 We will work collaboratively with the community to improve end-of-life care for the people of central Minnesota

 Our community health care initiative will implement comprehensive programs facilitating patient/family-centered end-of-life care. We will promote informed health care decisions and conversations related to health care directives, hospice care and palliative care.

 The purpose of the program is to bring Honoring Choices Minnesota to central Minnesota. We will provide opportunities for the people of our community to discuss and document their choices for medical treatment at the end of life.

 Multidisciplinary group formed (40)  November 2009  Sub Committee formed (15)  1 st grant submitted & awarded (February 2011)  Project Coordinator hired PT with 3 phases 1. Discovery 2. Pilot Project 3. Community engagement

 Name/logo established  2 nd grant – dedicated Project Coordinator  Moved into downtown office in May 2012  Patty Bresser, Prof/RN, SCSU  dedicated sabbatical to initiative ( )  Working with MN Council of Churches/HCM  2 ACP Facilitator Instructors trained

 Held 1 st ACP Facilitator class in February – 4 more scheduled for fall of 2012/winter 2013  Ongoing conversations with 3 potential pilots for 2013  Speaking engagements to various community groups  Website development: Planned “go live” on August 1st  Media blitz planned for community in fall  Pilot Project at Health Partners Clinic began  February, 2012

Dr. Patrick Lalley

 How can we honor or respect our patient’s choices if we don’t ask  Medical Home – in providing the highest quality of care to our patients, knowing their wishes for end of life care is OUR responsibility  It is likely to be a quality measure that enhances the clinics re-imbursement for high quality medical care  It is the right thing to do!!  Our standard process is ……….we don’t have a standard process for discussing, documenting, storing, or retrieving an advanced directive from the EMR.

 Pilot study involving patients over the age of 75 being seen for RHM visits with Drs. Maray/Lalley  Goal is to streamline and simplify a process for discussion, documentation, storage, and retrieval of a patient’s ACP using the “Respecting Choices” model  The process needs to be simple and meaningful to patients, as well as efficient, high quality, cost beneficial, and reproducible for all clinic staff  Educate clinic providers and staff on the value and techniques of ACP discussions with our patients

 It is all about the conversation ….goals, values, beliefs, and not just completing the form  Trained facilitators meet with patients and families to have these conversations – in the home, clinic, group meeting, etc.  Documentation of the ADP is in the electronic medical record

 Number of patients who have a completed Advanced Directive in the EMR ( compare pre/post study)  Patient/agent satisfaction survey  Number of additional requests for Advanced Directives through HIM department over the study timeline