Patients - Gundersen Health System

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Patients - Gundersen Health System

Respecting Choices®

Disease Specific-Patient Centered

Advance Care Planning:

A Program to Improve End-of-life

Decision Making

Linda Briggs, MS, MA, RN &

Sandy Schellinger, RN, MSN, NP

© Copyright 2009 All Rights Reserved – Gundersen Lutheran Medical Foundation, Inc.


Respecting Choices…An Advance

Care Planning System That Works

• In a 2008 study of all adult deaths in La Crosse

county, the following results indicate the ongoing

success of the Respecting Choices program

– At death, 90% of adults have written advance directives

– In 99% of cases, the AD is in the patient’s health record

– In 67% of cases, a POLST form is completed

– In virtually all cases, medical care was consistent with

patient’s preferences

• Hammes BJ, Rooney BL, Death and end-of-life planning in

one Midwestern community…ten years later, AAHPM poster

presentation 2009, Dallas, TX


The Problem: Planning for Patients

with Life-limiting Chronic Illness

• More than 90 million Americans live with

chronic illness

• 7 out of 10 Americans will die from chronic

illness

• CHF, COPD, Cancer, CAD, Renal failure,

PVD, Diabetes, Chronic liver failure,

Dementia


End-stage Chronic Illness

• Don’t fit the classification of “dying”

• Incomplete prognostic information

• Many have been “rescued”

• Slow, progressive decline in function

• Sudden complications without adequate

expression of health care preferences

• Difficult, confusing choices


Chronic Illness:

Slow Decline, Periodic Crisis, Death

Health Status

Decline

Crises

Time

Death

Field & Cassel, 1997


Tracking the Care of Patients with

Severe Chronic Illness

The Dartmouth Atlas of Health Care 2008

– Lead Author: John E. Wennberg

– The Dartmouth Institute for Health Policy and

Clinical Practice Center

for Health Policy Research

www.dartmouthatlas.org


Atlas Reports

• Extensive unwarranted variation in quality

of care delivered to Medicare recipients in

last two years of life

• Variations in spending are not due to

prevalence of chronic illness

• Variations in spending due to differences in

“supply-sensitive” care


“Supply-Sensitive Care”

• Services where the supply of specific

resources has a major influence on

utilization

• Physician visits, hospitalizations, ICU stays,

imaging services, among others


More is Not Better:

High-spending Regions Report…

• 32% higher per capita

hospital beds

• 65% more medical

specialists

• 26% fewer family

practitioners

• More hospital stays,

MD visits

• Mortality slightly

higher after AMI, hip

fracture

• More likely to report

poor communication

with MD and

inadequate continuity

of care

• No difference in

patient satisfaction


Why Can More care Be Worse?

• Hospitalizations are risky e.g., hospital

acquired infections claim 100,000 deaths

per year

• Increase use of diagnostic tests to find

problems that would not harm patient

• Increase complexity of care, e.g., more

MD’s, miscommunication, medical errors


Hospital

Inpatient

Reimbursements

per decedent

during last 2

years of life

Hospital days per

decedent during

last 2 years of

life

Reimburse per

day during last 2

years of life

Gundersen

Lutheran

18,359

13.5

1,355

Franciscan Skemp

19,194

15.8

1,210

Meriter, Madison,

WI.

22,166

18

1,233

St. Joseph's

Marshfield

23,249

20.6

1,126

UW Hospitals and

Clinics

28,827

19.7

1,462

Cleveland Clinic

31,252

23.9

1,307

St. Mary's Mayo

31,816

21.3

1,497

UCLA

58,557

31.3

1,871

US Average

25,860

23.6

1,096


• “Concern about the possibility that some

chronically ill and dying Americans might

be receiving too much care: more than they

and their families actually want or benefit

from.”

– Tracking the Care of Patients with Severe Chronic Illness,

www.dartmouthatlas.org pg. 4


One Solution…

Assist patients to make informed end-oflife

treatment choices well before a medical

crisis and develop plans to

honor these choices


Respecting Choices®

Disease Specific-Patient Centered

ACP Intervention: Key Features

‣ 1.5 hour interview with

patient and healthcare

agent in outpatient setting

‣ First assesses dyad’s

understanding of illness

‣ Structured interview that

integrates communication

techniques


Respecting Choices®

Disease-Specific, Patient Centered

ACP Intervention: Key Features

‣ Provides context for

decision making

through Statement of

Treatment Preference

form that assists in

clarifying goals for lifesustaining

treatment.


