1 Multi-Stakeholder Perspectives on Implementation of an Advance Care Planning Group Visit Hillary D. Lum, MD, PhD Sarah R Jordan, MS VA Eastern Colorado Geriatric Research Education and Clinical Center University of Colorado School of Medicine
With Gratitude 2 • Dorothy Dillon Eweson Lecturer on the Advances in Aging Research • National Institute on Aging Beeson K76 Award Mentors Team Team Cari Levy Adreanne Brungardt Kirbie Hartley Jean Kutner Andrea Daddato Sarah Jordan Rebecca Sudore Joanna Dukes Elisabeth Montgomery Dan Matlock Sue Felton Prajakta Shanbhag Jackie Jones Lierin Flanagan Robert Schwartz
Engaging in Advance Care Planning Talks 3 (ENACT) Group Visits Interactive discussions of Education and support advance care planning through group dynamics ENACT Group Visits Intervention Patient goal setting for Uses outpatient billing advance care planning codes & documentation actions Lum HD, Jones J, Matlock DD, et al. (2016) “Advance Care Planning Meets Group Medical Visits: The Feasibility of Promoting Conversations.” Annals of Family Medicine.
ENACT Group Visits Framework 4 Collaborative ACP Behavior Maintenance Learning Change Theory Theory ACP outcomes Social through group Pre- Process Action Contemplation dynamics and behavior change Individual Diverse Preparation Contemplation Experience Learners Bruffee. Collaborative Learning. 1993 Sudore et al. Novel Engagement. JAGS. 2008.
Intervention Core Components 5 Session 1 Session 2 1 Month Apart CONTENT (2 hour sessions) RESOURCES Check in, vital signs, medication review (30 min) Intervention Manual Introductions, rapport building (15 min) PREPARE pamphlet, 8-10 Participants video stories Facilitated ACP discussion (60 min) Physician + Easy-to-use advance Individualized goal setting (15 min) Social Worker directive forms Setting: Academic geriatric clinic Participants: Adults age 60 years and older Implementation guided by Manual, Facilitation Guides
Pilot RCT of ENACT Group Visits (n=110) 6 Difference = 29% Difference = 26% 100 Patients at 3 months (%) 100 71 70 75 44 50 25 0 Advance Directives Decision Maker Chosen Mailed ACP Materials ENACT Group Visits
Objectives 7 • Describe patient and clinic stakeholder perspectives related to personal and contextual factors of implementing the ENACT Group Visits study Questions related to: - Clinical appropriateness - Acceptability as part of clinical care - Level of burden
Methods 8 • Phone-based, semi-structured interviews at 6 months with random sample of 26% of patients (n=28) and 8 stakeholders Patients Stakeholders • Control: 9 patients (32%) • Primary care practitioners (n=4) • Group Visits: 19 patients (68%) • Social worker (n=1) • Mean 78 years, 71% female • Medical Assistants (n=3) • Inductive and deductive thematic analysis
Results: Key Themes Related to Acceptability 9 and Implementation 1. Group visits and mailed ACP materials both facilitated patient-centered communication of care preferences 2. Clinic-based group visits were well-received for ACP discussions 3. Patients and stakeholders identified barriers to clinic implementation
Theme 1: Facilitating Patient-centered 10 Communication of Care Preferences “ The fact that they did it [advance directive] at the hospital, and it was put in my record immediately, boy, it really took a lot of pressure off… I didn't have to worry about doing it. Because, you know, it's always easy to put things off .” “I never gave it much thought until I got the questionnaire. I thought, "What would I do? Who would be the one who would decide?" We just finalized it. And, it's also important that the hospital knows and the senior clinic knows. So this is going in my record.
Theme 1: Facilitating Patient-centered 11 Communication of Care Preferences Primary care practitioner: “It's just the icebreaker. It's getting them to think about it. It also means that, if I have a follow-up question and they've already gone through the group, when I ask about it, it doesn't seem so abrupt or out of the blue. So, it felt like an easier conversation because it felt like maybe they were doing their homework by following up with me. I think it just feels like a more natural conversation that's expected from their medical provider. It just allows me to really take good care of my patients .”
Theme 2: Clinic-based group visits are 12 well-received for ACP discussions Patient: “Being there, being able to ask the questions, hearing the other participants share was very meaningful . It was a significant advantage. I think it brought up some things that I hadn’t considered.” Primary care practitioner: “Even though I may be good at having those conversations with my patient and making sure we're establishing those goals, I need them to talk to other people about it… I think it's easier for some people to talk about it with strangers, initially. It can help set the stage for them to go talk about it in the real world with people who might not want to .”
Theme 3: Patients and stakeholders 13 identified barriers to clinic implementation Patient: “It was a little bit tight, I think if they had a little bit more room between people , that might help a little bit .” Medical Assistant: “We need to have the patients in the room on time and also we need to take the vitals, so it’s been kind of stressful. A little bit more help, that would make it a little bit different .” Social Worker: “The only weakness I can think of is the rooming process. Typically on Friday afternoons have some less staff for check in. We have gotten started a couple minutes late. Our medical assistants have gotten a little overwhelmed .”
Conclusions: ENACT Group Visits are 14 Feasible and Acceptable for Implementation 1. Group visits and mailed ACP materials both facilitated patient-centered communication of care preferences 2. Clinic-based group visits were well-received for ACP discussions 3. Patients and stakeholders identified barriers to clinic implementation
Next Steps 15 • Expand and test ENACT Group Visits intervention in multiple and diverse primary care settings • Conduct a robust evaluation of contextual factors using PRISM Feldstein and Glasgow. (2008) “ A Practical, Robust Implementation and Sustainability Model (PRISM) for Integrating Research Findings into Practice” The Joint Commission Journal of Quality and Patient Safety
Thank you! 16 • Dorothy Dillon Eweson Lecturer on the Advances in Aging Research • National Institute on Aging Beeson K76 Award Mentors Team Team Cari Levy Adreanne Brungardt Kirbie Hartley Jean Kutner Andrea Daddato Sarah Jordan Rebecca Sudore Joanna Dukes Elisabeth Montgomery Dan Matlock Sue Felton Prajakta Shanbhag Jackie Jones Lierin Flanagan Robert Schwartz
Advance care planning as preventative care 17 “Even though they may have the advance directives, I don't think I've always done the best job following up in terms of change. Because things change, this gave a wonderful reminder to not forget in the midst of talking about hypertension and diabetes and heart failure that you're addressing: ”Do you still feel the way you did in 2001 about your goals of care?" When you think about preventative health and health care maintenance, advance directives is right up there, too. Because that's usually an opportunity of, "Have things changed?" I still struggle with the times when there's something more acute going on, thinking about it, because we don't always have time. But I do think about it more now, bringing it up.”
18 Advance Care Planning Discussion Topics Ongoing Values Advance Directives conversations clarification Common medical (medical power of Surrogate (patients, family, treatment attorney, living decision makers decision makers, options will) (flexibility) clinicians) (risks, benefits, burdens) Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin N Am (2015)
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