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Wiltshire C, Budzynska K, Kulkarni P, Shoyinka N, Perkins DW. Group medicare wellness visits: A pilot exploration of an approach to wellness and preventive medicine for older adults. Prev Med Rep 2023; 36:102514. [PMID: 38116253 PMCID: PMC10728448 DOI: 10.1016/j.pmedr.2023.102514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/08/2023] [Accepted: 11/10/2023] [Indexed: 12/21/2023] Open
Abstract
Introduction The Medicare annual wellness visit was designed to address health risks and encourage evidence-based preventive care in aging. However, it can be challenging for providers to dedicate time for comprehensive attention to wellness during these visits. Our project implements a group setting for Medicare wellness visits (GMWV) as an efficient method for delivering high value preventive care. Methods Three hundred patients from two primary care ambulatory clinics in Detroit, MI in need of their annual Medicare visit were invited to participate in the pilot GMWV. Fifty-eight patients agreed and completed their GMWV. The visit included collection of vitals, vision screening, and risk assessment during check-in, followed by educational wellness presentations led by an interdisciplinary team of six healthcare professionals. Patients completed a post visit-satisfaction survey and researchers calculated rates of completion of health maintenance gaps (HMG), i.e. immunizations and cancer screenings, among participants. Results The average age of participants (N female = 48) was 74 years old. Thirty-four participants had more than one HMG at baseline. On average, 8 % of immunization gaps and 12 % of screening gaps were completed at or within one-year post GMWV. Participant feedback reported that 82 % of patients felt that they learned something new from the presentation and 81 % of patients felt satisfied with the amount of time they spent with their physician. Discussion GMWV is a feasible approach to promoting wellness and healthy aging that patients find satisfying although, additional study is needed to compare the effectiveness of this model to standard care.
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Affiliation(s)
- Charis Wiltshire
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, 939 Woodward Avenue, Detroit, MI 48201, United States
| | - Katarzyna Budzynska
- Department of Family Medicine, Henry Ford Hospital, 3370 E Jefferson Ave, Detroit, MI 48207, United States
| | - Pooja Kulkarni
- Department of Family Medicine, Henry Ford Hospital, 3370 E Jefferson Ave, Detroit, MI 48207, United States
| | - Nike Shoyinka
- Department of Family Medicine, Henry Ford Hospital, 3370 E Jefferson Ave, Detroit, MI 48207, United States
| | - Denise White Perkins
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, 939 Woodward Avenue, Detroit, MI 48201, United States
- Department of Family Medicine, Henry Ford Hospital, 3370 E Jefferson Ave, Detroit, MI 48207, United States
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Carter RZ, Ludwig M, Gao A, Tan A, Barwich D, Howard M. Primary care providers' perceptions on the integration of community-led advance care planning activities with primary care: a cross-sectional survey. BMC PRIMARY CARE 2023; 24:197. [PMID: 37743490 PMCID: PMC10519084 DOI: 10.1186/s12875-023-02144-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 08/30/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Advance care planning (ACP) is a process intended to help ensure people receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness. Barriers to implementing ACP in primary care settings exist. Community-led ACP initiatives exist in British Columbia to engage the public directly. These initiatives may help prepare people for conversations with their primary care providers. The objectives of this study were to elicit primary care providers' perceptions of the utility and desired content of community-led ACP activities and suggestions for integrating community-led ACP activities with primary care. METHODS We conducted an online cross-sectional survey of primary care providers practicing in British Columbia, Canada in 2021. Both quantitative and qualitative survey questions addressed ACP engagement in practice, the perceived role and desired outcomes of community-led ACP activities, and ways to integrate community-led ACP activities with primary care. RESULTS Eighty-one providers responded. Over 80% perceived a moderate or greater potential impact of community-led ACP activities. The most common reasons for not referring a patient to a community-led ACP activity were lack of awareness of the option locally (62.1%) and in general (44.8%). Respondents wanted their patients to reflect on their values, wishes and preferences for care, to have at least thought about their goals of care and to have chosen a substitute decision maker in the community. They indicated a desire for a summary of their patient's participation and a follow-up discussion with them about their ACP. They suggested ways to integrate referral to programs into existing health care system structures. CONCLUSIONS Community-led ACP activities were perceived to be useful to engage and prepare patients to continue ACP discussions with clinicians. Efforts should be made to establish and integrate community-based ACP initiatives within existing primary care systems to ensure awareness and uptake.
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Affiliation(s)
- Rachel Z Carter
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada.
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada.
| | - Monika Ludwig
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada
| | - Angela Gao
- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Amy Tan
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Doris Barwich
- Department of Medicine, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
- British Columbia Centre for Palliative Care, 300-601 Sixth St, New Westminster, BC, V3L 3C1, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
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Pajka SE, Kushel M, Handley MA, Olsen P, Li B, Enriquez C, Kaplan L, Sudore RL. Using behavioral theory to adapt advance care planning for homeless-experienced older adults in permanent supportive housing. J Am Geriatr Soc 2023; 71:2615-2626. [PMID: 36928791 PMCID: PMC10440262 DOI: 10.1111/jgs.18314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/31/2023] [Accepted: 02/18/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Older adults experiencing chronic homelessness (i.e., prolonged homelessness and a disabling condition) have low rates of advance care planning (ACP) despite high rates of morbidity and mortality. Rehousing of homeless-experienced individuals into permanent supportive housing (PSH) may present an opportunity to introduce ACP; but this is unknown. Therefore, we explored staff and resident perceptions of conducting ACP in PSH. METHODS We conducted semi-structured interviews with PSH staff (n = 13) and tenants (PSH residents) (n = 26) in San Francisco. We used the capability (C), opportunity (O), motivation (M), behavior (COM-B) framework within the Behavior Change Wheel model and the Theoretical Domains Framework (TDF) to inform interviews, categorize themes, and guide qualitative thematic analysis. RESULTS The mean age of PSH residents was 67 (SD = 6.1) years and 52% were women. Of staff, 69% were women. Important COM-B barriers included ACP complexity (C), complicated relationship dynamics (O), resource limitations (O), pessimism (M), variable staff confidence (M), and competing priorities (M). Facilitators included easy-to-use documents/videos, including the PREPARE for Your Care program (C), stability with housing (O), exposure to health crises (O), potential for strong relationships (O), and belief that ACP is impactful (M). Recommendations included adapting materials to the PSH setting, providing staff trainings/scripts, and using optional one-on-one or group sessions. CONCLUSIONS We identified behavioral determinants related to ACP for formerly chronically homeless older adults in PSH. Future interventions should include using easy-to-use ACP materials and developing resources to educate PSH residents, train staff, and model ACP in groups or one-on-one sessions.
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Affiliation(s)
- Sarah E Pajka
- Medical Student, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Margot Kushel
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, The University of California San Francisco, San Francisco, California, USA
| | - Margaret A Handley
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Pamela Olsen
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Celeste Enriquez
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Lauren Kaplan
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Department of Medicine, The University of California San Francisco, San Francisco, California, USA
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Matthieu MM, Ounpraseuth ST, Williams JS, Hu B, Adkins DA, Taylor LD, Oliver CM, Smith RM, Painter JT, McCullough JA, Garner KK. "Advancing" Advance Care Planning to Veterans in the Veterans Health Administration. Mil Med 2023; 188:786-791. [PMID: 35801841 DOI: 10.1093/milmed/usac196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/20/2022] [Accepted: 06/21/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The completion rate of Advance Directive (ADs) in the Veterans Health Administration (VHA) is unknown. There is substantial literature on the need for effective Advance Care Planning (ACP) that leads to an AD to ensure that health care preferences for patients are known. Advance Directive are essential to consider since ACP, which explains and plans Advance Directive, does not reach all individuals. Health inequities, such as those experienced in rural areas, continue to exist. While ACP may disproportionately affect rural-residing veterans and their providers, a VHA program was specifically designed to increase ACP engagement with rural veterans and to address several systemic barriers to ACP. MATERIALS AND METHODS This descriptive analysis seeks to identify patient, provider, and geographic characteristics associated with higher rates of ACP participation in VHA. An observational examination of the profile of veterans and the types of ACP (e.g., individual or in groups) using administrative data for all beneficiaries receiving VHA health care services in federal fiscal year (FY) 2020 was conducted as part of a national program evaluation. The measures include patient-level data on demographics (e.g., race, ethnicity, gender), unique patient identifiers (e.g., name, social security number), geographic characteristics of patient's location (e.g., rurality defined as Rural-Urban Commuting Areas [RUCA]), VHA priority group; provider-level data (e.g., type of document definition, clinic stop codes, visit date used to verify Advance Care Planning via Group Visits [ACP-GV] attendance; data not shown), and electronic health record note titles that indicated the presence of ACP in VHA (e.g., "Advance Directive [AD] Discussion" note title, "ACP-GV CHAR 4 code"). Pearson's chi-square statistics were used for between-group comparisons based on a two-sided test with a significance level of 0.05. RESULTS The overall rate of AD discussions among unique VHA users in FY2020 was 5.2% (95% CI: 5.2%-5.2%) and for Advance Care Planning via Group Visits, which targets rural veterans using groups, it was 1.8% (95% CI: 1.8%-1.9%). Advance Directive discussions in VHA are more successful at reaching middle age (M = 64; SD = 16), African Americans, males, veterans living in urban areas, and veterans with a VA disability (Priority Group 1-4). Advance Care Planning delivered in groups is reaching slightly younger veterans under the age of 75 years (M = 62; SD = 15), African Americans, females, disabled veterans (e.g., Priority Group 1-4), and more veterans residing in rural communities compared to the national population of VHA users. CONCLUSION Advance Directive discussion rates are low across VHA, yet intentional efforts with ACP via group visits are reaching veterans who are considered underserved owing to residing in rural areas. Advance Care Planning needs to be a well-informed clinical priority for VHA to engage with the entire veteran population and to support the completion of ADs.
