Advanced Care Planning : Who, What, When, Where, Why Dr. Tom ONeil Assistant Professor Department of Family Medicine Department of Internal Medicine University of Michigan Disclosure
I have no outside financial disclosures relevant to todays presentation I am Medical Director for Arbor Hospice Goals and Objectives Recognize accepted and available forms of advanced care planning Identify benefits to initiating and completing advanced care planning in the outpatient setting
Identify available tools and resources to aid in prognostication Know how to initiate advanced care planning discussions in clinic Review billing and coding issues related to Advanced Care Planning What?
What is Advanced Care Planning? A process of reflection and discussion between a patient, his or her family, and the health care providers for the purpose of clarifying values, treatment preferences, and goals of end of life care. Designed to protect patient autonomy More than a conversation
Durable Power of Attorney Health Care DPOA HC Designate a surrogate decision maker Active once patient lacks capacity or unable to speak for oneself Living Will Delineates specific medical therapies one would or would not want.
CPR, Ventilator, Dialysis, artificial hydration, etc. Advises physician and surrogate 5 Wishes Living Will document published and sold by Aging with Dignity Structures ACP conversation to 5 wishes Who would you want to make decisions
The type of medical treatment you do or do not want How comfortable you want to be How you want people to treat you What you want your loved ones to know https://www.agingwithdignity.org/five-wishes.php Prepare for your care.org Free online program through Geriatrics at UCSF
Aides in creating Living Will and DPOA document User friendly https://prepareforyourcare.org/ UM Forms
DPOA Form Living will form End of life plans Out of hospital DNR form Free!
http://uofmhealthsystem.org/documents/adult/ AdvanceDirectiveBooklet.pdf The Power of a Form Extent of Power differs state by state In states with a Living Will statute a living will be a legal document to can speak for itself. Michigan does not have a living will statute DPOA supersedes Living Will in preferences
POLST / MOLST Physician / Medical Orders for Life Sustaining Treatment Translate goals of care into medical orders Given my current medical condition I do or do not want Medical Orders
A.D.s and POLST Bomba, R et al. POLST: An improvement over traditional advanced directives. Cleve Clin J Med 2012; 79: 457-464 Who? Who needs ACP? Terminally Ill
Chronically Ill Leading causes of death in US
Heart Disease - #1 COPD - #3 Cerebrovascular Disease - #4 Alzheimer's Disease - #6 Diabetes Mellitus - #7 End Stage Renal Disease - #8 All adults over age 18
1990 Patient Self Determination Act All Medicare institutions must provide patients with information regarding Ads Cognitive impairment, CVD, NH resident associated with lost decision making capacity Why?
SUPPORT - 1995 4 year study at 5 hospitals with 9,105 seriously ill patients 21% of patients had advanced directives 49% of pts who desired CPR to be withheld didnt have DNR 46% of DNR orders with 48 hours of death 38% who died spent >10 days in ICU 50% of pts who died reported by family to have
severe pain > 50% of the time Benefits of AD Completion of Advanced Directives Increase pt and family satisfaction with EOL care Increase compliance of wishes and EOL care Decrease stress, anxiety, depression of family members following loss Reduce likely hood of dying in hospital
Cost benefit? Improvements in Outcomes 3746 patients, aged >60 who died 42.5% required decision making 70% of those lacked capacity Patients who completed advanced directives received care that was strongly associated
with their preferences Approx. 70% of community dwelling adults have an AD. Silveira, M. Advance Directives and Outcomes of Surrogate Decision Making before Death. N Engl J Med 2010;362:1211-8. When? If everyone needs it then when?
