webinar : wiser health care decisions and choices through knowledge

Webinar:Wiser Health Care Decisions and Choices

through Knowledge

1. Preparing a Written Agenda 2. Preparing a Medical History

3. Preparing Medication List4. Health Care Proxy verses a Living Will

5. Life-Sustaining Treatment MOLST Guidelines 6. Planning and Costs for Long-term Care7. Private care verses Nursing Home Care

Preparing a Written AgendaPart: 1

Written Agenda – Preparation Benefits

Allows you to stay in control of the

meeting.

Shows your willingness to take

an active role in your care.

Keeps you focused on the items you wish to discuss.

Provides an opportunity to summarize the

discussion

Provides an opportunity to

learn about your choices and plan of

action.

Agenda Preparation - outline

1. Date:

2. Agenda for visit with MD:

3. Objectives:

4. Discussion Topics:

5. Plan of action/next steps:

6. Additional questions:

7. Summary:

Agenda Preparation - Goals

Objectives

Establish a trusting and mutually beneficial relationship with the physician

Gain insight into your health care options

Establish health goals presently and for the future

*Date and include MD’s name on your agenda

Agenda Preparation - Discussion Topics

Why you selected this MD over another

Your past medical history and medication

review medical history, previous hospitalizations and surgeries

review medication list

review list of specialists on my team, preferred hospital, and pharmacy

Agenda Preparation - Discussion Topics

Your current healthcare issues and concerns

short of breath, light-headed, recent fall, pain, skin changes

Preventative care

measurements taken to prevent disease or injuries (regular check ups, regular physical activity)

Health care goals

avoid vision problems, cancer, improve flexibility, be more active, weight maintenance, healthy skin

Healthcare proxy/power of attorney/advance directives

Agenda Preparation – Plan of action

Action Plan

• Follow up appointment in 6 weeks

• Follow current medication plan with close

monitoring of questionable moles on skin.

• Make appointment with dermatologist.

• Additional actions?

Agenda Preparation – MD follow-up questions

Additional Questions

• What relationship does your practice have with

the local hospital?

• How quickly will my messages be received by you

and my calls returned?

• What happens if I need to see you on a day when

you are not in the office?

• What happens if I’m hospitalized?

• What other questions should be addressed?

Agenda Preparation - Guidelines (overview)

Make several agenda copies

for others attending the appointment. Date agenda and provide the name of

the MD.

Let the receptionist know you have an

agenda for the MD to

review prior to the

appointment, and have it placed in medical record.

Inform the MD that you

would like the agenda

reviewed prior to the

appointment so it can guide

the conversation.

Take notes on the agenda to

clarify the details of the

appointment.

Summarize the

appointment with the MD

to make certain

everything was discussed

and understood.

Ask if you can follow-up by phone or in

person if you have

additional questions.

Medical history and Medication ListPart: 2 and 3

Medical History- outline

1. Medical Conditions – add dates, procedures, conditions: a. Cardiac b. Neurology:

c. Oncology d. Orthopedic:

e. GI (gastrointestinal) f. Kidney (Renal) g. Skin h. Ear, Nose, Throat (ENT) i. Eyes 2. Surgeries3. Hospitalizations

Medical History – Preparation Benefits

Provides guidelines on proper treatment. (allergic

reaction, etc.)

Health history can easily be shared with

emergency personnel and new

health care providers

Provides immunization history enabling you to keep

current.

Doctors can avoid duplicating services

Provides guidelines for MD to respond to new health signs or

symptoms.

Medical History – Preparation conditions list (dates, treatments, present conditions, and so on.)

Cardiac• Hypertension (high blood pressure)• Occasional swelling of feet and ankles

Neurology • Prior hemorrhagic stroke

Urology • Frequent urinary tract infections

Orthopedic• Osteoarthritis, right hip replacement • Spinal stenosis of cervical and lumbar spine

GI (gastrointestinal)• GERD (gastro-esophageal reflux)• Diverticulosis

Kidney (Renal) • Stage III Kidney disease

Skin• Excessive thinning, dryness• Fungus of toe nails

Ear, Nose, Throat (ENT) • Post nasal drip

Eyes • Dry eyes

Surgeries• Pacemaker insertion• Left hip replacement

Hospitalization• For all surgeries• Fall resulting in hip fracture

NotesConditions1.12.12 blood pressure meds side effects

2.12.13 stroke

10.11.11 surgery on hip

9.11.10 eye virus treatment

Sept. 2011, April 2013

Medication History – preparation benefits

Provides information on medications taken and

assists with self-administered medications

Provides insight on potential conflicts

with herbal supplements and

vitamins.

