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  • Constance M. Ducharme, BSN RN CHPN, Ana Tuya Fulton, MD, … · 2019-01-30 · Constance M. Ducharme, BSN RN CHPN, Ana Tuya Fulton, MD, FACP, Kate Lally, MD, FACP, Ruth Scott, RN,
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Through the iden-fica-on of the advance care planning needs for this popula-on of pa-ents, Integra CCM launched an educa-onal program on advance direc-ves and advance care planning in the spring of 2017. Outreach was conducted to senior centers located in Rhode Island. Response rates were high and largely posi-ve. Advance care planning educa-on was provided in the community seEng (by a registered nurse cer-fied in pallia-ve and hospice care) at local senior centers across the state. Grant funding from the Geriatric Workforce Enhancement Program (GWEP) and tools from The Conversa-on Project we were able to provide educa-on to select senior popula-ons providing: educa-on on the importance of advance care planning, tools to use with family and physicians on how to express their wishes for care, providing the confidence to start a conversa-on with their family about what maQers most to them concerning their health care now and when they are unable to speak for themselves. The objec-ves of the curriculum were to enable par-cipants to: 1) Understand why having conversa-ons about their wishes is important, 2) Have tools to use with family and doctor to express their wishes, 3) Have confidence to start talking to their family about what maQers most to them Community sessions included a one hour power point presenta-on, a showing of videos from The Conversa-on Project, and a ques-on and answer period. The program has been well received in the senior seEngs as well as the medical community. At the -me of this publica-on, the program was delivered at five senior centers in Rhode Island. To date, a total of 50 seniors received the “What MaQers Most to You?” curriculum. Par-cipants were surveyed at the end of each session to help us evaluate the program. We asked par-cipants to assess the degree to which the learning objec-ves were met. On a scale of 1 to 5, with 5 being “Outstanding”, par-cipants overwhelmingly rated the presenta-on as having met the learning objec-ves. Par-cipants were also asked to answer three ques-ons about their experience and comfort with advance direc-ves before and a[er the session. These ques-ons were added to the survey at a later -me, therefore we present results from one senior center site. Half of respondents reported that they had not talked to their love ones about their wishes for end of life, 70% of respondents reported that they do not have a living will, and 91% reported that they feel comfortable having “the conversa-on” with loved ones as a result of the presenta-on. Lastly, par-cipants were asked to rate the speaker’s effec-veness and teaching strategy. Those results will be presented elsewhere.. Our ques-onnaire reflects that many seniors did not rate or complete what their next steps will be in advance care planning. As a result, we are conduc-ng follow-up visits to each site to assist par-cipants with comple-on of DPOA (durable power of health care). The follow-up session will be lead by a registered nurse cer-fied in pallia-ve and hospice care and a trained social worker. We will be mee-ng with seniors one-on-one and assis-ng them with comple-ng a DPOA and obtaining required signatures. The senior centers will assist par-cipants in providing copies of their DPOA to their family and health care team. During this session, we will also provide addi-onal educa-on on having con-nued conversa-ons with their family and loved ones on their goals for health care. What Matters Most to You? Constance M. Ducharme, BSN RN CHPN, Ana Tuya Fulton, MD, FACP, Kate Lally, MD, FACP, Ruth Scott, RN, BHA It is important to talk to your family and loved ones about the medical care that you would want or not want at end of life. In a survey from The American Journal of Preven-ve Medicine, of the 7946 respondents, only 26.3% had an advance direc-ve. The most frequently reported reason for not having one was lack of awareness. As a result we focused on providing educa-on and tools to the elderly popula-on regarding advance care planning. Integra Community Care Network, an Accountable Care Organiza-on (ACO) within the Rhode Island based Care New England health System, was founded in May 2014 to serve an aQributed popula-on of 130,000 Medicare, Medicare Advantage, Medicaid and Commercial pa-ents. The Integra Complex Care program (CCM) currently serves the top one to five percent of the highest u-lizers of health care dollars as well as the most clinically complex pa-ents. The majority of the aQributed popula-on is over 65 years of age and lacking advance direc-ves and goals of care for end of life. Though our community involvement, we discovered that most people don't like to talk about dying, especially their own death. Our pa-ents verbalized that two of the barriers for not comple-ng advance direc-ves are: access to health care educa-on on advance care planning and denial and procras-na-on. We aimed to address common barriers to comple-ng advance direc-ves by crea-ng and delivering a curriculum to seniors in a community-based seEng by a registered nurse cer-fied in pallia-ve and hospice care. We an-cipate that with increased educa-on around having conversa-ons about goals of end of life, we can increase the number of advance direc-ves in the state of Rhode Island, thereby improving care at end of life. BACKGROUND METHODS RESULTS RESULTS NEXT STEPS The local senior centers embraced our outreach and acknowledged there was a need for educa-on on advance care planning and having goals of care conversa-ons with loved ones. Local seniors were recep-ve to the presenta-on, and were o[en compelled to share their stories involving their experiences with family and friends at end of life. As a result of our community outreach we were able to bring together popula-ons of seniors and through their story sharing and our community outreach; we were able to provide educa-on on the importance of advance care planning. We will con-nue to evaluate the effec-veness and acceptability of the curriculum for seniors in community seEngs in Rhode Island. Addi-onal sessions have been scheduled, and outreach will be conducted to all 50 senior centers in Rhode Island. CONCLUSION 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00 Helped me understand why having conversa-ons about my wishes is important Gave me a tool to use with my family and my doctor to express my wishes Gave me confidence to start talking to my family about what maQers to me Degree to which Learning ObjecBves were met 0 5 10 15 20 25 Have you talked to your loved ones about the care that you would want or not want at end of life? Do you have an advance direc-ve or living will for health care? A[er this presenta-on, do you feel comfortable having “the conversa-ons” with your loved ones? ParBcipant Results NA/Other No Yes This publica,on was made possible by Grant U1QHP28737 from the Geriatric Workforce Enhancement Program of the Health Resources and Services Administra,on (HRSA), an opera,ng division of the U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Health Resources and Services Administra,on or the U.S. Department of Health and Human Services.

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Page 1: Constance M. Ducharme, BSN RN CHPN, Ana Tuya Fulton, MD, … · 2019-01-30 · Constance M. Ducharme, BSN RN CHPN, Ana Tuya Fulton, MD, FACP, Kate Lally, MD, FACP, Ruth Scott, RN,

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.

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