HealthPartners Targeted Approach for Advance Directives Honoring Choices Conference July 18, 2013 Christine Sylvester, Care Delivery Supervisor Kate Kellett, Regional Clinic Director

Advance care planning is a spectrum of decisions. based on patient preference and disease complexity. This work is part of HealthPartners enterprise-wide end of life care improvement activity.

Honoring Choices Targeted Honoring Choices Targeted Simple - Targeted > 65 - Mild chronic conditions Simple Self Directed Educate WellMild/ DiseaseMultiple/ComplexSevere/Complex Advance Care Planning Target Appropriate Patients

Background Why was the advance directive short form created? – HealthPartners committed to deploying Honoring Choices approach. – Deployment to primary care was not successful (no targeting). – Patients often not open to a facilitated intense advance care planning conversation. Form “too long” Patients wanted simpler document for first interaction – HP needed a SYSTEM WIDE approach for ALL 26 clinics. – The completion/return rate of Honoring Choices form was low when piloted. – Based on the patient’s preference, the clinic will offer either the one-page document or the Honoring Choices document.

Honoring Choices Form/Process TARGETING METHODOLOGY Multiple severe chronic disease Specialty focus – Cardiology (CHF) – Nephrology ( Kidney Failure) – Oncology (Metastatic Cancer) – Pulmonary (COPD) – Neurology (Dementia, Parkinsons) Nursing home/Assisted living Complex frail MSHO Palliative Care

Elements of Form Name a person to designate your wishes should you be unable to communicate these decisions. A secondary agent (health care proxy) is optional in the event the primary agent is unavailable. THIS IS CRITICAL first step for many patients. Choose your particular wishes about efforts to revive you if needed due to no pulse/no breathing.

Elements of Form Include other wishes if desired. May include religious beliefs, plans for funeral arrangements, donation of organs, any strong value or belief you want known. Have a notary sign this. Can be done by notaries in the clinic. Can be done by other notaries (bank, etc.) Reception staff will give or mail copies, the form will be scanned into EPIC and documented on the problem list.

Primary Care Clinic Flow Health Maintenance Alert in EPIC – 65 and older Advance directive offered to patients seeing their primary care provider One-page form presented with the option to use Honoring Choices form Rooming Nurse & Provider Nurse will identify patients who do not have advance directive on file Presents advance directive information to patient during rooming process Provider encourages completion of advance directive and answers questions Clinic Assistant (Receptionist) Offers notary if needed Verifies advance directive is signed and completed Scans advance directive into patient’s chart Provides patient with 3 copies EPIC format – Problem List & Administrative Tab for LOCATION of info

Primary Care Clinic Flow

Clinic Trainings Nursing leaders and Nurse Practitioner provided training to every primary care clinic One-hour lunch and learn session with webinar option for those who could not attend in person Workflow reviewed every six months through bi-annual standard work training Well received!

Outcome ↑ 1,791 patients Primary Care Patients (65 and Older) with Advance Directive in EPIC

Next Step Frail/Elderly Care model process to target complex primary care patients to Honoring Choices process Continued attention to 5 key specialties for Honoring Choices Further learning with our Multicultural populations When patients condition changes – Honoring Choices can be instituted (re- assess decisions)

Resources Facilitator Hotline Notary Public in every clinic Honoring Choices & POLST form also used in primary care, specialty and hospital HealthPartners Website is a resource- Forms and Information

Questions For more information… – Kate Kellett, Regional Clinic Director – Christine Sylvester, Care Delivery Supervisor