Keeps you focused on the items you wish to discuss.

Provides an opportunity to summarize the

discussion

Provides insight on potential allergic

reactions and conflicts with medications.

Medication List

Medication

• Aspirin• Atorvastatin

(Lipitor)

For Medical Condition

• For Heart• For Heart

Prescribing Physician

• Dr. Salem

Date Started

• Sept. 2012

Dosage & Frequency

• 325 mg - 1 x daily

Notes

• a.m. intake• p.m. intake

Daily Medications

Client: Jane DoeDOB: 06/01/41Allergies: Morphine, Bactrim DS, Seasonal Allergies (Pollen)

Medication List

Medication

• Multivitamin• Cranberry

Capsules• Vitamin D


• Prevention• Prevention of

UTI• Osteoporosis

and Cancer


• Dr. Brown• Dr. Smith

• Dr. Smith

Date Started

• Sept. 2012• Oct. 2011

• Oct. 2011

Dosage & Frequency

• 2 caps – 1x daily

• 500 mg.

Notes

• a.m.• a.m.

• a.m.

Vitamins, Herbal Medications & Nutritional Supplements


Medication List

Medication

• Tylenol

• Lidocaine Patch


• Pain

• Back Pain


• Dr. Brown

• Dr. Brown

End/Start Date

• Sept. 2012 (start)

• Sept. 2012

Dosage & Frequency

• 350 mg – 3x daily

• 500 mg.

Notes

• 6 a.m./2 p.m./8 p.m.

• 12 hrs on, 12 hrs. off.

Occasional or as Needed Medications


Medication List

Medication

• Flonase nasal spray

• Atopicalir


• Nasal congestion

• Eczema


• Dr. Brown

• Dr. Brown

End/Start Date

• Sept. 2012 (start)

• Jan. 2010

Dosage & Frequency

• 1x daily

• 2x daily

Notes

• Each nostril 2 weeks only.

• 12 hrs on, 12 hrs. off.

Previously Taken Medications


health Care Proxy vs. a LIVING WILL Part: 4

Health Care Proxy vs. Living Will

Both advanced directives, HCP and LW allow

individuals to retain control over medical

decisions.

Health Care Proxy (HCP) designates

another person to make medical

decisions should you be unable to do so.

LW allows you to list medical treatments that you would or would not want if

you became terminally ill and unable to make

decisions.

Both the HCP form and the LW once

signed remains valid unless you revoke

them.

Some states allow individuals to make

their own Health Care Proxy, but does not legally recognize

Living Wills (LW).

Health Care Proxy - Things to Consider

Proxy becomes effective when MD determines you are incapable of making or communicating health care issues.

Must be 18 to assign an Healthcare Agent who is designated to ensure your wishes

are honored.

You do not need a lawyer to complete Healthcare Agent form or make it legally binding.

Proxy must be signed by two adult

witnesses, neither of whom can be your

Health Care Agent or Alternate Agent.

Make a minimal of four copies of the

form. One for yourself, your

Healthcare agent, your alternate agent,

your physician and others.

Healthcare Agents or Alternate Agent can be anyone over 18, except

the administrator, operator, or employee

of a health care facility, unless that person is related to

you by blood, marriage or adoption.

Healthcare providers are bound to honor

your Healthcare Agent’s decisions as

if they were your own.

Living Will – Things to Consider

Provides guidelines to MDs, Healthcare Agents and others

on certain life-prolonging

treatments you desire should you be

in a permanent vegetative state.

The individual designated to invoke healthcare decisions on your behalf -- so make certain they fully understand

what your desires are.

Does not become effective unless you are incapacitated.

Requirements for LW vary by state, so

consider having a lawyer prepare it.

Share your LW document with those who can

administer your wishes. If no one

knows your wishes they can’t be

honored.

Usually requires certification by your MD and another MD

that you are terminally ill or

permanently unconscious before become effective.

In situations where you are not completely

incapacitated, you should have a health

care power of attorney or a health

care proxy act on your behalf.

MOLSTMassachusetts Medical Orders for Life-Sustaining TreatmentPart: 5

MOLST - GuidelinesMassachusetts Medical Orders for Life-Sustaining TreatmentNot designed for healthy

individuals. Suitable for those with advanced illness (life-threating disease, chronic

progressive disease, dementia or suitable for a DNR order.)

Using MOLST is voluntary. Patients or

Health Care Proxies can revoke MOLST at any

time.

