HealthPartners Overview of End-of-Life Care & Advance Care Planning

1. HealthPartners Overview of End-of-Life Care & Advance Care Planning Honoring Choices Minnesota July 19, 2012

2. End of Life/Palliative Care Steering Committee Co-chairs: Tom von Sternberg, MD, Beth Waterman Membership includes representatives from Regions Hospital, Specialty Care, HealthPartners Home Care, Geriatrics, Hospice & Palliative Care, Primary Care and the Health Plan Areas of Focus: REGIONS HEALTH PLAN PRIMARY CARE SPECIALTY CARE HOME CARE, GERIATRICS, HOSPICE & PALLIATIVE CARE COMMUNITY • Jim Risser, MD • Beth Heinz • Danielle Tencate Cole • Lora Heidin • Karen Kraemer • Kate Kellet • Terry Carter • Tyler Schmidtz • Rachel Nygard • Mary Lou Irvine • Tom von Sternberg, MD • Beth Werner • Mary Lou Irvine • Tom von Sternberg, MD • Donna Zimmerman • Beth Heinz

3. Regions Palliative Care referrals • Criteria in Epic • Auto referral for Medical ICU patients over 85 • Surgical ICU will add auto referral • Presence at care rounds • Expanding to Emergency Dept: Physician Orders for Life Sustaining Treatment (POLST) and consults • Increasing Palliative Care provider coverage • Partnership with oncology Nurse Practitioner

5. Regions Advance Directives • Using the Honoring Choices and POLST forms • 56% of patients 65+ have Advance Directives (1/11-2/12) • Lean project • Design workflows to obtain Advance Directives and ensure copy is available in Epic • Interdisciplinary effort (Palliative Care, Hospital Medicine, Nurse, Care Management, Chaplaincy, HIM) • Comprehensive review of current process, identification of potential barriers, and ideas for new models • Early fall 2012 goal for implementation

6. Health Plan Disease & Case Management • Staff training and awareness resulted in increased referrals for Palliative Care, Advance Care Planning and Hospice • Advance Directive measure: 8543 patients screened, 3262 completed • EBAN project successes spread to all patients/members

7. Hospice, Palliative Care & Adv Care Planning Referrals Disease & Case Management

8. EBAN Experience • Eban is a letter from the Asanti people of Ghana. It represents security, safety and trust. It was chosen as the symbol of the EBAN Experience to represent the coming together of cultures to improve the health of all.

9. EBAN Experience • Adopted by HealthPartners as an organizational initiative for addressing health disparities and equitable care in 2011. • The EBAN Experience is a year-long collaborative of teams created to address issues of health disparities in the communities served by HealthPartners. • Creative strategies that partner health care professionals and community members.

10. EBAN Experience • Areas of focus include: • Increased rates of advance directives • Increased pediatric immunization rates • Improve diabetes health outcomes through education • Results • Improved the rate of completed Advance Directives in the MSHO African-American population from 25% to 32% by year end. • Narrowed the disparity gap between Whites and African Americans from 25% to 21%

11. Health Plan • HealthPartners.com • Current information in Health and Wellness tab in “Additional Resources” Future Plans: • New “Care-giving Health Center” in Health & Wellness tab will provide information on advance care planning, shared decision making, etc.

12. Primary Care Advance Directives • Workflow is with care team, with Epic prompt and notary • Pilots at Riverside, Brooklyn Center, Como, West for patients 65+ • Using short form with brochure and/or Honoring Choices form • Expanding to all locations in 9/12 and then to younger population, i.e, 50 and over • Staff Education

13. Specialty Care Oncology • Sharing NP resource with Regions Palliative Care • Population: new diagnosis, pancreatic and lung cancer, any stage 3 and 4 • Facilitated conversations with nurse practitioner or social worker • Measure: since 1/11, 701 (23%) of all cancer patients have Advance Directives in EPIC

14. Specialty Care Regions Heart Center • Population: Heart Failure Class II, III, IV • Providers initiate conversation then RN “facilitator” meets with patient • Measure: 83.5% of Class III and IV, 45% of Class II have Advance Directives

