Multifaceted Approaches to Advance Care Planning. Rebecca Sudore, MD & select PCQN Members

Transcription

1 Multifaceted Approaches to Advance Care Planning Rebecca Sudore, MD & select PCQN Members

2 Agenda Define ACP Clinician Training: Karen Knops, MD Overlake Hospital Health Systems: Chris Pietras, MD, UCLA Community Engagement: Sherry Michael, MSW, Collabria Care Patient Activation Questions & Action Planning

3 What is ACP? We are on the same page, yet we can t seem to agree on anything.

4 Standardizing ACP Definition No formal prior definition Most oftenà life sustaining treatments & advance directives 2014 IOM report: various descriptions

5 Delphi Panelà Definition Delphi convened to rank ACP outcomes. Unable to agree on a definitionà halted Who Cares? à A consensus definition needed to standardize research and guide policy and quality metrics.

6 10 Rounds of Delphi Panel Example Tension: Values vs. Treatments Documentation of treatment preferences for CPR is the most important. vs. DNR/DNI may say less about a patient's overall values and is less informative than documented discussions of values, preferences, and goals.

7

8 Consensus Definition of ACP Definition: ACP is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. Goal: The goal of ACP is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.

9 Consensus Definition of ACP Definition: ACP is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding current and future medical care. Goal: The goal of ACP is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.

10 Agenda Define ACP Clinician Training: Karen Knops, MD Overlake Hospital Health Systems: Chris Pietras, MD, UCLA Community Engagement: Sherry Michael, MSW, Collabria Care Patient Activation Questions & Action Planning

11 Advance Care Planning: Clinician Training OVERLAKE MEDICAL CENTER SPRING 2017 PCQN

12 Where we ve been, who we are In 1952, Seattle Eastside residents of Bellevue formed the nonprofit Overlake Memorial Hospital Association, and opened a 56-bed hospital in marked the opening of the Heart & Vascular Center and the Neuroscience Institute in Overlake now totals 349 licensed beds and directly employs over 120 providers through its affiliate, Overlake Medical Clinics. 1 million East side residents Palliative care inpatient consult service established 2010 Inpatient à clinics TBD

13 Summary Past Overlake Efforts No formal staff training to date Palliative care social workeràpalliative Care teamà Hospital care teams WA State POLST, end-of-life laws, SDM tool certification program Honoring Choices Trained facilitator (MSW) Outpatient DPOA for healthy individuals

14 Summary Training experiences elsewhere Observations of what works for ACP clinician training Effort employs all aspects of the organization (including marketing) Roles are clear Right tools, not just a mandate Coupled with other pillars and initiatives* Effort is sustained Atlantic Health, Meridian, Hackensack University Healthcare System, Wellspan, Reading Health System, Lehigh Valley Health Network

15 Concerns Plans or Planning? Conversations that produce no document can still help Poor conversations = Poor documents Good documents can be usurped by poor communication later Unintended consequences of early ACP People who pursued ACP are health literate, carefully choose proxy, tend to limit intervention EHR - got documentation? Upgrade pending Linking notes

16 Concerns Limits of qualitative data Plans are useless, but planning is everything Dwight Eisenhower Everybody has a plan - until they get punched in the face Mike Tyson

17 ACP training: 30 years and counting

18 Exploring narrative co-creation Anticipate < Summarize the context < Concern yourself - beyond the physical ^ Explore/Explain in context of goals and challenges ^ Next steps may be a document, may be home work or follow up conversation > Document! > - Alternative to SHARE matches other training, can be a part of the experience

19 Exploring training: Narratives Anticipation Right tool for the job (POLST, AD, language, adolescent version, etc) Right participants (capacitated patient, likely surrogates, trusted healthcare professional) Right mindset for patient and provider Talk about talking about it Coaching model Kenosis Patient anticipation /poster

20 Exploring narrative co-creation Documentation Obtaining existing documents before visits, preplanning documents Written literature, BC/WC, recording Systems: EMR, interprovider communication

21 Next Steps Workshop using 2 clinical scenarios BBNfoundation.org trained actors with videotaping Coordinate with existing efforts, key stakeholders Patient/physician satisfaction

22 Documents: ACP training materials Tools that compel Not one more thing We have an obligation to delight Reminders EMR, environmental cues It is easier to implement for ACP if the steps are second nature Manage downside risks of ACP while promoting increased use of ACP Promote ACP as a process, from Planning to Plan to POLST completion or request for PAS

23 Nobody Wants to Read Your Sh*t -by Steven Pressfield What s the answer? 1) Streamline your message. Focus it and pare it down to its simplest, clearest, easiest-tounderstand form. 2) Make its expression fun. Or sexy or interesting or scary or informative. Make it so compelling that a person would have to be crazy NOT to read it. 3) Apply that to all forms of writing or art or commerce. *this talk was created with the ASCEND process

24 Advance Care Planning and the Electronic Health Record Chris Pietras MD Palliative Care Program Director Hospice and Palliative Medicine Fellowship Program Director UCLA Department of Medicine

25 We re trying to make the electronic health record work for us! Remind us to engage in advance care planning Streamline documentation of advance care planning Make it easy to find and review any previous documentation

26 Goals of Care Notes and Templates

27 Alternate Goals of Care Note Template Suggestions as to important aspects of the conversation Most people free type without a template

28 Tabs: Advance Directives

29 Tabs: Goals of Care

30 Inpatient POLST Reminders: At Admission and Discharge A text prompt (i.e., a line of text within the order set is added when the provider is completing the order set -- not a pop-up or best practice advisory/ BPA), appears only: At admission: POLST is present: POLST form is present and should be reviewed At discharge: No POLST, and code status is MODIFIED or DNR: Recommended to complete a POLST form.

31 Outpatient ACP Reminders: Health Care Maintenance Decision not to include yet Until sufficient resources in place Until training done or available

32 Planned Clinician Performance Feedback In collaboration with leadership reinforcement of the importance of ACP Monthly reports of both institutional and individual metrics E.g., Advance directives, POLST, GOC notes

33 Summing it up: using the EHR to promote ACP Remind us to engage in advance care planning Streamline documentation of advance care planning The conversation: GOC notes Advance Directives and POLST forms Make it easy to find and review any previous documentation And alert us to any inconsistencies in the current plan Promote performance improvement and selfevaluation

34 Collabria Care Palliative Services April 20, 2017

35 History

36 Partners in Palliative Care (PIPC) pilot

37 Partners in Palliative Care (PIPC) pilot

38 Community Engagement Professional and community outreach Latino Outreach Latino Outreach Liaison Community organizations, health fairs, educational presentations Increased Latino outreach efforts due to pilot

39 Partners in Palliative Care Two primary goals of PIPC were: Reduce ER / Hospitalizations Facilitate Advance Care Planning Developed a team: PNN, MSW, CHW Team intake approach Consent form ACP participation CHW Interpretation / cultural awareness

40 Advance Care Planning in the Home Not in crisis mode Time for clarification of goals of care Opportunity for family/friend involvement Spiritual and cultural issues Multiple interdisciplinary team visits Allow additional time for interpretation Facilitate conversations with physicians

41 Latino Community - CHW 45 % of PIPC patients were monolingual Complex medical - psycho/social issues Average age 58 CHW provided interpretation, cultural awareness CHW role enhanced trust/relationship building Available for physician visits with PNN Knowledge of community resources Present for ACP conversations ACP conversations average 2-3 visits

42 ACP Conversations Scenarios as time allows with patient and family incorporating goals of care and spiritual beliefs with dementia crossing cultural barriers a series of conversations Questions?

43 414 South Jefferson St. Napa, CA