Advance Care Planning in the Chronic Kidney Disease Population A Quality Improvement Project

Transcription

1 Advance Care Planning in the Chronic Kidney Disease Poplation A Qality Improvement Project BARBARA WEIS MALONE DNP, FNP-C, FNKF ASSOCIATE PROFESSOR, UNIVERSITY OF COLORADO COLLEGE OF NURSING 2017 TENTH NATIONAL DNP CONFERENCE

2 Objectives By the end of the presentation, the participant will be able to: Recognize the need advance care planning in a specialty and primary care poplation Understand the vale of advance care planning programs that collect medical drable power of attorney and advance directives in specialty and primary care clinics Appreciate the vale of qality improvement (QI) projects in the field of advance care planning and palliative care for a potential DNP project The presenter has no disclosres

3 The Prpose and Aim of this Qality Improvement Project Aim of this Qality Improvement Project To improve end-of-life qality of care for patients with CKD throgh their participation in ACP, specifically the completion of the advance directive and an MDPOA forms Primary prpose To determine the impact of an Advanced Care Planning (ACP) intervention on pre-dialysis otpatient Chronic Kidney Disease (CKD) patients 65 and older participation in ACP on patients withot docmented Advance Directive (AD) or Medical Drable Power of Attorney (MDPOA) in the electronic medical record (EMR) To determine the completion of AD and MDPOA forms (as defined by scanned into the EMR) Secondary prpose To determine the impact of demographic variables on patient participation in ACP, specifically patient age, gender, race, and stage of CKD for the prpose of tailoring an evidence-based ACP program

4 WHAT IS ADVANCE CARE PLANNING AND WHAT TYPE OF ADVANCE DIRECTIVES ARE ADDRESSED IN CLINICAL CARE? Volntary ACP - Volntary discssion abot the care the person wold want to receive if they become nable to speak for themselves, inclding the goals, wishes, and preferences An Advance Directive - is a docment telling providers to stop or not start life-sstaining treatments if the person is in a terminal condition and can t make decisions or if the person is in a persistent vegetative state (living will) - POLST, MOLST, Five Wishes Medical Drable Power of Attorney - is a docment signed naming a srrogate (s) to make healthcare decisions if and when the person is not able to. It can either be effective immediately or when the person is in a vegetative state Palliative Care - is an approach that improves the qality of life of patients and their families facing the problem associated with life-threatening illness Hospice care services provided to Medicare Recipients for EOL care by referral primary care with certification that patient has < 6 mos. to live

5 Significance of the Problem Consider the effect of the baby boomers ( ), the prediction is there will be 72.8 million people by 2030 aged older than 65 years old. (CDC, 2013) Accordioning to the Institte of Medicine (IOM) many US adlts have not addressed their personal end-oflife care (IOM, 2014) Mltiple pblic and private organizations recommend advanced care planning (ACP) as essential to qality care and yet nationally, a small percentage of patients report engaging in sch discssions (AARP, 2016, IOM, 2014,) The elderly poplation > 75 on dialysis has dobled in the last two decades. Costs for caring for patients with ESRD now represent 7% of total Medicare spending, 1/3 attribtable to hospitalizations dring the last 6 months of life (USRDS, 2014) Patients with ESRD die more often in ICU and receive fewer palliative care and hospice care referrals than patients with dementia, cancer and other organ failre (Sharp et al, 2016) Patients want to talk abot endof-life care and have made decisions abot their personal preferences regarding lifesstaining treatment (Davison, 2012)

6 IRB Approval Process and Stdy Timeline Apply IRB Hospital where the patients wold be seen Determined to be exempt Low Risk / No vlnerable poplation Apply IRB UCCS Project facilitator readied herself by shadowing palliative care providers Informed Consent created Medical Director sends ot letter to Providers Project Commences PDSA IRB Amendment MDPOA PDSA Staff Meeting Trial Implementation + 3 months ( Institte of Health Care Improvement 60 sbjects recrited Stdy completed (as mch data as possible in 3 months.)

7 84% 16% 96% % of No Intervention and Intervention that completed MDPOA 4% Reslts: Inferential Statistics Nmber of MDPOA Post first visit Statistically significant The amont of MDPOAs completed at the face-to-face visit exceeded expectations with little difference between grops. Statistically significant and is a simple, low resorce, time-efficient collection that has been associated with a good death. McNemara = p =.000 (< 0.5)

8 Ftre Directions/Sstainability Nrsing Implications Sstainability Coding for ACP Monies Nrses are well posed to be in the forefront of leadership in the palliative care movement Nrses niqe talents make them ideal candidates to address ACP needs of the patients A reminder system in the EMR cold increase confidence and prompt nrses to complete AD/ MDPOAs (Boot and Wilson, 2014) Advanced Practices Nrses are eligible for ACP CPT payments Nrses have a chance to be involved in creating pblic policy in palliative care Compatible with DNP essentials Potential for ACP program Provides a evidencebased cost-effective, and sstainable delivery system In line with the organizational and national mission to increase completion of AD/MDPOA in EMR In line with the greater primary care, nephrology, and palliative care commnities to improve qality of interventions in ACP CPT Code CPT Code $86 $73 PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf

9 ACP Provider Learning Resorces NIH National Institte on Aging(English and Spanish HO and Hotline) ***Coalition for the Spportive Care for the Care of Kidney Patientshttp:// *** Advance Care Planning: An Introdction for Pblic Health and Aging Services Professionals (free corse offering contining edcation credit) The Conversation Project Nice starter MDPOA kit jst developed ANNA edcational modles on End-of-Life and Palliative Care National Kidney Fondation Patient Handot American Bar Association Commission on Law and Aging

10 References Boot, M., & Wilson, C. (2014). Clinical nrse specialists 'perspectives on advance care planning conversations: A qalitative stdy. International Jornal of Palliative Nrsing, 20(1), Centers for Medicare & Medicaid, Minimm Data Set 3.0 Pblic Reports: MDS 3.0 (2014) Freqency Report. Reports/index.html. Colorado Hospital Association. (2011). Yor right to make healthcare decisions. Retrieved from Davison, S.N. (2012). Advance Care Planning in patients with chronic kidney disease. Seminars in Dialysis, 25(6), Institte of Medicine of the National Academies (2015). Dying in America. The National Academies Press, Washington, D.C. Sharp, T., Moran, E., K. & Barclay, S. (2013). Do the elderly have a voice? Advance care planning discssions with frail and older adlts. British Jornal of General Practice, e642-e657. U.S. Department of Health and Hman Services, Health Resorces and Services Administration. (2011). Developing and implementing a QI project. Retrieved from W. Edwards Deming Institte. (2016). PDSA cycle. Retrieved from management-system/pdsacycle