When will then be now? Soon. 1 Performance status most powerfully related to prognosis The ability to function (independently perform activities of daily living) represents the sum
total of all biological and patho-physiological processes 1-Spaceballs movie dialogue. 1987 Best Question Would you be surprised if this patient died in the next 12 months? Renal failure odds ratio 3.5 Malignancy odds ratio 12
Moroni et al. The surprise question in advanced cancer patients: A prospective study among general practioners. Palliat Med published online 24 March 2014 How? Remember Its a process 1. Introduce topic and give info 2. Facilitate discussion w/patient and family /
surrogate 3. Document the conversation Remember to complete forms 4. Review and update PRN 5. Apply the wishes with aide of surrogate Introducing the Concept Id like to talk with you about possible health
care decision in the future; this is something I do with all my patient so I can be sure that I know and follow your wishes. Have you given any thought to how you wish to be cared for? DPOA Is there anyone who helps you make decisions?
If you were unable to make those decisions, who would you want to do that for you? Quality of Life Values How can we help you live well? What do you hope for, for your family? When you think about balancing living longer and quality of life, how would you approach this
balance? Needs How can we make this time meaningful? Quality of Life What do you enjoy doing now? How can we help you do more of this? What is your life like outside the hospital or
clinic? What is most important to you right now? http://depts.washington.edu/oncotalk/learn/modules/Modules_03.pdf Quality of Life What is the hardest part of this for you and your family right now? When you think about the future, what worries you the most?
When you think about the future, what do you hope for? http://depts.washington.edu/oncotalk/learn/modules/Modules_03.pdf Document the Conversation Who was present What was discussed What were patients reasons for wanting / not wanting specific interventions
What were goals Plan going forward Complete appropriate forms Review and Update PRN
A time of Diagnosis After hospitalization After decline When appropriate family can be present at an appointment How (much)?
Billing and Coding ACP Issues New CPT Codes for ACP as of Jan 1, 2016 May be billed by MD/PA/NP Can be billed with other E/M Codes Must be separate and identifiable Must have documentation to justify Time spent specifically on ACP must be mentioned in your note. Can bill as many times as necessary
Billing Codes Code 99497 99497.1 99497.2 99497.3 Time Frame
Note can bill for outpatient and inpatient care RVUs 1.5 2.9 4.3 5.7 ACP Billing
Except when billed with AWV patients are subject to copays and coinsurance Use modifier 25 when billing with office visit Use modifier 33 when billing with AWV ACP Billing Documentation Include time spent separately on billing / coding Discussion of goals / preferences
Complex medical decision making Explanation of Advanced Directives Engaging patients and family members Advanced Care Planning ACP is a conversation but not just a document Documents matter! ACP improves EOL care
Can start anytime and revise anytime Choose billing codes accordingly Set stage and choose words wisely Bibliography Bomba, R et al. POLST: An improvement over traditional advanced directives. Cleve Clin J Med 2012; 79: 457-464 Moroni et al. The surprise question in advanced cancer patients: A prospective study among general practioners. Palliat Med published online 24 March 2014
Aitken. Incorporating advanced care planning into Family Practice. Am Fam Physician 1999 Feb 1:59(3):605-612 Braun U. et al. Reconceptualizing the Experience of Surrogate Decision Making: Reports vs. Genuine decisions. Ann Fam Med. 2009;7;249-253 A controlled trial to improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognosis and Preference for Outcomes and Risks of Treatment. (SUPPORT) JAMA. 1995; 274:1591-1598 Silviera, MJ et al. Advanced Directives and Outcomes of Surrogate Decision Making Before Death. NEJM. 362; 12 Luckett, T. et al. Advanced Care Planning for adults with CKD: A systematic integrative review. Am J Kidney Dis 2014 Houben, CHM et al. Efficacy of Advanced Care Planning: A systematic review and meta-analysis. JAMDA 2014.
Patel K. Advanced Care Planning in COPD. Respirology (2012) 12, 72-28 Silviera MJ et al. Advanced Care Planning Completion by Elderly Americans: A decade of change. J Amer Ger Soc 2014 Deterin, K. The Impact of Advanced Care Planning on end of life care in elderly patients: randomised controlled trial. BM 2010; 340:c1345
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