Improving Advance Care Planning in Wisconsin

1. Improving Advance Care Planning in Wisconsin March 29, 2012 John Maycroft, M.P.P., Policy Analyst John.Maycroft@wismed.org

2. BREAKING NEWS: Important Statistic…

3. 100% of people will die

4. If you’re not pictured here, Elijah Eight Immortals Enoch You need an advance care plan!

5. More Statistics • 90% of people say they would prefer to die at home, but only 20% do • The median length of service in 2010 was 19.7 days. The average length of service was 67.4 days • About 29% of people have advance directives

6. More statistics • Less than 50 percent of the severely or terminally ill patients studied had an advance directive in their medical record. • Only 12 percent of patients with an advance directive had received input from their physician in its development. • Between 65 and 76 percent of physicians whose patients had an advance directive were not aware that it existed. -AHRQ 2003

7. Lung cancer patients receiving early palliative care experienced less depression, increased quality of life and survived 2.7 months longer than those receiving standard oncologic care

8. Like Others, WI Population Grows Older…and Will Need Intense Resources

9. Mounting Pressure to Improve Conversations About Chronic Debilitating Careand End-of-Life Patients Hospice Nurses Employer community Physicians Employee Trust Funds

10. Opportunity • To Convene Disparate Stakeholders • To Harmonize Efforts, Share Language • Providers • Community • To Improve “Patient Experience” via Shared Decision Making • For Better Patient Engagement Around an Uncomfortable Topic

11. Respecting Choices La Crosse, Wisconsin Mission: To assist organizations, communities, and individuals worldwide in implementing advance care planning practices that support informed healthcare decisions.

12. Scaling Up Honoring Choices Minnesota Twin Cities, Minnesota An effort of the Twin Cities Medical Society and its Foundation to encourage families and communities to have discussions regarding end-of-life care choices.

14. Advance Care Planning Project What it is not: • A push for one particular decision over another • Legislation • POLST

15. The Idea The Wisconsin Medical Society proposes to serve as a convener, coordinator and catalyst to build clinical pilot projects based on proven concepts, methodologies, training systems and materials, combined with aggressive outreach in communities across the state.

16. Clinical Collaboration • Health systems agree to: • A shared approach, including pilot projects • A shared language around advance care planning • Share lessons • Not compete around advance care planning • Contribute financially

17. Clinical Pilots • At least one pilot at each health system in the Milwaukee and Madison areas • Offer facilitated ACP conversations to a targeted patient demographic • Utilize Respecting Choices training and principles • Learn lessons for broader implementation

18. A Better Advance Directive Although legally acceptable ADs can take many forms, standardization will improve patient care and participant engagement. A standardized AD should be understandable across literacy levels.

19. Advance care plans must follow the patient, And be accessible in the medical record!

20. Short-range metrics • # of patients offered facilitated conversations • # of patients who accept facilitated conversations • # of new & updated advance care plans brought into the medical record

21. Potential Long-range metrics • Δ in average and median hospice and ICU days in last six months of life • # of ADs a patient has completed by the end of life (a way to “track the conversation”) • Satisfaction and depression rates among family members six months after a loved one’s death.

22. Wider Implementation • Clinical pilots teach the lessons necessary for wider implementation through a system • Inside the health systems, broaden to more challenging situations and demographics • Potential for pilots at long-term care facilities, workplaces, etc. • Expansion across Wisconsin

23. Community Outreach Bring an understanding of advance care planning to all Wisconsinites, and expand the conversation among individuals, family, friends, loved ones and their communities.

24. Community Outreach • Multicultural Organizations • Senior Groups • Faith Communities • Disability Community • LGBT Organizations

25. Media Outreach • Television • Internet • Social Media • Newspapers • Consider the Conversation

26. Financial Resources • Project costs of $250,000 for 2012 • Internal costs for pilots • Later, larger expenditures for public outreach

27. Physicians’ Duty To Give Permission for Conversation To Give Reassurance for Conversation To Give Encouragement for Conversation Not to Make or Force the Patient’s Decision

28. Challenges Collaboration Physician and Stakeholder Understanding Wisconsin-Specific Legal Barriers Competition for Resources, Priority Community Awareness Building

29. Moving Forward The Society is building formal commitment, participation and funding for this project beginning Fall 2011, with development of pilot projects and outreach in 2012. For more information, contact John Maycroft, Policy Analyst for the Wisconsin Medical Society, at 608.442.3766 or john.maycroft@wismed.org.

30. Discussion