1 Incorporating Advanced Care Planning into the GLHC Community Health Record 2017 Summit Series Flint & Genesee County Sept 14, 2017 CREATING CARE-CONNECTED COMMUNITIES Brought to you by 2 Lori Kunkel, MHSA Vice President of Programs Steve Spieker, LPC Manager of Solution Support CREATING CARE-CONNECTED COMMUNITIES 1
3 Who Knows Your Wishes? CREATING CARE-CONNECTED COMMUNITIES 4 Who Knows Your Wishes? CREATING CARE-CONNECTED COMMUNITIES 2
5 Who Knows Your Wishes? CREATING CARE-CONNECTED COMMUNITIES 6 Who Knows Your Wishes? CREATING CARE-CONNECTED COMMUNITIES 3
Advance Care Planning (ACP) Project A Project of the Greater Flint Health Coalition GLHC Summit September 14, 2017 ADV 12B GLHC.Summit.091417lk The realities of end of life care: Often no one knows, and never will for certain, what the patient wanted No matter what decision is made, families and healthcare professionals live with considerable uncertainty about their decision, resulting in lasting distress Incredible amounts of staff time are spent attempting to sort through the ethical complexities of end of life care decisions 8 4
Genesee County s Aging Population Joint CHNA identified Effective Care Delivery for an Aging Population as one of the top community health needs. Median age of Genesee County residents has increased over 13% in the past 15 years, with individuals aged 55 and older representing a disproportionately high amount of the total population. Percentage of residents 65 years and older increased 31.03% from 11.6% in 2000 to 15.2% in 2013. Older residents as a population have an increased need for social supports and health care services. 9 The purpose of the Greater Flint Health Coalition s Advance Care Planning (ACP) Project is to develop a systemic approach to ACP in Genesee County. The goals, in addition to making advance directives (ADs) the norm for all residents ages 55 years and older, are to: 1. Create an effective plan that defines specific instructions and the selection of a well prepared healthcare agent 2. Make the plan available to healthcare providers and treating physicians 3. Demonstrate evidence that plans were honored 10 5
The ACP Project is utilizing Gundersen Health System s Respecting Choices model to develop the ACP system for Genesee County. 11 Starting Point: Genesee County s Baseline ACP Data 12 6
ACP Baseline Data Data collected from all three Genesee County hospitals Reviewed medical records for deaths occurring from January 1, 2013 through June 30, 2013 Excluded deaths in the emergency department Total number of hospital deaths during time period: 504 Mean age of death: 70.7 years Range of ages at death (youngest to oldest): 20 100 years (one 13 year old) Percentage of deaths which are male: 49.2% or female: 50.8% Percentage of deaths by ethnicity (n=504) o White: 73.5% o African American: 24.3% o Hispanic: 1.2% o Other: 1.0% 13 ACP Baseline Data Percentage of patients stating they had an advance directive (AD) (percentage of decedents with any type of AD) (n=501): Yes: 27.5% (138) Percentage of patients with AD document found in the medical record at the time of death (total patients=499): Yes: 29.5% (147) Type of AD document (n=156, some patients had multiple types): o Durable Power of Attorney for Health Care (AD): 90.4% (141) o Living Will: 3.2% (5) o Personal Letter: 3.2% (5) o Other: 3.2% (5) Percentage of deaths with a Michigan Durable Power of Attorney for Health Care: 28% Percentage of Deaths with other form of AD: 3% 14 7
Advance Care Planning is more than checking boxes on a form and signing a document such as a living will. What is Advance Care Planning (ACP)? 16 8
Advance Care Planning (ACP) Definition: Advance Directive (AD) A plan, made by a capable person or their surrogate, for future medical care regarding treatments or goals of care for a possible or probable event. This plan could be expressed: Orally or in writing If written, it could be in strict accord with specific state statutes or simply a documentation of the plan, e.g., a physician s note. Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 17 Advance Care Planning (ACP) Definition: Advance Care Planning (ACP) A communication process of planning for future medical decisions. This process, to be effective, needs to meet similar standards as the process of informed consent, i.e., the person planning needs to Understand selected possible future situations and choices; Reflect on personal goals, values, and beliefs; and Discuss these choices and plans with those who might need to carry out the plan Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 18 9
Advance Care Planning (ACP) Relationship of ACP to ADs ADs are only as good as the process of planning: If the person planning does not understand, reflect on, or discuss their choices/options adequately, the plan has a high probability of failure ADs success is directly tied to the quality of the planning process or ACP Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 19 Respecting Choices ACP Program ACP micro systems have been developed around the following Five Promises of Respecting Choices : 1. We will initiate a discussion with every adult 2. We will provide skilled facilitation 3. We will make sure that plans are clear 4. We will store and be able to retrieve plans when needed 5. We will follow plans appropriately as needed Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 20 10
