Multi-Stakeholder Perspectives on Implementation of an Advance Care - - PowerPoint PPT Presentation

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Hillary D. Lum, MD, PhD Sarah R Jordan, MS VA Eastern Colorado Geriatric Research Education and Clinical Center University of Colorado School of Medicine

Multi-Stakeholder Perspectives on Implementation of an Advance Care Planning Group Visit

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With Gratitude

• Dorothy Dillon Eweson Lecturer on the

Advances in Aging Research

• National Institute on Aging

Beeson K76 Award



Team Adreanne Brungardt Andrea Daddato Joanna Dukes Sue Felton Lierin Flanagan



Mentors Cari Levy Jean Kutner Rebecca Sudore Dan Matlock Jackie Jones Robert Schwartz



Team Kirbie Hartley Sarah Jordan Elisabeth Montgomery Prajakta Shanbhag

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Engaging in Advance Care Planning Talks (ENACT) Group Visits

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.

Patient goal setting for advance care planning actions Interactive discussions of advance care planning Education and support through group dynamics Uses outpatient billing codes & documentation ENACT Group Visits Intervention

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ENACT Group Visits Framework

Social Process Diverse Learners

ACP outcomes through group dynamics and behavior change

• Bruffee. Collaborative Learning. 1993

Sudore et al. Novel Engagement. JAGS. 2008.

Collaborative Learning Theory

Individual Experience

ACP Behavior Change Theory

Maintenance Pre- Contemplation Contemplation Preparation Action

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CONTENT (2 hour sessions)

Check in, vital signs, medication review (30 min) Introductions, rapport building (15 min) Facilitated ACP discussion (60 min) Individualized goal setting (15 min) RESOURCES Intervention Manual PREPARE pamphlet, video stories Easy-to-use advance directive forms 8-10 Participants

Session 2

1 Month Apart Physician + Social Worker

Session 1

Intervention Core Components

Setting: Academic geriatric clinic Participants: Adults age 60 years and older Implementation guided by Manual, Facilitation Guides

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Difference = 26% Difference = 29%

44 71 70 100

25 50 75 100

Advance Directives Decision Maker Chosen Patients at 3 months (%) Mailed ACP Materials ENACT Group Visits

Pilot RCT of ENACT Group Visits (n=110)

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Objectives

• 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

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Methods

• Phone-based, semi-structured interviews at 6

months with random sample of 26% of patients (n=28) and 8 stakeholders

• Inductive and deductive thematic analysis

Patients

• Control: 9 patients (32%)
• Group Visits: 19 patients (68%)
• Mean 78 years, 71% female

Stakeholders

• Primary care practitioners (n=4)
• Social worker (n=1)
• Medical Assistants (n=3)

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Results: Key Themes Related to Acceptability 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

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Theme 1: Facilitating Patient-centered Communication of Care Preferences

“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.

“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.”

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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 1: Facilitating Patient-centered Communication of Care Preferences

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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.”

Theme 2: Clinic-based group visits are well-received for ACP discussions

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.”

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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.”

Theme 3: Patients and stakeholders identified barriers to clinic implementation

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Conclusions: ENACT Group Visits are 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

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Next Steps

• Expand and test ENACT

Group Visits intervention in multiple and diverse primary care settings

• Conduct a robust evaluation
• f 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

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Thank you!

• Dorothy Dillon Eweson Lecturer on the

Advances in Aging Research

• National Institute on Aging

Beeson K76 Award



Team Adreanne Brungardt Andrea Daddato Joanna Dukes Sue Felton Lierin Flanagan



Mentors Cari Levy Jean Kutner Rebecca Sudore Dan Matlock Jackie Jones Robert Schwartz



Team Kirbie Hartley Sarah Jordan Elisabeth Montgomery Prajakta Shanbhag

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“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

• pportunity 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.”

Advance care planning as preventative care

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Values clarification Ongoing conversations (patients, family, decision makers, clinicians) Surrogate decision makers (flexibility) Advance Directives (medical power of attorney, living will) Common medical treatment

• ptions

(risks, benefits, burdens)

Advance Care Planning Discussion Topics

Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin N Am (2015)