1. Addressing Advance Care Planning in Wisconsin The name “Honoring Choices Wisconsin” is used under license from Twin Cities Medical Society Foundation. Joyce Hart Smerick Honoring Choices Wisconsin Program Coordinator Respecting Choices First Steps® Faculty Melissa Hale, MSW, LCSW ProHealth Care Advance Care Planning Coordinator

2. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY Objectives At the conclusion of this presentation, participants will be able to: 1) Define advance care planning (ACP) 2) Identify the key elements in making ACP a routine part of care 3) Describe three ways to implement ACP in a health care organization

3. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY World Death Rate Holding Steady At 100 Percent NewsNews survival ISSUE 3102 Jan 22, 1997survivalISSUE 3102 GENEVA, SWITZERLAND—World Health Organization officials expressed disappointment Monday at the group's finding that, despite the enormous efforts of doctors, rescue workers and other medical professionals worldwide, the global death rate remains constant at 100 percent....

4. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY The Facts 70% prefer to die at home 70% die in an institution

5. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY The Facts 60% Don’t want to burden 56% Have not communicated their wishes

6. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY The Facts 80% would like doctor to talk about EOL 7% say doctor has talked about EOL

7. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY Advance care planning is a process. future medical decisions, including end-of-life preferences. 1 2 3 UnderstandingReflecting on Discussing

8. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY Why is this important? Without planning: The care you receive may not reflect your wishes Your health care providers may not know your treatment preferences Your family may be left wondering if they are making the right decision

9. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY 55 year old male Severe MVA trauma No advance directive Family divided Court involved

10. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY 84 year old male Severe stroke Advance directive says: o No feeding tube o No ventilator Comfort care provided

11. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY The La Crosse Experience 90% of decedents have an advance directive 99.4% of those decedents’ advance directives were found in the medical record where they died 99.5% of treatment decisions were found consistent with instructions Dramatic effect on family satisfaction (LADS 2007-08, Detering et al. 2012)

12. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY Honoring Choices Wisconsin an initiative of the Wisconsin Medical Society The mission of Honoring Choices Wisconsin is to promote the benefits of and improve processes for advance care planning across the state, in health care settings and in the community.

13. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY HCW in Clinical Settings Make ACP a part of routine care by ensuring conversations are: Offered Scheduled Conducted Documented Brought into the medical record

14. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY Respecting Choices Model FIRST STEPS Create POAHC and consider when a serious neurological injury would change goals of treatment. Healthy adults who have not planned. NEXT STEPS Determine what goals of treatment should be followed if complications result in “bad” outcomes. Adults with progressive, life-limiting illness, suffering frequent complications LAST STEPS Establish a specific plan of care expressed in medical orders. Adults whom it would not be a surprise if they died in the next 12 months.

15. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY Key Elements System Design Facilitator Education Continuous QI Community Involvement

16. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY 2012 Community Care, Inc. Fort HealthCare/Rainbow Hospice/ADRC Group Health Cooperative of SCW Meriter ProHealth UW Health 2013 Adoray Agrace Aspirus Baldwin AMC Froedtert Mayo – Eau Claire St. Croix RMC ThedaCare UWHP-Watertown 2014 Amery Hospital & Clinic Bellin Health Mercy Health System Hudson Hospital & Clinic Reedsburg AMC Westfields Hospital & Clinic

17. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY Learn lessons for broader implementation Test new workflows and processes Give newly trained facilitators opportunities to practice their skill Trial Implementations

18. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY “I’ve always wanted to focus on the conversation rather than the form, and now with this new workflow, I can.” Clinical social worker and facilitator

19. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY “Thank you! I’ve wanted to do this for a long time, but didn’t know how to begin.” Clinic patient

20. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY HCW in the Community A full time Community Engagement Specialist Collaboration with Wisconsin Public Television Work with local coalitions and participating organizations Faith ambassador programs

21. AN INITIATIVE OF THE WISCONSIN MEDICAL SOCIETY

23. ProHealth Care Advance Care Planning 1. ACP Timeline/Pilot 2. Strategic Implementation 3. Future Goals

24. Overview of ProHealth Care Wisconsin’s largest integrated health care delivery system in Waukesha and Dodge Counties (between Madison and Milwaukee) Treats more than 400,000 patients/year between two hospitals, 17 primary care clinics, home health and hospice services, long-term care, and senior residence communities Long-standing service to community: Waukesha Memorial opened in 1914; Oconomowoc established in 1954; formed ProHealth Care in 1998 Network of nearly 1,000 physicians and more than 4,800 employees

25. October, 2013 ProHealth Care (PHC) leadership identified implementing the Honoring Choices program at PHC as a 2013-2014 strategic initiative after reflecting on the following: An important statistic: 100% of people die 70% of people say they would prefer to die at home, but only 20% do Less than 50% of the severely or terminally ill patients studied had an advance directive in their medical record. 29% of people have advance directives. Between 65-76% of physicians whose patients had an advance directive were not aware that it existed. (AHRQ, 2003)

