Establishing Advance Directives Using video patient education in the office practice Arnold Goldberg MD Brown Medical School Kathy Kastner Healthtv

What is Healthtv Patient Education tv network based in hospitals: 3 hours of programming 8 repeats daily Started in Canada, now across U.S. Education developed from needs/benefits surveys with patients Advance Directives education driven by State and Federal requirements

Considerations: making the video State to State Inconsistencies in: Terminology: Advance Directive, Living Will, Power of Attorney, Durable Power of Attorney, DNR, DNR(Comfort), POLST; Forms and and practices Healthtv serves national audience: Federal vs State interpretations and jurisdiction he Patient Self-Determination Act (PSDA) was passed by the U.S. Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990. Effective on December 1, 1991, this legislation required many hospitals, Nursing Homes, home health agencies, hospice providers, HMOs, and other health care institutions to provide information about advance health care directives to adult patients upon their admission to the healthcare facility.[1][2] This law does not apply to individual doctors. The Patient Protection and Affordable Care Act, passed in 2010, authorized reimbursements for counseling regarding advance directives (once every five years), if patients did not understand their rights. [3] The requirements of the PSDA are as follows: * Patients are given written notice upon admission to the health care facility of their decision-making rights, and policies regarding advance health care directives in their state and in the institution to which they have been admitted. Patient rights include: 1. The right to facilitate their own health care decisions 2. The right to accept or refuse medical treatment 3. The right to make an advance health care directive * Facilities must inquire as to the whether the patient already has an advance health care directive, and make note of this in their medical records. * Facilities must provide education to their staff and affiliates about advance health care directives. * Health care providers are not allowed to discriminately admit or treat patients based on whether or not they have an advance health care directive.

Making the video: Input and issues Balancing legal requirements and Patient/family educational needs How to contextualize inconsistent terminology What to include, what not to include based on video benefits and limitations Putting human face to an AD

Evaluating Impact: Healthtv Survey Methodology: The patient and/or visitor (on behalf of patient) completes a 3 question pre-viewing questionnaire. The patient and visitor then watch the video on Healthtv (video repeats 8 times daily) The patient and/or visitor (on behalf of patient) then answers post-viewing questionnaire. Answers are charted

Pre-Survey Healthtv: Pre-survey ages ranged from 45 - 85, 80 F 43 M; chosen at random Before watching Advance Directives: Please circle yes or no 1. Do you know what an Advance Directive is? Yes No 2. Do you understand the purpose of having an Advance Directive? Yes No 3. If yes: to the above: Have you completed an Advance Directive? Yes No

Pre-Survey Results Healthtv 123 Patients surveyed across 5 States Question #1 Know what an AD is? Y=41, N=82 33% Knew Question #2 Understand purpose of AD? Y=43, N=80 35% Understood Question #3 Have you completed AD? Y=22 N=101 82% Did not have AD

Healthtv Video: Advance Directives

Post- Survey Survey Post: After watching Advance Directives: 1. Do you know what an Advance Directive is now? Yes No 2. Did this video help teach you the purpose of an Advance Directive? Yes No 3. Did this video motivate you to complete an Advance Directive? Yes No 4. Do you intend to complete an Advance Directive? Circle: Yes or No If yes, a) In the next week b) In the next month c) At the next visit to your doctor 5. Would you like assistance completing an Advance Directive? Yes or No

Post-Survey Results Healthtv 1. Do you understand what an AD is now? Of 82 who didn’t know before watching, after watching: Y= 79, No=3; ^96% 2. Did the Video teach the purpose of an AD? Of 80 who didn’t know before watching, after watching: Y=78, No=4; ^95% 3. Did the Video Motivate you to complete AD? Of 101 who didn’t have AD, after watching were motivated: Y=98,No=15,Maybe=10; ^97%

Changes: Healthtv Of the 82 patients who did not know what an AD was prior, 79 knew afterwards: improved 96% Of the 80 patients who did not know the purpose of an AD prior, 76 knew afterwards: improved 95% Of the 101 patients who did not have an AD, after the video: 98 motivated to complete improved 95% Of the 101 who did not have an AD, after the video intended to complete: 98 1= Maybe,4=No improved 97% Of the 98 intending to complete: 40 within a month 58 at next doctor’s visit LIMITATIONS: No ability to follow up

Advanced Directive Pilot Project Query: Could the success of Healthtv in the hospital setting be translated to an outpatient setting?

