MultifacetedApproachestoAdvanceCarePlanning

RebeccaSudore,MD&selectPCQNMembers

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

What is ACP?

“We are on the same page, yet we can’t seem to agree on anything.”

Standardizing ACP Definition

• No formal prior definition

• Most oftenà life sustaining treatments & advance directives

• 2014 IOM report: various descriptions

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.

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.”

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.”

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.”

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

O V E R L A K E M E D I C A L C E N T E RS P R I N G 2 0 1 7

P C Q N

Advance Care Planning:Clinician Training

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 1960.

• 2014 marked the opening of the Heart & Vascular Center and the Neuroscience Institute in 2015.

• 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 2010Inpatient à clinics TBD

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

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

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

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

ACP training: 30 years and counting

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

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 – email/poster

Exploring narrative co-creation

Documentation� Obtaining existing documents before visits, “pre-

planning” documents� Written literature, BC/WC, recording� Systems: EMR, interprovider communication

Next Steps

� Workshop using 2 clinical scenarios¡ BBNfoundation.org – trained actors with videotaping

� Coordinate with existing efforts, key stakeholders¡ Patient/physician satisfaction

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

“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-to-understand 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

Advance Care Planning and the Electronic Health RecordChris Pietras MD

Palliative Care Program Director

Hospice and Palliative Medicine Fellowship Program Director

UCLA Department of Medicine

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

Goals of Care Notes and Templates

Alternate Goals of Care Note Template´ Suggestions as to

important aspects of the conversation

´ Most people free type without a template

Tabs: Advance Directives

Tabs: Goals of Care

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.”

Outpatient ACP Reminders:Health Care Maintenance

´ Decision not to include yet´Until sufficient resources in place´Until training done or available

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

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 self-

evaluation

Collabria Care Palliative ServicesA p r i l 2 0 , 2 0 1 7

History

Partners in Palliative Care (PIPC) pilot

Partners in Palliative Care (PIPC) pilot

Community Engagement

Professional and community outreach

Latino Outreach Latino Outreach LiaisonCommunity organizations, health fairs, educational presentations

Increased Latino outreach efforts due to pilot

Partners in Palliative Care

Two primary goals of PIPC were:Reduce ER / HospitalizationsFacilitate Advance Care Planning

Developed a team: PNN, MSW, CHWTeam intake approachConsent form – ACP participationCHW – Interpretation / cultural awareness

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

Latino Community - CHW45 % of PIPC patients were monolingualComplex medical - psycho/social issuesAverage 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

ACP ConversationsScenarios – as time allows

– with patient and family – incorporating goals of care and spiritual beliefs– with dementia– crossing cultural barriers– a series of conversations

Questions?

414 South Jefferson St. Napa, CA 94559707.258.9080

www.collabriacare.org