Streamlining education about advance care planning has helped patients articulate their end-of-life care needs, saved staff time and reduced stress levels for providers at Methodist Physicians Clinic, Omaha, Neb.
“It’s the No. 1 place to reduce costs and give patients exactly what they want,” says Todd Grages, FACMPE, FACHE, MGMA member, president and chief executive officer of the system, which comprises 25 sites and employs 300 providers. “But it takes a lot of work.”
At Methodist, that work entailed educating staff, streamlining resources, investing in personnel and hosting events to inform patients about their end-of-life care options. The goal was to ensure that staff could field a growing number of patient questions, such as:
- What is an advance directive and how do I fill one out?
- How is a living will different from an advance directive and a medical power of attorney?
Streamlining processes
The process reflects the team’s dedication to educate patients about their care options at all stages of their lives, and to ensure that those patients receive the type of care they request at any and every facility.
Prior to the new process, staff didn’t have answers to patient questions about advance directives or know who could field them. “There was a lot of confusion about what form to use and who should handle the questions,” says Rhonda Rowley, RN, BSN, director of medical home administration, Methodist.
To arm staff with answers, a committee composed of clinic managers and medical home administration, hospital nurse leaders, social workers and pastoral personnel took the following actions:
- Offered training for everyone in the clinics
- Created an advance care packet for patients
- Consolidated the different forms
- Encouraged all health coaches to become notaries and ensure at least one notary per clinic
- Scheduled regular “Decisions days” — events to educate patients about advance care planning
The work was completed in a few months and results have been positive. “Having staff know how to answer questions and where to direct patients for more information has made physicians happy,” Rowley says.
Steven Bailey, MD, medical director of quality and process improvement, Methodist, concurs. “Creating a medical plan for end-of-life care helps avoid more tests and more things that actually do nothing more than provide more discomfort,” Bailey explains. “There’s a sweet spot we can hit there. It’s the No. 1 opportunity to give the kind of care patients really want and to reduce costs.”
The question of identifying what patients really want is a new dynamic in healthcare that requires honest, open communication with patients about where they are in life, what they want and what they’re willing to compromise, said Atul Gawande, MD, MPH, professor, Harvard School of Public Health and Harvard Medical School, Cambridge, Mass., during the MGMA 2015 Annual Conference in Nashville, Tenn.
From a practical perspective, it requires providers to shift their attention from diagnosis and cure to helping patients age gracefully or less painfully, which is new for some. “Doctors learn how to fix things,” he told audience members, so the problems of frailty and aging are uncomfortable for them.
One example: A doctor who recommends a surgical fix for an enlarged thyroid for a woman with advanced breast cancer.
Educating patients
Talking about advance directives prompts patients to think about whether they want ventilator support, a feeding tube and other efforts to extend life while considering quality-of-life issues. Ideally these conversations occur well before illness strikes. “It’s important to complete advance directives when patients are well, without the pressure of illness or an emergency,” Rowley says.
The ideal scenario is that providers do what is in the best interest of patients to reduce suffering and improve quality (versus quantity) of life, explains Bailey, who sees advance directives as a portal for early and candid discussions about palliative and hospice care.
Advance directives can also alleviate some of the pressure on physicians when patients say things like, “You do whatever you think is right, doctor.”
The preference is to act as a team in which care team members are guides, he adds.
Processes
Staff members at Methodist ask about advance directives during Medicare wellness visits to ensure patients understand their options and complete the standardized forms. The system has committed to having one staff person per clinic become a notary, which costs $90 in Nebraska and Iowa, who can finalize and file forms in EHRs to ensure the decisions are factored into care plans once patients are transferred to a hospital or skilled nursing facility.
The team at Methodist scheduled four Decisions days in 2015, which attracted about 160 patients, and has received positive feedback. “We have heard that people were grateful for the resources,” Rowley says. The team will retool the schedule for future events after learning that some attendees left when they saw a line. “Our format was not conducive to groups of people arriving at the same time and kind of formed a bottleneck,” Rowley explains. “We lost some of them who didn’t want to wait.”
The system’s first event, which was last month, included a group presentation at 9 a.m. followed by an opportunity for patients to ask questions, engage in conversation with staff members and complete paperwork with notaries available.
Learn more about National Healthcare Decisions Day, a 50-state initiative to help patients with advance directives.
Members can download the advance care packet created by Methodist Physicians Clinic.
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