By Diane Drago, PFCC Advisor
Advance care planning (ACP) and end-of-life decisions—topics that few people can escape, yet we rarely want to discuss it until we’re forced to in a crisis. Research and anecdotal evidence demonstrate the tremendous benefits of quality ACP. For patients and families, ACP can provide a higher quality of end-of-life care, higher health care satisfaction, lower anxiety levels, and less depression among caregivers. For healthcare professionals and health systems, it enables better quality of care and decision making, fewer end-of-life hospitalizations and readmissions, and much higher patient satisfaction.
Having the difficult conversations about quality ACP is a keystone of Patient and Family Centered Care. Despite the enormous benefits and importance of ACP, what is the reality at UMHS?
- Completion of all UMHS faculty and staff’s own ACPs still remains a work in progress.
- In the most recent survey (October 2016) of patients aged 65+ being served at UMHS clinics, only three clinics had more than 40% of their patients’ ACP on file—Dexter Family Medicine (the highest at 43%), East Ann Arbor Geriatrics at 41% and West Ann Arbor General Medicine at 40.3%. The other clinics had results ranging from 15.4% to 38.2% completion rate. While these figures show an increase since the beginning of 2016, they still fall short of UMHS’ goals.
Research studies across the spectrum demonstrate that these completion rates are the norm across the U.S. The “gold standard” in ACP remains Gunderson Health System’s “Respecting Choices” program. Since its inception, this program in LaCrosse County, Wisconsin, data consistently shows that they have achieved nearly a 100% completion rate across all adult residents in the county, along with 99% of the ACPs available in the patient’s medical records and treatment consistent with the patients’ wishes.
The UMHS Initiative
Efforts are being undertaken at UMHS to improve ACP completion rates and enhance communication around this issue. In late 2015, an ACP Steering Committee was established. Members include 13 physicians and nurse managers, administrators from Ambulatory Care Services, Medical Benefits, and Social Work, and PFCC Advisors.
The committee is charged with cultivating “a culture of advance care planning” at UMHS. It serves as the internal panel of experts in ACP and patient-centered end-of-life care. Responsibilities include: (1) developing and implementing a strategic plan to embed ACP into clinical practice, (2) ensuring patients and clinicians have earnest conversations on ACP, and (3) working to see that ACP documentation flows seamlessly throughout the institution and community.
The objectives of the ACP Steering Committee are:
- Improve the quality of ACP conversations across care settings.
- Increase the rates of advance directives completion and documentation for patients aged 65+ with a UM primary care physician.
- Increase rates of code status documentation for UMHS patients.
- Increase the percentage of times healthcare providers use documented end-of-life wishes to make care decisions.
- Improve transparency and coordination of ACP documentation with local health care partners.
The Work to Date
The Steering Committee identified two priority areas: Patient/Caregiver Education and Engagement and Patient-Provider Communication and Documentation. To achieve the committee’s objectives, it is critical to ensure that patients and caregivers fully understand the status of their health/illness and to enable them to engage in robust ACP conversations and shared decision making. Therefore, the majority of the work done in 2016 has focused on the burning issue of revising UMHS’ ACP booklet available to patients and families.
The information currently used at UMHS was developed in 2011, based largely on the State of Michigan’s information. The committee discovered that patients, caregivers and front line workers found the 2011 materials confusing and not user-friendly (patients thought that three forms had to be completed), did not meet plain language standards, is costly to print, and had been developed without any patient or caregiver input. Further, the committee learned that the materials were disconnected and found in at least three different “homes” within UMHS.
The committee embarked on an exhaustive study of best practices in ACP materials, including the previously mentioned Gunderson method, as well as other Michigan-based initiatives and materials, such as the work done by the Washtenaw Health Initiative, St. Joseph Mercy Hospital-Ann Arbor, and the Henry Ford Health System. Within several months, a new, patient-centered, user-friendly booklet was created, incorporating plain language principles and patient and caregiver input. It includes clear and straightforward information on advance directives and DPAs for health care; the forms themselves with instructions; and referral to the Patient Education Clearinghouse for FAQs and the DNR form.
Work is also continuing on the development and improvement of the culture and processes to support patient-provider communications. The November “Talk Turkey” initiative was one of those endeavors.
Watch for these next steps in the months ahead:
- UMHS is currently reviewing the new materials.
- The new materials will be piloted with UMHS primary care patients.
- Creation of a new ACP page on the Patient Education Clearinghouse.
- Development of more patient-centered educational materials.
For more information on the ACP Steering Committee
Contact Kathryn Shindeldecker (firstname.lastname@example.org)