Respecting Choices®

Disease-Specific, Patient Centered

ACP Intervention: Key Features

‣ Delivered by trained

professional facilitator

who has clinical

experience, comfort

level with issues, and

good communication

skills


DS-PCACP Interview Stages

1. Assess illness beliefs, goals, values

2. Explore experiences

3. Explain purpose of ACP

4. Clarify goals for life-sustaining treatment

5. Summarize what was learned

6. Develop follow-up plan


Expected Outcomes

• Assessment of

patient’s

understanding of

illness and

complications

• Clarification of goals,

values, and beliefs

• Understanding of

treatment benefits and

burdens

• Documentation in

medical record of

patient goals for care

in situations of worst

outcomes

• Strengthening role of

healthcare agent

• Identification of need

for referrals for other

services


DS-PCACP Research

• AHRQ funded randomized control study

• Pilot replication with cardiac surgical

patients

• Pilot replication with adolescents with

HIV/AIDS


Patient-Centered Approach

to Advance Care Planning in

End-Stage Illness

Karin T. Kirchhoff, PhD, RN, FAAN - Principal Investigator

Bernard J. Hammes, PhD

Linda A. Briggs, MS, MA, RN

Karen A. Kehl, PhD, RN, ACHPN

Funded by the Agency for Healthcare Research and Quality

5R01HS013374-04

04

20


Method

Design

Randomized controlled study, stratified by patient

disease (CHF vs. ESRD) and site (La Crosse vs. Madison)

– Randomization by sealed envelope method

Subjects

Patients with end-stage CHF or ESRD patients and their

surrogate health care decision makers from areas

around La Crosse and Madison, WI

• 312 dyads (patient & surrogate)

– 133 La Crosse CHF

– 98 La Crosse ESRD

– 45 Madison CHF

– 36 Madison ESRD


Method

• Pairs complete baseline questionnaires on

demographics, and functional status.

• Pairs assigned to the usual care group receive

standard advance directive care.

• Pairs assigned to the intervention group receive, in

addition to standard advance directive care, the

intervention interview by trained interveners/facilitators.

Patients in both groups

complete:

•Statement of Treatment

Preferences

•Decisional Conflict Scale

•Knowledge of ACP

Surrogates in both group

complete:

•Statement of Treatment

Preferences for the Patient

•Knowledge of ACP


Elements of PC-ACP Intervention

• An in-depth structured interview with patient

and surrogate in outpatient setting

• Exploration of dyad's understanding,

experiences, and goals for living well

• Use of active communication techniques to

engage dyad

• Use of decision-aide tool (Statement of

Treatment Preferences) to assist in clarifying

goals for life-sustaining treatment

• Delivered by trained facilitator


Results

Congruence on Statement of Treatment Preferences

100.00%

90.00%

80.00%

70.00%

Percent congruent

60.00%

50.00%

40.00%

30.00%

20.00%

10.00%

0.00%

1 2 3 4 Latitude

Control 56.25% 54.10% 67.21% 57.14% 41.94%

Intervention 88.57% 75.76% 86.57% 82.61% 82.61%

Situation number


Conclusion

• The increased agreement on the Statement of

Treatment Preference form indicates that

intervention surrogates are more prepared to

make future decisions for their loved one

Patients and surrogates were highly satisfied

with the quality of the communication (mean

patient rating of 15.9 on a 1-171

17 scale)

• Care was consistent with documented

preferences

– Results submitted for publication


Cardiac Surgery

Patients N=32

Intervention group:

Increase

patient/healthcare

agent congruence

Decrease difficulty

in making choices

No difference in

anxiety

Song, 2005


DS-PCACP with Adolescents with

HIV/AIDS

• Medically stable adolescents (14-21 years

of age) and parent/guardian

• N=38 dyads, 92% Black

• Significant increase in understanding of

patient goals over control group

• Intervention patients rated the quality of

communication very good to excellent

• Lyon, 2009, Pediatrics 123(2)


Goals of Advance Care Planning

• Ensure clinical care consistent with wishes

• Improve decision-making process

– Facilitate shared decision-making among

patient, physician and proxy

– Allow proxy to speak on behalf of patient

– Respond with flexibility to unforeseen clinical

situations

– Provide education regarding issues


A Means to a Better End…

• Improve patient outcomes

– Improve patient well-being by reducing over

treatment and under treatment

– Reduce patient concern’s regarding burden on

family and significant others

• Teno,1994


Allina Hospitals and Clinics

• Integrated system with a patient

centered care model

• One Electronic Medical record

• 11 hospitals in MN and WI

• 85 Primary Clinics

• 4 th largest medical group in the US

• > 120,000 hospital admissions

• 4.5 Million Clinic visits

• Home and Community Services 28

County Service Area (Home Care,

Hospice, Palliative Care, Care

Navigation, Senior Care Transitions,

Care Management, DME)

• 110,000 Home Care and Hospice visits

• 15 Community Pharmacies

• Medical Transportation

• Medical Laboratories


Patient and Family Centered Care Goal:

Aim: All patient’s and families goals, wishes, values and health care preferences will be

honored at any point of care at any time and care setting.


