Beyond POLST Great Plains QIN Huddle July 21, 2020 A partnership - PDF document

Better Together Beyond POLST Great Plains QIN Huddle – July 21, 2020 A partnership activity of the University of North Dakota (UND) Geriatric and Age Friendly TeleECHO series Mobility ‐ Prescription for Physical Activity: August 11, 2020 Featured Speaker: Donald Jurivich, DO Chair of Geriatrics, UND School of Medicine & Health Sciences 1 Geriatric and Age Friendly 4Ms Framework  What Matters?  Medication  Mentation  Mobility 2 2

How The Documents Differ Advance Directive POLST Order DNR Order Is a legal document Is a medical order Is a medical order For anyone 18 or older For those who may die within 12 – 18 For those who are critically ill and do not months given advanced life ‐ limiting illness want CPR attempted when close to death or advance frailty May name a decision maker Does not name a decision maker Does not name a decision maker Communicates general wishes about Communicates medical treatments specific Communicates specific decision about medical treatments in future states to the current state of health. Patient has a preference to attempt resuscitation in light of health. Reviewed periodically specific diagnosis and prognosis when of current state of health. Reviewed during discussing goals of care and treatment inpatient stays and on all admissions decisions. Reviewed regularly Filled out by patient Filled out by health care professional after Filled out by attending provider after conversation with the patient and/or their discussion with patient, family or from health care decision maker POLST order Risk and benefits of particular Risk and benefits of particular treatments Risk and benefits of particular treatments treatments are rarely reviewed are reviewed by trained facilitator and the are reviewed by provider provider Valid when the patient signs in Valid when the physician signs and is valid Valid during current admission once the presence of two witnesses or notary across all care settings. Patient/agent may physician signs. Not signed by sign patient/agent. 3 3 What Matters Activity Take a moment to think of a time when someone you loved was dying. Think about who this person was and how this news/process made you feel. Did the person you thought of have Advance Care Planning? [post in the chat] • If yes, do you feel it helped? • If no, do you feel one would have been helpful and if so why/how? 4

My Story What Matters "I do not want to get to the end of my life and find that I just lived the length of it. I want to have lived the width of it as well." ‐ Diane Ackerman 5 5 Best Practices • Ask the older adult What Matters most, document it and share What Matters across the healthcare team • Align the care plan with What Matters most • Review high ‐ risk medication use and document it • Deprescribe or avoid high ‐ risk medications • Identify and manage factors contributing to depression 6 6

Best Practices... [continued] • Screen for mobility limitations • Include the family/caregiver • Patient portal access and visit summaries • Interdisciplinary care team • Motivational interviewing • Share advance care planning between settings with care transitions 7 7 Life Context & Priorities http://www.ihi.org/Engage/Initiatives/Age ‐ Friendly ‐ Health ‐ Systems/Documents/IHI_Age_Friendly_What_Matters_to_Older_Adults_Toolkit.pdf 8 8

Goals and Preferences http://www.ihi.org/Engage/Initiatives/Age ‐ Friendly ‐ Health ‐ Systems/Documents/IHI_Age_Friendly_What_Matters_to_Older_Adults_Toolkit.pdf 9 9 When to Hold Discussions  Medicare Annual Wellness Visits and other clinic visits  New diagnosis or change in health status  Life ‐ stage change  Chronic disease management  Inpatient visits  Financial/legal planning  Holiday gatherings 10 10

Resources  Motivational Interviewing  South Dakota MOST  Advance Care Planning SD  Comfort One SD  Honoring Choices North Dakota 11 11 National Initiatives  What Matters Most  Advance Care Planning ‐ The Conversation Project  Five Wishes  Center to Advance Palliative Care  AFHS What Matters to Older Adults  Serious Illness Conversation Guide  Better Care Playbook  The Conversation Project 12 12

Summary Beyond POLST  Personal Impact  Other Factors  Best Practices  Assessment and Community Resources  National Initiatives 13 13 Beyond POLST What has been the COVID ‐ 19 impact? 14 14

Commitment to Act What is the first/next step you can take to improve advance care planning in your organization or with your family? [Post your ideas in the chat] 15 15 Geriatric and Age Friendly TeleECHO 2nd Tues 3rd Tues Upcoming Topics 12 PM CT 12 PM CT Mobility: Prescription for Physical Activity August 11 August 18 Medications: Medication Update September 8 September 15 Mentation: Depression in Older Adults October 13 October 20 What Matters: Decision ‐ Making Capacity November 10 November 17 https://ruralhealth.und.edu/projects/project ‐ echo/topics/geriatrics 16 16

Great Plains Quality Care Coalition Better Together. Improve care in your community and organization Partner with an experienced team of quality improvement experts Access to tools, resources and education Connect with healthcare partners in your community Share ideas and best practices Learn how to better utilize data to drive improvement FREE assistance through funding by the Centers for Medicare & Medicaid Services Learn more, sign up or access current participants: https://greatplainsqin.org/initiatives/quality ‐ care ‐ coalition/ 17 North Dakota Team North Dakota Jayme Steig, PharmD, RPh Quality Improvement Advisor Jayme.Steig@greatplainsqin.org Nikki Medalen Quality Improvement Advisor Nikki.Medalen@greatplainsqin.org Michelle Lauckner, RN Quality Improvement Advisor Michelle.Lauckner@greatplainsqin.org 18

South Dakota Team South Dakota Stacie Fredenburg, BA Quality Improvement Advisor Stacie.Fredenburg@greatplainsqin.org Lori Hintz, RN, CDP, CADDT Quality Improvement Advisor Lori.Hintz@greatplainsqin.org 19 Great Plains QIN Team Krystal Hays Dee Kaser, RN, CDE Jeremy Frink Nancy Beaumont DNP, RN, CADDCT, CDP, RAC ‐ CT Quality Improvement Advisor Information Technology Director Task Order Director Regional Project Manager Tammy Wagner Ryan Sailor, MBA Keri McDermott, BA Lorrie Lendvoy RN, LSSGB, CADDCT, CDP Chief Executive Officer Communications Director Statistician Quality Improvement Advisor 20 20

Better Together Great Plains QIN aspires to make health in our region the best in the nation https://greatplainsqin.org 800/458 ‐ 4262 This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Innovation Network ‐ Quality Improvement Organization for North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 12SOW ‐ GPQIN ‐ 24/0720 21