appointments. We also periodically survey participants to understand how well the process worked for them and actions they may have taken on their own as part of the process. Entira Family Clinics: We have updated our documentation of a HCD in our EMR to include certain fields and to be standardized this is to be able to run a report for tracking. The scanned document is also found in an AD folder in a standardized way. Ridgeview Hospital: We have a spreadsheet where we track referrals. Presbyterian Homes: We track who files copies of advance care planning documents. HealthPartners: Our data comes from our electronic medical record (EPIC). We also have engineered our health maintenance tracking to prompt when patient doesn t have ACP. This is one way we have embedded advance directives into the workflow of clinic visits. 3

4 Question 3. What is a significant recent success? Allina: We had two recent experiences in our ICU. A 52 yr old who the staff felt would not have had an ACP but one was discovered in the EMR which outlined beautifully his wishes. Really helped the staff to relax. In another story, a person without any family had indicated that he wanted his neighbor to be his proxy. The ICU staff called the neighbor came in and attended to the staff questions and the care of the patient. Fairview: Additional FTE allocated HealthEast: Advance Care Planning, Advance Care Directive and Honoring Choices Minnesota are terms that are increasingly finding their way into staff vocabulary. This is resulting in a more comfortable/confident conversation with all our patients. We are also finding the public more knowledgeable and engaged in the process, although there is still a long way to go. Park Nicollet: Initiation of two pilots in Primary Care that addressed the rooming process and created a referral source for our group classes, development of an effective intranet ACP webpage, and creation of a Life Stages model for ACP delivery and a new Appointment of Health Care Agent short form. Light the Legacy: The fact that by the end of this month we will have conducted our 7 th Advance Care Planning Facilitator training class, with three additional classes planned for the remainder of the year, for a total of 74 newly trained ACP Facilitator throughout central MN. The most unique class was an all STUDENT class and a class dedicated to the St. Cloud Veterans Administration (VA). Light the Legacy/St. Cloud State University: The dean of the School of Health & Human Services approved the offering of a new 2 credit inter-disciplinary elective course on ACP Facilitator Certification. Students will become certified ACP facilitators and will have opportunities to practice their skills in the community in partnership with Light the Legacy in St. Cloud. She also approved matching grant funds up to $2500 to cover additional costs. Thrivent: An employee scheduled an ACP appointment because they d seen ACP listed on our Fit for Life tracker a small but cool success from our efforts to integrate ACP awareness into the overall health and wellness space at Thrivent. Entira Family Clinics: o Started with offering at 2 clinics - then expanded to 4 clinics - as of July will offer to patients at all 12 Entira clinics. o We have had 2 patient volunteers go through facilitator training and are using them in this process, a cost effective way of helping our patients and giving our patient volunteers a chance to broaden their skills! 4

5 o Because of using Volunteers, we can offer this service at a patient s home (for our elderly patients and their families). This has been a great success and wonderful feedback from those involved. Ridgeview Hospital: Two staff became certified as instructors for basic and POLST. Presbyterian Homes: Families and staff report the satisfaction of giving patients their preferred care. Lakeview: On a monthly basis we get approximately 30 HCDs from patients and/or people in the community turning them into our HIM dept. We ask every patient if they have an Advance Directive. HealthPartners: Recent success includes a few. We now have an enterprise report card across our entire enterprise. One of the measures on it includes how often wishes were honored in patients who die. We also have a nurse practitioner who recently started and conducts group visits for nephrology patients begin facilitation of honoring choices Question 4. What is a significant recent challenge? Allina: Leadership spread in a large organization. Storing and retrieval of documents is a continuing challenge. Fairview: (Ongoing rather than recent) Gaps across points of care: 1) ensuring the patient s story continues (rather than restarts) across transitions; and 2) measuring data with 4 EMR platforms still in place. HealthEast: Some patients seem reluctant to engage in a conversation and learn the importance of careful and thoughtful completion of their HCM. HealthEast seems to sense a dichotomy: referred patients (especially in-patients) want to complete their documents quickly, not necessarily using the best descriptive terminology; Public walk-ins (those who learned of HCM through non-physician sources) are more thoughtful and willing to spend the time to better ensure accuracy. Not every referral will result in a meaningful conversation or in a completed HCD. This seems to be especially true where the patient s primary language is not English and they have little or no family locally. Park Nicollet: Lack of effective documentation within EMR, over reliance on volunteer facilitators 5

