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10/23/2018
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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, MCMMary Graham, LMSW
Manager of Community Engagement, GLHC
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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 healthcare 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 itemsTalk with your Patient AdvocateMeet with a MCM FacilitatorComplete 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)
Creating Care Connected Communities
Over 9 Million Patients
Creating Care Connected Communities
Contributors
• 294 Sites/ Organizations• 48 Counties• Out of state• 11 Types of Data
Creating Care Connected Communities
Access Options
Creating Care Connected Communities
ACP Documents in VIPRThrough August 2018 – Document Type
Advance Care Directive 3134Advance Care Directive - Card Only 14Advance Care Directive - Other State 112Asthma Action Plan 1318Authorization to Visit 1Care Plan 4Certificate of Disability 18Code Status/Orders 89Code Status/Orders with Organ Donation 14Complex Care Plan 2Designation of Patient Advocate 5700Designation of Patient Advocate – NO BLOOD 370Do Not Resuscitate 2513Durable Power of Attorney – Finance Only 1983Durable Power of Attorney for Healthcare 23909Guardianship 378Living Will – Treatment Preferences 1712
Medication History 2Mental Health Power of Attorney 1Michigan Physician Orders for Scope of Treatment (MI-POST) 25Military Advance Care Directive 6OB ACOG Antepartum Record 1364OB Gestational Diabetic Flow Sheet 8OB Lab Flow Sheet 942OB Prenatal Physical 209OB Transitional Care 1OB Tubal Consent 2Organ Donation 12Physician Orders for Life-Sustaining Treatment (POLST) 115Post Death Request 5Release of Information 337Revoked Document 8Statement Of Incapacity 14Statement of Treatment Preferences (SOTP) 1445Telemedicine Visit Summary 1085Grand Total 46852
Creating Care Connected Communities
ACP Documents in VIPRThrough August 2018 – Source Type
Type TotalAttorney 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
Creating Care Connected Communities
ACP Documents in VIPRThrough August 2018 – County
County TotalBarry 773
Genesee 7811Grand Traverse 12
Gratiot 11Ingham 93
Kalamazoo 3Kent 9753
Macomb 166Mason 20
Mecosta 250Montcalm 66Muskegon 4182Newago 50Oakland 510Osceola 479Ottawa 850
State-Wide 266Washtenaw 21557
Total 46852
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Call for information or a free appointment
616-421-4840www.makingchoicesmichigan.org
