1. Advance Directives Quality Improvement Project Daniel Jones MD, Joe Adragna MD, Mutki Kulkarni MD, Jill Tirabassi MD, Luke Miller MD, Karin VanBaak MD University of Colorado Family Medicine Residency Program

2. www.medschool.ucdenver.edu Thank you Corey Lyon, DO for your mentorship

3. www.medschool.ucdenver.edu Objective Discuss why we chose advance directives (AD) as a QI project Describe our implemented processes and our measured outcomes. Discuss what we learned and are still learning.

4. www.medschool.ucdenver.edu Background Why we chose advance directives: – Our perception that our hospitalized patients rarely have advance directives in the chart – We felt were not regularly addressing this with our clinic patients (no process) – To improve our patient’s understanding of AD Studies show that “advance care planning improves end of life care, patient and family satisfaction, and reduces stress, anxiety and depression in relatives.” Detering K, Hancock A, et al. The impact of advance care planning on end of life care in elderly patients: randomized controlled trial. BMJ 2010; 340: 1345.

5. www.medschool.ucdenver.edu R3 QI Project description Barriers to organizing a quality improvement project in our program – 6 resident schedules – Multiple part-time faculty – Role out of new clinic model – Misunderstandings around AD amongst medical professionals, MAs, nurses and patients

6. www.medschool.ucdenver.edu R3 QI Project description (cont) Barrier solutions – Lead faculty mentor – PCMH Lead resident each month – Regularly scheduled meetings throughout the month – Online storage drive accessible by all team members – “Dynamic document” to pass project information

7. www.medschool.ucdenver.edu Literature Review Interventions to Promote the Use of Advance Directives Cochrane SR reviewed: – Most effective interventions were: Combining informational materials with interactive visits Continuing conversation over multiple visits, not just one session – Other interventions that contribute to overall success: Group visits Visits in non-clinical setting Family present Staff available to answer questions after pt leaves (eg call line) Most ineffective method: Passive education of patients using written materials Tamayo-Vela ́zquez et al. Interventions to promote the use of advance directives: An overview of systematic reviews. Patient Education and Counseling 80 (2010)

8. www.medschool.ucdenver.edu Baseline Data Random chart review – Results Date range to obtain 100 non-duplicate charts meeting our inclusion criteria – 8/22/14-10/10/14 Number of charts indicating that the patient has an AD – 12/100=12% Number of charts indicating that the patient has an AD and a scanned copy exists in the chart – 2/100=2%

9. www.medschool.ucdenver.edu Review of Outside Clinic Processes and Expert Opinion UCH Senior’s clinic – MA reviews schedule/huddle sheet Manually checks chart to see if ADs exist Consulted with palliative care director, Dr. Nowels, who recommended: – Annual exams + hospital f/u visits – One specific AD form

10. www.medschool.ucdenver.edu Faculty & Resident Survey-Baseline I am satisfied with the number of inpatients that I take care of who have completed AD – 17/24 (71%) disagree or strongly disagree It is easier for me to practice medicine in the hospital when my patients have ADs – 24/24 (100%) agree of strongly agree Patients receive better care in the hospital when they have ADs – 14/24 (58%) agree or strongly agree AF Williams Clinic is adequately obtaining and scanning ADs in to the charts of patients that I take care of at University Hospital – 16/24 (67%) disagree or strongly disagree

11. www.medschool.ucdenver.edu Patient Advisory Council (PAC) Lead resident for 10/2014 attended a regularly scheduled meeting to discuss our project – Received feedback on our goal of increasing AD completion – Physician? What about an attorney. – Misunderstandings surrounding Colorado statute – Were open to education – Bigger is better? – Received feedback on our proposed process – Impact on other concerns?

12. www.medschool.ucdenver.edu Aim Statement Patients over 50 years old seen for either their annual preventative exam or an establish care visit and all patients seen for a hospital follow up visit will receive a MDPOA form. All the patients who receive an MDPOA will receive outreach calls and patient reminder letters to facilitate the return of completed MDPOAs to clinic and scanned into EPIC. All MDPOAs returned into clinic will be documented in the FYI section, marked in the health history section, and scanned into EPIC to be readily available to the health care team. Over 3 months, greater than 80% of eligible patients will have received an MDPOA with a >50% return rate. This will be achieved by using a team based approach with CTAs and MAs distributing the MDPOA forms, providers reviewing the forms with patients, and CTAs/MAs making outreach efforts for patients to return their completed forms.