6 Light the Legacy: We have been growing so fast and the momentum and need is great that we are in the process of seeking our own Non-profit status. Maintaining sustainability is also an ongoing challenge. Light the Legacy/St. Cloud State University: Seeking grant funding to cover the expense of the on-line modules through Respecting Choices so students won t have additional costs above tuition. Limited opportunities for other faculty to become ACP instructors. Thrivent: We have an ongoing challenge of keeping the ACP opportunity in front of employees. We know that when we do activities to raise awareness, people sign up for appointments. When we don t do activities to raise awareness, the appointments trickle in. Another challenge we face is having senior leaders recognizing the importance of ACP and the role we have. Entira Family Clinics: o Contacting patients that were given the paperwork but a facilitator was not available for the warm hand off many attempts to contact patient via phone with no response. o We would like to add a patient volunteer at each of our clinics but the challenge is finding these people and then getting them through training in a timely matter to handle our patient load of patients requesting this service. Ridgeview Hospital: Trying to help clarify the difference between the advance care planning document and POLST that people would be resuscitated unless there is a physician order not to do this. Presbyterian Homes: We currently have many priorities for staff to implement. Lakeview: Finding the time to promote ACP more than we do currently. HealthPartners: Significant challenges include: a. POLST forms following the patient b. Clarity for hospital physicians in interpreting DNR as it relates to elective intubation c. Electronic medical record changes are very slow. 6

7 Question 5. What 2-3 key points have you learned in the last year? Allina: ACP is defined differently by different people. What do we count as an ACP? Technology will transform the way we complete, store, and retrieve information for the future. Fairview: Employee engagement is important-make it personal! Embed and communicate ACP as ongoing- not a project, not an implementation you can wait out! HealthEast: Project progress can be impacted by team member work load. It is not prudent to simply use standard effectivity rates and projected staff availability. It is very important to not only consider holidays and vacation time, but also to consider time/staff unavailable to the project, such as scheduled CEU training time and the potential for subject matter expert reassignment, Scheduling space to use for meeting with patients has been troublesome. HealthEast has developed a standard list of venues where Facilitators can meet. This list takes into account the services the Facilitator provides, and lists their availability. The goal is to make the HCM experience a one-stop-shopping event for the patient. For example, some of the services to be expected should include notary and photocopy services. Park Nicollet: Assignment of health care agent with an associated quality conversation may be the best choice for some individuals. Prompts within the medical record are essential to assuring the introduction of ACP. Creating a culture change requires consistency/repetition of message and lots of patience it is a slow, but worthwhile process! Light the Legacy: Balance balance balance!!! o To keep things manageable. Your organization needs to be manageable while moving forward in progressive motion, as long as the mission and the vision of the organization is achieved. o To be open to new ideas and growth areas in your area, because what you thought you were starting with may take on a totally different look. o I remember what Patty Bresser and I learned when down at Respecting Choices in April to get trained as certified POLST Instructors; sometimes you have to just throw something at the wall and see what sticks, but you ll never know what that is unless you try something! Light the Legacy/St. Cloud State University: o That students are interested in advance care planning and are willing to become certified. o That the need is great and healthcare providers want to improve their skills to assist their patients. 7

8 Thrivent: We have learned that terminology is very important and can be confusing. You have to keep talking about ACP or people put it aside for another time. Approaching people on this topic isn t difficult and most are interested in learning more. Entira Family Clinics: o Communicate, communicate, communicate to staff about what a great service this is for our patients not just one more project or thing to do. o Minimize hand offs as much as possible the face to face with patient when the provider has discussed with the patient is the most effective way to get a hold of them - cold calling is hard to do and not as effective. o Have a timeline and workflow created with the staff involved in the process be flexible with updating or changing process after receiving feedback from those doing the work. o This is such a great program for our patients! We are really excited to be a part of it and improve our patients during their end of life decision making~ shows we truly care for them their entire life as our patients! Ridgeview Hospital: Patients who are referred do not seem to know what this is about. We are continuing to try new things to help them better understand when facilitator calls to schedule an appointment. Presbyterian Homes: Presentations have to be flexible to meet needs and time allotted to topic. We have also have added some information and links for special groups - esp. the Catholic Health Care Directive approved by the Catholic Bishops and accompanying Guidelines. HealthPartners: EMR challenges require huge system and community collaboration. Minority communities still have unique and closely held approaches surrounding end of life care. END OF RESPONSES 8