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

2. 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

3. 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 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.

4. 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

5. 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

6. Pre-Survey
Healthtv: Pre-survey ages ranged from , 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

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

8. Healthtv Video: Advance Directives

9. 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

10. 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%

11. 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: 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

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

13. 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

14. 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

15. 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.

16. 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.

17. 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

18. 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= % Understood
Question #3 Have you completed AD? One yes said yes, the rest either said No or NA :94% did not have an AD

19. 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

20. 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

21. 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

22. 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.

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