Department of Family Medicine at Brown University Family Care Center: Level 3 PCMH Community Hospital in Pawtucket, RI Population are the Underserved of the Blackstone Valley. 39 Family Medicine Residents and 16 Medical Faculty, 2 Academic Behavioralists, 3 Social Workers from hospital, and Integrated Primary Care 33,000 visits per year, 12,500 patients Centricity is our EMR

The Family Care Center Hospital Based Practice and JACHO approved Absence of documented Advanced Directives in the patient’s EMR Randomized Chart review revealed 5% Both a documentation issue and an education and patient centered deficiency

Methodology: Pilot Project Methods: IRB approved as QI project Video web site placed on the computers in the exam rooms. Prior to starting appointment patient is asked if he or she has an advanced directive. If the patient says yes and has the paper work completed the EMR and chart is brought up to date if necessary. If the patient does not have an advanced directive completed or does not know what this is, then they are asked if they would like to watch a 1 minute video on advanced directives.

Methodology: Pilot Project (cont’d) The patient completes a 3 question pre-viewing questionnaire. The patient then watches the video The patient then answers the post-viewing questionnaire. The patient is given the RI Advanced Directive forms: DPOA and a Living Will A social worker is available to answer questions if necessary.

Pre-Survey Brown: Pre-survey ages ranged from 21 to 84, 12 F and 9 M; chosen at random. Before watching Advance Directives: Please circle yes or no 1. Do you know what an Advance Directive is? Yes No 2. Do you understand the purpose of having an Advance Directive? Yes No 3. If yes: to the above: Have you completed an Advance Directive? Yes No

Pre-Survey Results Pilot Study 23 Patients tested at this point Question #1 Know what an AD is: Y=14, N=9 61% Knew Question # 2 Understand purpose of AD Y=15, N=8 65% Understood Question #3 Have you completed AD? One yes said yes, the rest either said No or NA :94% did not have an AD

Post- Survey Survey Post: After watching Advance Directives: 1. Do you know what an Advance Directive is now? Yes No 2. Did this video help teach you the purpose of an Advance Directive? Yes No 3. Did this video motivate you to complete an Advance Directive? Yes No 4. Do you intend to complete an Advance Directive? Circle: Yes or No If yes, a) In the next week b) In the next month c) At the next visit to your doctor 5. Would you like assistance completing an Advance Directive? Yes or No

Post-Survey Results Pilot Study 1. Do you understand what an AD is now? Y=22, N=1 : 96% ^of 35% 2. Did the Video teach the purpose of an AD? Y=19,No=4:83% ^of 18% 3. Did the Video Motivate? Y=17,N=4,NA=1,maybe=1: 82% 4. Do you intend to complete an AD? Y=17,N=4,maybe=1 and NA=1: 82% 3 needed help they said and the rest did not need

Changes: Pilot Of the 9 patients who did not know what an AD was pre video 8 knew afterwards: improved 88% Of the 8 patients who did not know the purpose of an AD prior 7 knew afterwards: improved 88% Of the 22 patients who did not have an AD after the video 17 said they would complete an AD 1 maybe and 4 said No: 81% intended now and 82% said the video motivated them to complete an AD One new patient has completed an AD so far and 2 patients have brought in their AD they previously completed

Conclusions 94% of the patients did not have AD The use of a video explaining Advanced Directives appears to inform and teach the purpose and the meaning of an AD as well as motivate patients to complete one in the near future.

Resources Compassion and choices www.compassionandchoices.org/ National Hospice and Palliative Care Organization www.nhpco.org/ Pallmed: hospice and palliative medicine blog http://www.pallimed.org/ #hpm Hospice and Palliative Medicine twitter chat Wednesday 9pm E