Chronic Advancing Disease:

Continuum of Care Model

DISEASE SPECIFIC ADVANCE CARE PLANNING

Disease modifying therapies to abort illness or treat for possible cure

Presentation / Exacerbation of chronic progressive illness

Hospice

Benefit

Bereavement

Care

Palliative Care

Diagnosis

of illness

Therapies to relieve suffering

and/or improve quality of life

Home Care

Palliative Care

6m Death

-----------------

-----------------

-----------------

Hospice Care


END OF LIFE – patients and families

most likely to die in the next 6-12

months. Ongoing discussions on a

regular basis by care team, i.e. PCP,

Hospice , Palliative Care, hospital

staff around goals, values, and

health care wishes as their health

progresses. As a result the patient

may complete a POLST form and

update current HCD.

End

of Life

Disease Specific

Patient Centered

Advance Care

Planning

(DS-PCACP)

Basic Advance Care

Planning

Goal: Allina Advance Care

Planning Standard

across the care continuum

2009-2013

DSPCACP - All patients and families

with chronic advancing illness most

likely to die in the next several years

have assistance in intentionally

discussing goals, values and health

care wishes specific to their own

individual situation by a trained ACP

facilitator. Outcome: Documentation of

ACP session in medical record;

completed documents, i.e. HCD,

statement of treatment preferences,

POLST.

BASIC ACP - All Patients 50 and older are encouraged to

identify a POAHC, discuss and clarify health care wishes,

goals, and values for a sudden health event where they may

be unable to speak for themselves. A HCD may be completed

as a result of basic ACP.


Where to Begin in Such a large

Health System?

2008 System Goal: Improving Care of Heart Failure

across the Care Continuum demonstrated by

reducing the number of unplanned hospital

readmissions by 10%

• ACP Pilot DSPCACP in Heart Failure Population

– 2008 ACP Goal: complete 250 DSPCACP session with

heart failure patients and their surrogate.

• 268 sessions completed by 10 trained facilitators (palliative

care clinicians)


100

ACP Treatement Preferences

DSPCACP

Sessions

80

60

40

20

0

L Surv /H T m t

H Surv /L F x n

H Surv/L Cog

Code Status

Comf ort Care

Not Sure

Not Sure

Full Treatment

Comf ort Care

Summary

of

Treatment

Choices

What do you understand about your condition?

What care might you want under various circumstances? e.g.:

Low probability of survival, but with good function,

High likelihood of survival with functional impairment,

High likelihood of survival with cognitive impairment.

What do you know about CPR? Has your doctor talked about how it might apply in your case?


Honoring Patient Wishes Current State within Allina

1/1/08 - 10/08 Heart Failure Patients:

Availability of HCD in EMR

Source Ace Report and ACP Audit

90

80

70

60

50

40

30

20

10

0

ACP n=220

89%

83%

40%

No ACP n=6,621

16%

HCD (%)

HCD In chart (%)


40.0%

35.0%

30.0%

25.0%

23.0%

20.4%

20.0% 18.8%18.9% 19.3%

Allina Hospitals and Clinics

Percent HF (Pdx) Unique Patients That Had One or More Readmissions Within 30 Days

Median Readmit Rate

17.1%

22.7%

18.9%

20.1%

22.3%

23.8%

22.5%

19.6%

21.1%

24.9%

21.8%

21.2%

19.7%19.6%

17.9%

24.1%

16.5% 17.0% 20.4%

25.1%

24.4%

16.8%

20.0% 19.6%19.8%

17.6%

20.9%

19.4%

19.7%

19.8%

HF

Readmission

Rate Allina

Health System

vs. with ACP

20%

15.0%

2008 Goal = 18.12%

10.0%

% Rehospitalization of ACP pts 1/1/08-10/08

Source ACP Chart Audit

5.0%

0.0%

2006 1

2006 3

2006 5

2006 7

2006 9

2006 11

2007 1

2007 3

2007 5

2007 7

20

2007 9

2007 11

2008 1

15% 15%

2008 3

2008 5

2008 7

2008 9

2008 11

19%

15

10

5

0

30 days 60 days 90 days

3


Outcomes of ACP in Patients Dying of Heart Failure, 2008

100

90

80

70

60

50

40

30

20

10

0

No

ACP

ACP

No

ACP

ACP

No

ACP

ACP

Deaths (%) HCD in chart Hospice LOS


Allina Implementation Strategies

• Engaged leadership and key stakeholders to create consistent message.

