Advance Care Planning in Rural Primary Care Practice

Advance Care Planning in Rural Primary Care Practice: A Quality Improvement Project NAOMI OLSON DOCTORAT E OF NURSE PRACT ITIO NER CANDIDAT E CREIG HTON U NIVERSITY COLLEG E OF NURS ING

Background Advance care directives were first endorsed in 19761 Patient Self-Determination Act, passed in 19901 By 2030 there will be about 72. 1 million people over the age of 65 2 The United States has 46. 2 million rural residents that reside in 72% of the nation's land 3 In 2006, of all the adults 60+ served by the Area Agency on Aging in Nebraska, 76% were living in rural areas 4

Background Continued Only about 18% to 36% of adults in the United States have advance care directives, of these only one third of providers are aware of plans 5 More than 25% of health care dollars spent in an American’s life span is spent in the final months of their life 2 Increasing the number of completed advance care directives could help decrease the amount of money spent in these situations Primary care providers have an opportunity to discuss plans for health care across the lifespan

Significance Quantity of life or years of life < quality of life Public health issue because of the potential to avert preventable distress 6 Reimbursement for counseling of advance care planning 6 Health People 20207

Clinical Problem Growing aging population Large population of aging adults in the rural setting Lack of awareness and communication between providers and patients Primary care providers must address this clinical problem and educate and discuss the topic of advance care directives with their patients.

Purpose The purpose of this quality improvement project is to implement an educational program in a rural primary care setting about advanced directives. Two specific aims: ◦ 1) to educate primary care providers and to provide an avenue for the initiation of a discussion about advances directives with their patients, and ◦ 2) to educate patients and to provide a means to communicate their needs with their primary care provider.

Theoretical Framework Patient education through caring and dialogue ◦ Rhea Sanford’s middle range theory 6 Caring Dialogue

Literature Review Cases studies (level 5) to randomized control trials (level 1) MEDLINE and CINAHL ◦ advance directives, advance care planning, rural, primary care, end of life care, education and rural healthcare Good Death Barriers to Implementation of Advance Care Directives Rural Barriers Interventions for Completing Advance Care Directives

Rural Barriers for Advance Care Directives Triple jeopardy ◦ growing old ◦ remote area ◦ fewer local health services and care providers Fewer resources ◦ lawyers

Methods Quality improvement project Pre-intervention provider interview Brochures in exam rooms Track Medicare Wellness visits pre and post intervention

Setting, Population, and Sample Satellite clinic of academic hospital ◦ Grand Island, Nebraska Patients 65 > Medicare insurance -wellness appointments August 2016 to October 30, 2016 Convenience sample Exclusion: ◦ ◦ Patients <65 Patients over the age of 65 with an existing advance care directive Patients attending appointments that are cognitively impaired without the presence of family Patients that are currently enrolled in a palliative care or hospice program

Provider Questionaire Provider Questionnaire What percentage of your patients do you discuss advance care directives with? 1: (0 -25%) 2: (26 -50%) 3: (51 -75%) 4: (>75%) What percentage of your patients have advance care directives? 1: (0 -25%) 2: (26 -50%) 3: (51 -75%) 4: (>75%) What barriers do you experience to completing advance care directives with your patients? 1: time barriers 2: lack the necessary training 3: patients aren’t ready 4: other How comfortable are you discussing advance care directives with patients? 1: very comfortable 2: comfortable 3: uncomfortable 4: very uncomfortable Are you aware there is a CPT code for Medicare billing when discussing advance care directives? 1: yes 2: no What resources would be helpful to you in discussing advance care directives with patients? Additional Comments:

Advance Directive Brochure

Data Collection and Analysis Number of advance care directives with use of brochure ◦ Compared with a retrospective study of Advance Care Directives Descriptive statistics and qualitative analysis ◦ provider responses to questionnaire

Results- Survey Demographics 5/8 providers seeing Wellness patients responded to survey ◦ one Nurse Practitioner and four Physicians participated ◦ Two females, three males ◦ 40% have been practicing for >10 years

Survey Results 40% of participating providers estimated that between 26 -50% of their patients already had completed advance directives Patients with AD Discuss AD 0 0, 5 >75% 1 51 -75% 1, 5 26 -50% 2 0 -25% 2, 5 3 3, 5

Survey Results other Time Patients aren't ready

Intervention Results 5 5 4 1 Pre intervention AD discussed No AD discussion Post intervention

Discussion Participation was limited Participants excited to discuss the topic- need for improvement Transition of the clinic 3 -month intervention period resulted in a greater than 33% increase in advance directive discussion and completion of documentation Caring through dialogue is an effective strategy for this topic

Clinical Implications Insight to the barriers affecting advance directive completion Reveals a successful method for facilitation of advance directive discussion Many providers discussed need for outpatient clinic for this topic

DNP Essentials Met Essential I: Scientific Underpinnings for Practice Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health Essential VIII: Advanced Nursing Practice

References 1. Library of Congress. H. R. 4449 - 101 st Congress (1989 -1990): Patient Self Determination Act of 1990 | Congress. gov | https: //www. congress. gov/bill/101 st-congress/house-bill/4449. Accessed February 2, 2017. 2. Morhaim DK, Pollack KM. End-of-life care issues: A personal, economic, public policy, and Journal of Public Health. 2013; 103(6). doi: 10. 2105/ajph. 2013. 301316. public health crisis. American 3. Ashcraft AS, Owen DC. End-of-life planning in a rural elderly cohort. Geriatric Nursing. 2016; 37(1): 71 -74. doi: 10. 1016/j. gerinurse. 2015. 11. 009. 4. Nebraska Department of Health and Human Services. Aging. Home. 2007. http: //dhhs. ne. gov/medicaid/aging/Pages/Aging. Home. aspx. Accessed February 2, 2017. 5. Nelson JM, Nelson TC. Advance directives. The Nurse Practitioner. 2014; 39(11): 34 -40. doi: 10. 1097/01. npr. 0000454979. 98327. 89. 6. Centers for Disease Control and Prevention. Advance care planning: Ensuring your wishes are known and unable to speak for yourself. 2010. honored if you are http: //www. cdc. gov/aging/pdf/advanced-care-planning-critical-issue-brief. pdf. Accessed June 13, 2014. 7. United States Department of Health and Human Services. Older adults | Healthy People 2020. http: //www. healthypeople. gov/2020/topicsobjectives 2020/overview. aspx? topicid=31. Accessed February 8. Sanford RC. Caring through Relation and Dialogue: A Nursing Perspective for Patient Education. Advances in 2000; 22(3): 1 -15. doi: 10. 1097/00012272 -200003000 -00002. 2, 2017. Nursing Science.

Questions, Comments, and Recommendations Thank you for your time!

Acknowledgements Thank you to my committee members for all of you time and effort! A special thanks to my committee chair, Dr. Todd §Chelsea Enninga, MSN, APRN, GNP-BC, FNP-BC, ACHPN CHI Health St. Francis Supportive Care §Kandis L. Mc. Cafferty Ph. D, RNC-OB, C-EFM Assistant Professor, Creighton University College of Nursing §Martha Todd, Ph. D, APRN-NP Associate Professor, College of Nursing