15. Specialty Care Nephrology • Population: Chronic Kidney Disease stage 4, 5 • Provider initiates conversation then RN facilitation or Advance Care Directives Class (group session), follow-up phone call Beginning work: Pulmonary Future work: Neurology

16. Geriatrics, Home Care, Hospice Geriatrics/Home Care • Standardized workflow, documents and where to locate in EPIC. • Measure: 75% with Advance Directives documented • Increased long term care facility adoption of POLST

17. Geriatrics, Home Care, Hospice Palliative Care/Hospice • Facilitated discussion with admission • Hospice measure: 960 of 1000 patients in 2011 completed POLST • Palliative Care measure: 273 admissions in 2011 with 227 completed Advance Directives using Honoring Choices Minnesota document • Coordinating with inpatient Palliative Care consult team and weekly rounding

18. Community • Alliance of Community Health Plans (ACHP) Palliative Care workgroup • National Quality Forum (NQF) Hospice workgroup • Institute for Healthcare Improvement (IHI): The Conversation Project by Ellen Goodman • EPIC and Health Information Exchange • End of Life training course with Jim Risser, MD and Richard Heinrich, MD (2 days, twice a year) • St. Paul Area Council of Churches • EBAN project

19. Community Honoring Choices Minnesota • CEO and Senior Leadership support • Member of Advisory Committee • Ambassador Program participation (Kate Kellet with primary)

20. HealthPartners End of Life/Palliative Care Initiatives REGIONS HEALTHPLAN PRIMARY CARE SPECIALTY CARE GERATRICS, HOME CARE & HOSPICE COMMUNITY Jim Risser MD, Beth Heinz, Danielle TencateCole Lora Hedin, Karen Kraemer Kate Kellet Terry Carter, Dave Slowinske, Tyler Schmidtz, Rachel Nygard Mary Lou Irvine, Tom von Sternberg MD, Beth Werner Mary Lou Irvine, Tom von Sternberg MD, Donna Zimmerman, Beth Heinz • Advance Directive workflow • Short form, brochure and/or Honoring Choices form • Facilitator available • Pilots at Riverside, Brooklyn Center, West, Como; to all sites 9/12 • Epic “prompt” on health maintenance screen • Population Health workflow component • Palliative Care benefit • Commercial • MSHO • Care and Disease Management • Spreading learnings from EBAN project • Referrals to Palliative Care, Advance Care Planning, Hospice • HealthPartners.com • Inpatient and ED Palliative Care consult • Outpatient resources for consults • Oncology clinic partnership • Focus for FIT Quality team • LEAN project: Advance Directives • Measuring patient anxiety and pain • Cardiology CHF patients class II, III and IV • Honoring choices form and facilitator • Oncology • New cancer diagnosis patient identified in pre-visit planning • Focus on pancreatic, lung and any Stage 3 and 4 cancers • Honoring choices form and facilitator • Nephrology • Chronic Kidney Disease patients- stage 4 and 5 identified in pre-visit planning • Honoring Choices form, facilitator or Advance Care Directives class • Cardiology CHF All- Collaboration with hospice and palliative care • Pulmonary • Neurology • Geriatrics/Home Care • Honoring choices or POLST form • Standardized workflow for EPIC or out of system providers and homecare EMR • Nursing home adoption of POLST form • Palliative Care/Hospice • Facilitated discussion on advance care planning at admission • Honoring choices or POLST form • Coordination with inpatient palliative care consult team • ICSI Workgroup • ACHP Palliative Care workgroup • HIE/EPIC • Honoring Choices MN • Ambassador program • Public television • EBAN project • St Paul area Council of Churches

21. Challenges/Opportunities • Meeting cultural needs of patients • EPIC modification that meets needs of community • Limitation with Palliative Care benefit • Improving website location and accessibility (HealthPartners.com and My Partner) • Building awareness • Incorporating into Employee Wellness Program