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Affiliation(s)
- Monica M Matthieu
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
- School of Social Work, Saint Louis University, St. Louis, MO 63103, USA
| | - Songthip T Ounpraseuth
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - J Silas Williams
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
| | - Bo Hu
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, AR 72205, USA
| | - David A Adkins
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
| | | | - Ciara M Oliver
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
| | - Robin M Smith
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
| | - Jacob T Painter
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, North Little Rock, AR 72118, USA
- Division of Pharmaceutical Evaluation & Policy, University of Arkansas for Medical Sciences, College of Pharmacy, Little Rock, AR 72205, USA
| | - Jane Ann McCullough
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, North Little Rock, AR 72118, USA
| | - Kimberly K Garner
- Department of Psychiatry, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, AR 72205, USA
- Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, North Little Rock, AR 72118, USA
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Li S, Xie J, Chen Z, Yan J, Zhao Y, Cong Y, Zhao B, Zhang H, Ge H, Ma Q, Shen N. Key elements and checklist of shared decision-making conversation on life-sustaining treatment in emergency: a multispecialty study from China. World J Emerg Med 2023; 14:380-385. [PMID: 37908803 PMCID: PMC10613793 DOI: 10.5847/wjem.j.1920-8642.2023.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/20/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Shared decision-making (SDM) has broad application in emergencies. Most published studies have focused on SDM for a certain disease or expert opinions on future research gaps without revealing the full picture or detailed guidance for clinical practice. This study is to investigate the optimal application of SDM to guide life-sustaining treatment (LST) in emergencies. METHODS This study was a prospective two-round Delphi consensus-seeking survey among multiple stakeholders at the China Consortium of Elite Teaching Hospitals for Residency Education. Participants were identified based on their expertise in medicine, law, administration, medical education, or patient advocacy. All individual items and questions in the questionnaire were scored using a 5-point Likert scale, with responses ranging from "very unimportant" (a score of 1) to "extremely important" (a score of 5). The percentages of the responses that had scores of 4-5 on the 5-point Likert scale were calculated. A Kendall's W coefficient was calculated to evaluate the consensus of experts. RESULTS A two-level framework consisting of 4 domains and 22 items as well as a ready-to-use checklist for the informed consent process for LST was established. An acceptable Kendall's W coefficient was achieved. CONCLUSION A consensus-based framework supporting SDM during LST in an emergency department can inform the implementation of guidelines for clinical interventions, research studies, medical education, and policy initiatives.
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Affiliation(s)
- Shu Li
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Jing Xie
- Department of Infectious Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ziyi Chen
- Department of Neurology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Jie Yan
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
| | - Yuliang Zhao
- Department of Nephrology, West China Hospital, West China School of Medicine, Chengdu 610041, China
| | - Yali Cong
- Institute of Medical Humanities, School of Foundational Education, Peking University Health Science Center, Beijing 100191, China
| | - Bin Zhao
- Department of Emergency Medicine, Beijing Jishuitan Hospital, Fourth Medical College of Peking University, Beijing 100035, China
| | - Hua Zhang
- Clinical Epidemiology Research Center, Peking University Third Hospital, Beijing 100191, China
| | - Hongxia Ge
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Qingbian Ma
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Ning Shen
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing 100191, China
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Dube D, Sussman T, Brotman S, de Vries B, Gutman G. Advance Care Planning among Older Gay Men Living with HIV in Montreal, Canada: Challenges to Thinking and Talking about Future Care. JOURNAL OF HOMOSEXUALITY 2022; 69:756-772. [PMID: 33433307 DOI: 10.1080/00918369.2020.1855029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This qualitative study employed a cross sectional focus group design to explore how older gay men living with HIV, experience, perceive, and engage with advance care planning (ACP). Seven gay men 50+, residing in Montreal, Canada, participated in a focus group that was audio-recorded, transcribed, and thematically analyzed. Findings suggested that social isolation, preoccupations with day-to-day living, and managing disclosures related to sexual orientation and HIV status created barriers to these men's capacities to think about let alone talk about future care. These findings challenge current conceptualizations of ACP, which position reflection as an individual process that precedes allocating a decision-maker and communicating care preferences. Analyses further revealed that relational connections helped create a space where ACP could occur for participants. Hence, improving the uptake of ACP amongst older gay men with HIV may require interventions that embed such discussions into broader programs aimed at building support and community.
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Affiliation(s)
- Denis Dube
- School of Social Work, McGill University, Montreal, Quebec, Canada
| | - Tamara Sussman
- School of Social Work, McGill University, Montreal, Quebec, Canada
| | - Shari Brotman
- School of Social Work, McGill University, Montreal, Quebec, Canada
| | - Brian de Vries
- Department of Gerontology, San Francisco State University, San Francisco, California, USA
| | - Gloria Gutman
- Department of Gerontology, Simon Fraser University, Vancouver, British Columbia, Canada
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Daddato AE, Staton EW, Bettcher BM, Shanbhag P, Lum HD. Human-Centered Design of an Advance Care Planning Group Visit for Mild Cognitive Impairment. THE GERONTOLOGIST 2021; 62:1226-1237. [PMID: 34940855 PMCID: PMC9451012 DOI: 10.1093/geront/gnab181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While advance care planning (ACP) is critical for ensuring optimal end-of-life outcomes among individuals with mild cognitive impairment (MCI), many individuals who may benefit from ACP have not initiated this process. This article aims to describe the iterative design of an MCI group visit-based intervention and evaluate the feasibility and acceptability of the intervention. RESEARCH DESIGN AND METHODS We used human-centered design, rapid-cycle prototyping, and multiple methods to adapt an ENgaging in Advance Care planning Talks (ENACT) Group Visits intervention. We convened an advisory panel of persons with MCI and care partners (n = 6 dyads) to refine the intervention and conducted a single-arm pilot of 4 MCI ENACT intervention prototypes (n = 13 dyads). We used surveys and interviews to assess outcomes from multiple perspectives. RESULTS The advisory panel affirmed that ACP is a priority for individuals with MCI, described the need for ACP in a group setting, and suggested refinements to ACP resources for the MCI ENACT intervention. Feasibility of recruitment was limited. MCI ENACT intervention participants strongly agreed that group discussions provided useful information and recommended the intervention. Themes supporting acceptability included (a) feedback on acceptability of the intervention, (b) previous experiences with ACP, and (c) reasons for participation, including desire for discussions about MCI and how it relates to ACP. DISCUSSION AND IMPLICATIONS Despite stakeholders' positive ratings of acceptability of the MCI ENACT intervention, future work is needed to enhance the feasibility of recruitment to support implementation into clinical settings.
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Affiliation(s)
- Andrea E Daddato
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elizabeth W Staton
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Brianne M Bettcher
- Alzheimer’s and Cognition Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Prajakta Shanbhag
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hillary D Lum
- Address correspondence to: Hillary D. Lum, MD, PhD, Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 E. 17th Ave., Mail Stop B179, Aurora, CO 80045, USA. E-mail: ; Twitter handle: @hdaylum
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Ahluwalia SC, Bandini JI, Kogan AC, Bekelman DB, Olsen B, Phillips J, Sudore RL. Impact of group visits for older patients with heart failure on advance care planning outcomes: Preliminary data. J Am Geriatr Soc 2021; 69:2908-2915. [PMID: 34077563 PMCID: PMC8497395 DOI: 10.1111/jgs.17283] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Advance care planning (ACP) is critically important for heart failure patients, yet important challenges exist. Group visits can be a helpful way to engage patients and caregivers in identifying values and preferences for future care in a resource-efficient way. We sought to evaluate the impact of group visits for ACP among older adults with heart failure and their caregivers on ACP-related outcomes. METHODS We conducted a mixed-methods pilot study evaluating the impact of an ACP group visit for older adults with heart failure and their caregivers on ACP-related outcomes including readiness and self-efficacy. The evidence-based PREPARE for Your Care video-based intervention was used to guide the group visits. Twenty patients and 10 caregivers attended one of the five 90-min group visits led by a trained facilitator. Group visit participants completed pre-, post-, and 1-month follow-up surveys using validated 5-point ACP readiness and self-efficacy scales. Qualitative feedback obtained within 3 days of a group visit was analyzed using a directed content analysis. RESULTS Patient participants had a median age of 78 years. Approximately half were female while caregiver participants were mostly female. Participants were predominantly white. Patient readiness scores improved significantly pre-to-post (+0.53; p = 0.002) but was not sustained at 1-month follow-up. Patient and caregiver self-efficacy showed some improvement pre-to-post but was also not sustained at follow-up. Interviews revealed positive impacts of group visits across the three themes: encouraging reviewing or revisiting prior ACP activities, motivating patients to take direct steps towards ACP, and serving as a "wake-up" call to action. CONCLUSIONS Disease-focused group visits may have a short-term effect on ACP outcomes but ongoing touchpoints are likely necessary to sustain ACP over time. The results highlight a need for follow-up ACP conversations after a single group visit. Timing for follow-ups and the ideal person to follow-up ACP conversations needs to be explored.