Implementation of the Respecting Choices Model 21 ACP Implementation in Genesee County ACP Task Force (Steering Committee) Ascension Genesys Health System Hurley Medical Center McLaren Flint Genesee County Medical Society Genesee County Osteopathic Society Genesys PHO McLaren Physician Partners Blue Cross Blue Shield of Michigan HAP Midwest McLaren Health Plan Genesys Hurley Cancer Institute Valley Area Agency on Aging Greater Flint Health Coalition 22 11
ACP Implementation in Genesee County Pilot Team Approach Perfect initial processes and materials to develop best practices Make workload manageable Gradually build ACP facilitation skills Gather data on initial successes to demonstrate program effectiveness and motivate others to participate Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 23 ACP Implementation in Genesee County Initial ACP Pilot Sites Organization McLaren Flint Hurley Medical Center Genesys PHO Genesys Health System Others Pilot Pilot Count Cancer Center 1 Internal Medicine Residency Program 2 Chronic Obtrusive Pulmonary Disease (COPD) Patients referred from multiple settings: Medical/surgical units, Emergency Department, Inpatient settings such as critical care and outpatient settings. Family Practice (One multiple and one single provider practice) 4 & 5 Genesys High-need Patient Navigation Project 6 Genesys Convalescent Center 7 UAW Union Hall through the UAW Trust 8 DaVita Dialysis Center, Ballenger Pointe Location 9 Genesys Hurley Cancer Institute 10 3 24 12
ACP Implementation in Genesee County ACP Task Force and Pilot Activities: Determined focus population Created uniform educational materials Selected branding for initiative Developed standard AD document Agreed upon outcome measures Assisted with development of ACP scripts and workflows Received training and create workforce knowledgeable in ACP Developed a community wide ACP document storage and retrieval system 25 Respecting Choices ACP Program ACP micro systems have been developed around the following Five Promises of Respecting Choices : 1. We will initiate a discussion with every adult 2. We will provide skilled facilitation 3. We will make sure that plans are clear 4. We will store and be able to retrieve plans when needed 5. We will follow plans appropriately as needed Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 26 13
The Role of the ACP Facilitator To promote To expedite To assist To guide ACP Facilitation Activities Promote person centered ACP conversations through exploration of understanding of ACP, past experiences, and living well Provide information on three decisions for First Steps ACP Develop a follow up plan to meet with individual and chosen patient advocate to complete the ACP process 14
First Steps ACP: Three Decisions Choosing a patient advocate Identifying cultural, religious, spiritual, or personal beliefs that might influence treatment decisions Exploring goals of care for a severe, permanent brain injury and a poor cognitive outcome Goals of ACP Facilitation Assess understanding of ACP Promote understanding of role of patient advocate Promote discussion between individual and the patient advocate; clarify goals and values Review and discuss the three decisions of First Steps ACP Complete a written plan Create strategies to communicate plan 15
Goals of ACP Facilitation For individuals with chronic illness: Explore understanding of illness Explore experiences (including past hospitalizations) Explore living well Assist in making informed decisions using the Decision Making Framework Create a plan that honors individual s decisions Respecting Choices ACP Program ACP micro systems have been developed around the following Five Promises of Respecting Choices : 1. We will initiate a discussion with every adult 2. We will provide skilled facilitation 3. We will make sure that plans are clear 4. We will store and be able to retrieve plans when needed 5. We will follow plans appropriately as needed Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 32 16
Advance Directive Standard AD for use in Genesee County Documents ACP decision making goals 1. Choosing a decision maker 2. Discussing and deciding on goals of care 3. Identifying any personal, cultural, or religious beliefs that may affect decisions Document meets legal requirements for Michigan Advance Directive Law Section 20201 Michigan Public Health Code, 1978 PA 368, MCL 333.20201 Advance Directive Making My Advance Directive Legal Patient signature & date Two witness signatures Advocate signature(s) Does NOT require notary * All signature dates of patient and witnesses must match, advocate can sign AFTER but not BEFORE 17
Advance Directive Following completion of advance directive document: 1. Review document for quality 2. Make copies for: Patient Advocate Physician 3. Keep or scan into your system 4. Upload to Great Lakes Health Connect Established a hard wired system so all will know process. Inform patient Document can be changed or updated at any time The Five D s of when to review Decade Death Divorce Diagnosis Decline The document will not be used unless you are unable to make your own decisions 18
Respecting Choices ACP Program ACP micro systems have been developed around the following Five Promises of Respecting Choices : 1. We will initiate a discussion with every adult 2. We will provide skilled facilitation 3. We will make sure that plans are clear 4. We will store and be able to retrieve plans when needed 5. We will follow plans appropriately as needed Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 37 Storage and Retrieval of ACP Information Standards for: Documentation of the ACP conversation Storage and retrieval of document Making referrals to providers; other resources 19