26. October, 2013 Current state of ACP Identified that current state AD documents were: Difficult to find in various Epic applications Not kept current by patients or clinicians Not accessible to all clinicians needing documents to make care decisions

27. December, 2013 Clarified Role Responsibilities Hospital Inpatient RNs Home Health RNs Inpatient Physicians Clinic Physicians Clinic Medical Assistants Clinic Patient Service Representatives ACP Facilitators Social Workers Chaplains Health Information Management Specialists

28. 2013 Pilot Overview Lung and pancreatic cancer Oncology Registry Approached by ACP Facilitator after approval from oncologist Oncology PatientsHealth Coach Patients 65 and older 3+ chronic conditions Participants in Health Coach program Approached by HC RN and then referred to ACP Facilitator based on interest

29. Goals Accomplished 69% of people invited were scheduled 100% of people who completed ACP had documentation in EMR – 100% 86% of people who participated in ACP had a written plan Participants surveys rated >3 – 100% rated 4 or 5 Agents felt more prepared after ACP – 5 = 100% Facilitators became more confident Number of facilitations = confidence and skill 100% Participants & Agents rated Facilitator skill at 5

30. Successes Detailed process and script to follow resulted in more meaningful conversations and completed process Conversation more in-depth with agent present Due to strong interest and need – expanded to all health coach locations Identified and completed process for those who had AD but was not in Epic or not current

31. Challenges Physician understanding and support Witnesses Especially at clinics and patient homes Scheduling facilitations at clinics 3 of 4 Facilitators located primarily at hospitals Room availability Incorporating facilitations into daily work Oncology population were late stage – most already had AD recently completed

32. Lessons Learned Improved data collection process Dedicated person and process for handling referrals, scheduling, assigning facilitators and follow up Dedicated staff time for facilitations Increase in AMB or mobile facilitators Facilitations need to be completed more upstream

33. Next Steps: 2014 Train additional facilitators and facilitator trainers Organization wide communication and education Conduct employee/physician facilitations Continue to expand across the continuum of care – next phase of HCW planning started this month ACP an integral piece in PHC End-of-Life/Palliative Strategy Finalize Epic Navigator, Smartset, and referral order

34. ProHealth ACP Timeline 2013 Trained 4 facilitators; created smart phrases and ACP Note type in EPIC; pilot 2014 Trained 13 facilitators; Employee incentive started; hired ACP Coordinator 2015 Create ACP Department; Trained 12 more facilitators (total of 30); Ambulatory Pilot

35. ACP and Epic Advance directives and ACP documentation must be available to clinicians at the time of care if the patient’s decisions are to be honored

36. Epic current state AD information asked at admission and documented in RN navigator No standardized process/documentation in OP/AMB setting (AMB Pilot March 2015) Documents scanned into Epic Media Tab Sort by document type (AD is always first) ACP Facilitators using ACP Note type

37. Advance Care Planning Activity: Centralized Information

38. Medical Treatment Preferences completed once by provider/ACP facilitator, viewable across multiple encounters

39. ACP Note Smart Text

40. Physician Support and Participation: Summary The basic role of physicians is to: Understand the ACP process and importance Initiate planning discussions/ACP referrals Review written plans that have been entered into the medical record Make plans more specific as patient’s health condition changes Convert plans into orders when appropriate Initiate program referrals (Palliative, Hospice)

41. ACP 2015 Calendar January 13 Waukesha Community Recreation Center January 22 National Kidney Foundation Living Well Program Feb 10, 11 & 12 Employee Lunch & Learn WMH February 11 Facilitator’s Meeting February 18 Home Health and Angel’s Grace Staff Meetings March 23 PCHMG Stoneridge Pilot Begins March 26 & 31 Employee Lunch & Learn Riverwood March 27 & 30 Employee Lunch & Learn OMH April 6, 7 & 8 Regency Education Booths April 13-16 NHDD Events at OMH, DNG and WMH April 18 Waukesha Community Health Fair April 23 Community Class at WMH May 15 Facilitator’s Meeting May 28 Wisconsin Comprehensive Cancer Control Summit July 27 Heart Failure Class WMH Sept 18 WI Council of Nephrology Social Workers Oct 6 WMH All Staff Meeting Nov 1 Dia de Los Muertos Event November 5 National Kidney Foundation Professional Symposium

42. Future Success Metrics Decrease ICU utilization at end of life Increase Palliative Care and Hospice referrals Longer hospice stays Increase % of patients with AD available in Epic Standardized documentation and retrieval of information

43. Thank you! The name “Honoring Choices Wisconsin” is used under license from Twin Cities Medical Society Foundation.