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Want to boost your number of advance directives?

January 2015
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Published in the January 2015 issue of Today’s Hospitalist

JUST OVER A YEAR AGO, the University of Florida Medical Center at Gainesville realized that very few of its hospitalized patients had completed advance directives. Even for those who had, the hospitalists at the 900-bed facility had trouble locating those directives in the electronic health record.

As a result, clinicians often lacked vital information about what patients wanted in terms of end-of-life care or surrogate decision-making. That meant that aggressive care was often continued, even for nursing-home patients with chronic hospital readmissions.

“We did a great job asking patients if they had an advance directive because regulatory bodies require us to ask,” says Anthony Clarizio, a co-chair of what is now UF Health’s Community wide Advance Directives Initiative, a project set up two years ago to tackle the issue. Where the system fell short was in not consistently collecting an advance directive from patients who had one or not offering patients and families the opportunity to complete or update one.

At the same time, UF providers realized that “talking with patients at the hospital about completing an advance directive wasn’t ideal because there is so much going on,” Mr. Clarizio adds, particularly when clinicians have no training in end-of-life discussions. Before the initiative, the percentage of hospitalized patients with completed advance directives on file was about 6%. Today, the rate of completion with directives entered in the EHR has jumped to 15%.

While those figures are still low, members of the initiative are working to engage more patients on end-of-life issues through community outreach, Web site modifications and staff training. Those interventions ” and others to be rolled out this year “have all been designed to build a culture in which discussing advance directives is an integral part of patient care.

EHR modifications
To launch its advance-directive initiative, the health system convened a multidisciplinary team of 40 different providers from throughout the organization and the community. Mr. Clarizio, for example, is executive director of ElderCare of Alachua County, the lead community organization for senior services.

In planning an ambitious project, the system had a lot going for it. For one, University of Florida Medical Center at Gainesville is part of UF Health, which encompasses several hospitals and outpatient clinics, as well as affiliated home care agencies and post-acute facilities. Many inpatient and outpatient locations share the same electronic health record, and UF Health providers who work in local nursing homes can access that record remotely.

But the EHR “and UF Health’s Web site “both needed to be modified. When the initiative began, for instance, copies of advance directives were filed under a media tab in the EHR, intermingled with many other types of forms.

“That didn’t make it easy for providers to pull up an advance directive and know what patients wanted,” Mr. Clarizio points out. The fix was for the IT department, working with the project team, to create a unique electronic prefix for advance directives.

“That prefix sorts advance directives into their own subcategory within the media tab,” he explains. “Now, we just click on a box.”

The downloadable advance directive form on the system Web site was also redesigned. “We revised our advance directive to make it easier and less legalistic, with Spanish on the back, so it’s friendlier,” says Sheri Kittelson, MD, a hospitalist at UF Health who directs the palliative care program launched last year. The Web site also now features a video to teach patients about the importance of advance directives and how to complete a living will and designate a surrogate decision-maker.

Training the trainers
The initiative has also made a major push with community outreach. To get the word out about the revised advance-directive Web site, an educational campaign was rolled out at a high-traffic local senior center and an oncology clinic.

Another ongoing project component is having palliative care resource nurses work with patients, families and staff throughout the academic center. Those nurses, who have received training from an end-of-life nursing education consortium, are experts in advance directives and in state laws and policies.

UF Health is also developing a program to “train the trainers” who will implement advance directives in their respective clinic or inpatient unit. Helping trainers feel comfortable with difficult end-of-life conversations is essential in academic settings, Dr. Kittelson says, because those centers have such high provider turnover.

“We’ll need to have ongoing educational efforts with multiple tools, from written literature to technology,” she says.

As part of that program, UF Health is implementing a survey to gauge how comfortable trainers feel pre- and post-training with end-of-life discussions.

“Our goal is to enhance those practitioners’ comfort level,” says Anne Meiring, UF Health’s patient experience improvement specialist and the initiative co-chair. “Not everyone is comfortable with these conversations, so the surveys will help us gauge how effective our training is and identify people in each clinic or unit who might be the most reliable.”

A major investment
Another major initiative development: last January’s launch of UF Health’s palliative care program. Dr. Kittelson is one of eight hospitalists who now work part time delivering palliative care.

Since the program was founded, the number of consults has doubled. (Dr. Kittleson notes that the three-year-old palliative care program at UF Health Jacksonville has an advance-directive completion rate of 86%.) As part of her job as program director, she meets regularly with representatives from UF Health’s local nursing homes and hospice providers.

“We’re standardizing the transfer process so patients going to SNFs carry with them a code status and an advance directive,” Dr. Kittelson notes. Standardizing advance directives and DNRs for SNF patients, she points out, can decrease hospital readmissions.

In working with nursing homes, UF Health was able to leverage an NIH grant given to a local agency on aging to promote better transitional care and fewer readmissions. In addition, UF Health has invested nearly $1 million to support the advance-directives initiatives as a foundation of its palliative care program.

“It was our CMO and chief quality officer who asked us to start this initiative,” says Ms. Meiring. “We have critical backing from them to make sure the project is sustained.”

The system plans to develop electronic reminders for patients, urging them to complete and bring advance directives to their annual physicals. Also being developed: call-center scripts about advance directives that will be used when patients first enter the health system. Plus, the UF College of Medicine is launching a two-year palliative care educational program across all disciplines.

“We’ve done a great job setting an internal foundation for how to target community outreach and handle all these interventions,” says Mr. Clarizio. “But we’ve just scratched the surface.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.