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Affiliation(s)
- Sangeeta C. Ahluwalia
- RAND Corporation, Santa Monica, CA
- UCLA Fielding School of Public Health, Los Angeles, CA
| | | | - Alexis Coulourides Kogan
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
| | - David B. Bekelman
- Department of Medicine, Eastern Colorado VA HCS and Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus
| | - Bonnie Olsen
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
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Kwak J, Jamal A, Jones B, Timmerman GM, Hughes B, Fry L. An Interprofessional Approach to Advance Care Planning. Am J Hosp Palliat Care 2021; 39:321-331. [PMID: 34096333 DOI: 10.1177/10499091211019316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
CONTEXT Advance care planning (ACP) can improve patients' outcomes at end of life, and interprofessional collaboration has been recommended to facilitate ACP. However, role confusion in ACP facilitation among team members from different disciplines exists, and health professional disciplines' expectations for interprofessional collaboration in ACP are unclear. OBJECTIVE To review expectations of major health professional organizations for ACP competencies, in order to identify gaps and opportunities for promoting interprofessional collaboration in ACP facilitation. METHODS Guidelines and recommendations for ACP across disciplines including chaplaincy, medicine, nursing, psychology, and social work were identified and analyzed using content analysis. Main themes were then reviewed against national consensus statements on 4 ACP outcomes (process outcomes, action outcomes, quality of care outcomes, and healthcare outcomes) and mapped into existing domains for interprofessional education competency: values/ethics, roles/responsibilities, interprofessional communication, and teams and teamwork. RESULTS Three major content themes were identified: professional commitment to advocating for patients' values and self-determination, professional responsibility to facilitate ACP, and specific tasks in ACP. These themes addressed mostly process and action outcomes of ACP but not quality of care outcomes or healthcare outcomes. Few disciplines included interprofessional collaboration as part of ACP competency. CONCLUSION There is a need for standardized competency guidelines for interprofessional collaboration in ACP as an important first step in reducing confusion among roles and other challenges in facilitating ACP. Further efforts in practice, research, and policy are needed to facilitate interprofessional ACP, achieve competencies, and improve patients' outcomes.
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Affiliation(s)
- Jung Kwak
- School of Nursing, 12330The University of Texas at Austin, Austin, TX, USA
| | - Aleena Jamal
- 12330The University of Texas at Austin, Austin, TX, USA
| | - Barbara Jones
- Steve Hicks School of Social Work, Dell Medical School, 12330The University of Texas at Austin, Austin, TX, USA
| | - Gayle M Timmerman
- School of Nursing, 12330The University of Texas at Austin, Austin, TX, USA
| | - Brian Hughes
- 101595HealthCare Chaplaincy Network and United Health Group, Garland, TX, USA
| | - Liam Fry
- Dell Medical School, 12330The University of Texas, Austin, TX, USA
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Schickedanz HB, Polzin R, Vassar SD, Brown AF, Kim KJ. Primary care provider-led group visits for advance care planning in the safety net. J Am Geriatr Soc 2021; 69:1404-1406. [PMID: 33797751 DOI: 10.1111/jgs.17098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Heather B Schickedanz
- Department of Family Medicine, Harbor-UCLA Medical Center, Los Angeles, California, USA.,Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rhonda Polzin
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA
| | - Stefanie D Vassar
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Arleen F Brown
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Karen J Kim
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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When do Physicians and Nurses Start Communication about Advance Care Planning? A Qualitative Study at an Acute Care Hospital in Japan. Asian Bioeth Rev 2021; 12:289-305. [PMID: 33717339 PMCID: PMC7747333 DOI: 10.1007/s41649-020-00135-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 10/28/2022] Open
Abstract
Although advance care planning (ACP) can lead to more patient-centered care, the communication around it can be challenging in acute care hospitals, where saving a life or shortening hospitalization is important priorities. Our qualitative study in an acute care hospital in Japan revealed when specifically physicians and nurses start communication to facilitate ACP. Seven physicians and 19 nurses responded to an interview request, explaining when ACP communication was initiated with 32 patients aged 65 or older. Our qualitative approach employed descriptive analysis to identify major themes, which included "initiation by patients" and "initiation by healthcare professionals." In the latter case, seven specific triggers were identified: (1) when the patients' medical condition changed in terms of symptom relief, (2) when the patients' medical condition changed in terms of prognostic prediction, (3) when serious events occurred, (4) when a choice of treatment was presented, (5) when the location for end-of-life care was chosen, (6) when the patients' cognitive function deteriorated, and (7) when serious events settled down. Within this group of healthcare professionals, physicians were more focused on changes in their patients' medical condition, whereas nurses focused more on their patients' desire for a long-term perspective. Nurses encouraged patients to consider ACP themselves, which developed into an approach to respect patients' autonomy. In acute care hospitals, it appeared to be desirable to have an early discussion where patients could understand the significance ACP, which would matter even after their discharge from the hospital.
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Clinician Perspectives on Group Visits for Advance Care Planning Among Caregivers and Older Adult Patients With Heart Failure. J Am Board Fam Med 2021; 34:375-386. [PMID: 33833006 PMCID: PMC8108709 DOI: 10.3122/jabfm.2021.02.200270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is critical for older adults with heart failure; however, patient-level and clinician-level barriers exist. Although a group visit (GV) approach to engage patients in ACP has proven effective among general geriatric populations, little is known about clinician perceptions/likelihood of referral. METHODS Qualitative study to understand clinician perspectives on GVs for ACP among older adult patients with heart failure and caregivers. Twenty physicians and advance practice providers participated in telephone-based interviews guided by a semistructured research protocol. Transcripts were analyzed using a grounded theory approach. RESULTS Results highlight variability in clinician engagement in ACP but greater agreement around the factors that prompt discussions. Qualitative themes included (1) inherent properties of GVs (characteristics that make GVs ideal for most but less ideal for some, risk-to-benefit ratio); (2) purpose of GVs (general education, "priming the pump" for subsequent discussions, providing tools for action); and (3) format and procedures for GVs (inclusion/exclusion considerations, organizing by unifying characteristic, link back to clinicians). CONCLUSIONS This is the first study to gain clinician insights into ACP GVs specific to patients and caregivers affected by heart failure. Results shed light on an important topic and suggest key considerations for conducting GVs for ACP.
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Jia Z, Stokes SC, Pan SY, Leiter RE, Lum HD, Pan CX. Heart to Heart Cards: A Novel, Culturally Tailored, Community-Based Advance Care Planning Tool for Chinese Americans. Am J Hosp Palliat Care 2021; 38:650-657. [PMID: 33499666 DOI: 10.1177/1049909121989986] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
CONTEXT A paucity of literature describes the growing Chinese American community's end-of-life (EOL) priorities and preferences. OBJECTIVE Develop a culturally-tailored advance care planning (ACP) tool to understand the EOL preferences of this underserved minority group. METHODS Informed by the Cultural Appropriateness Theory, the Chinese American Coalition for Compassionate Care (CACCC) developed Heart to Heart (HTH) Cards using a 3-step approach. First, CACCC created and refined a list of bilingual, culturally relevant EOL issues. Next, CACCC organized the EOL issues into a card deck. Finally, CACCC developed a unique playstyle of the cards-the HTH Café. From 2014-2019, CACCC recruited Chinese American volunteers and participants for HTH Cafés. Following each Café, participants completed an anonymous survey describing their sociodemographics, top 3 cards, and café evaluation. RESULTS The 54 HTH Cards were organized into 4 suits (spiritual, physical, financial/legal, and social). Each card displayed a culturally-tailored EOL issue in English and Chinese. Playstyles included one-on-one and group formats (ie. HTH Café). CACCC volunteers conducted 316 HTH Cafés for 2,267 Chinese American adults. Most participants were female (61.6%), between 18-50 years old (56.7%), lived in California (80.2%) and born in Asia (74.3%). The top priority (25.5%) was "If I'm going to die anyway, I don't want to be kept alive by machines." Participants thought the session was pleasant (99.5%) and expressed intent to complete advance directives (86.5%). CONCLUSION HTH Cards represents the first, theory-driven, culturally-tailored ACP tool for Chinese Americans. More research is needed to establish its impact on ACP conversations and outcomes.
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Affiliation(s)
- Zhimeng Jia
- Department of Psychosocial Oncology and Palliative Care, 1855Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sandy C Stokes
- Chinese American Coalition for Compassionate Care, Cupertino, CA, USA
| | - Shirley Y Pan
- Chinese American Coalition for Compassionate Care, Cupertino, CA, USA
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, 1855Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hillary D Lum
- VA Eastern Colorado Health Care System, Geriatric Research Education and Clinical Center, Aurora, CO, USA.,Division of Geriatric Medicine, 12225University of Colorado School of Medicine, Aurora, CO, USA
| | - Cynthia X Pan
- Division of Palliative Medicine and Geriatrics, NewYork-Presbyterian Queens, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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Feasibility of Group Visits for Advance Care Planning Among Patients with Heart Failure and Their Caregivers. J Am Board Fam Med 2021; 34:171-180. [PMID: 33452095 PMCID: PMC8607823 DOI: 10.3122/jabfm.2021.01.200184] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Group visits have the potential to help patients identify their health care values and engage in the emotionally and cognitively challenging task of advance care planning (ACP) in a resource-efficient manner by providing a forum for social learning and social support. OBJECTIVE To evaluate the feasibility and acceptability of disease-specific group visits for patients with heart failure and their caregivers. DESIGN Feasibility trial of a 90-minute group visit held for 10 separate groups and led by a trained facilitator using the video-based PREPARE for Your Care ACP tool. SETTING/SUBJECTS Older adults with recent hospitalization for heart failure (n = 36; median age, 74 years) and their caregivers (n = 21). MEASUREMENTS Pre- and post-visit surveys and a postvisit telephone interview assessing perceived value and acceptability; structured nonparticipant observations to assess process and feasibility. RESULTS Mean scores from the postgroup visit evaluation showed that participants reported that they felt comfortable discussing ACP in a group (4.59), understood the information covered (4.70), and were able to identify and clarify their health care values (4.43). Interview and observation data demonstrated that participants were able to identify and clarify their preferences by listening and learning from a diverse range of perspectives in the group and that the disease-focused nature of the group visit created a supportive space for participants to share their experiences. CONCLUSIONS Disease-focused ACP group visits were feasible to conduct and acceptable to participants, underscoring their value as an efficient intervention to engage patients and caregivers in the otherwise time- and resource-intensive task of ACP.