Keep copy of form with the patient at discharge or between care

settings. Keep it in a place it can be easily seen (door, bedside, or

refrigerator) or in the patient’s purse or wallet. A copy should also

be with the medical records.

MOLST form must be honored as any other medical order. If other orders “Comfort (CC) Care” or “ (DNR) Do not Resuscitate” exist the most recent order must be

honored.

Standardized form containing valid medical orders for life-sustaining

treatment based on patient’s own preferences

and goals of care.

Massachusetts Medical Orders for Lift-Sustaining Treatment (MOLST)

A Cardiopulmonary Resuscitation: for a patient in cardiac or respiratory arrest

O Do Not Resuscitate O Attempt Resuscitation B Ventilation: for a patient in respiratory distress

O Do Not Intubate and Ventilate O Intubate and VentilateC Transfer to Hospital

O Do Not Transfer to Hospital O Transfer to Hospital (unless needed for comfort)

DPatient or patient’s representative signature

Required – Fill in every line for valid orders

Select one circle below to indicate who is signing Section D:O Patient O Health Care Agent O Guardian O Parent/Guardian* of minorSignature of patient confirms this form was signed of patient's own free will and reflects his/her wishes and goals of care as expressed in the Section E signer. Signature by the patient’s representative (indicated above) confirms that this form reflects his/her assessment of the patient’s wishes and goals of care, or if those wishes are unknown, his/her assessment of the patient’s best interests. *A guardian can sign to the extent permitted by MA law. Consult legal counsel with questions about guardian’s authority. Signature____________________________ Date________________________Legible Printed Name of Signer______________________ Date _______________________


Clinician signatureERequiredFill in every line for valid orders

Signature of Physician, Nurse Practitioner or Physician Assistant confirms that this form accurately reflects his/her discussion(s) with the signer in Section D.

Health Care Agent Printed Name___________________ ___________ Telephone Number ______

Primary Care Physician Printer Name___________________________ Telephone Number_______OptionalExpiration date and other patient care contacts

This form does not expire unless expressly stated. (Expiration date (if any) of this form:__________Health Care Agent Printed Name ____________________________________ Telephone Number ________Primary Care Printed Name _________________________________________ Telephone Number ________

SEND THIS FORM WITH THE PATIENT AT ALL TIMES.HIPAA permits disclosure of MOLST to health care providers as necessary for treatment.


Statement of Patient Preferences for Other Medically-Indicated Treatment

F INTUBATION AND VENTILATIONSelect one circle

Refer to Section B on Page 1 O Use intubation and ventilation as checked O Undecided in Section B, but short term only O Did not discuss

NON-INVASIVE VENTILATION (e.g. Continuous Positive Airway Pressure – CPAP

Select one circle

Refer to Section B on Page 1 O Use intubation and ventilation as checked O Undecided in Section B, but short term only O Did not discuss

DIALYSIS

Select one circle

O No dialysis O Use dialysis O Undecided O Use artificial nutrition, but short term only O Did not discuss

ARTIFICIAL NUTRITION

Select one circle

O No artificial nutrition O Use artificial nutrition O Undecided O Use artificial nutrition, but short term only O Did not discuss

ARTIFICIAL NUTRITION

Select one circle

O No artificial nutrition O Use artificial nutrition O Undecided O Use artificial nutrition, but short term only O Did not discuss Other treatment preferences specific to the patient’s medical condition and care _____________________________________________________________________________________________


PATIENT orPatient’s representative signatureGRequiredFill in every line for valid orders

Select one circle below to indicate who is signing Section G:O Patient O Health Care Agent O Guardian* O Parent/Guardian* of minorSignature of patient confirms this form was signed of patient’s representative (indicated above) confirms that this form reflects his/her assessment of the patient’s wishes and goals of care, or if those wishes are unknown, his/her assessment of the patient’s best interests. *A guardian can sign to the extent permitted by MA law. Consult legal counsel with questions about guardian’s authority.

______________________________________________________________ ___________________________Signature of Patient (or Person Representing the Patient) Date of Signature

_____________________________________________________ _______________________Legible Printed Name of Signer Telephone of Signer

CLINCIANsignature

HRequired Fill in every line for valid orders.

Signature of physician, nurse practitioner or physician assistant confirms that this form accurately reflects his/her discussion(s) with the signer in Section G.