• Culture: ACP needs to be a normal part of conversation for all patients.

• Started Pilot with a specific population of patients vs. basic ACP

– Easier to “sell” ACP because these patients really needed ACP.

• Identified clear outcomes and measures.

• Small test of changes to gain buy in and adjust processes and

workflow.

• Set up Systems for success

– i.e. ACP on order sets for heart failure patients.

• Train engaged and interested staff (Palliative Care RN’s and SW’s, RN

Care Managers in the Clinic)

– Some staff were required to get trained as ACP is part of their role but

may not be the right “fit” to facilitate ACP discussions


Allina Barriers/Challenges

• Lack of centralized ACP documentation.

• Large Health System

• Primary Care Physicians

• Implemented DSPCACP before Basic

– Most patients did not have basic ACP before session

which made the actual session longer and complex

• Palliative Care Program Director managing ACP

program

– Pros and Cons

• Economics – ACP role does not pay for itself.


Honoring wishes at time of death:

68 year old male with CHF, COPD,

Respiratory Failure

• ACP Session: 6/23/08; Understood his condition as having heart disease and diabetes.

Also understands that he is at risk for kidney failure. His disease burden included

dizziness, fear of falling, swelling in his legs, shortness of breath and dependence on

oxygen. Quality of life dramatically changed by his limited declining status. Hope for

improvement of sores on his legs but knows he cannot cure his lung disease. Statement

of Treatment preferences – full code; also, if he suffered a serious complication with low

probability of survival or he survived a serious event and had significant cognitive or

functional deficits he would want to stop all efforts to keep him alive and focus on

comfort. ACP note and HCD documents were in the EMR.

• Date of death: 7/27/08; EMR Death D/C summary and course of care during

hospitalization – In ICU on BiPAP for respiratory failure. Deterioration in mental status.

• Per MD note in summary, “In Accordance with his well stated previous wishes and

wishes of his family, aggressive medical treatments were discontinued and the

patient was made comfort cares only. The patient was kept comfortable with PRN

morphine. The patient died peacefully on 7/27 with family present.”


Improving Families confidence and

reducing burden of decision making

• 64 y/o married male with end-stage ischemic cardio-myopathy, s/p aortic

valve replacement. Waiting for heart transplant. ACP Session completed

3/26/08: full code try CPR for 3-4 minutes if it does not work let me go. If

seriously ill and was cognitively or functionally impaired” just let me go”

• 5/27/08 hospitalized for worsening heart failure. 6/8/08 received heart

transplant which was uneventful. Re-intubated 8 days after transplant.

Went downhill; subsequent infections and multi-system organ failure.

• Per MD D/C summary, “ The family has been extremely supportive

throughout this ordeal and the decision was made on Mr. H’s wishes not to

be kept alive on life-support.” Died 7/7/08

• Decision Making: Per hospital staff and spouse, there were three times

during the last few weeks of life where the spouse needed to make

treatment decisions. Each time she pulled out the documents and

referenced the ACP session discussions to help her make the decision.


Allina ACP goals

• 2009

– 750 patients (500 heart failure and 250 other chronic illness) will receive

ACP session resulting in completed and documented advance care plan.

– 250 Allina Home and Community Services – Home Care patients will have

a documented basic advance care plan

• 2010

– 5000 patients and employees of the Allina Health System will have a

documented advance care plan.

• 3000 Disease Specific ACP session will be completed for patients with

chronic advanced illness.

• 1500 basic ACP documented for Allina patients age greater than 50

years old.

• 1000 Allina employees will have a basic ACP documented.

• 400 POLST forms completed for patients in hospice, LTC, AL, TCU

• 2013

– All patients greater than age 50 years old will have a documented ACP in

their medical record.


Summary:

Advance Care Planning in Allina

Basic and Disease

Specific Advance Care

Planning

A Process

Health Care Directive /

Living Will

POLST

A Patientdirected

Document

A Physician’s

Order


Next Steps/Questions

• When does Advance Care Planning become

standard/best practice?

• Are there other opportunities to research use of

ACP for patients other cultures and diseases.

• ACP reimbursement:

– Government and Third Party Payers payment for ACP

• Minnesota U Care reimbursing for ACP as of 7/1/09

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