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15
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Sokol-Hessner L, Allen G, Cluett J. Improving Ambulatory Health Care Proxy Completion Rates. Am J Med Qual 2020; 35:491-499. [DOI: 10.1177/1062860620915280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Frechman E, Dietrich MS, Walden RL, Maxwell CA. Exploring the Uptake of Advance Care Planning in Older Adults: An Integrative Review. J Pain Symptom Manage 2020; 60:1208-1222.e59. [PMID: 32645455 PMCID: PMC7342022 DOI: 10.1016/j.jpainsymman.2020.06.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Advance care planning (ACP) is essential to elicit goals, values, and preferences of care in older adults with serious illness and on trajectories of frailty. An exploration of ACP uptake in older adults may identify barriers and facilitators. OBJECTIVE To conduct an integrative review of research on the uptake of ACP in older adults and create a conceptual model of the findings. METHODS Using Whittemore and Knafl's methodology, we systematically searched four electronic databases of ACP literature in older adults from 1996 through December 2019. Critical appraisal tools were used to assess study quality, and articles were categorized according to level of evidence. Statistical and thematic analysis was then undertaken. RESULTS Among 1081 studies, 78 met inclusion criteria. Statistical analysis evaluated ACP and variables within the domains of demographics, psychosocial, disability and functioning, and miscellaneous. Thematic analysis identified a central category of enhanced communication, followed by categories of 1) provider role and preparation; 2) patient/family relationship patterns; 3) standardized processes and structured approaches; 4) contextual influences; and 5) missed opportunities. A conceptual model depicted categories and relationships. CONCLUSIONS Enhanced communication and ACP facilitators improve uptake of ACP. Clinicians should be cognizant of these factors. This review provides a guide for clinicians who are considering implementation strategies to facilitate ACP in real-world settings.
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Affiliation(s)
- Erica Frechman
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA.
| | - Mary S Dietrich
- Vanderbilt University Schools of Medicine and Nursing, Nashville, Tennessee, USA
| | - Rachel Lane Walden
- Vanderbilt University Eskind Biomedical Library, Nashville, Tennessee, USA
| | - Cathy A Maxwell
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA
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Matthieu MM, Ounpraseuth ST, Painter J, Waliski A, Williams JS, Hu B, Smith R, Garner KK. Evaluation of the national implementation of the VA Diffusion of Excellence Initiative on Advance Care Planning via Group Visits: protocol for a quality improvement evaluation. Implement Sci Commun 2020; 1:19. [PMID: 32885180 PMCID: PMC7427851 DOI: 10.1186/s43058-020-00016-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 12/02/2022] Open
Abstract
Background Traditionally, system leaders, service line managers, researchers, and program evaluators hire specifically dedicated implementation staff to ensure that a healthcare quality improvement effort can “go to scale.” However, little is known about the impact of hiring dedicated staff and whether funded positions, amid a host of other delivered implementation strategies, are the main difference among sites with and without funding used to execute the program, on implementation effectiveness and cost outcomes. Methods/design In this mixed methods program evaluation, we will determine the impact of funding staff positions to implement, sustain, and spread a program, Advance Care Planning (ACP) via Group Visits (ACP-GV), nationally across the entire United States Department of Veterans Affairs (VA) healthcare system. In ACP-GV, veterans, their families, and trained clinical staff with expertise in ACP meet in a group setting to engage in discussions about ACP and the benefits to veterans and their trusted others of having an advance directive (AD) in place. To determine the impact of the ACP-GV National Program, we will use a propensity score-matched control design to compare ACP-GV and non-ACP-GV sites on the proportion of ACP discussions in VHA facilities. To account for variation in funding status, we will document and compare funded and unfunded sites on the effectiveness of implementation strategies (individual and combinations) used by sites in the National Program on ACP discussion and AD completion rates across the VHA. In order to determine the fiscal impact of the National Program and to help inform future dissemination across VHA, we will use a budget impact analysis. Finally, we will purposively select, recruit, and interview key stakeholders, who are clinicians and clinical managers in the VHA who offer ACP discussions to veterans, to identify the characteristics of high-performing (e.g., high rates or sustainers) and innovative sites (e.g., unique local program design or implementation of ACP) to inform sustainability and further spread. Discussion As an observational evaluation, this protocol will contribute to our understanding of implementation science and practice by examining the natural variation in implementation and spread of ACP-GV with or without funded staff positions.
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Affiliation(s)
- Monica M Matthieu
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College for Public Health and Social Justice, School of Social Work, Saint Louis University, Saint Louis, MO USA
| | - Songthip T Ounpraseuth
- College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Jacob Painter
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Angie Waliski
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - James Silas Williams
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA
| | - Bo Hu
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Robin Smith
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA
| | - Kimberly K Garner
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA.,Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Little Rock, AR USA
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Lum HD, Dukes J, Daddato AE, Juarez-Colunga E, Shanbhag P, Kutner JS, Levy CR, Sudore RL. Effectiveness of Advance Care Planning Group Visits Among Older Adults in Primary Care. J Am Geriatr Soc 2020; 68:2382-2389. [PMID: 32726475 DOI: 10.1111/jgs.16694] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 06/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Group visits can support health behavior change and self-efficacy. In primary care, an advance care planning (ACP) group visit may leverage group dynamics and peer mentorship to facilitate education and personal goal setting that result in ACP engagement. OBJECTIVE To determine whether the ENgaging in Advance Care Planning Talks (ENACT) group visits intervention improves ACP documentation and readiness in older adults. METHODS This randomized clinical trial was conducted among geriatric primary care patients from the University of Colorado Hospital Seniors Clinic, Aurora, CO, from August 2017 to November 2019. Participants randomized to ENACT group visits (n = 55) participated in two 2-hour sessions with discussions of ACP topics and use of ACP tools (i.e., Conversation Starter Kit, Medical Durable Power of Attorney form, and PREPARE videos). Participants randomized to the control arm (n = 55) received the Conversation Starter Kit and a Medical Durable Power of Attorney form by mail. The primary outcomes included presence of ACP documents or medical decision-maker documentation in the electronic health record (EHR) at 6 months, and a secondary outcome was ACP readiness (validated four-item ACP Engagement Survey) at 6 months. RESULTS Participants were a mean of 77 years old, 60% female, and 79% white. At 6 months, 71% of ENACT participants had an advance directive in the EHR (26% higher) compared with 45% of control arm participants (P < .001). Similarly, 93% of ENACT participants had decision-maker documentation in the EHR (29% higher) compared with 73% in the control arm (P < .001). ENACT participants trended toward higher readiness to engage in ACP compared with control (4.56 vs 4.13; P = .16) at 6 months. CONCLUSION An ACP group visit increased ACP documentation and readiness to engage in ACP behavior change. Primary care teams can explore implementation and adaptation of ACP group visits into routine care, as well as longer-term impact on patient health outcomes. J Am Geriatr Soc 68:2382-2389, 2020.
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Affiliation(s)
- Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,Geriatric Research Education and Clinical Center, Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Joanna Dukes
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Andrea E Daddato
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Gerontology, University of Massachusetts Boston, Boston, Massachusetts, USA
| | - Elizabeth Juarez-Colunga
- Division of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Prajakta Shanbhag
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jean S Kutner
- Division of General Internal Medicine , Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cari R Levy
- Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Eastern Colorado Health Care System, Aurora, Colorado, USA.,Division of Health Care Policy and Research, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rebecca L Sudore
- Division of Geriatric Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Nurse Educators Establish and Evaluate Community Coalition to Promote Statewide Advance Care Planning Through RE-AIM. J Hosp Palliat Nurs 2020; 22:305-311. [PMID: 32568939 DOI: 10.1097/njh.0000000000000662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this quality improvement project was to evaluate a statewide initiative promoting Advance Care Planning (ACP) to educate and support multidisciplinary ACP educators and provide tools to start ACP conversations in a predominantly rural state of the Upper Midwest. Individual objectives were to (1) motivate people of different professions and backgrounds to support the vision and (2) implement a system to educate and maintain a pipeline of ACP educators in appropriate methodologies to enable ACP in distant communities. The Advance Care Planning: Quality Conversations coalition was formed in 2015 to improve health care across the life span. The Reach-Effectiveness-Adoption-Implementation-Maintenance framework was applied to evaluate the project. Outcome variables were measured before, during, and after program implementation through service statistics and a questionnaire. Participation in the coalition's membership team between September 2015 and September 2019 ranged from 18 to 36 with a median of 27 and mode of 27. At least 20 different professions were represented. The coalition provided funds for educating 9 ACP instructors and 180 facilitators according to the Respecting Choices-First Steps ACP program. The coalition's mission has generated sustained interest for 4 years. Key elements and obstacles to implementing a statewide coalition were identified.
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20
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Flaherty E, Bartels SJ. Addressing the Community-Based Geriatric Healthcare Workforce Shortage by Leveraging the Potential of Interprofessional Teams. J Am Geriatr Soc 2020; 67:S400-S408. [PMID: 31074849 DOI: 10.1111/jgs.15924] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/22/2019] [Accepted: 02/13/2019] [Indexed: 12/01/2022]
Abstract
As Americans live longer lives, we will see an increased demand for quality healthcare for older adults. Despite the growth in the number of older adults, there will be a decrease in the supply of a primary care physician workforce to provide adequately for their care and health needs. This article reviews the literature that explores ways to address the primary care workforce shortage in a community-based geriatric healthcare setting, with special attention to elevating the role of nurses and caregivers and shifting the way we think about delivery of care and end-of-life conversations and planning. The shift is toward a more integrated and collaborative approach to care where medical and nonmedical, social services, and community providers all play a role. Several models have demonstrated promising positive benefits and outcomes to patients, families, and providers alike. The goal is to provide high quality care that addresses the unique attributes of older adults, especially those with complex conditions, and to focus more on care goals and priorities. The many barriers to scaling and spreading models of care across varied settings include payment structures, lack of education and training among all stakeholders, and, at the top of the list, leadership resistance. We address these barriers and make recommendations for a path forward where healthcare providers, policymakers, patients, families, and everyone else involved can play a role in shaping the workforce caring for older adults. J Am Geriatr Soc 67:S400-S408, 2019.
