Webinar:Wiser Health Care Decisions and Choices
through Knowledge
1. Preparing a Written Agenda 2. Preparing a Medical History
3. Preparing Medication List4. Health Care Proxy verses a Living Will
5. Life-Sustaining Treatment MOLST Guidelines 6. Planning and Costs for Long-term Care7. Private care verses Nursing Home Care
Preparing a Written AgendaPart: 1
Written Agenda – Preparation Benefits
Allows you to stay in control of the
meeting.
Shows your willingness to take
an active role in your care.
Keeps you focused on the items you wish to discuss.
Provides an opportunity to summarize the
discussion
Provides an opportunity to
learn about your choices and plan of
action.
Agenda Preparation - outline
1. Date:
2. Agenda for visit with MD:
3. Objectives:
4. Discussion Topics:
5. Plan of action/next steps:
6. Additional questions:
7. Summary:
Agenda Preparation - Goals
Objectives
Establish a trusting and mutually beneficial relationship with the physician
Gain insight into your health care options
Establish health goals presently and for the future
*Date and include MD’s name on your agenda
Agenda Preparation - Discussion Topics
Why you selected this MD over another
Your past medical history and medication
review medical history, previous hospitalizations and surgeries
review medication list
review list of specialists on my team, preferred hospital, and pharmacy
Agenda Preparation - Discussion Topics
Your current healthcare issues and concerns
short of breath, light-headed, recent fall, pain, skin changes
Preventative care
measurements taken to prevent disease or injuries (regular check ups, regular physical activity)
Health care goals
avoid vision problems, cancer, improve flexibility, be more active, weight maintenance, healthy skin
Healthcare proxy/power of attorney/advance directives
Agenda Preparation – Plan of action
Action Plan
• Follow up appointment in 6 weeks
• Follow current medication plan with close
monitoring of questionable moles on skin.
• Make appointment with dermatologist.
• Additional actions?
Agenda Preparation – MD follow-up questions
Additional Questions
• What relationship does your practice have with
the local hospital?
• How quickly will my messages be received by you
and my calls returned?
• What happens if I need to see you on a day when
you are not in the office?
• What happens if I’m hospitalized?
• What other questions should be addressed?
Agenda Preparation - Guidelines (overview)
Make several agenda copies
for others attending the appointment. Date agenda and provide the name of
the MD.
Let the receptionist know you have an
agenda for the MD to
review prior to the
appointment, and have it placed in medical record.
Inform the MD that you
would like the agenda
reviewed prior to the
appointment so it can guide
the conversation.
Take notes on the agenda to
clarify the details of the
appointment.
Summarize the
appointment with the MD
to make certain
everything was discussed
and understood.
Ask if you can follow-up by phone or in
person if you have
additional questions.
Medical history and Medication ListPart: 2 and 3
Medical History- outline
1. Medical Conditions – add dates, procedures, conditions: a. Cardiac b. Neurology:
c. Oncology d. Orthopedic:
e. GI (gastrointestinal) f. Kidney (Renal) g. Skin h. Ear, Nose, Throat (ENT) i. Eyes 2. Surgeries3. Hospitalizations
Medical History – Preparation Benefits
Provides guidelines on proper treatment. (allergic
reaction, etc.)
Health history can easily be shared with
emergency personnel and new
health care providers
Provides immunization history enabling you to keep
current.
Doctors can avoid duplicating services
Provides guidelines for MD to respond to new health signs or
symptoms.
Medical History – Preparation conditions list (dates, treatments, present conditions, and so on.)
Cardiac• Hypertension (high blood pressure)• Occasional swelling of feet and ankles
Neurology • Prior hemorrhagic stroke
Urology • Frequent urinary tract infections
Orthopedic• Osteoarthritis, right hip replacement • Spinal stenosis of cervical and lumbar spine
GI (gastrointestinal)• GERD (gastro-esophageal reflux)• Diverticulosis
Kidney (Renal) • Stage III Kidney disease
Skin• Excessive thinning, dryness• Fungus of toe nails
Ear, Nose, Throat (ENT) • Post nasal drip
Eyes • Dry eyes
Surgeries• Pacemaker insertion• Left hip replacement
Hospitalization• For all surgeries• Fall resulting in hip fracture
NotesConditions1.12.12 blood pressure meds side effects
2.12.13 stroke
10.11.11 surgery on hip
9.11.10 eye virus treatment
Sept. 2011, April 2013
Medication History – preparation benefits
Provides information on medications taken and
assists with self-administered medications
Provides insight on potential conflicts
with herbal supplements and
vitamins.
Keeps you focused on the items you wish to discuss.
Provides an opportunity to summarize the
discussion
Provides insight on potential allergic
reactions and conflicts with medications.
