CNS as Health Coach: Advanced Care Planning to Promote

Effective Care Transitions

Ann Loth, RN, MS, ACNS-BC

Minnesota NACNS Annual ConferenceOctober 26, 2012

Advance Care Planning: Advance Care Planning: What is it?What is it?

• Process–Assesses individual values–Communication of values related to

goals of care–Promotes self-determination

Advance Care Planning http://depts.washington.edu/bioethx/topics/adcare.htm

AHRQ Research in Action 2003

Advanced Care Planning: Advanced Care Planning: Who is it For?Who is it For?

• EVERYONE!– Especially those living with chronic

disease

Advance Care Planning http://depts.washington.edu/bioethx/topics/adcare.htmlAHRQ Research in Action 2003

Advanced Care Planning: Advanced Care Planning: How is it Provided?How is it Provided?

• Human to Human– Primary Care Providers related to close

relationship with patient

– Specialist related to specialized knowledge

– Health Care Team related to ongoing care & relationship

AHRQ Research in Action 2003

Quality & Current Health Care• Pay for Quality Health Care–Centers for Medicare & Medicaid

Services (CMS)• Value Based Purchasing (VBP)• 30 Day Readmission Rates •Mortality Rates

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf

Chronic Disease in Minnesota

http://www.health.state.mn.us/divs/orhpc/flex/pubs/stratis.pdf

Advanced Care Planning

• Many patients have not participated in an effective advance care planning.

– Per AHRQ studies, less than 50% of severely or terminally ill patients have an advanced directive in their medical record.

– 65-76% of physicians whose patients had an advanced directive were not aware that it existed.

AHRQ. Research in Action ,2003

Advanced Care Planning

Patients do not talk with their families about their wishes

Patients do want to discuss these wishes with their health care team

Selman et al. 2007; Dougherty et al. 2007, Kass-Partelmes et al. 2003

Spheres of Influence

Advanced Care Planning Of the health care team, the CNS/Nurse is well suited

to lead this discussion

o CNS interacts directly with patient and their families

o CNS develops processes to assist the Nurse at Point of Care to lead this discussion

o CNS Influences multidisciplinary teams in having conversations with patients and families.

Kirkhoff et al, 2010, Mahon 2010, Waterworth et al., 2010, Goodlin et al., 2008, Selmen, 2007

Key Concepts of Nursing as a Discipline

• Health and Caring – Purposeful intent of the patient/nurse relationship

• Consciousness – The informational pattern of the relationship

• Mutual Process – The way in which the relationship unfolds

Newman et al. 2008

Key Concepts of Nursing as a Discipline

• Presence – The resonance of the relationship

• Meaning - The importance of the relationship

• Translator – Moving illegible to legible

Newman et al. 2008; Scott, J.C. 1998

Motivational Interviewing

• Integrates relationship buildingo Readiness assessmento Open Ended Questionso Affirmationo Reflective Listeningo Summarizing

• Patient leads - Nurse facilitates the conversation

Newnham-Kanas et al. 2010

Appreciative InquiryDiscovery

• Patient Values• What is going right• What brings peace, joy and happiness

Dream• What might life be like?• Rooted in reality of health• Hopes

Design• Discernment rooted in values• Who else may need to be in the plan to make the dream a reality?

Destiny• Hopes move into reality• New meanings for hope• Cure versus treatment• Treatment versus EOL

Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006

Appreciative InquiryDiscovery• Patient Values• What is going right• What brings peace, joy and happiness

Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006

What is most important to you at this time of your life?

What brings you peace, joy and happiness to your life?

What is working well in your life at this time?

What makes you want to get out of bed each morning?

Patient and Family Values

Care connected to Values brings more meaning and purpose to life and closure of live

Appreciative InquiryDream

• What might life be like?• Rooted in reality of health• Hopes

What has worked well for you in the past?

What do you hope for knowing we cannot change your disease?

From what you are telling me, it sounds like ________ is really important to you and hope that ___________ can happen, is that right?

Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006

Patient and Family’s Hopes

Dreams/Hopes comes in many different colors and assisting the patient and family to identify their dream assists in building a plan to support that dream

Appreciative Inquiry

Design• Discernment rooted in values• Who else may need to be in the plan to make the dream a reality?

How do you see that happening for you?

When you did __________ what helped you to be successful?

What are you willing to do to get there, such as, …………….?

I am understanding your family is worried about you going home alone, how do you see yourself following through on your own?

Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006

What Does ‘IT’ Look Like?

WhatWhereWith WhomWith What Resources

Appreciative Inquiry Being at home with your family has

been your goal and I understand how hard you have fought this disease, but you are tired. Going home with hospice sounds like a great plan.

You have said all along you did not want to start dialysis, now you are going to try the diet and fluid restriction again, with a little more control

You have shared you wanted more time to live, but also with quality to your life. Your decision to try the LVAD makes sense.

Destiny• Hopes move into reality• New meanings for hope• Cure versus treatment• Treatment versus EOL

Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006

Putting the Dream into Reality

Helping the patient and family to identify important steps in their treatment course related to their trajectory in their disease process.

Appreciative InquiryDiscovery

• Patient Values• What is going right• What brings peace, joy and happiness

Dream• What might life be like?• Rooted in reality of health• Hopes

Design• Discernment rooted in values• Who else may need to be in the plan to make the dream a reality?

Destiny• Hopes move into reality• New meanings for hope• Cure versus treatment• Treatment versus EOL

Richer, Ritchie, & Marchionni, 2009; Gordon, 2008; Moore & Charvat, 2007; Sullivan Havens, Woods, & Leeman, 2006

Advance Care Planning• Patient focused

o Family and health care team recognize and affirm patient wishes

o Promotion of self-determination

• Within the Art of Nursingo The CNS has the advance practice expertise to

initiate, develop, promote Advance Care Planning

Clinical Nurse Specialist

Facilitate Advance Care Planning with Patients and

Families

Influence Nursing Practice to Encompass

Advance Care Planning

Develop Processes for

Quality Patient Centered Care

Advance Care Planning• The CNS: shifts “the nurse’s purpose from

objective problem-solver to sojourner in discovery, interpretation, and revelation.”

Newman et al. 2008 p. E23