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Affiliation(s)
- Ellen Flaherty
- Dartmouth Centers for Health & Aging, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stephen J Bartels
- The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
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Howard M, Langevin J, Bernard C, Tan A, Klein D, Slaven M, Barwich D, Elston D, Arora N, Heyland DK. Primary care clinicians' confidence, willingness participation and perceptions of roles in advance care planning discussions with patients: a multi-site survey. Fam Pract 2020; 37:219-226. [PMID: 31536615 DOI: 10.1093/fampra/cmz050] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND People who engage in advance care planning (ACP) are more likely to receive health care that is concordant with their goals at the end of life. Little discussion of ACP occurs in primary care. OBJECTIVE The objective of this study was to describe primary care clinicians' perspectives on having ACP conversations with their patients. METHODS We conducted a survey of family physicians and non-physician clinicians in primary care in 2014-2015. We compared family physicians and non-physician clinicians on willingness, confidence, participation and acceptability for other clinicians to engage in six aspects of ACP (initiating, exchanging information, decision coaching, finalizing plans, helping communicate plans with family members and other health professionals) on scales from 0 = not at all/extremely unacceptable to 6 = very/all the time/extremely acceptable. RESULTS The response rate was 72% (n = 117) among family physicians and 69% (n = 64) among non-physician clinicians. Mean ratings (standard deviation [SD]) of willingness were high (4.5 [1.4] to 5.0 [1.2] for physicians; 3.4 [1.8] to 4.6 [1.6] non-physician clinicians). There was little participation (mean ratings 2.4 [1.7] to 2.7 [1.6] for physicians, 1.0 [1.5] to 1.4 [1.7] for non-physician clinicians). Non-physician clinicians rated confidence statistically significantly lower than physicians for all ACP aspects. Acceptability for non-physician clinician involvement was high in both groups (mean acceptability ratings greater than 4). CONCLUSION Current engagement of primary care clinicians in ACP is low. Given the high willingness and acceptability for non-physician clinician involvement, increasing the capacity of non-physician clinicians could enable uptake of ACP in primary care.
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Affiliation(s)
- Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton
| | | | - Carrie Bernard
- Department of Family Medicine, McMaster University, Hamilton.,Department of Family and Community Medicine, University of Toronto, Calgary
| | - Amy Tan
- Department of Family Medicine, University of Calgary, Calgary
| | - Doug Klein
- Department of Family Medicine, University of Alberta, Edmonton
| | - Marissa Slaven
- Department of Family Medicine, McMaster University, Hamilton.,Division of Palliative Care, McMaster University, Hamilton
| | - Doris Barwich
- Division of Palliative Care, Department of Medicine, University of British Columbia, Vancouver
| | - Dawn Elston
- Department of Family Medicine, McMaster University, Hamilton
| | - Neha Arora
- Department of Family Medicine, McMaster University, Hamilton
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston.,Department of Public Health, Queen's University, Kingston.,Department of Critical Care Medicine, Kingston General Hospital, Kingston, Canada
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Howard M, Robinson CA, McKenzie M, Fyles G, Sudore RL, Andersen E, Arora N, Barwich D, Bernard C, Elston D, Heyland R, Klein D, McFee E, Mroz L, Slaven M, Tan A, Heyland DK. Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings. Ann Fam Med 2020; 18:110-117. [PMID: 32152014 PMCID: PMC7062494 DOI: 10.1370/afm.2471] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 05/12/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Online programs may help to engage patients in advance care planning in outpatient settings. We sought to implement an online advance care planning program, PREPARE (Prepare for Your Care; http://www.prepareforyourcare.org), at home and evaluate the changes in advance care planning engagement among patients attending outpatient clinics. METHODS We undertook a prospective before-and-after study in 15 primary care clinics and 2 outpatient cancer centers in Canada. Patients were aged 50 years or older (primary care) or 18 years or older (cancer care) and free of cognitive impairment. They used the PREPARE website over 6 weeks, with reminders sent at 2 or 4 weeks. We used the 55-item Advance Care Planning Engagement Survey, which measures behavior change processes (knowledge, contemplation, self-efficacy, readiness) on 5-point scales and actions relating to substitute decision makers, quality of life, flexibility for the decision maker, and asking doctors questions on an overall scale from 0 to 21; higher scores indicate greater engagement. RESULTS In total, 315 patients were screened and 172 enrolled, of whom 75% completed the study (mean age = 65.6 years, 51% female, 35% had cancer). The mean behavior change process score was 2.9 (SD 0.8) at baseline and 3.5 (SD 0.8) at follow-up (mean change = 0.6; 95% CI, 0.49-0.73); the mean action measure score was 4.0 (SD 4.9) at baseline and 5.2 (SD 5.4) at follow-up (mean change = 1.2; 95% CI, 0.54-1.77). The effect size was moderate (0.75) for the former and small (0.23) for the latter. Findings were similar in both primary care and cancer care populations. CONCLUSIONS Implementation of the online PREPARE program in primary care and cancer care clinics increased advance care planning engagement among patients.
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Affiliation(s)
- Michelle Howard
- CORRESPONDING AUTHOR: Michelle Howard, PhD, Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main St W, 5th Fl, Hamilton, Ontario, Canada L8P 1H6,
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Fink RM, Kline DM, Bailey FA, Handel DL, Jordan SR, Lum HD, Fischer SM. Community-Based Conversations about Advance Care Planning for Underserved Populations Using Lay Patient Navigators. J Palliat Med 2020; 23:907-914. [PMID: 31944875 DOI: 10.1089/jpm.2019.0470] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Widespread community engagement in advance care planning (ACP) is needed to overcome barriers to ACP implementation. Objective: Develop, implement, and evaluate a model for community-based ACP in rural populations with low English language fluency and health care access using lay patient navigators. Design: A statewide initiative to improve ACP setting/subjects-trained in a group session approach, bilingual patient navigators facilitated 1-hour English and Spanish ACP sessions discussing concerns about choosing a surrogate decision maker and completing an advance directive (AD). Participants received bilingual informational materials, including Frequently Asked Questions, an AD in English or Spanish, and Goal Setting worksheet. Measurement: Participants completed a program evaluation and 4-item ACP Engagement Survey (ACP-4) postsession. Results: For 18 months, 74 ACP sessions engaged 1034 participants in urban, rural, and frontier areas of the state; 39% were ethnically diverse, 69% female. A nurse or physician co-facilitated 49% of sessions. Forty-seven percent of participants completed an ACP-4 with 29% planning to name a decision maker in the next 6 months and 21% in the next 30 days; 31% were ready to complete an AD in the next 6 months and 22% in the next 30 days. Evaluations showed 98% were satisfied with sessions. Thematic analysis of interviews with facilitators highlighted barriers to delivering an ACP community-based initiative, strategies used to build community buy-in and engagement, and ways success was measured. Conclusion: Patient navigators effectively engaged underserved and ethnically diverse rural populations in community-based settings. This model can be adapted to improve ACP in other underserved populations.
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Affiliation(s)
- Regina M Fink
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Danielle M Kline
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - F Amos Bailey
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Daniel L Handel
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sarah R Jordan
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado, USA
| | - Stacy M Fischer
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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Taylor GH, Krakauer EL, Sanders JJ. "Find Out What They Lack, Try to Provide": A Qualitative Investigation of Palliative Care Services Adapted to Local Need in a Low-Resource Setting. J Palliat Med 2020; 23:792-800. [PMID: 31910351 DOI: 10.1089/jpm.2019.0406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: People in low- and middle-income countries with serious health problems rarely have access to palliative care. Promising models of palliative care delivery have emerged in India despite widespread poverty and poor health care infrastructure. Objective: To explore structural and philosophical aspects of palliative care delivery in a low-resource setting. Design: One author spent six months as a participant observer at Pallium India (PI), a nongovernmental organization recognized for leadership in palliative care delivery in Kerala, India. We collected administrative data, conducted semistructured interviews with key stakeholders, and observed clinical encounters and other organization-led events. Results: We performed 73 interviews with patients, families, clinicians, staff, and volunteers, and observed 180 patient encounters. The majority of palliative care patients did not have cancer. Many had chronic diseases that were not immediately life threatening. Services addressed a broad range of patients' medical, psychological, social, and/or financial needs. PI's care delivery maximizes accessibility. Conclusions: PI employs an expansive definition of palliative care and adapts services to respond to patients' diverse needs. This accessible, people-centered care is necessary in low-resource settings to alleviate multifaceted suffering caused by gaps in the health care system, poor social support, and poverty.