13. www.medschool.ucdenver.edu Aim Statement Specific: – Patients over 50 years old seen for either their annual preventative exam or an establish care visit and all patients seen for a hospital follow up visit will receive a MDPOA form.

14. www.medschool.ucdenver.edu Aim Statement Measurable – Greater than 80% of eligible patients will have received an MDPOA with a >50% return rate.

15. www.medschool.ucdenver.edu Aim Statement Actionable – Team based approach with CTAs and MAs distributing the MDPOA forms – providers reviewing the forms with patients – All the patients who receive an MDPOA will receive outreach calls and patient reminder letters to facilitate the return of completed MDPOAs to clinic and scanned into EPIC. – All MDPOAs returned into clinic will be documented in the FYI section, marked in the health history section, and scanned into EPIC to be readily available to the health care team.

16. www.medschool.ucdenver.edu Aim Statement Relevant – More of our patient’s who are hospitalized will have a documented AD.

17. www.medschool.ucdenver.edu Aim Statement Time frame – 3 months – Monthly PDSA cycles for review

18. www.medschool.ucdenver.edu MDPOA

19. Process Map

20. www.medschool.ucdenver.edu Process Map (cont.)

21. www.medschool.ucdenver.edu Process Map (cont.)

22. www.medschool.ucdenver.edu Intervention We will measure the following: – The number of eligible patients who are given an AD packet This will require a manual audit each week/month by the PCMH resident leader of the month. – AD returned This will be tracked using our Excel registry tracking form. – Whether the form was returned before or after the two outreach efforts (we will be detailed to show whether the phone call or letter seems to be most effective)

23. www.medschool.ucdenver.edu During Project Adjustments – PDSA reviews Repetitive reminders to providers and staff via email and staff/provider meeting Huddle forms Incentivized MA competition Advertisement campaign for our patients

24. www.medschool.ucdenver.edu During Project Adjustments – PDSA reviews Do you have a medical decision maker? Complete your MDPOA form today! Ask your medical team for more information. Studies show that advance care planning improves end of life care, patient and family satisfaction, and reduces stress, anxiety and depression in relatives. * Did you know that Colorado has no system in place to designate a decision maker? We believe it is important for all of our patients to have a designated decision maker. This is called a MDPOA. *Detering K, Hancock A, et al. The impact of advance care planning on end of life care in elderly patients: randomized controlled trial. BMJ 2010; 340: 1345.

25. www.medschool.ucdenver.edu Results: Before & After

26. www.medschool.ucdenver.edu Results

27. Result & Interventions In-person update at Provider Meeting L e a d M A t o l a b e l h u d d l e s h e e t s Re-education email to MAs and ProvidersGo Live email to clinic APEX Redesign with required AD during rooming Competition amongst MAs with reward Lead MA to use patient portal Educational session at staff meeting MAs completed their own MDPOA All rooms stocks with forms C o m p l e t e A D i n t h e r o o m b e f o r e l e a v i n g t h e o f f i c e

28. www.medschool.ucdenver.edu Result: Provider Satisfaction

29. www.medschool.ucdenver.edu Final AD Returned 24 from patients meeting inclusion criteria 29 from patients NOT meeting inclusion criteria –Credit to APEX

30. www.medschool.ucdenver.edu Discussion Identification of eligible population Activation of workflow Provider time Incomplete barrier breakdown Expense of mailers Patient portal utilization Immediate completion improves return rates Realistic goals? E-huddle

31. www.medschool.ucdenver.edu Practice Improvement (P.I.) Improvements seen: – Increased knowledge about ADs = less fear about discussing MAs, CTAs, Faculty, residents and patients – AD process in place: Providing AD answering questions (FAQ sheets for staff) getting into charts – Pt's at high risk of hospitalization now more likely to have AD in chart indirect benefits – more AD being given to all pts not just those fitting our criteria – prepared for future QI projects learned importance of stable team members, dynamic documents

32. www.medschool.ucdenver.edu Future PDSA/Improvements 3-6 month, planned re-audit of charts Continue monthly PDSA

33. www.medschool.ucdenver.edu Conclusion QI projects are difficult in a complex clinic but can have success with: – frequent re-evaluation and adjustments – education at all levels – involving consistently present staff – patience - will likely take months to see results AD are often overlooked in medical encounters but can have great benefit to our pts.

34. www.medschool.ucdenver.edu Questions?