advance care planning - pcqn€¦ · ´remind us to engage in advance care planning ´streamline...
TRANSCRIPT
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MultifacetedApproachestoAdvanceCarePlanning
RebeccaSudore,MD&selectPCQNMembers
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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
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What is ACP?
“We are on the same page, yet we can’t seem to agree on anything.”
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Standardizing ACP Definition
• No formal prior definition
• Most oftenà life sustaining treatments & advance directives
• 2014 IOM report: various descriptions
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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.
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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.”
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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.”
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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.”
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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
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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
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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
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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
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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
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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
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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
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ACP training: 30 years and counting
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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
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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
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Exploring narrative co-creation
Documentation� Obtaining existing documents before visits, “pre-
planning” documents� Written literature, BC/WC, recording� Systems: EMR, interprovider communication
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Next Steps
� Workshop using 2 clinical scenarios¡ BBNfoundation.org – trained actors with videotaping
� Coordinate with existing efforts, key stakeholders¡ Patient/physician satisfaction
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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
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“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
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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
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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
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Goals of Care Notes and Templates
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Alternate Goals of Care Note Template´ Suggestions as to
important aspects of the conversation
´ Most people free type without a template
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Tabs: Advance Directives
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Tabs: Goals of Care
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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.”
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Outpatient ACP Reminders:Health Care Maintenance
´ Decision not to include yet´Until sufficient resources in place´Until training done or available
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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
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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
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Collabria Care Palliative ServicesA p r i l 2 0 , 2 0 1 7
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History
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Partners in Palliative Care (PIPC) pilot
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Partners in Palliative Care (PIPC) pilot
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Community Engagement
Professional and community outreach
Latino Outreach Latino Outreach LiaisonCommunity organizations, health fairs, educational presentations
Increased Latino outreach efforts due to pilot
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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
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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
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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
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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?
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414 South Jefferson St. Napa, CA 94559707.258.9080
www.collabriacare.org