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Affiliation(s)
- Grace H Taylor
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Eric L Krakauer
- Department of Global Health and Social Medicine, Harvard Medical School, Global Palliative Care Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Ariadne Labs, Boston, Massachusetts, USA
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Grossman D, Katz A, Lock K, Caraiscos VB. A Retrospective Study Reviewing Interprofessional Advance Care Planning Group Discussions in Pulmonary Rehabilitation: A Proof-of-Concept and Feasibility Study. J Palliat Care 2019; 36:219-223. [DOI: 10.1177/0825859719896421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Advance care planning (ACP) is a process of reflection and discussion wherein a patient, in consultation with a health-care provider, family, and/or loved ones, clarifies values and treatment preferences and establishes goals, including a plan for end-of-life (EOL) care. Advance care planning encompasses appreciating and understanding illness and treatment options, elucidating patient values and beliefs, and identifying a substitute decision maker (SDM) or designating a power of attorney (POA) for personal care. These discussions have proven to be effective in improving patient–family satisfaction, reducing anxiety regarding EOL care in patients and family members, and improving patient-centered care by empowering patients to direct their care at EOL. However, ACP conversations are often difficult to have due to the sensitive nature of such discussions. Objective: The aim of this study was to determine whether group facilitation for teaching and discussing ACP enhances participants’ understanding of ACP and allows them to feel comfortable and supported when discussing these sensitive issues. Methods: Patients who were registered in North York General Hospital’s (NYGH) pulmonary rehabilitation program from June 2016 until August 2017 were given the opportunity to attend two 1-hour sessions related to ACP. The first session was dedicated to educating patients on ACP, explaining the hierarchy of the SDM and the role of the POA for personal care. The second session, provided a short time later, was devoted to discussions of values, wishes, fears, and trade-offs for future medical and EOL care. These discussions led by the supportive care nurse practitioner and a physician who are members of the NYGH Freeman Palliative Care Team were held in a group-facilitated format. Anonymous feedback forms, including both qualitative and quantitative feedback, were completed by the participants and analyzed. Participants: Analysis of a sample of 30 participants who attended 1 or 2 of the ACP sessions revealed that 21 identified as female and 9 identified as male. The average age of the participants was 76 years. Findings: Participants felt the content was relevant to their needs and were comfortable asking questions with all feedback averages ranging from good to very good. Participants appreciated the opportunity to share their thoughts in an open and interactive format. Conclusion: Discussing issues relevant to ACP, including providing information about ACP, sharing fears, wishes, and tradeoffs, were well-received in a group-support environment. Future studies should assess the impact of ACP group discussion on the individual, such as identifying a POA, having discussions regarding wishes and values with the SDM/POA, and examining the clinical impact of such sessions.
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Affiliation(s)
- Daphna Grossman
- Freeman Centre for the Advancement of Palliative Care, North York General Hospital, Toronto, Ontario, Canada
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amanda Katz
- Sackler Faculty of Medicine, Tel Aviv University Israel, Tel Aviv, Israel
| | - Karen Lock
- Freeman Centre for the Advancement of Palliative Care, North York General Hospital, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Valerie B. Caraiscos
- Freeman Centre for the Advancement of Palliative Care, North York General Hospital, Toronto, Ontario, Canada
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Meehan E, Sweeney C, Foley T, Lehane E, Burgess Kelleher A, Hally RM, Shanagher D, Korn B, Rabbitte M, Detering KM, Cornally N. Advance care planning in COPD: guidance development for healthcare professionals. BMJ Support Palliat Care 2019; 12:bmjspcare-2019-002002. [PMID: 31685522 DOI: 10.1136/bmjspcare-2019-002002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/19/2019] [Accepted: 10/21/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine current practices, attitudes and levels of confidence related to advance care planning (ACP) in patients with chronic obstructive pulmonary disease (COPD) among healthcare professionals working in Ireland. This will inform future clinical guidance development. METHODS A cross-sectional survey of healthcare professionals. RESULTS There were 143 participants (109 general practitioners, 25 nurses, 7 physiotherapists and 2 consultant physicians). The majority (82%, n=117) cared for patients with COPD weekly, but only 23% (n=33) had initiated ACP with a patient with COPD over the previous 6 months. Overall, 59% (n=85) answered ≥6 of 8 general knowledge questions correctly. Participants demonstrated positive attitudes towards ACP (mean score 3.6/5.0), but confidence levels were low (2.2/4.0). Most thought ACP was appropriate for patients with severe or very severe COPD (71%, n=101%, and 91%, n=130, respectively) but were unsure or felt that it was not appropriate for those with mild-moderate COPD. However, almost all participants (97%, n=139) stated that if a patient expressed a desire to have ACP discussions, they would comply. Topics most likely to be discussed related to diagnosis and treatment options. Death and end-of-life issues were rarely discussed. The death of a family member or friend and participation in support groups were identified as new 'triggers' for initiating ACP. CONCLUSIONS Targeted education to improve general knowledge and confidence levels among healthcare professionals, together with initiatives to increase public awareness of ACP so that patients themselves might be more inclined to start the discussion, may help increase the uptake of ACP for this patient group.
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Affiliation(s)
| | | | - Tony Foley
- School of Medicine, University College Cork, Cork, Ireland
| | - Elaine Lehane
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | | | - Ruth M Hally
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | | | - Bettina Korn
- Hospice Friendly Hospital Programme, St. James's Hospital, Dublin, Ireland
| | - Mary Rabbitte
- All Ireland Institute of Hospice and Palliative Care, Dublin, Ireland
| | - Karen Margaret Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
- Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Nicola Cornally
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
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Risk J, Mohammadi L, Rhee J, Walters L, Ward PR. Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis. BMJ Open 2019; 9:e030275. [PMID: 31537570 PMCID: PMC6756326 DOI: 10.1136/bmjopen-2019-030275] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice? DESIGN A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting. SETTING Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews. RESULTS The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging. CONCLUSION Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice. PROSPERO REGISTRATION NUMBER CRD42018088838.
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Affiliation(s)
- Jo Risk
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Leila Mohammadi
- Library, Flinders University, Adelaide, South Australia, Australia
| | - Joel Rhee
- General Practice Academic Unit, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Lucie Walters
- Rural Health, Flinders University, Adelaide, South Australia, Australia
| | - Paul R Ward
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Nassikas NJ, Baird GL, Duffy CM. Improving Advance Care Planning in a Resident Primary Care Clinic. Am J Hosp Palliat Care 2019; 37:185-190. [PMID: 31476887 DOI: 10.1177/1049909119872757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Two-thirds of chronically ill patients do not have an advance directive. The primary aim of this study was to develop an intervention to increase the documentation of advance directives in elderly adults in an internal medicine resident primary care clinic. The secondary aims were to improve resident confidence in discussing advance care planning and increase the number of discussions. METHODS The study was a pre- and postintervention study. The study intervention was a 30-minute educational session on advance care planning. Study participants were patients aged 65 years and older who were seen in an internal medicine residency primary care clinic over a 6-month period and internal medicine residents. Clinic encounters were reviewed for the presence of advance care planning discussions before and after the intervention. Resident confidence was measured on a Likert scale. RESULTS Two hundred ninety-five eligible patients were seen in the clinic from January 1, 2017, to June 30, 2017, and included in the analysis performed between 2017 and 2018. The mean number of documented advance care planning discussions increased from 2.24 (95% confidence interval [CI]: 1.0-4.9) during the preintervention period to 8.94 (95% CI: 5.94-13.24]) during the postintervention period (P = .0011). Following the intervention, residents overall reported increased confidence in discussing advance care planning. CONCLUSION A relatively modest intervention to increase advance care planning discussions is feasible in an internal medicine primary care clinic and can improve the confidence of residents with end-of-life discussion.
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Affiliation(s)
- Nicholas J Nassikas
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Grayson L Baird
- Lifespan Biostatistics Core, Rhode Island Hospital, Providence, RI, USA
| | - Christine M Duffy
- Department of Medicine, Warren Alpert Medical School, Providence, RI, USA
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Parikh M, Rajendran I, D'Amico S, Luo M, Gardiner P. Characteristics and Components of Medical Group Visits for Chronic Health Conditions: A Systematic Scoping Review. J Altern Complement Med 2019; 25:683-698. [PMID: 30945935 DOI: 10.1089/acm.2018.0524] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objectives: Chronic health conditions are a major challenge to the health care system. Medical Group Visits (MGVs) are a valuable health care delivery model used in a variety of medical settings and patient populations. We conducted a systematic scoping review of MGV research literature for chronic health conditions to summarize the characteristics and individual components of MGVs in the United States of America and Canada. Design: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review methodology and searched five databases using nine widely used MGV-related terms. Subjects: We included studies conducted in the United States and Canada, whose participants were >18 years old and attended an MGV conducted in a medical setting by a billable health care provider. We excluded groups related to diabetes, pregnancy, and cancer. Results: Of 3777 studies identified, we found 55 eligible studies of which 9 are randomized controlled trials and 46 are observational studies. The majority of studies were conducted in academic medical centers, were observational in design, and recruited patients using physician referrals. The three most frequently studied groups include a combination of several chronic conditions (n = 12), chronic pain conditions (n = 10), and cardiovascular disease (n = 9). Curriculum components included didactics (n = 55), experiential activities (n = 27), and socializing components (n = 12). Didactic areas include (1) medical topics such as symptoms management (n = 27) of which 14 included pain management, and (2) lifestyle/educational component (n = 33) that comprised of talks on nutrition (n = 29), exercise (n = 20), stress (n = 16), and sleep (n = 10). The top integrative medicine (IM) modalities (n = 13) included: mindfulness techniques (n = 8), meditation (n = 6), and yoga (n = 5). Substantial heterogeneity was observed in the recruitment, implementation, curriculum components, and outcomes reported. Conclusion: The MGV is a model of patient-centered care that has captured the attention of researchers. IM modalities are well represented in the curriculum components of MGVs. Further investigation into the components identified by this study, may help in better targeting of group interventions to patients and contexts, where it is most likely to be effective.