____________________________________________________ ________________________ Signature of Physician, Nurse Practitioner, Or Physician Assistant Date of Signature

_____________________________________________________ _______________________Legible Printed Name of Signer Telephone of Signer

Additional Instructions For Health Care ProfessionalsFollow orders listed in A, B and C and honor preferences listed in F until there is an opportunity for a clinician to review as described below. Any change to this form requires the form to be voided and a new form to be signed. To void the form, write VOID in large letters across both sides of the form. If no new form is completed, no limitations on treatment are documented and full treatment may be provided. Re-discuss the patient’s goals for care and treatment preference as clinically appropriate to disease progression, at transfer to a new care setting or level of care, or if preferences change. Revise the form when needed to accurately reflect treatment preferences. The patient or health care agent (if the patient lacks capacity), guardian*, or parent/guardian* of a minor can revoke the MOLST form at any time and/or request and receive previously refused medically-indicated treatment.

Long-term Care Costs and Home Care vs. Nursing Home Care

Part 6 & 7

Private Home Healthcare vs. Nursing Home Care

In-home care has risen at less than (1) one percent annually during the past five years

according to Genworth Financials 2013 annual Cost of Care Survey. Average hourly rates

($19 to $21) for HHA/CNA will vary depending on location and skills required. Also, LPN and RN rates will be higher and vary depending on

care level required. Assisted Living, Nursing home, costs have increased by more than (4) four percent a year

based on Genworth Financials 2013 Cost of Care survey. Rates

($108 to $230 per day) vary depending on location and type

of facility. Adult day center averages $67 per day.

Over the past 10 years there has been a steady move away from traditional nursing home care to

less-expensive options that include in-home care and adult day care.

Planning for long-term care should take place long before

need arises because youth is not a guarantee that long term care

will not be required.

Majority of people over age 65 will require some type of

long-term care, and 40 percent will require a period

of care in a nursing home according to Centers for Medicare and Medicaid

Services.

Long-term Care Funding Fundamentals

Seniors and families facing nursing home decisions should first

determine if Medicare is an option; however, it

only pays for “approved” agencies (VNA, etc).

Many long-term care insurances have limits

on what they will pay (2-5 years) while others will pay as long as you live.

Health and Disability Insurance often only

covers very limited and specific types of long-

term care, and disability policies don’t cover any

at all.

Even if you or your loved one does not need care

today, it’s wise to look at the costs now and in five years to gauge what the financial impact would

be.

Life Insurance options for long-term care

coverage. *Combination (life/long-

term care) products*Accelerated Death

Benefits (ABDs)*Life Settlements

*Viatical Settlements

Most forms of insurance (Private/HMO) follow

same rules as Medicare. If Insurance covers long-term care, it’s typically only for skilled, short-

term medically necessary care.

If you are in poor health or already receiving

long-term care services, you may not quality for

long-term care insurance. However, coverage at a higher

“non-standard” rate may be purchased.


Paying Privately through * reverse mortgages

* annuities*trusts

Deferred Long-term Care Annuity available for

those up to 85 years old. In exchange for a single premium payment, one

receives a stream of monthly income for a

specified period of time.

Reverse Mortgage provides cash (lump-sum

payment, monthly payment, or line of credit) against one’s home value without

selling the home. Many pros and cons to this

option; seek professional advise.

Deferred Long-term Care Annuity creates two funds (one-term care

expenses and separate fund to be used as one

desires).

If long-term care fund is not used it can be passed onto heirs.

Annuity may not be enough to pay for long-

term care expenses.Annuity can affect your eligibility for Medicaid. Speak with a specialist

about your options.

Annuities are provided by insurance company to pay for long-term care.* Immediate annuity*Deferred long-term

care annuity

Immediate annuity is available for purchase

regardless of your current health status.

Single premium payment is turned into a monthly

income for a specific period of time or the

rest of your life.


Trusts are legal entities that allows a person

(the trustor) to transfer assets to another person

(trustee).

Charitable Remainder Trust value will only payout the amount

based on your donation. When you pass the

funds in the trust go to the charity you selected.

Donation may affect your Medicaid eligibility.

Trusts are used to provide flexible

control of assets for the benefit of minor

children or older adults or a person with

a disability.

Medicaid Disability Trusts are limited to

those with disabilities who are younger than 65

and qualify for public benefits. This type of trust is exempt from rules regarding trusts

and Medicaid eligibility.

If beneficiary with disability receives

Medicaid Disability Trust, the state can recover any amount

remaining in the trust when he or she dies. See a specialist advice

prior to setting up a trust.

Two types of trusts can help pay for long-term

care.*Charitable Remainder

Trusts*Medicaid Disability

Trusts

Charitable Remainder Trusts allow you to use your assets to pay for

long-term care services (while you are alive)

and also contribute to a charity of your

choice and reduce your tax burden at the

same time.

QuestionsEnd

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