ACP Storage and Retrieval System The ACP Project contracted with Great Lakes Health Connect, the State s largest and most trusted HIE network for the development of a community wide ACP document storage and retrieval system. Over 130 hospital facilities, including Genesys, Hurley, and McLaren Flint 4,000 primary, specialty, and allied health organizations 17,000+ providers Other member organizations: Provider organizations FQHCs Health plans Home health/dme Community mental health Local public health Employer clinics Diagnostic centers * By signing AD document, patient agrees to have it uploaded to Great Lakes Health Connect Storage system (may opt out) 39 ACP Storage and Retrieval System Any ACP facilitator may upload ACP documents as a scanned document via a secure web portal accessible through the internet. GLHC reviews all documents for patient name, signature and readability and notifies the submitter of the document s verification or rejection. 40 20
ACP Storage and Retrieval System Physicians/healthcare providers have access to their patients information through GLHC s Virtual Integrated Patient Record (VIPR). ACP documents will be available to Genesee County s three hospitals and eventually all of GLHC s network. 41 Great Lakes Health Connect Requires registration and password for upload and/or download Determine what option works for uploading the document ACP facilitator to upload Other designated individual or department, i.e. hospital registration or medical records Greater Flint Health Coalition 21
Respecting Choices ACP Program ACP micro systems have been developed around the following Five Promises of Respecting Choices : 1. We will initiate a discussion with every adult 2. We will provide skilled facilitation 3. We will make sure that plans are clear 4. We will store and be able to retrieve plans when needed 5. We will follow plans appropriately as needed Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 43 Role of Providers in ACP Initiate ACP discussions Invite participation Make referrals for ACP facilitation Answer individual s questions Review written plans entered into the medical record Retrieve plans Use plans to guide clinical decision making 22
Educational Materials Information booklet Guide Information sheet Health literate information Patient advocate information Educational Materials 4 Fact Sheets Durable power of attorney for healthcare v. living will CPR or no CPR Help with breathing Tube feeding 23
Promotional Materials Posters Buttons Presentation slide deck Online Resource Availability WEBSITE www.yourhealthyourchoice.org 24
Online Resource Availability Advance Care Planning To refer to an ACP facilitator or obtain information on advance care planning contact: 25
Expected Outcomes Outcome Measures Increase the percentage of written advance directives at the time of death; availability; appointment of advocate Reduce hospital deaths Increase hospice admissions Increase median hospice length of stay Increase transfer of patient preferences to medical orders Increase family reports of end of life discussions Individuals rate a high level of satisfaction with facilitation Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 51 Expected Outcomes Process Measures Within organizations, written policies on ACP including standards on Review, entry, and transfer of written AD s ACP team roles and responsibilities Community engagement campaign resulting in increased numbers of individuals motivated to participate in ACP ACP facilitators reporting high satisfaction regarding the impact of their interventions on their professional roles and responsibilities Copyright 2012 All Rights Reserved. Gundersen Lutheran Medical Foundation, Inc. NC 52 26
53 170 Registered Submitters 80 sites including: Hospitals Clinics Hospice Home Health SNF & LTC Agencies PHOs Attorneys CREATING CARE-CONNECTED COMMUNITIES Types of Information Submitted 54 Advance Care Directive Advance Care Directive Other State Asthma Action Plan Care Plan Certificate of Disability Code Status/Orders Complex Care Plan Consent Anatomical Gift Designation of Patient Advocate Designation of Pt Advocate NO BLOOD Do Not Resuscitate Durable Power of Attorney Finance Only Durable Power of Attorney for Healthcare Guardianship Individualized Care Plan Living Will Michigan Physician Orders for Scope of Treatment (MI POST) Military Advance Care Directive OB ACOG Antepartum Records Organ Donation Physician Orders for Life Sustaining Treatment (POLST) Post Death Request Prenatal Physical Statement of Treatment Preferences CREATING CARE-CONNECTED COMMUNITIES 27
Advance Care Directives are gaining momentum in Michigan 55 2013 143 Pilot began September 2013 CREATING CARE-CONNECTED COMMUNITIES Advance Care Directives are gaining momentum in Michigan 56 2013 143 2014 1,484 2015 3,378 2016 7,939 2017 10,699 OVER 23,000 DOCUMENTS Through August 31st CREATING CARE-CONNECTED COMMUNITIES 28
GLHC Remains Committed to Quality 57 1. Does the Patient s Name Match? 2. Does the Title Match? 3. Is it a readable copy? CREATING CARE-CONNECTED COMMUNITIES GLHC Remains Committed to Advance Care Directives 58 CREATING CARE-CONNECTED COMMUNITIES 29
59 CREATING CARE-CONNECTED COMMUNITIES 30