Begin with the End in Mind:

Transcription

1 Begin with the End in Mind: Health Information Technology as a link to honoring a person s advance directive Carol Robinson DNP, MS, BSN, RN, CHPN Community Coordinator, MCM Mary Graham, LMSW Manager of Community Engagement, GLHC 1

2 Making Choices Michigan 10/23/2018 Community-based, 501 (c)(3); wholly-owned subsidiary of Great Lakes Health Connect Goal: Move the ACP conversation from the healthcare environment to the community-at-large Vision: foster a community culture where it is acceptable to talk about health care choices, including end of life, and to respect and honor those choices. Mission: encourage and facilitate advance health care planning by the people of Michigan. 2

3 Advance Care Planning (ACP) Discuss Reflect on your values and beliefs Decide Choose your Patient Advocate(s) Document Write your wishes in an Advance Directive (Durable Power of Attorney for Healthcare) Share your plan 3

4 Advance Care Planning Is important for all adults, 18+ It is thinking and talking about future healthcare decisions Prepares your Patient Advocate(s) to speak for you if you cannot (e.g. car accident or illness) 4

5 Living Well If you were having a good day What would happen on that day? Who would you talk to? What would you do? 5

6 Three Decisions: 1. What personal beliefs do you have that might impact your decisions? For example: What does your family think about quality versus quantity of life? What do you think about it? Who makes the important decisions in your family? Do you have a faith belief? If you do not, does your family? Could their beliefs impact decisions about your care? 2. What healthcare would you like to receive if you have a severe, permanent brain injury? 3. Who do you want to choose as your Patient Advocate(s)? 6

7 Exploring Goals of Treatment Imagine this scenario: A sudden event (such as a car accident or illness) leaves you unable to communicate. You are receiving all the care needed to keep you alive. The doctors believe there is little chance you will ever recover the ability to know who you are or who you are with.. 7

8 Explore your end of life beliefs 1. What personal beliefs do you have that might help you choose the care you want or do not want? Visitors, lighting, quiet, finances, being home? 2. Would certain practices give you comfort? Prayer, music, readings, certain foods, pets? 3. Would you like to talk to someone about these beliefs or concerns? 8

9 Next Steps Follow-up items Talk with your Patient Advocate Meet with a MCM Facilitator Complete an Advance Directive 9

10 Creating an effective Advance Directive Holt, G. E., Sarmento, B., Kett, D., & Goodman, K. W. (2017). 10

11 MCM Advance Directive 11

12 Then... Give copies to your Patient Advocate, your healthcare team and your family Keep a copy of your Advance Directive where it can be easily found Take a copy with you if you go to a hospital or nursing home and ask them to place it in your medical record Consider registering your AD (for free) with Great Lakes Health Connect 12

13 MCM Services Advance Directive (co-branding with attribution) Evidence-based, standardized ACP Communication training Respecting Choices ELNEC Communication education System design and implementation to hardwire ACP success in practices and community organizations 13

14 Grand Rapids, MI ~ Best Place to die in America Policy and Politics to Drive Change in End-of-Life Care: Assessing the Best and Worst Places to Die in America. McPherson, A. & Parikh, R.B. (2017). Generations Most people want to die at home, but many land in hospitals getting unwanted care. McPherson, A. & Parikh, R.B. (2017). The Washington Post 14

15 GLHC s Contribution GLHC long-time partner with MCM Review each submission and post within one business day Can take manual upload or interfaced EMR submissions Committed to supporting patient care by providing information at the point of care. VIPR is patient-based, clinical information (not payer-specific or claims-based) Creating Care Connected Communities

16 Over 9 Million Patients Creating Care Connected Communities

17 Contributors 294 Sites/ Organizations 48 Counties Out of state 11 Types of Data Creating Care Connected Communities

18 Access Options Creating Care Connected Communities

19 ACP Documents in VIPR Through August 2018 Document Type Advance Care Directive 3134 Advance Care Directive - Card Only 14 Advance Care Directive - Other State 112 Asthma Action Plan 1318 Authorization to Visit 1 Care Plan 4 Certificate of Disability 18 Code Status/Orders 89 Code Status/Orders with Organ Donation 14 Complex Care Plan 2 Designation of Patient Advocate 5700 Designation of Patient Advocate NO BLOOD 370 Do Not Resuscitate 2513 Durable Power of Attorney Finance Only 1983 Durable Power of Attorney for Healthcare Guardianship 378 Living Will Treatment Preferences 1712 Medication History 2 Mental Health Power of Attorney 1 Michigan Physician Orders for Scope of Treatment (MI-POST) 25 Military Advance Care Directive 6 OB ACOG Antepartum Record 1364 OB Gestational Diabetic Flow Sheet 8 OB Lab Flow Sheet 942 OB Prenatal Physical 209 OB Transitional Care 1 OB Tubal Consent 2 Organ Donation 12 Physician Orders for Life-Sustaining Treatment (POLST) 115 Post Death Request 5 Release of Information 337 Revoked Document 8 Statement Of Incapacity 14 Statement of Treatment Preferences (SOTP) 1445 Telemedicine Visit Summary 1085 Grand Total Creating Care Connected Communities

20 ACP Documents in VIPR Through August 2018 Source Type Type Total Attorney 1,384 Community Organization 344 HIE 161 Home Health 775 Hospice 1,168 Hospital 31,431 Individual 4 Outpatient Clinic 8,507 PHO 1,542 Senior Living Center 21 SNF/LTC 430 Telemedicine 1,085 Grand Total 46,852 Creating Care Connected Communities

21 ACP Documents in VIPR Through August 2018 County County Total Barry 773 Genesee 7811 Grand Traverse 12 Gratiot 11 Ingham 93 Kalamazoo 3 Kent 9753 Macomb 166 Mason 20 Mecosta 250 Montcalm 66 Muskegon 4182 Newago 50 Oakland 510 Osceola 479 Ottawa 850 State-Wide 266 Washtenaw Total Creating Care Connected Communities

22 Call for information or a free appointment Info@gl-hc.org 22