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Affiliation(s)
- Manasi Parikh
- 1Department of Family Medicine and Boston Medical Center, Boston, MA
| | - Iniya Rajendran
- 2Department of Internal Medicine, Boston Medical Center, Boston, MA
| | - Salvatore D'Amico
- 1Department of Family Medicine and Boston Medical Center, Boston, MA
| | - Man Luo
- 1Department of Family Medicine and Boston Medical Center, Boston, MA
| | - Paula Gardiner
- 3Department of Family Medicine and Community Health, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, MA
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Fahner JC, Beunders AJ, van der Heide A, Rietjens JA, Vanderschuren MM, van Delden JJ, Kars MC. Interventions Guiding Advance Care Planning Conversations: A Systematic Review. J Am Med Dir Assoc 2019; 20:227-248. [DOI: 10.1016/j.jamda.2018.09.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/11/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022]
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Hall CC, Lugton J, Spiller JA, Carduff E. CPR decision-making conversations in the UK: an integrative review. BMJ Support Palliat Care 2019; 9:1-11. [PMID: 30108041 PMCID: PMC6579491 DOI: 10.1136/bmjspcare-2018-001526] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/26/2018] [Accepted: 07/11/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) discussions with patients and their caregivers have been subjected to intense ethical and legal debate in recent years. Legal cases and national guidelines have tried to clarify the best approach to DNACPR discussions; however, there is little evidence of how best to approach them from the patient, family or caregiver perspective. This paper describes published accounts of patient, family and caregiver experiences of discussions about advance cardiopulmonary resuscitation (CPR) decision making. METHODS An integrative review of the UK literature between 2000 and 2016 including qualitative and quantitative studies was conducted. Worldwide, 773 abstracts were identified, and 20 papers from the UK were included in the final analysis. RESULTS Patient, family and caregivers prefer discussions to be initiated by someone trusted, and wishes for family involvement vary depending on the context. Timing of discussions should be individualised, though discussions earlier in the illness are often preferable. Discussions held in the acute setting are suboptimal. CPR decisions should be part of a wider discussion about future care and adequate communication skills training is important. CONCLUSIONS The findings of this review are at odds with the current statutory framework and potentially challenging for medical professionals who are working in a stretched health service, with pressure to discuss DNACPR decisions at the earliest opportunity. With increasing focus on person-centred care and realistic medicine, patient narratives must be considered by doctors and policy makers alike, to minimise harm.
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Lum HD, Barnes DE, Katen MT, Shi Y, Boscardin J, Sudore RL. Improving a Full Range of Advance Care Planning Behavior Change and Action Domains: The PREPARE Randomized Trial. J Pain Symptom Manage 2018; 56:575-581.e7. [PMID: 29940209 PMCID: PMC6138565 DOI: 10.1016/j.jpainsymman.2018.06.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 12/15/2022]
Abstract
CONTEXT Advance care planning (ACP) engagement includes a wide range of behaviors and actions related to discussions and documentation, yet few ACP intervention studies measure the full process. OBJECTIVES The objective of the study was to compare the effects of an easy-to-read advance directive (AD) versus an ACP web site plus the AD (PREPARE + AD) on Behavior Change Processes and Actions, including discussions and documentation. METHODS Secondary data were from a completed ACP trial. Participants were primary care patients, ≥60 years old, with two comorbidities. We used the validated ACP Engagement Survey to examine six-month change in subscales measuring Behavior Change Processes (knowledge, contemplation, self-efficacy, readiness) and Actions (decision makers, quality of life, flexibility for decision makers, asking clinicians questions), specifically related to discussions and documentation. We used adjusted mixed-effects linear models to compare mean change and engagement over time. RESULTS Compared to the AD-only, PREPARE + AD resulted in greater increases in all Behavior Change Processes subscales and Actions related to decision makers, quality of life, and flexibility (all P-values ≤0.005). Both interventions significantly increased the proportion of participants who engaged in ACP discussions (PREPARE + AD, 99.5%; AD-only, 93.3%) and documentation (PREPARE + AD, 99.5%; AD-only, 90.4%), with greater increases for PREPARE + AD (all P-values <0.001). CONCLUSION Both PREPARE plus an easy-to-read AD and an AD-only markedly increased ACP engagement in a full range of ACP behaviors, including discussions and documentation, and engagement was nearly 100% with PREPARE + AD. Future ACP studies should examine a full range of ACP behaviors beyond ADs and the impact of PREPARE and easy-to-read AD implementation on health care systems.
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Affiliation(s)
- Hillary D Lum
- Eastern Colorado VA Geriatric Research Education and Clinical Center, Denver, Colorado, USA; Division of Geriatric Medicine, Department of Medicine, University of Colorado, Aurora, Colorado, USA.
| | - Deborah E Barnes
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA; Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Mary T Katen
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Ying Shi
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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Brisebois A, Ismond KP, Carbonneau M, Kowalczewski J, Tandon P. Advance care planning (ACP) for specialists managing cirrhosis: A focus on patient-centered care. Hepatology 2018; 67:2025-2040. [PMID: 29251778 DOI: 10.1002/hep.29731] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/28/2017] [Accepted: 12/11/2017] [Indexed: 01/07/2023]
Abstract
UNLABELLED Advance care planning (ACP) and goals of care designation (GCD) are being integrated into modern health care. In cirrhosis, uptake and adoption of these practices have been limited with physicians citing many perceived barriers and limitations. Recognizing the many tangible benefits of ACP and GCD processes in patients with life-limiting chronic diseases, the onus is on health practitioners to initiate and direct these conversations with their patients and surrogates. Drawing upon the literature and our experiences in palliative care and cirrhosis, we provide an actionable framework that can be readily implemented into a busy clinical setting by a practitioner. Conversation starters, visual aids, educational resources (for patients and practitioners), and videos of mock physician-patient scenarios are presented and discussed. Importantly, we have customized each of these tools to meet the unique health care needs of patients with cirrhosis. The inherent flexibility of our approach to ACP discussions and GCD can be further modified to accommodate practitioner preferences. CONCLUSION In our clinics, this assemblage of "best practice tools" has been well received by patients and surrogates enabling us to increase the number of outpatients with cirrhosis who have actively contributed to their GCD before acute health events and are supported by well-informed surrogates. (Hepatology 2018;67:2025-2040).
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Affiliation(s)
- Amanda Brisebois
- Division of General Internal Medicine, Department of Medicine and Division of Palliative Care, Department of Oncology, University of Alberta, Edmonton, AB, Canada.,PPRISM Non-Cancer Palliative Care Clinic, Edmonton, AB, Canada
| | - Kathleen P Ismond
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,CEGIIR, University of Alberta, Edmonton, AB, Canada
| | - Michelle Carbonneau
- University of Alberta Hospital, Edmonton, AB, Canada.,Cirrhosis Care Clinic, Edmonton, AB, Canada
| | | | - Puneeta Tandon
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,CEGIIR, University of Alberta, Edmonton, AB, Canada.,Cirrhosis Care Clinic, Edmonton, AB, Canada
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Strategies used to facilitate the discussion of advance care planning with older adults in primary care settings: A literature review. J Am Assoc Nurse Pract 2018; 30:270-279. [DOI: 10.1097/jxx.0000000000000025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zapata C, Lum HD, Wistar E, Horton C, Sudore RL. Feasibility of a Video-Based Advance Care Planning Website to Facilitate Group Visits among Diverse Adults from a Safety-Net Health System. J Palliat Med 2018; 21:853-856. [PMID: 29461918 DOI: 10.1089/jpm.2017.0476] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Primary care providers in safety-net settings often do not have time to discuss advance care planning (ACP). Group visits (GV) may be an efficient means to provide ACP education. OBJECTIVES To assess the feasibility and impact of a video-based website to facilitate GVs to engage diverse adults in ACP. DESIGN Feasibility pilot among patients who were ≥55 years of age from two primary care clinics in a Northern California safety-net setting. Participants attended two 90-minute GVs and viewed the five steps of the movie version of the PREPARE website ( www.prepareforyourcare.org ) concerning surrogates, values, and discussing wishes in video format. Two clinician facilitators were available to encourage participation. MEASUREMENTS We assessed pre-to-post ACP knowledge, whether participants designated a surrogate or completed an advance directive (AD), and acceptability of GVs and PREPARE materials. RESULTS We conducted two GVs with 22 participants. Mean age was 64 years (±7), 55% were women, 73% nonwhite, and 55% had limited literacy. Knowledge improved about surrogate designation (46% correct pre vs. 85% post, p = 0.01) and discussing decisions with others (59% vs. 90%, p = 0.01). Surrogate designation increased (48% vs. 85%, p = 0.01) and there was a trend toward AD completion (9% vs. 24%, p = 0.21). Participants rated the GVs and PREPARE materials a mean of 8 (±3.1) on a 10-point acceptability scale. CONCLUSIONS Using the PREPARE movie to facilitate ACP GVs for diverse adults in safety net, primary care settings is feasible and shows potential for increasing ACP engagement.
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Affiliation(s)
- Carly Zapata
- 1 Division of Hospital Medicine, Department of Medicine, University of California , San Francisco, California
| | - Hillary D Lum
- 2 VA Eastern Colorado Geriatric Research Education and Clinical Center (GRECC) , Denver, Colorado.,3 Division of Geriatric Medicine, Department of Medicine, University of Colorado , Aurora, Colorado
| | - Emily Wistar
- 4 Caleb G. Clark Potrero Hill Health Center , Department of Public Health, San Francisco, California.,5 Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California , San Francisco, California
| | - Claire Horton
- 5 Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California , San Francisco, California
| | - Rebecca L Sudore
- 6 Division of Geriatrics, Department of Medicine, University of California , San Francisco, California.,7 San Francisco Veterans Affairs Medical Center , San Francisco, California
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Walker E, McMahan R, Barnes D, Katen M, Lamas D, Sudore R. Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety. J Pain Symptom Manage 2018; 55:256-264. [PMID: 28943360 PMCID: PMC5794631 DOI: 10.1016/j.jpainsymman.2017.09.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Documenting patients' advance care planning (ACP) wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about ACP documentation practices in the electronic health record. OBJECTIVES The objective of this study was to describe ACP documentation practices and the accessibility of documented discussions in the electronic health record. METHODS Participants were primary care patients at the San Francisco Veterans Affairs Medical Center, were ≥60 years old, and had ≥2 chronic/serious health conditions. In this cross-sectional study, we assessed the prevalence of ACP documentation, including any legal forms/orders and discussions in the prior five years. We also determined accessibility of discussions (i.e., accessible centralized posting vs. inaccessible free text in progress notes). RESULTS The mean age of 414 participants was 71 years (SD ± 8), 9% were women, 43% were nonwhite, and 51% had documented ACP including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders lacked accompanying explanatory documentation. Most (55%) discussions were not easily accessible, including 70% of those documenting changes in treatment preferences from prior forms/orders. CONCLUSION Half of chronically ill, older participants had documented ACP, including one-third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying documented explanatory discussions, and the majority of documented discussions were not easily accessible, even when wishes had changed. Ensuring that patients' preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients' wishes are honored.
