constance m. ducharme, bsn rn chpn, ana tuya fulton, md, … · 2019-01-30 · constance m....

Throughtheiden-fica-onoftheadvancecareplanningneedsforthispopula-onofpa-ents,IntegraCCMlaunchedaneduca-onalprogramonadvancedirec-vesandadvancecareplanninginthespringof2017.OutreachwasconductedtoseniorcenterslocatedinRhodeIsland.Responserateswerehighandlargelyposi-ve.Advancecareplanningeduca-onwasprovidedinthecommunityseEng(byaregisterednursecer-fiedinpallia-veandhospicecare)atlocalseniorcentersacrossthestate.GrantfundingfromtheGeriatricWorkforceEnhancementProgram(GWEP)andtoolsfromTheConversa-onProjectwewereabletoprovideeduca-ontoselectseniorpopula-onsproviding:educa-onontheimportanceofadvancecareplanning,toolstousewithfamilyandphysiciansonhowtoexpresstheirwishesforcare,providingtheconfidencetostartaconversa-onwiththeirfamilyaboutwhatmaQersmosttothemconcerningtheirhealthcarenowandwhentheyareunabletospeakforthemselves.Theobjec-vesofthecurriculumweretoenablepar-cipantsto:1)  Understandwhyhavingconversa-onsabouttheirwishesisimportant,2)  Havetoolstousewithfamilyanddoctortoexpresstheirwishes,3)  HaveconfidencetostarttalkingtotheirfamilyaboutwhatmaQersmostto

themCommunitysessionsincludedaonehourpowerpointpresenta-on,ashowingofvideosfromTheConversa-onProject,andaques-onandanswerperiod.

TheprogramhasbeenwellreceivedintheseniorseEngsaswellasthemedicalcommunity.Atthe-meofthispublica-on,theprogramwasdeliveredatfiveseniorcentersinRhodeIsland.Todate,atotalof50seniorsreceivedthe“WhatMaQersMosttoYou?”curriculum.Par-cipantsweresurveyedattheendofeachsessiontohelpusevaluatetheprogram.Weaskedpar-cipantstoassessthedegreetowhichthelearningobjec-vesweremet.Onascaleof1to5,with5being“Outstanding”,par-cipantsoverwhelminglyratedthepresenta-onashavingmetthelearningobjec-ves.Par-cipantswerealsoaskedtoanswerthreeques-onsabouttheirexperienceandcomfortwithadvancedirec-vesbeforeanda[erthesession.Theseques-onswereaddedtothesurveyatalater-me,thereforewepresentresultsfromoneseniorcentersite.Halfofrespondentsreportedthattheyhadnottalkedtotheirloveonesabouttheirwishesforendoflife,70%ofrespondentsreportedthattheydonothavealivingwill,and91%reportedthattheyfeelcomfortablehaving“theconversa-on”withlovedonesasaresultofthepresenta-on.Lastly,par-cipantswereaskedtoratethespeaker’seffec-venessandteachingstrategy.Thoseresultswillbepresentedelsewhere..

Ourques-onnairereflectsthatmanyseniorsdidnotrateorcompletewhattheirnextstepswillbeinadvancecareplanning.Asaresult,weareconduc-ngfollow-upvisitstoeachsitetoassistpar-cipantswithcomple-onofDPOA(durablepowerofhealthcare).Thefollow-upsessionwillbeleadbyaregisterednursecer-fiedinpallia-veandhospicecareandatrainedsocialworker.Wewillbemee-ngwithseniorsone-on-oneandassis-ngthemwithcomple-ngaDPOAandobtainingrequiredsignatures.Theseniorcenterswillassistpar-cipantsinprovidingcopiesoftheirDPOAtotheirfamilyandhealthcareteam.Duringthissession,wewillalsoprovideaddi-onaleduca-ononhavingcon-nuedconversa-onswiththeirfamilyandlovedonesontheirgoalsforhealthcare.

WhatMattersMosttoYou?

