A Care Management Strategy to improve Advance Care Planning Discussions in the Patient Centered Medical Home
Alverta H. Robinson, BSN, RN-BC, MSA, LNHA
Background
Interventions
Results
Advance care planning (ACP) is a communication process wherein people plan for a time when they cannot make decisions for themselves. It includes reflections, deliberation and determination of person’s values and wishes or preferences for treatment at the end of life. Evidence supports the effectiveness of ACP to improve the end of life experiences of patients and families. Despite the known benefits of ACP, often people with lifelimiting illnesses facing an acute health crisis have not spoken up about their preferences. (Howard, et al., 2015)
• RN Care managers were required to attend 2-day formal training as Advance Care Plan Facilitators
Each year we increased the number of advance care planning discussions in the high risk patient population. Over a 6 year span of time we increased advance care planning discussions
• Providers referred patients to the RN Care Manager for ACP counseling using an electronic referral in the patient record. • The RN Care Managers held discussions with patients and families in the office, home and in the hospital setting when needed. • Standard ACP documentation was used to document ACP discussions in the patient medical record. In addition all completed ACP documents were scanned in the medical record.
Completed Advance Care Plans 2012-2018 673
427 354 177 30 2012
225
81 2013
2014
2015
2016
2017
Sample ACP Smart Sets
Objective To improve the number of advance care planning discussions in a targeted group of high risk patients To complete advance care planning facilitated discussions with patients and families, resulting in a completed Advance Directive.
Conclusion RN Care Managers in the Patient Centered Medical Home are integral members of the health care team. Their relationships with patients, families and physicians have improved the completion of advance care planning in the medical home. The increase in Advance Care Planning discussion can also be attributed to an increase in RN Care Managers. The Center for Medicare and Medicaid Services will now reimburse providers for having Advance Care planning discussions with their patients.. This could potentially decrease the use of RN Care Managers for Advance Care Planning.
References Howard, M., Benard, C., Tan, A., Slaven, M., Klein, D., & Heyland, D. (2015). Advance care plannig Let's start sooner. Canadian Famly Physician, 61(8), 663-665.
2018