For many providers, this is where advance care planning (ACP) can play an important role.
Partnering to promote ACP conversations and advance directive completion
Mercy Family Health Center in Toledo, Ohio, faced an all-too-familiar problem for primary care practices: Despite having many patients that would benefit from ACP conversations, the practice lacked the trained personnel to orchestrate them. Rather than invest financial and staff resources to develop ACP capacity in-house, Mercy turned to partnering with Sincera—a palliative care and advanced care planning branch of Mercy's longtime partner, Hospice of Northwest Ohio.
Through a grant-funded Nurse-in-Residence program, Sincera embedded an RN specializing in ACP in the Mercy clinic. The specialist provides Mercy patients with access to ACP and facilitates completion of advance directives while limiting the interruption to practice workflow.
Some physicians struggled to understand the purpose and role of the new team member, and worried that the initiative would add more responsibility to their already-full plates.
Focus first on physician buy-in to drive referrals
Nurse-in-Residence program strikes balance between involving physicians and burdening them
To address the providers' concerns and make the program run as smoothly as possible, Sincera took deliberate steps to ensure the Nurse-in-Residence program was as easy to implement as possible.
Here are Sincera's three key steps:
1. Have the RN specialist do the patient screening, but make sure the physician has the final say on who receives the referral
Every morning, the ACP specialist reviews the charts of all patients age 65 and older that will be visiting the office that day. She or he flags patients that would benefit from an advance care planning conversation based on their medical conditions, prioritizing those that have been diagnosed with CHF, COPD, cancer, or diabetes. Sincera doesn't use a standardized screening process and instead casts a wide net across patients that could be considered risky.
Importantly, it is up to the physician to decide which patients will be referred to the ACP specialist. By having physicians give a simple "yea/nay" to pre-screened patients, they act as gatekeepers to their patients and don't need to worry about any part of the process happening without their go-ahead.
2. Provide physician with warm handoff scripting, but give them creative freedom to tailor conversations to their patients' needs
To facilitate the in-visit referral, Sincera provides physicians with recommended scripting tailored to different patient situations. Does the patient have complex care needs? Have they been visiting the ED too frequently? Do they have a short life expectancy? Each situation warrants a slightly different approach, and Sincera experts have crafted scripting accordingly, leaving it up to physician discretion to implement.
3. Put the RN specialist in charge of follow-up and execution, but make sure to circle back with the physician to ensure everyone is on the same page
Once the physician has made the referral and the patient has agreed to meet with the ACP specialist, the physician takes a back seat. It's up to the ACP specialist to schedule follow-up in the location of the patient's choosing and orchestrate the ACP conversation. Once that conversation and resulting advance directive signature has taken place, it's time to loop the provider back in. The ACP specialist helps the patient schedule a follow-up office visit with their PCP. To ensure all parties are on the same page, the patient, ACP specialist, and PCP meet as a group to review the care preferences and advance directives, and ensure proper documentation storage. As an incentive, this follow-up conversation, like the initial ACP conversation is now billable courtesy of CMS' 2015 Outpatient Final Rule.
After implementing these steps to simplify the physician role in the ACP process, Sincera saw referral numbers skyrocket. In just six months, 565 patients received in-office referrals and 365 completed ACP conversations. Based on the success of the Nurse-in-Residence partnership pilot, Sincera and Mercy are in the process of determining how to scale the embedded ACP model across all of Mercy's outpatient facilities, expanding access to ACP across the system.