Begin with the End in Mind - Great Lakes Health Connect · 9/21/2018 1 Begin with the End in Mind: Health Information Technology as a link to honoring a person’s advance directive

9/21/2018

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Begin with the End in Mind: Health Information Technology as

a link to honoring a person’s advance directive

Carol Robinson DNP, MS, BSN, RN, CHPN®

Community Coordinator, MCM

Mary Graham, LMSW

Manager of Community Engagement, GLHC

9/21/2018

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Making Choices Michigan

• Community-based, 501 (c)(3); wholly-owned subsidiary

of Great Lakes Health Connect

• Goal: Move the ACP conversation from the healthcare

environment to the community-at-large

• Vision: foster a community culture where it is

acceptable to talk about health care choices,

including end of life, and to respect and honor those

choices.

• Mission: encourage and facilitate advance health

care planning by the people of Michigan.

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Advance Care Planning (ACP)

Discuss

• Reflect on your values and beliefs

Decide

• Choose your Patient Advocate(s)

Document

• Write your wishes in an Advance Directive (Durable

Power of Attorney for Healthcare)

• Share your plan

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Advance Care Planning

• Is important for alladults, 18+

• It is thinking and talking about future healthcare decisions

• Prepares your Patient Advocate(s) to speak for you if you cannot (e.g. car accident or illness)

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Living Well

If you were having a good day …

• What would happen on that day?

• Who would you talk to?

• What would you do?

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Three Decisions:

1. What personal beliefs do you have that might impact your decisions? • For example:

• What does your family think about quality versus quantity of life? What do you think about it?

• Who makes the important decisions in your family?

• Do you have a faith belief? If you do not, does your family? Could their beliefs impact decisions about your care?

2. What healthcare would you like to receive if you have a severe, permanent brain injury?

3. Who do you want to choose as your Patient Advocate(s)?

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Exploring Goals of TreatmentImagine this scenario:

A sudden event (such as a car accident or illness) leaves

you unable to communicate. You are receiving all the

care needed to keep you alive. The doctors believe there

is little chance you will ever recover the ability to know

who you are or who you are with…..

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Explore your end of life beliefs

1. What personal beliefs do you have that might help you choose the care you want — or do notwant?

• Visitors, lighting, quiet, finances, being home?

2. Would certain practices give you comfort?

• Prayer, music, readings, certain foods, pets?

3. Would you like to talk to someone about these beliefs or concerns?

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Next Steps

Follow-up items

Talk with your Patient Advocate

Meet with a MCM Facilitator

Complete an Advance Directive

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Creating an effective Advance Directive

Holt, G. E., Sarmento, B.,

Kett, D., & Goodman, K. W.

(2017).

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MCM Advance Directive

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Then. . .

• Give copies to your Patient Advocate, your healthcare team and your family

• Keep a copy of your Advance Directive where it can be easily found

• Take a copy with you if you go to a hospital or nursing home and ask them to place it in your medical record

• Consider registering your AD (for free) with Great Lakes Health Connect

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MCM Services

• Advance Directive (co-branding with attribution)

• Evidence-based, standardized ACP Communication training• Respecting Choices®

• ELNEC® Communication education• System design and implementation to hardwire ACP success in practices and community organizations

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Grand Rapids, MI ~ Best Place to die in America

Policy and Politics to Drive Change in End-of-Life Care: Assessing the Best and Worst Places to Die in America.

McPherson, A. & Parikh, R.B. (2017). Generations

Most people want to die at home, but many land in hospitals getting unwanted care.

McPherson, A. & Parikh, R.B. (2017). The Washington Post

Creating Care Connected Communities

GLHC’s Contribution

• GLHC long-time partner with MCM

• Review each submission and post within one business day

• Can take manual upload or interfaced EMR submissions

• Committed to supporting patient care by providing information at the point of care.

• VIPR is patient-based, clinical information (not payer-specific or claims-based)


Over 9 Million Patients


Contributors

• 294 Sites/ Organizations

• 48 Counties

• Out of state

• 11 Types of Data


Access Options


ACP Documents in VIPRThrough August 2018 – Document Type

Advance Care Directive 3134

Advance Care Directive - Card Only 14

Advance Care Directive - Other State 112

Asthma Action Plan 1318

Authorization to Visit 1

Care Plan 4

Certificate of Disability 18

Code Status/Orders 89

Code Status/Orders with Organ Donation 14

Complex Care Plan 2

Designation of Patient Advocate 5700

Designation of Patient Advocate – NO BLOOD 370

Do Not Resuscitate 2513

Durable Power of Attorney – Finance Only 1983

Durable Power of Attorney for Healthcare 23909

Guardianship 378

Living Will – Treatment Preferences 1712

Medication History 2

Mental Health Power of Attorney 1

Michigan Physician Orders for Scope of Treatment (MI-POST) 25

Military Advance Care Directive 6

OB ACOG Antepartum Record 1364

OB Gestational Diabetic Flow Sheet 8

OB Lab Flow Sheet 942

OB Prenatal Physical 209

OB Transitional Care 1

OB Tubal Consent 2

Organ Donation 12

Physician Orders for Life-Sustaining Treatment (POLST) 115

Post Death Request 5

Release of Information 337

Revoked Document 8

Statement Of Incapacity 14

Statement of Treatment Preferences (SOTP) 1445

Telemedicine Visit Summary 1085

Grand Total 46852


ACP Documents in VIPRThrough August 2018 – Source Type

Type Total

Attorney 1,384

Community Organization 344

HIE 161

Home Health 775

Hospice 1,168

Hospital 31,431

Individual 4

Outpatient Clinic 8,507

PHO 1,542

Senior Living Center 21

SNF/LTC 430

Telemedicine 1,085

Grand Total 46,852


ACP Documents in VIPRThrough August 2018 – County

County Total

Barry 773

Genesee 7811

Grand Traverse 12

Gratiot 11

Ingham 93

Kalamazoo 3

Kent 9753

Macomb 166

Mason 20

Mecosta 250

Montcalm 66

Muskegon 4182

Newago 50

Oakland 510

Osceola 479

Ottawa 850

State-Wide 266

Washtenaw 21557

Total 46852

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Call for information or a free appointment

616-421-4840

www.makingchoicesmichigan.org

[email protected]

http://www.makingchoicesmichigan.org/