ProHealth Care Sharing the Experience Honoring Choices Pilot 2013

Transcription

1 ProHealth Care Sharing the Experience Honoring Choices Pilot 2013 Deb Bina RN, BSN Patty Starr RN, MSN

2 Who do we serve? Our regional integrated health network includes: Waukesha Memorial, a major tertiary-care hospital Oconomowoc Memorial, an acute-care hospital Rehabilitation Hospital of Wisconsin More than 125 primary care physicians and specialists practicing at 15 ProHealth Care Medical Associates clinics throughout Waukesha County Home health care Hospice care Rehabilitation services Assisted and independent living communities West Wood Health & Fitness Center

3 Overview Oncology Patients Lung and pancreatic cancer Oncology Registry Approached by ACP Facilitator after approval from oncologist Health Coach Patients 60 and older 3+ chronic conditions Participants in Health Coach program Approached by HC RN and then referred to ACP Facilitator based on interest

4 Goals Accomplished >50% of people invited were scheduled 69% 100% of people who completed ACP had documentation in EMR 100% >50% of people who participated in ACP had a written plan 86% Participants surveys rated >3 100% rated 4 or 5 Agents felt more prepared after ACP 5 = 100% Facilitators became more confident Number of facilitations = confidence and skill 100% Participants & Agents rated Facilitator skill at 5 Facilitators able to incorporate into routines of care Challenging at times with role and competing priorities

5 Successes Detailed process and script to follow resulted in more meaningful conversations and completed process Conversation more in-depth with agent present Due to strong interest and need expanded to all health coach locations Identified and completed process for those who had AD but was not in Epic or not current Brought heightened awareness of Advance Care Planning (ACP) throughout PHC and community Overwhelming positive feedback Several situations where ACP was completed and soon after patient was hospitalized with decisions needing to be made resulting in wishes being followed

6 Challenges Physician engagement and support Witnesses Especially at clinics and patient homes Scheduling facilitations at clinics 3 of 4 Facilitators located primarily at hospitals Room availability Incorporating facilitations into daily work Oncology population were late stage most already had AD recently completed

7 Changes Due to low volumes of ACP Facilitations & large interest from other Health Coach locations, we opened up to all 6 HC locations (initially started with 1 location) This population was served at clinic locations & their homes Most facilitations with HC patients resulted in spouse &/or agent ACP facilitations as well Accepted a couple oncologist referrals

8 Results 52 invited 36 scheduled 16 refused Majority were oncology patients who had recently completed AD 31 fully completed Average length of facilitation - 60 minutes Overwhelming positive responses on surveys Survey return a challenge

9 Lessons Learned Improved data collection process Dedicated person and process for handling referrals, scheduling, assigning facilitators and follow up Dedicated staff time for facilitations Increase in AMB or mobile facilitators Facilitations need to be completed more upstream

10 Next Steps Train additional facilitators and facilitator trainers Organization wide communication and education Increase community education events Conduct employee/physician facilitations Continue to expand across the continuum of care next phase of HCW planning starts in Nov ACP an integral piece in PHC EOL/Palliative Strategy Finalize Epic Navigator, SmartForm & referral order

11 Future Success Metrics Decrease ICU utilization at end of life Increase Palliative Care and Hospice referrals Longer hospice stays Increase % of patients with AD available in Epic Standardized documentation and retrieval of information

12 Questions?