1. ADVANCE DIRECTIVES VENTURE BEHAVIORAL HEALTH

2. Decision Making/Advance Directives Venture Behavioral Health respects the rights of Medicaid members to make choices and decisions about their care. Members can make their wishes known by completing an Advance Directive for Health Care.

3. WHAT IS ADVANCE DIRECTIVES The Michigan Patient Self Determination Act* of December 1, 1991, enacted by congress, stated that “Advance Directives is defined as follows: …the term “advance directives” means a written instruction, such as a living will or durable power of attorney for health care, recognized under State Law and relating to the provision of such care when the individual is incapacitated.” (*42USCS 1395cc(f)(3) originally enacted as par of the Omnibus Budget Reconciliation Act of 1990, P.L. 101-508, 4206)

4. Durable Power of Attorney for Health Care in Michigan Although a living will and a durable power of attorney are different, they achieve the same results… “The advance self- determination of medical treatment by a patient in the event he or she becomes incapacitated.”

5. Living Wills A living will is a written document that is signed and witnessed stating the wishes of an individual concerning medical treatment decisions. Living wills are not really a" Will” and not recognized by statute in Michigan.

6. Durable Power of Attorney (DPOA) for Health Care A Durable Power of Attorney (DPOA) for Health Care is a specific appointment of an individual (the agent) to make decisions regarding the health care of the patient (the principle) in the event of his or her incapacity. DPOA for Health Care has been adopted in Michigan. DPOA for Health Care first became effective in December 19,1990 and restated by the Estates and Protected Individuals Code effective April 1, 2000.

7. Provisions of DPOA for Health Care in Michigan The Act provides that: Any person 18 years or older, Of sound mind at the time of designation, May designate another person who is 18 years of older to exercise powers concerning care, custody and medical treatment decisions for the patient. This person is to be known as a “Patient Advocate”.

8. Provisions of DPOA for Health Care in Michigan The designation must be in writing, signed and witnessed by two witnesses Witnesses cannot be: spouse, parent, child, grandchild, sibling, presumptive heir, known devisee, physician, patient advocate, employee of a life or health insurance provider for the patient, Employee of a health facility that is treating the patient, or Employee of a home for the aged where the patient resides. (Defined by Michigan law)

9. Provisions of DPOA for Health Care in Michigan The designation may include at statement of the patient’s desires for care, custody and medical treatment and may authorize the patients advocate to exercise those powers which the patient could have exercised absent of his or her disability.

10. Provisions of DPOA for Health Care in Michigan The “patient advocate” must sign the acceptance of the designation as a patient advocate (and successor advocate, if named) prior to implementation of the DPOA for Health Care. There are specific statements that acceptance statement must contain. [MCLA 700.5507(4)] Authority under a designation shall not be exercised by “patient advocates” unless and until the patient is unable to participate in medical treatment decisions.

11. Who Must Comply With This Law The Michigan law applies to all Medicare/Medicaid participating health care entities: Hospitals Skilled nursing facilities Home health agencies Hospice programs HMOs/CMPs Other prepaid organizations and comprehensive outpatient rehabilitation facilities.

12. What Must a Health Care Entity Do? Written Requirements: Must provide all adult patient, residents or enrollees with written information regarding the following two matters: 1. The individual’s rights under the Michigan state law to make health care decisions which includes the right to accept or reject medical or surgical treatment and the right to execute an advance directive 2. The policies of the Health Care entity respecting the implementation of such a right to accept or reject health care treatment.

13. What Must a Health Care Entity Do? Oral Requirements: The Health Care entity must ask the individual upon admission (at intake), and periodically thereafter, if he or she has executed any form of an advance directive and to document in a prominent part of the clinical record the individual’s response. If the individual does have a advance Directive for Medical Care, the Health Care entity shall request a copy of the advance directive and maintain it in the individual clinical record.

14. What Must a Health Care Entity Do? Compliance with state laws: The Health Care entity is required to insure that the patient or resident has complied with the state legal requirements regarding advance directives (i.e. properly executed it and used the proper form).

15. What Must a Health Care Entity Do? Education The Health Care entity is required to provide written information to the client/Medicaid member of their rights, under Michigan law, to make decisions concerning health care and their right to formulate an advance directive. The Health Care provider must also educate its staff on advance directives regulations and issues.

16. Patient Advocate’s Rights, Authority, Responsibilities, and Limitations Authority under a designation shall not be exercised by “patient advocate” unless and until the patient is unable to participate in medical treatment decisions.

17. Patient Advocate’s Rights, Authority, Responsibilities, and Limitations A “patient advocate” shall: 1.Act in accordance with the standards of care applicable to fiduciaries in exercising his or her powers. 2.Take reasonable steps to follow the desires, instruction, or guidelines given by the patient while the patient was able to participate in care, custody or medical treatment decisions (either orally or written).

18. Patient Advocate’s Rights, Authority, Responsibilities, and Limitations A “patient advocate” will: 3.Will not exercise the DPOA powers, concerning the patients care custody and medical treatment, if the patient is able to participate in the decision of their medical care. 4.Will not make medical decisions to withhold or withdraw treatment from a patient who is pregnant that would result in the pregnant person’s death.

19. Patient Advocate’s Rights, Authority, Responsibilities, and Limitations A “patient advocate” shall: 5.Make a decision to withhold or withdraw treatment which would allow a patient to die only if the patient had expressed in a clear and convincing manner that the patient advocate is authorized to make such a decision, and that the patient acknowledge that such a decision could or would allow the patient’s death. 6.Shall not delegate his or her powers to another individual without prior authorization by the patient.

20. Additional Provisions in Michigan Law According to MI law the DPOA is: 1. Suspended if the patient regains ability to participate in medical treatment. 2. Revoked upon the death of the patient. 3. Additional provisions include: A. Incapacity of Patient B. Binding Effect C. Petition to Probate Court D. Pregnancy E. Limitation on Health Care Provider F. Limitations of Life an health Insurance Companies G. Not be construed to condone, allow, permit, authorize or approve suicide or homicide.

21. Advance Directives Questions and Answers How does advance directives effect mental health and substance abuse services? Federal and State regulations and laws and VBH policies require that treatment facilities’ identify in the member’s clinical records: 1. Identify if that the client has been asked if they have an Advance Directive PDPOA for Health Care. 2. Documentation must be in a prominent part of the clinical record and must be updated regularly. 3. The Provider shall request a copy of the Advance Directive (DPOA for Health Care) and maintain it in the client’s record.

22. Advance Directives Questions and Answers Does the law require everyone have a DPOA for Health Care? No. Advance Directives are for adult clients only. Any person 18 years or older.

23. Advance Directives Questions and Answers What are other requirements of Advance Directives that effect mental health and substance abuse services? The organization must provide training to all staff regarding advance directives. 1. The organization must provide written information, in simple to understand language, to its adult clients including the organizations policies and description of applicable state laws. 2. Provide all adult clients with written information, in simple to understand language, that reflects changes in law as soon as possible.

24. Durable Power of Attorney for Health Care in Michigan This training is to offer you some basic information related to DPOA for Health Care. For more specific information please read the Venture Behavioral Health’s Policy on Advance Directives and/or the applicable laws and regulations related to this topic.

25. Why is an Advance Directive Important? Advance Directives protects the rights of clients/patient to make health care choices that affect their lives.