Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Empowering Providers to Engage in Advance Care Planning

8/25/2015 1:18:52 PM | 5 comments

Surveys suggest that the majority of Americans would prefer not to receive life-prolonging care if they were suffering due to an incurable condition. Unfortunately, 75 percent of people hospitalized with a critical illness are unable to make their wishes known. In these cases, having an advance care plan (ACP) in place can help to ensure that patients receive end-of-life care that's consistent with their values and preferences.
Advance care planning has also become an important topic for acute care providers. Hospitals must now report the percentage of inpatients age 65 and older who were engaged in this sort of planning by their doctors. However, CMS estimates that only about 55 percent of older inpatients have a "goals of care" conversation documented in their charts.
In 2013, CEP America launched a national palliative care educational program that equips providers with the tools they need to facilitate these important discussions. Recent data indicates that our hospitalist providers demonstrate very high rates of ACP documentation.
In this post, I'll share more about advance care planning, why it's important and how healthcare organizations can support their providers in identifying and managing these patients.

What Is an ACP?

An ACP is a living document expressing a patient's end-of-life care preferences. It specifies types of care the person would like to pursue and withhold, including:
  • CPR, in the event of cardiac arrest
  • Emergency interventions (ranging from comfort care to full treatment)
  • Setting of care (hospital, ICU)
  • Antibiotics use
  • IV fluids
  • Tube feedings
  • Intubation
Some people create their own advance directives in the form of living wills or a healthcare power of attorney. However, acute care providers have a unique opportunity to ensure that all patients have an opportunity to express their treatment preferences. When appropriate, physicians can write "scope of treatment" orders to be posted near the patient's bed and recorded in the chart. These orders then travel with the person between care settings (e.g., hospital, nursing home).
Physicians should also be proficient in completing POLST forms. POLST stands for Physician Orders for Life-Sustaining Treatment. It is a "live" ACP for persons with serious illness — at any age. POLSTs are physician orders to be legally followed by any hospital, nursing home or emergency service team, even when the signing provider is not on staff at these facilities. The POLST form provides specific medical orders reflecting the patient's preferences for current treatment in the setting of their illness (e.g., do not resuscitate, but transfer for medical care).
It's important to note that the goals of care reflected in an ACP are moving targets. Advanced care planning is an ongoing process in which patients and their loved ones redefine their goals of care as their conditions and illnesses evolve. Using a patient-centered approach, we must help patients to identify their changing values and hopes to determine their next care decisions.
In order to begin the planning process, a provider engages the patient and family in a "goals of care" conversation. For example, let's say a patient is hospitalized with a chronic, debilitating illness such as advanced COPD. The provider would discuss the prognosis, letting the patient and family know where the person is in the disease process and what the future is likely to hold. The patient, family and provider would then discuss various treatment options, including curative, palliative and hospice care. The resulting plan would be documented and revisited any time the patient's health status, preferences or care setting changed.
Advance care planning has many benefits. First and foremost, it respects patients' rights by putting them in control of their own care. They are free to say no to unwanted procedures and interventions, and they can rest assured that their goals, wishes, values and preferences will be respected if they can't speak for themselves. The plan also allows patients to determine their quality of life. (For example, it might make it easier for a dying patient to avoid an ICU stay or to remain at home with loved ones.)
Advance care planning also benefits hospitals. Research shows that the process can help to improve patient satisfaction. Patients are less likely to be readmitted when their goals are known. And palliative care (which is often incorporated into an ACP) is correlated with decreased readmission rates, length of stay and cost of care. Most fundamentally, advance care planning furthers the hospital's mission of providing compassionate, patient-centered care.

Empowering Providers

Though advance care planning has many benefits and ACP documentation is now tracked by CMS, compliance with this quality measure remains low.
In my experience, it's not because providers don't see value in it. Surveys show that our CEP America physicians, PAs and NPs have always a strong desire for additional training in palliative care. I suspect part of the problem is that their training programs didn't offer much instruction around end-of-life care planning. So naturally, they worry that they won't be effective in helping their patients make these difficult decisions.
To encourage engagement in advance care planning, CEP America operationalized a national palliative care initiative in 2013. Our aim was to equip providers with tools and tips to help them feel confident when leading goals of care conversations. We also hoped the program would increase ACP documentation rates for the benefit of our hospital clients.
The program encompasses three main educational components:
Workshops. This three-hour interactive program is offered at our annual and regional gatherings and open to all interested providers. It's taught in a mixed didactic and case study format and covers patient identification, prognostication and communication strategies. Participants practice their skills by simulating a "goals of care" conversation with actors while a moderator guides and coaches them. CME credit is available.
Pocket Guides. We've created a handy quick-reference guide to the goals of care conversation that providers can print out or download to a mobile device. It covers the steps to follow, plus useful phrases and scripting for each part of the conversation.
Webinars. These hour-long educational presentations introduce the importance of palliative care and the "goals of care" conversation. We offer 3 to 4 webinars a year with playback available through our internal website. One advantage of this format is that it allows us to engage the entire healthcare team, including the nurse leaders and staff at our hospitals.
In addition, CEP America has implemented an integrated Palliative Care Clinical Pathway at several of its client hospitals. Emergency and hospitalist providers at these sites work together to identify and manage patients who might benefit from palliative care. The pathway includes many useful tools, including checklists, scripting for leading conversations, prognostication tools, sample orders and satisfaction surveys.
So how is it working? Well, in 2014, CEP America providers reported creating ACPs (reflecting patient or proxy decision-maker preferences) for 84 percent of the inpatients in our care. That's far above the national average of 55 percent.
We're proud to have operationalized our palliative care efforts on a national level. However, I don't think the program accounts for all of our success. First and foremost, we are lucky to have very skilled and compassionate hospitalist providers throughout our organization. They're motivated to initiate these conversations, because they know advanced care planning is best for patients. The skills they learn in our programs simply enhance their natural ability and empathy. 

Thanks for all you hard work and for your commitment to palliative care.
8/30/2015 7:29:36 PM

Shauna Conry
Thank you for your comments. Shaun you are spot on; we are so thrilled that Governor Brown signed the bill allowing PAs and NPs to discuss and sign POLST forms starting in Jan 2016.
8/27/2015 5:11:32 PM

Shaun Partlow
Thank you so much for this important discussion. It is worth noting that Gov. Jerry Brown of California has just signed a law allowing PAs and NPs to sign POLST forms. We should see those ACP numbers go up even further.
8/27/2015 4:02:54 PM

Rick Newell
Shauna, great piece. Thanks for being such a strong advocate for Advanced Care Planning and Palliative Care!
8/26/2015 2:23:56 PM

Savoy Brummer
I just had to do this for a family member of mine. Nice article.
8/26/2015 6:25:44 AM