1. ACP at Allina

2. 2012 System Direction Primary care focus to align with a strong primary care vision (ACO & Allina Health) Revision of ACP as a baseline component of care in a primary care environment

3. 2012 System Direction Advance Care Planning is a pathway / process we walk with patients Need to focus the work to defined population

4. Basic ACP Offered to all patients age 65 and over Begin with focused population Research offering an electronic version

5. Basic ACP 0.6 FTE coordinator and volunteers for evening sessions at the clinics Evolve clinic partnerships Possible external site offerings to meet population needs

6. Complex ACP Offer facilitated complex ACP sessions to targeted populations Morbidity predictive model Focused diagnoses Provide ability / resources to continue discussions with patient and family over time

7. Redesign of Support Processes New order flow process to primary clinic Complex ACP Facilitators are responsible along with primary care for ACP within a population and provide back up support to hospitals for non-primary care patients

8. Redesign of Support Processes Change in EMR documentation - Reflect “decision maker” as well as agent Develop process to verify completion of document Scanning available at hospital and Primary Care site

9. 2012 Process Measures Population age 65 and older with a basic ACP Morbidity & disease appropriate with complex session documented ACP overview with hospital patients over 65

10. 2013 Outcomes Measures Hospital days in the last 6 months Are we following HCD wishes? Length of Stay hospice Quality words measured - “Goals” & “Wishes”

11. Questions?