Designing an Advance Care Planning System that Shapes Hospital Utilization

Cost of Care and Inpatient Days in the Last Two Years of Life (region levels: state, hospital, 2012) Hospital Inpatient Days & Intensity/Decedent in Last 2 Years of Life Total Cost of Care/ Decedent During Last 2 Years of Life National Average 19.3 $80, 378 Wisconsin Average 16.2 $68,278 10 th percentile 13.8 $60,783 Ministry -St Josephs 17.9 $63,526 University of Wisconsin 16.1 $82,162 Bellin Memorial 12.6 $59,002 Gundersen Health System 12.1 $57,191 (The Dartmouth Atlas of Health Care, 2015) 2

Cost of Care in the Last Two Years of Life (2010 data) Hospital Inpatient Days/Patient in Last 2 Years of Life Hospital Care Intensity Total Cost of Care/Patient During Last 2 Years of Life National Average 19.3 1.0 $80,378 Wisconsin Average 16.2.78 $68,278 Ministry St. Joseph s 17.9.79 $63,526 University of Wisconsin 16.1.70 $82,162 10 th percentile 13.8.63 $59,002 Gundersen Health System 12.1.55 $57,191 (The Dartmouth Atlas of Health Care, 2015) 3

$16,000 Reimbursements per decedent for inpatient hospitalization during the last six months of life (in USD) $14,000 $12,000 $10,000 $8,000 Rochester Appleton Eau Claire La Crosse Madison Marshfield $6,000 $4,000 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year Trend data from the Dartmouth Atlas. This data suggests that La Crosse Health Region had a lower raise in health care cost over time compare to similar health systems in Wisconsin. 4

REDESIGNING THE HEALTHCARE SYSTEM TO SHAPE HOSPITAL UTILIZATION 6

The Desired Outcome of Advance Care Planning (ACP) is To know and honor a patient s informed plans, by Creating an effective planning process, including Selecting a well-prepared health care agent or proxy, when possible Creating specific instructions that reflect informed decisions that are geared to the person s state of health Making these plans available to the treating health professionals Assuring that plans are incorporated into medical decisions, when needed 7

ADVANCE CARE PLANNING Is most effectively done in stages Does not attempt to plan for ALL possibilities in a single document, which is both impossible and unnecessary 8

Stages of Advance Care Planning Over an Individual s Lifetime First Steps Create an AD that identifies healthcare agent and goals of care for permanent brain injury Next Steps Identify goals of care, if illness complications result in bad outcomes Last Steps Identify goals of care, expressed as medical orders using POLST paradigm Healthy adults or those who have not planned Individuals with advanced illness, complications, frequent 9 encounters Individuals whom it would not be a surprise if they died in the next 12 months 9

Design Elements of an Effective ACP Program Leadership Matters System Redesign ACP Education & Facilitator Certification Honoring Individual Preferences for Future Medical Care Community Engagement Sustained ACP System Management 10

Key Element #1: System Redesign Building an infrastructure that hardwires excellence Key infrastructure/workflows ACP team and processes/workflows Reliable medical record storage and retrieval, transfer of documents and ACP information Effective, standardized document (e.g., Power of attorney for healthcare, Statement of Treatment Preference form, POLST paradigm form) 11

Key Element #2: Education & Training Skilled Facilitation Training all staff to be competent to play their designed role Identifying and training staff as ACP facilitators and key members of ACP team 12

Key Element #3: Community Education and Engagement Develop strong partnerships with community groups and leaders Reach out to communities with common, consistent, repetitive messages Develop strategies to meet the needs of diverse communities 13

Key Element #4: Sustained ACP System Management Leadership support ACP Coordinator Continuous Quality Improvement 14

Five Promises of an Advance Care Planning System PROMISE #1 We will initiate the conversation PROMISE #3 We will make sure plans are clear PROMISE #2 We will provide assistance with advance care planning PROMISE #4 We will maintain and retrieve plans PROMISE #5 We will appropriately follow plans 15

IS THERE EVIDENCE THAT SUCH A SYSTEM CAN BE DESIGNED AND BE SUCCESSFUL? 16

Prevalence, Availability, and Consistency of Advance Directives in La Crosse County after the Creation of an ACP System in 1991-1993 LADS I Data collected in 95/ 96 N=540 LADS II Data collected in 07/ 08 N=400 P value Decedents with ADs (%) 459 (85.0) 360 (90.0).023 ADs found in the medical record where the person died (%) Treatment decisions found consistent with instructions 437 (95.2) 358 (99.4) <.001 98% 99.5% 0.13 (Hammes & Rooney, 1998) (Hammes, Rooney, & Gundrum, 2010) 17

Advance Care Planning Study Setting: Tertiary hospital in Melbourne, Australia Participants: Competent, English-speaking patients 80 or older admitted to internal medicine, cardiology, or pulmonary services Excluded if they were expected to die or discharged within 24 hours, had an AD, or did not have family Method: The intervention group received ACP developed from the La Crosse model (Respecting Choices) and the control patients received the local standard of care (Detering, Hancock, Reade, and Silvester, 2010) 18

Patient Satisfaction Questionnaire* Variable Intervention Group (N= 133) Control Group (N=139) P Value Overall level of satisfaction with hospital care <0.001 Very satisfied 125 (93) 91 (65) Satisfied 6 (5) 40 (29) Not satisfied 2 (2) 8 (6) *Questionnaire administered at hospital discharge. Values are percentages, unless stated otherwise. 19

Study Outcomes When Subjects Died ACP Control P value Deaths 29 27 Wishes know and respected 25 (86%) 8 (30%) <0.001 Death in the ICU 0 (0) 4 (15%) 0.03 Family Stress 5 15 <0.001 Family Anxiety 0 3 0.02 Family Depression 0 5 0.002 20 20

Survival to Hospital Discharge After In-Hospital CPR, According to Year and Race (Ehlenbach et al., 2009) 21

CPR Attempts at GHS: A 20-year Comparison 1988 & 1989 1998 & 1999 2006, 2007, & 2008 P Value # of CPR attempts 153 100 101 CPR attempts per 1000 admissions Alive at discharge after CPR attempt 5.8 4.6 2.8 P = 0.001 12% 22% 33% p = 0.002 22

Respecting Choices ACP: Helping to Achieve the Triple Aim 23

References 1. Detering, K. M., Hancock, A. D., Reade, M. C., Silvester, W. (2010). The impact of advance care planning on end-of-life care in elderly patients: Randomised controlled trial. BMJ, 340, c1345. 2. Hammes BJ, ed. Having Your Own Say: Getting the Right Care When It Matters Most. Washington, DC: CHT Press; 2012. 3. Hammes, B. J.; Briggs, L. A. (2011). Respecting Choices : Building a Systems Approach to Advance Care Planning. La Crosse, WI: Gundersen Lutheran Medical Foundation, Inc. 4. Hammes, B. J., Rooney, B. L., & Gundrum, J. D. (2010). A comparative, retrospective, observational study of the prevalence, availability, and utility of advance care planning in a county that implemented an advance care planning microsystem. Journal of American Geriatrics Society, 58(7), 1249 1255 5. Hammes BJ, Briggs LA, Silvester W, et al. Implementing a care planning system: How to fix the most pervasive errors in health care. Health Affairs Blog. Posted January 2, 2015. http://healthaffairs.org/blog/2015/01/02/implementing-a-care-planning-system-how-tofix-the-most-pervasive-errors-in-health-care/. Accessed March 24, 2016. Copyright 2015 Health Affairs by Project HOPE The People-to-People Health Foundation, Inc. 24