Addressing Advance Care Planning in Wisconsin The name “Honoring Choices Wisconsin” is used under license from Twin Cities Medical Society Foundation

Addressing Advance Care Planning in Wisconsin

The name “Honoring Choices Wisconsin” is used under license from Twin Cities Medical Society Foundation.

Joyce Hart Smerick Honoring Choices Wisconsin Program CoordinatorRespecting Choices First Steps® Faculty

Melissa Hale, MSW, LCSWProHealth CareAdvance Care Planning Coordinator

AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY

Objectives

• At the conclusion of this presentation, participants will be able to:

1) Define advance care planning (ACP)

2) Identify the key elements in making ACP a routine

part of care

3) Describe three ways to implement ACP in a health

care organization


World Death Rate Holding Steady At 100 PercentNews • survival • ISSUE 31•02 • Jan 22, 1997

GENEVA, SWITZERLAND—World Health Organization officials expressed disappointment Monday at the group's finding that, despite the enormous efforts of doctors, rescue workers and other medical professionals worldwide, the global death rate remains constant at 100 percent. . . .

http://www.theonion.com/features/news/

http://www.theonion.com/channels/survival/

http://www.theonion.com/issue/3102/


The Facts

70% prefer to die

at home

70% die in an

institution


The Facts

60% Don’t want to burden

56% Have not

communicated their wishes


The Facts 80% would like doctor to talk about EOL

7% say doctor has

talked about EOL


Advance care planning is a process.

future medical decisions, including end-of-life preferences.

1 2 3

Understanding Reflecting on Discussing


Why is this important?

Without planning:• The care you receive may not reflect

your wishes

• Your health care providers may not know your treatment preferences

• Your family may be left wondering if they are making the right decision


• 55 year old male

• Severe MVA trauma

• No advance directive

• Family divided

• Court involved


• 84 year old male• Severe stroke• Advance directive says:o No feeding tubeo No ventilator

• Comfort care provided


The La Crosse Experience

• 90% of decedents have an advance directive

• 99.4% of those decedents’ advance directives were

found in the medical record where they died

• 99.5% of treatment decisions were found consistent with

instructions

• Dramatic effect on family satisfaction

(LADS 2007-08, Detering et al. 2012)


Honoring Choices Wisconsinan initiative of the Wisconsin Medical Society

The mission of Honoring Choices Wisconsin is

to promote the benefits of and improve processes for

advance care planning across the state,

in health care settings and in the community.


HCW in Clinical SettingsMake ACP a part of routine care by ensuring conversations are:

Offered

Scheduled

Conducted

Documented

Brought into the medical record


Respecting Choices ModelFIRST STEPS

Create POAHC and consider when a serious neurological injury would change goals of treatment.

Healthy adults who have not planned.

NEXT STEPS

Determine what goals of treatment should be followed if complications result in “bad” outcomes.

Adults with progressive,life-limiting illness, suffering

frequent complications

LAST STEPS

Establish a specific plan of care expressed in medical orders.

Adults whom it would not be a surprise if they died in the

next 12 months.


Key Elements

System Design

Facilitator Education

Continuous

QICommunity Involvement


2012

• Community Care, Inc.

• Fort HealthCare/Rainbow Hospice/ADRC

• Group Health Cooperative of SCW

• Meriter

• ProHealth

• UW Health

2013

• Adoray

• Agrace

• Aspirus

• Baldwin AMC

• Froedtert

• Mayo – Eau Claire

• St. Croix RMC

• ThedaCare

• UWHP-Watertown

2014

•Amery Hospital & Clinic

•Bellin Health

•Mercy Health System

•Hudson Hospital & Clinic

•Reedsburg AMC

•Westfields Hospital & Clinic


Learn lessons for broader implementation

Test new workflows and processes

Give newly trained facilitators opportunities to practice their skill

Trial Implementations


“I’ve always wanted to focus on the conversation rather than the form, and now with this new workflow, I can.”

Clinical social worker and facilitator


“Thank you! I’ve wanted to do this for a long time, but didn’t know how to begin.”

Clinic patient


HCW in the Community• A full time Community Engagement Specialist

• Collaboration with Wisconsin Public Television

• Work with local coalitions and participating organizations

• Faith ambassador programs



ProHealth CareAdvance Care Planning

1. ACP Timeline/Pilot2. Strategic Implementation

3. Future Goals

Overview of ProHealth Care• Wisconsin’s largest integrated health care delivery system

in Waukesha and Dodge Counties (between Madison and Milwaukee)

• Treats more than 400,000 patients/year between two hospitals, 17 primary care clinics, home health and hospice services, long-term care, and senior residence communities

• Long-standing service to community: Waukesha Memorial opened in 1914; Oconomowoc established in 1954; formed ProHealth Care in 1998

• Network of nearly 1,000 physicians and more than 4,800 employees

October, 2013• ProHealth Care (PHC) leadership identified implementing

the Honoring Choices program at PHC as a 2013-2014 strategic initiative after reflecting on the following:

• An important statistic: 100% of people die

• 70% of people say they would prefer to die at home, but only 20% do

• Less than 50% of the severely or terminally ill patients studied had an advance directive in their medical record.

