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Northeast Florida Medicine
Vol. 67, No. 1 2016
29
CME
- identify questions that the person needs to have answered
and develop a plan to obtain needed information;
- and ensure that plans are developed in a clear and
complete manner and direct the participant to com-
municate it to those who need to know.
What are the benefits?
There aremany benefits to a comprehensive and structured
approach to ACP. Most notably, this methodology ensures
that patients are provided care and treatment consistent
with their goals and values. Over its 20-plus year history,
Respecting Choices® demonstrated results such as fewer
hospital readmissions, plans that are clear and available to
health care providers, high patient and family satisfaction
with hospital care, an increase in surrogate understanding
of patient goals of care, decrease in decisional conflict, re-
duction in stress, anxiety and depression among surviving
relatives, and an improvement in the prevalence of written
advance directives.
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Benefits to the health care team included:
integration of specific and easy-to-understand plans into
medical decision making; integration of ACP into routine
patient care, resulting in timely decisions appropriate to
stage of illness; decrease in moral distress of health care
providers and clinicians workingwith patients and surrogates
on end-of-life decision making; and a shift in time spent
by physicians and the health care team on crisis end-of-life
decision making to time spent on early and effective ACP.
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Comparing data
Acomparisonof data of hospitals inNortheast Florida com-
munities (FernandinaBeach, Jacksonville, JacksonvilleBeach,
Orange Park and St. Augustine) to La Crosse, Wisconsin, the
state of Florida, the United States, and hospitals at the 90th,
50th and 10th percentiles demonstrates the effectiveness of
an integrated ACP approach6 (Figure 1). La Crosse has the
fewest number of hospital admissions per 1,000 decedents
during the last six months of life, the lowest percentage of
decedents admitted to critical care during the hospital stay in
which death occurred, the fewest inpatient days per decedent
during the last six months of life and the lowest percentage of
decedents hospitalized at least once during the last six months
of life. La Crosse also has the lowest inpatient spending per
decedent during the hospitalization in which death occurred
and the lowest inpatient spending per decedent during the
last six months of life.
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What has been done in
Northeast Florida so far?
Six health systems/hospitals (Baptist Health, Brooks
Rehabilitation, Flagler Hospital, Mayo Clinic Florida, St.
Vincent’s HealthCare and UF Health Jacksonville) par-
ticipated in the first phase of Honoring Choices® Florida
implementation. Eight small patient/participant popula-
tions at the sites were selected to test ACP processes and
the new document.The sites implemented the advance care
planning programs between April and September 2014 and
collected data through November 2014. Site populations
included patients in primary care offices (Baptist Health,
Mayo Clinic Florida and UF Health Jacksonville), Radi-
ation Oncology (St. Vincent’s Medical Center Riverside),
an inpatient acute care unit (St. Vincent’s Medical Center
Southside), a transitional care unit (UFHealth Jacksonville),
an inpatient rehabilitation unit (Brooks Rehabilitation), a
cardiac rehabilitation outpatient clinic (Baptist Health), as
well as an employee group (Flagler Hospital). Cumulative
data reflected
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:
- 663 patients/participants approached
- 229 (35 percent) participated in a
facilitative conversation
- 104 (45 percent) completed an ACP document
- Facilitators spent an average of 25 minutes
per patient/participant.
Successes demonstrated
from these pilot groups include:
The pilot groups developed a commonACP document and
a standardized set of patient educationmaterial which helped
when training facilitators, ensuring that a consistent message
was communicated. The six competing community health
systems/hospitals collaborated, in partnershipwithCommu-
nity Hospice of Northeast Florida as program convener, to
develop strategies and test systems for ACP implementation.
Storage and retrieval systems for completed documents were
created for electronic medical record systems. The program
managers also formulated implementation plans and revised
as appropriate. All processes allowed for engagement of the
patient/participant and family. All pilot partner participants
identified best practices and implemented those practices
as the pilots evolved. The pilot partner hospitals also had
patients/participants complete a post-conversation survey.
Those surveys reflected a high satisfaction rate. All pilot part-
ners participated in organizational education to encourage
planning and engage site leadership and staff. Participants