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Affiliation(s)
- Evan Walker
- Department of Medicine, UCSF, San Francisco, California.
| | - Ryan McMahan
- UCSF School of Medicine, San Francisco, California
| | - Deborah Barnes
- San Francisco Veterans Affairs Medical Center, San Francisco, California; Department of Psychiatry, UCSF, San Francisco, California; Department of Epidemiology & Biostatistics, UCSF, San Francisco, California
| | - Mary Katen
- Division of Geriatrics, Department of Medicine, UCSF, San Francisco, California
| | - Daniela Lamas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
| | - Rebecca Sudore
- San Francisco Veterans Affairs Medical Center, San Francisco, California; Division of Geriatrics, Department of Medicine, UCSF, San Francisco, California
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Arnett K, Sudore RL, Nowels D, Feng CX, Levy CR, Lum HD. Advance Care Planning: Understanding Clinical Routines and Experiences of Interprofessional Team Members in Diverse Health Care Settings. Am J Hosp Palliat Care 2017; 34:946-953. [PMID: 27599724 PMCID: PMC5851789 DOI: 10.1177/1049909116666358] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Interprofessional health care team members consider advance care planning (ACP) to be important, yet gaps remain in systematic clinical routines to support ACP. A clearer understanding of the interprofessional team members' perspectives on ACP clinical routines in diverse settings is needed. METHODS One hundred eighteen health care team members from community-based clinics, long-term care facilities, academic clinics, federally qualified health centers, and hospitals participated in a 35-question, cross-sectional online survey to assess clinical routines, workflow processes, and policies relating to ACP. RESULTS Respondents were 53% physicians, 18% advanced practice nurses, 11% nurses, and 18% other interprofessional team members including administrators, chaplains, social workers, and others. Regarding clinical routines, respondents reported that several interprofessional team members play a role in facilitating ACP (ie, physician, social worker, nurse, others). Most (62%) settings did not have, or did not know of, policies related to ACP documentation. Only 14% of settings had a patient education program. Two-thirds of the respondents said that addressing ACP is a high priority and 85% felt that nonphysicians could have ACP conversations with appropriate training. The clinical resources needed to improve clinical routines included training for providers and staff, dedicated staff to facilitate ACP, and availability of patient/family educational materials. CONCLUSION Although interprofessional health care team members consider ACP a priority and several team members may be involved, clinical settings lack systematic clinical routines to support ACP. Patient educational materials, interprofessional team training, and policies to support ACP clinical workflows that do not rely solely on physicians could improve ACP across diverse clinical settings.
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Affiliation(s)
- Kelly Arnett
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, University of California, San Francisco, CA, USA
- San Francisco VA Medical Center, San Francisco, CA, USA
| | - David Nowels
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cindy X. Feng
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Cari R. Levy
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Denver-Seattle Center for Veteran-centric and Value-driven Research (DiSCoVVR), Denver, CO, USA
| | - Hillary D. Lum
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
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Robinson MT, Holloway RG. Palliative Care in Neurology. Mayo Clin Proc 2017; 92:1592-1601. [PMID: 28982489 DOI: 10.1016/j.mayocp.2017.08.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 07/25/2017] [Accepted: 08/07/2017] [Indexed: 12/12/2022]
Abstract
Palliative medicine is a specialty that focuses on improving the quality of life for patients with serious or advanced medical conditions, and it is appropriate at any stage of disease, including at the time of diagnosis. Neurologic conditions tend to have high symptom burdens, variable disease courses, and poor prognoses that affect not only patients but also their families and caregivers. Patients with a variety of neurologic conditions such as Parkinson disease, dementia, amyotrophic lateral sclerosis, brain tumors, stroke, and acute neurologic illnesses have substantial unmet needs that can be addressed through a combination of primary and specialty palliative care. The complex needs of these patients are ideally managed with a comprehensive approach to care that addresses the physical, psychological, social, and spiritual aspects of care in an effort to reduce suffering. Early discussions about prognosis, goals of care, and advance care planning are critical as they can provide guidance for treatment decisions and allow patients to retain a sense of autonomy despite progressive cognitive or functional decline. With the rapid growth in palliative care across the United States, there are opportunities to improve the palliative care knowledge of neurology trainees, the delivery of palliative care to patients with neurologic disease by both neurologists and nonneurologists, and the research agenda for neuropalliative care.
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Affiliation(s)
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
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Bauer NS, Azer N, Sullivan PD, Szczepaniak D, Stelzner SM, Downs SM, Carroll AE. Acceptability of Group Visits for Attention-Deficit Hyperactivity Disorder in Pediatric Clinics. J Dev Behav Pediatr 2017; 38:565-572. [PMID: 28816910 PMCID: PMC5657442 DOI: 10.1097/dbp.0000000000000492] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Children with attention-deficit hyperactivity disorder (ADHD) have ongoing needs that impair home and school functioning. Group visit models are a promising way to deliver timely parenting support but family and provider acceptance has not previously been examined. The objective was to describe the acceptability of ADHD group visits in busy pediatric clinics based on caregivers, child participants and facilitators. METHODS Data were analyzed from school-age children and caregivers who participated in one of two 12-month long randomized controlled studies of the ADHD group visit model from 2012 to 2013 or 2014 to 2015. Feedback was obtained using semi-structured questions at each study end, by telephone or at the last group visit. Sessions were audio-recorded, transcribed and themes were extracted by participant type. RESULTS A total of 34 caregivers, 41 children and 9 facilitators offered feedback. Caregivers enjoyed the "support group" aspect and learning new things from others. Caregivers reported improved understanding of ADHD and positive changes in the relationship with their child. Children were able to recall specific skills learned including how skills helped at home or school. Facilitators acknowledged systems-level challenges to offering group visits but felt the group format helped increase understanding of families' needs, improved overall care, and provided innovative ways to engage with families. CONCLUSION The majority of comments from families and facilitators highlighted a variety of benefits of the use of a group visit model for ADHD chronic care. Despite systems-level barriers to implementation, families and facilitators felt the benefits outweighed the challenges.
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Affiliation(s)
- Nerissa S. Bauer
- Department of Pediatrics, Indiana University School of Medicine, Section of Children’s Health Services Research, Indianapolis, IN
- Center for Health Services Research, Regenstrief Institute Inc., Indianapolis, IN
| | - Nina Azer
- Department of Pediatrics, University of Kentucky, Lexington, KY
| | - Paula D. Sullivan
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Dorota Szczepaniak
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Stephen M. Downs
- Department of Pediatrics, Indiana University School of Medicine, Section of Children’s Health Services Research, Indianapolis, IN
- Center for Health Services Research, Regenstrief Institute Inc., Indianapolis, IN
| | - Aaron E. Carroll
- Center for Health Services Research, Regenstrief Institute Inc., Indianapolis, IN
- Department of Pediatrics, Indiana University School of Medicine, Section of Pediatric and Adolescent Comparative Effectiveness Research, Indianapolis, IN
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Dukes J, Brungardt A, Lum HD. Using Group Visits To Teach Residents About Advance Care Planning. J Palliat Med 2017; 20:1187-1188. [PMID: 28792789 DOI: 10.1089/jpm.2017.0306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joanna Dukes
- 1 Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine , Aurora, Colorado
| | - Adreanne Brungardt
- 1 Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine , Aurora, Colorado
| | - Hillary D Lum
- 1 Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine , Aurora, Colorado
- 2 Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center , Denver, Colorado
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Landa V, García J. Dissemination of advanced directives as a tool to promote health in death and grief / La difusión del documento de voluntades anticipadas como una herramienta de promoción de la salud en muerte y duelo. STUDIES IN PSYCHOLOGY 2017. [DOI: 10.1080/02109395.2017.1334352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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A Group Visit Initiative Improves Advance Care Planning Documentation among Older Adults in Primary Care. J Am Board Fam Med 2017; 30:480-490. [PMID: 28720629 PMCID: PMC5711729 DOI: 10.3122/jabfm.2017.04.170036] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 02/08/2017] [Accepted: 02/13/2017] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Group visits for advance care planning (ACP) may help patients document preferences for decision makers and future care. We assessed the impact of a primary care-based ACP group visit (ACP-GV) intervention on older adults' ACP documentation and why patients participated. METHODS Older adults (>65 years) in primary care participated in a 2-session ACP-GV intervention that promotes group dynamics, peer-based learning, and goal setting. Charts were reviewed at baseline, 3 months, and 12 months for documentation of decision makers and ACP forms. We described patients' reasons for participating through analysis of transcripts. RESULTS 118 patients (mean age 76 years; 62% female and 82% white) participated in 16 ACP-GV cohorts. From baseline to 3-month follow-up, documentation of decision maker preferences increased from 39% to 81%, and was 89% at 12-month follow-up. Patients with completed ACP forms increased from 20% to 57% at 3 months, and was 67% at 12 months. Reasons for participating included recognizing the importance of ACP, curiosity, participation recommended by primary care provider, desire to talk with family/friends, and desire to complete advance directives. CONCLUSIONS This ACP-GV intervention increased ACP documentation among patients with diverse reasons for participating. This is a patient-centered approach to ACP in primary care.
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Stange KC. In This Issue: Confronting Constraints on Individual Behavior & Outcomes. Ann Fam Med 2016; 14:98-9. [PMID: 27386619 PMCID: PMC4781507 DOI: 10.1370/afm.1925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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