• 29% of people have advance directives.• Between 65-76% of physicians whose

patients had an advance directive were not aware that it existed. (AHRQ, 2003)

October, 2013 Current state of ACP

• Identified that current state AD documents were:• Difficult to find in various Epic applications• Not kept current by patients or clinicians• Not accessible to all clinicians needing documents

to make care decisions

December, 2013Clarified Role Responsibilities

• Hospital Inpatient RNs• Home Health RNs• Inpatient Physicians

• Clinic Physicians• Clinic Medical Assistants• Clinic Patient Service Representatives

• ACP Facilitators• Social Workers• Chaplains

• Health Information Management Specialists

2013 Pilot Overview

• Lung and pancreatic cancer• Oncology Registry• Approached by ACP Facilitator after approval from oncologist

Oncology Patients Health Coach Patients

• 65 and older• 3+ chronic conditions• Participants in Health

Coach program• Approached by HC RN

and then referred to ACP Facilitator based on interest

Goals Accomplished

• 69% of people invited were scheduled • 100% of people who completed ACP had

documentation in EMR – 100%• 86% of people who participated in ACP had a written

plan • Participants surveys rated >3 – 100% rated 4 or 5• Agents felt more prepared after ACP – 5 = 100%• Facilitators became more confident

• Number of facilitations = confidence and skill• 100% Participants & Agents rated Facilitator skill at 5

Successes

• Detailed process and script to follow resulted in more meaningful conversations and completed process

• Conversation more in-depth with agent present• Due to strong interest and need – expanded to all

health coach locations• Identified and completed process for those who

had AD but was not in Epic or not current

Challenges• Physician understanding and support• Witnesses

• Especially at clinics and patient homes• Scheduling facilitations at clinics

• 3 of 4 Facilitators located primarily at hospitals• Room availability

• Incorporating facilitations into daily work• Oncology population were late stage – most already

had AD recently completed

Lessons Learned• Improved data collection process• Dedicated person and process for handling

referrals, scheduling, assigning facilitators and follow up

• Dedicated staff time for facilitations• Increase in AMB or mobile facilitators• Facilitations need to be completed more upstream

Next Steps: 2014• Train additional facilitators and facilitator trainers• Organization wide communication and education• Conduct employee/physician facilitations• Continue to expand across the continuum of care –

next phase of HCW planning started this month• ACP an integral piece in PHC End-of-Life/Palliative

Strategy• Finalize Epic Navigator, Smartset, and referral order

ProHealth ACP Timeline2013

Trained 4 facilitators; created smart phrases and ACP Note type in EPIC; pilot

2014Trained 13 facilitators; Employee incentive started;

hired ACP Coordinator2015

Create ACP Department; Trained 12 more facilitators (total of 30); Ambulatory Pilot

ACP and Epic

• Advance directives and ACP documentation must be available to clinicians at the time of care if the patient’s decisions are to be honored

Epic current state

• AD information asked at admission and documented in RN navigator

• No standardized process/documentation in OP/AMB setting (AMB Pilot March 2015)

• Documents scanned into Epic• Media Tab• Sort by document type (AD is always first)

• ACP Facilitators using ACP Note type

Advance Care Planning Activity: Centralized Information

Medical Treatment Preferences completed once by provider/ACP

facilitator, viewable across multiple encounters

ACP Note Smart Text

Physician Support and Participation: Summary

The basic role of physicians is to:• Understand the ACP process and importance• Initiate planning discussions/ACP referrals• Review written plans that have been entered

into the medical record• Make plans more specific as patient’s health

condition changes• Convert plans into orders when appropriate• Initiate program referrals (Palliative, Hospice)

ACP 2015 Calendar• January 13 Waukesha Community Recreation Center

• January 22 National Kidney Foundation Living Well Program• Feb 10, 11 & 12 Employee Lunch & Learn WMH

• February 11 Facilitator’s Meeting• February 18 Home Health and Angel’s Grace Staff Meetings

• March 23 PCHMG Stoneridge Pilot Begins• March 26 & 31 Employee Lunch & Learn Riverwood• March 27 & 30 Employee Lunch & Learn OMH• April 6, 7 & 8 Regency Education Booths

• April 13-16 NHDD Events at OMH, DNG and WMH• April 18 Waukesha Community Health Fair• April 23 Community Class at WMH • May 15 Facilitator’s Meeting

• May 28 Wisconsin Comprehensive Cancer Control Summit• July 27 Heart Failure Class WMH

• Sept 18 WI Council of Nephrology Social Workers• Oct 6 WMH All Staff Meeting• Nov 1 Dia de Los Muertos Event

• November 5 National Kidney Foundation Professional Symposium•

Future Success Metrics

• Decrease ICU utilization at end of life• Increase Palliative Care and Hospice referrals• Longer hospice stays• Increase % of patients with AD available in Epic• Standardized documentation and retrieval of

information

Thank you!

The name “Honoring Choices Wisconsin” is used under license from Twin Cities Medical Society Foundation.