1. in the Primary Care Medical Home (PCMH)
Improving Health Care Proxy Identification and Advance Directive Completion
in the Primary Care Medical Home (PCMH)
Zach Junga, MD; Scott Snyder, MD; Sarah Ordway, MD; Camille Costan-toth, MD; Brian Cervoni, MD; Mary Andrews, MD Walter Reed National Military Medical Center, Bethesda, MD
1. Stone NJ, Robinson J, Lichtenstein AH, et al ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013
2. Pencina MJ, Navar-Boggan AM, D'Agostino RB, et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med 2014
BACKGROUND
BALANCING MEASURES
PROCESS MEASURES
Three quarters of US adults have not completed an advance directive.1
Most common reason is lack of awareness.1
Emergency contact is not the same as surrogate decision maker in about 33% of patients.2
Among resident empaneled patients ≥ 65 years in one internal clinic, 0 patients had a health care proxy and advance directive in the EMR.
Primary care physicians may help facilitate discussions about advance directives and document patient wishes in the EMR.
PDSA Cycle 1: 16/20 patients received 5 Wishes
PDSA Cycle 2: 41/51 patients received 5 Wishes
PDSA Cycle 3: 18/51 patients had Relay Health and were sent a copy of the 5 Wishes document
RESULTS
AIM STATEMENT
Increase the rate of health care proxy (HCP) identification and advance directive (AD) completion in AHLTA to 20% in patients ≥ 65 years old in the Internal Medicine Residency Continuity Clinic within three months of the intervention.
INTERVENTION
PDSA Cycle 1 (N=20)
Identify a representative sample of resident empaneled patients using 2 resident panels of which 5% had a HCP and AD in the EMR.
At first visit, discuss 5 Wishes, complete Wish 1 (HCP) and upload to EMR. patient instructed to return with 5 Wishes in 5 weeks.
PDSA Cycle 2 (N=31)
Identify resident empaneled patients ≥ 65 years old seen in one internal medicine clinic 3Nov – 7Dec2015
LPN distributes Wish 1 to patient during check-in which is uploaded into EMR after completion.
PCM discusses 5 Wishes with patient; patient instructed to return with the document completed in 5 weeks.
PDSA Cycle 3 (N=20+31)
PCM sends secure electronic message with 5 Wishes to these same patients with instructions to complete and return.
Seventy-one percent of resident respondents (N=28) believe proxy identification and advance directives should be a part of panel management
Seventy-five percent said they spend no time discussing advance care planning during clinic
Eleven percent said they spend >10 minutes discussing advance care planning during clinic week
Twenty-five percent of patients completed a Health Care Proxy
Zero percent of patients returned a completed copy of the 5 Wishes document by the completion of the study
DISCUSSION
Did not achieve primary goal of 20% HCP and AD completion rate, but did achieve goal with HCP identification.
While intervention did not achieve AD completion goal, 51 patients were counseled on HCP and AD completion.
According to residents, the greatest barrier to implementation was time; patient continuity was also a concern.
Before expanding to other clinics, a more efficacious method is required to increase the HCP and AD completion rate at WRNMMC.
Additionally, EMR access to HCP and AD information is difficult as there is no specific and highly visible location for these documents.
REFERENCES
1. Rao JK. Completion of advance directives among US consumers. Am J Prev Med. 2014;46:65-70.
2. Song MK, Ward SE. Disconnect between emergency contacts and surrogate decision-makers in the absence of advance directives. Palliat Med Sep;27(8):
Disclaimer: The opinions are solely those of the authors and do not represent an endorsement by the Department of Defense. This is a U.S. Government work. There are no restrictions on its use. There are no conflicts of interest, financial disclosures, grant support or writing assistance.