ConstanceM.Ducharme,BSNRNCHPN,AnaTuyaFulton,MD,FACP,KateLally,MD,FACP,RuthScott,RN,BHA

Itisimportanttotalktoyourfamilyandlovedonesaboutthemedicalcarethatyouwouldwantornotwantatendoflife.InasurveyfromTheAmericanJournalofPreven-veMedicine,ofthe7946respondents,only26.3%hadanadvancedirec-ve.Themostfrequentlyreportedreasonfornothavingonewaslackofawareness.Asaresultwefocusedonprovidingeduca-onandtoolstotheelderlypopula-onregardingadvancecareplanning.IntegraCommunityCareNetwork,anAccountableCareOrganiza-on(ACO)withintheRhodeIslandbasedCareNewEnglandhealthSystem,wasfoundedinMay2014toserveanaQributedpopula-onof130,000Medicare,MedicareAdvantage,MedicaidandCommercialpa-ents.TheIntegraComplexCareprogram(CCM)currentlyservesthetoponetofivepercentofthehighestu-lizersofhealthcaredollarsaswellasthemostclinicallycomplexpa-ents.ThemajorityoftheaQributedpopula-onisover65yearsofageandlackingadvancedirec-vesandgoalsofcareforendoflife.Thoughourcommunityinvolvement,wediscoveredthatmostpeopledon'tliketotalkaboutdying,especiallytheirowndeath.Ourpa-entsverbalizedthattwoofthebarriersfornotcomple-ngadvancedirec-vesare:accesstohealthcareeduca-ononadvancecareplanninganddenialandprocras-na-on.Weaimedtoaddresscommonbarrierstocomple-ngadvancedirec-vesbycrea-nganddeliveringacurriculumtoseniorsinacommunity-basedseEngbyaregisterednursecer-fiedinpallia-veandhospicecare.Wean-cipatethatwithincreasededuca-onaroundhavingconversa-onsaboutgoalsofendoflife,wecanincreasethenumberofadvancedirec-vesinthestateofRhodeIsland,therebyimprovingcareatendoflife.

BACKGROUND

METHODS

RESULTS

RESULTS

NEXTSTEPS

Thelocalseniorcentersembracedouroutreachandacknowledgedtherewasaneedforeduca-ononadvancecareplanningandhavinggoalsofcareconversa-onswithlovedones.Localseniorswererecep-vetothepresenta-on,andwereo[encompelledtosharetheirstoriesinvolvingtheirexperienceswithfamilyandfriendsatendoflife.Asaresultofourcommunityoutreachwewereabletobringtogetherpopula-onsofseniorsandthroughtheirstorysharingandourcommunityoutreach;wewereabletoprovideeduca-onontheimportanceofadvancecareplanning.Wewillcon-nuetoevaluatetheeffec-venessandacceptabilityofthecurriculumforseniorsincommunityseEngsinRhodeIsland.Addi-onalsessionshavebeenscheduled,andoutreachwillbeconductedtoall50seniorcentersinRhodeIsland.

CONCLUSION

1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

Helpedmeunderstandwhyhavingconversa-onsaboutmywishesisimportant

Gavemeatooltousewithmyfamilyandmydoctortoexpressmywishes

GavemeconfidencetostarttalkingtomyfamilyaboutwhatmaQerstome

DegreetowhichLearningObjecBvesweremet

0 5 10 15 20 25

Haveyoutalkedtoyourlovedonesaboutthecarethatyouwouldwantornotwantatendof

life?

Doyouhaveanadvancedirec-veorlivingwillforhealthcare?

A[erthispresenta-on,doyoufeelcomfortablehaving“theconversa-ons”withyourloved

ones?

ParBcipantResults

NA/OtherNoYes

Thispublica,onwasmadepossiblebyGrantU1QHP28737fromtheGeriatricWorkforceEnhancementProgramoftheHealthResourcesandServicesAdministra,on(HRSA),anopera,ngdivisionoftheU.S.DepartmentofHealthandHumanServices.ItscontentsaresolelytheresponsibilityoftheauthorsanddonotnecessarilyrepresenttheofficialviewsoftheHealthResourcesandServicesAdministra,onortheU.S.DepartmentofHealthandHumanServices.