1. CNS as Health Coach: Advanced Care Planning to Promote Effective Care Transitions Ann Loth, RN, MS, ACNS-BC Minnesota NACNS Annual Conference October 26, 2012

2. Advance Care Planning: What is it? Process – Assesses individual values – Communication of values related to goals of care – Promotes self-determination Advance Care Planning http://depts.washington.edu/bioethx/topics/adcare.htmhttp://depts.washington.edu/bioethx/topics/adcare.htm AHRQ Research in Action 2003

3. Advanced Care Planning: Who is it For? EVERYONE! – Especially those living with chronic disease Advance Care Planning http://depts.washington.edu/bioethx/topics/adcare.htmlhttp://depts.washington.edu/bioethx/topics/adcare.html AHRQ Research in Action 2003

4. Advanced Care Planning: How is it Provided? Human to Human – Primary Care Providers related to close relationship with patient – Specialist related to specialized knowledge – Health Care Team related to ongoing care & relationship AHRQ Research in Action 2003

5. Quality & Current Health Care Pay for Quality Health Care – Centers for Medicare & Medicaid Services (CMS) Value Based Purchasing (VBP) 30 Day Readmission Rates Mortality Rates http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based- purchasing/index.html http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf

6. Chronic Disease in Minnesota

7. http://www.health.state.mn.us/divs/orhpc/flex/pubs/stratis.pdf

8. Advanced Care Planning Many patients have not participated in an effective advance care planning. – Per AHRQ studies, less than 50% of severely or terminally ill patients have an advanced directive in their medical record. – 65-76% of physicians whose patients had an advanced directive were not aware that it existed. AHRQ. Research in Action,2003

9. Advanced Care Planning  Patients do not talk with their families about their wishes  Patients do want to discuss these wishes with their health care team Selman et al. 2007; Dougherty et al. 2007, Kass-Partelmes et al. 2003

10. Spheres of Influence Patient/Family Organization Nursing Practice

11. Advanced Care Planning  Of the health care team, the CNS/Nurse is well suited to lead this discussion o CNS interacts directly with patient and their families o CNS develops processes to assist the Nurse at Point of Care to lead this discussion o CNS Influences multidisciplinary teams in having conversations with patients and families. Kirkhoff et al, 2010, Mahon 2010, Waterworth et al., 2010, Goodlin et al., 2008, Selmen, 2007

12. Key Concepts of Nursing as a Discipline Health and Caring – Purposeful intent of the patient/nurse relationship Consciousness – The informational pattern of the relationship Mutual Process – The way in which the relationship unfolds Newman et al. 2008

13. Key Concepts of Nursing as a Discipline Presence – The resonance of the relationship Meaning - The importance of the relationship Translator – Moving illegible to legible Newman et al. 2008; Scott, J.C. 1998

14. Motivational Interviewing Integrates relationship building o Readiness assessment o Open Ended Questions o Affirmation o Reflective Listening o Summarizing Patient leads - Nurse facilitates the conversation Newnham-Kanas et al. 2010

15. Appreciative Inquiry Discovery Patient Values What is going right What brings peace, joy and happiness Dream What might life be like? Rooted in reality of health Hopes Design Discernment rooted in values Who else may need to be in the plan to make the dream a reality? Destiny Hopes move into reality New meanings for hope Cure versus treatment Treatment versus EOL Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006

16. Appreciative Inquiry Discovery Patient Values What is going right What brings peace, joy and happiness Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006  What is most important to you at this time of your life?  What brings you peace, joy and happiness to your life?  What is working well in your life at this time?  What makes you want to get out of bed each morning? Patient and Family Values Care connected to Values brings more meaning and purpose to life and closure of live

17. Appreciative Inquiry Dream What might life be like? Rooted in reality of health Hopes  What has worked well for you in the past?  What do you hope for knowing we cannot change your disease?  From what you are telling me, it sounds like ________ is really important to you and hope that ___________ can happen, is that right? Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006 Patient and Family’s Hopes Dreams/Hopes comes in many different colors and assisting the patient and family to identify their dream assists in building a plan to support that dream

18. Appreciative Inquiry Design Discernment rooted in values Who else may need to be in the plan to make the dream a reality?  How do you see that happening for you?  When you did __________ what helped you to be successful?  What are you willing to do to get there, such as, …………….?  I am understanding your family is worried about you going home alone, how do you see yourself following through on your own? Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006 What Does ‘IT’ Look Like? What Where With Whom With What Resources

19. Appreciative Inquiry  Being at home with your family has been your goal and I understand how hard you have fought this disease, but you are tired. Going home with hospice sounds like a great plan.  You have said all along you did not want to start dialysis, now you are going to try the diet and fluid restriction again, with a little more control  You have shared you wanted more time to live, but also with quality to your life. Your decision to try the LVAD makes sense. Destiny Hopes move into reality New meanings for hope Cure versus treatment Treatment versus EOL Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006 Putting the Dream into Reality Helping the patient and family to identify important steps in their treatment course related to their trajectory in their disease process.

20. Appreciative Inquiry Discovery Patient Values What is going right What brings peace, joy and happiness Dream What might life be like? Rooted in reality of health Hopes Design Discernment rooted in values Who else may need to be in the plan to make the dream a reality? Destiny Hopes move into reality New meanings for hope Cure versus treatment Treatment versus EOL Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006

21. Advance Care Planning Patient focused o Family and health care team recognize and affirm patient wishes o Promotion of self-determination Within the Art of Nursing o The CNS has the advance practice expertise to initiate, develop, promote Advance Care Planning

22. Clinical Nurse Specialist Nursing Practice Facilitate Advance Care Planning with Patients and Families Influence Nursing Practice to Encompass Advance Care Planning Develop Processes for Quality Patient Centered Care

23. Advance Care Planning The CNS: shifts “the nurse’s purpose from objective problem-solver to sojourner in discovery, interpretation, and revelation.” Newman et al. 2008 p. E23