Medication List
Medication
• Aspirin• Atorvastatin
(Lipitor)
For Medical Condition
• For Heart• For Heart
Prescribing Physician
• Dr. Salem
Date Started
• Sept. 2012
Dosage & Frequency
• 325 mg - 1 x daily
Notes
• a.m. intake• p.m. intake
Daily Medications
Client: Jane DoeDOB: 06/01/41Allergies: Morphine, Bactrim DS, Seasonal Allergies (Pollen)
Medication List
Medication
• Multivitamin• Cranberry
Capsules• Vitamin D
For Medical Condition
• Prevention• Prevention of
UTI• Osteoporosis
and Cancer
Prescribing Physician
• Dr. Brown• Dr. Smith
• Dr. Smith
Date Started
• Sept. 2012• Oct. 2011
• Oct. 2011
Dosage & Frequency
• 2 caps – 1x daily
• 500 mg.
Notes
• a.m.• a.m.
• a.m.
Vitamins, Herbal Medications & Nutritional Supplements
Client: Jane DoeDOB: 06/01/41Allergies: Morphine, Bactrim DS, Seasonal Allergies (Pollen)
Medication List
Medication
• Tylenol
• Lidocaine Patch
For Medical Condition
• Pain
• Back Pain
Prescribing Physician
• Dr. Brown
• Dr. Brown
End/Start Date
• Sept. 2012 (start)
• Sept. 2012
Dosage & Frequency
• 350 mg – 3x daily
• 500 mg.
Notes
• 6 a.m./2 p.m./8 p.m.
• 12 hrs on, 12 hrs. off.
Occasional or as Needed Medications
Client: Jane DoeDOB: 06/01/41Allergies: Morphine, Bactrim DS, Seasonal Allergies (Pollen)
Medication List
Medication
• Flonase nasal spray
• Atopicalir
For Medical Condition
• Nasal congestion
• Eczema
Prescribing Physician
• Dr. Brown
• Dr. Brown
End/Start Date
• Sept. 2012 (start)
• Jan. 2010
Dosage & Frequency
• 1x daily
• 2x daily
Notes
• Each nostril 2 weeks only.
• 12 hrs on, 12 hrs. off.
Previously Taken Medications
Client: Jane DoeDOB: 06/01/41Allergies: Morphine, Bactrim DS, Seasonal Allergies (Pollen)
health Care Proxy vs. a LIVING WILL Part: 4
Health Care Proxy vs. Living Will
Both advanced directives, HCP and LW allow
individuals to retain control over medical
decisions.
Health Care Proxy (HCP) designates
another person to make medical
decisions should you be unable to do so.
LW allows you to list medical treatments that you would or would not want if
you became terminally ill and unable to make
decisions.
Both the HCP form and the LW once
signed remains valid unless you revoke
them.
Some states allow individuals to make
their own Health Care Proxy, but does not legally recognize
Living Wills (LW).
Health Care Proxy - Things to Consider
Proxy becomes effective when MD determines you are incapable of making or communicating health care issues.
Must be 18 to assign an Healthcare Agent who is designated to ensure your wishes
are honored.
You do not need a lawyer to complete Healthcare Agent form or make it legally binding.
Proxy must be signed by two adult
witnesses, neither of whom can be your
Health Care Agent or Alternate Agent.
Make a minimal of four copies of the
form. One for yourself, your
Healthcare agent, your alternate agent,
your physician and others.
Healthcare Agents or Alternate Agent can be anyone over 18, except
the administrator, operator, or employee
of a health care facility, unless that person is related to
you by blood, marriage or adoption.
Healthcare providers are bound to honor
your Healthcare Agent’s decisions as
if they were your own.
Living Will – Things to Consider
Provides guidelines to MDs, Healthcare Agents and others
on certain life-prolonging
treatments you desire should you be
in a permanent vegetative state.
The individual designated to invoke healthcare decisions on your behalf -- so make certain they fully understand
what your desires are.
Does not become effective unless you are incapacitated.
Requirements for LW vary by state, so
consider having a lawyer prepare it.
Share your LW document with those who can
administer your wishes. If no one
knows your wishes they can’t be
honored.
Usually requires certification by your MD and another MD
that you are terminally ill or
permanently unconscious before become effective.
In situations where you are not completely
incapacitated, you should have a health
care power of attorney or a health
care proxy act on your behalf.
MOLSTMassachusetts Medical Orders for Life-Sustaining TreatmentPart: 5
MOLST - GuidelinesMassachusetts Medical Orders for Life-Sustaining TreatmentNot designed for healthy
individuals. Suitable for those with advanced illness (life-threating disease, chronic
progressive disease, dementia or suitable for a DNR order.)
Using MOLST is voluntary. Patients or
Health Care Proxies can revoke MOLST at any
time.
Keep copy of form with the patient at discharge or between care
settings. Keep it in a place it can be easily seen (door, bedside, or
refrigerator) or in the patient’s purse or wallet. A copy should also
be with the medical records.
MOLST form must be honored as any other medical order. If other orders “Comfort (CC) Care” or “ (DNR) Do not Resuscitate” exist the most recent order must be
honored.
Standardized form containing valid medical orders for life-sustaining
treatment based on patient’s own preferences
and goals of care.
Massachusetts Medical Orders for Lift-Sustaining Treatment (MOLST)
A Cardiopulmonary Resuscitation: for a patient in cardiac or respiratory arrest
O Do Not Resuscitate O Attempt Resuscitation B Ventilation: for a patient in respiratory distress
O Do Not Intubate and Ventilate O Intubate and VentilateC Transfer to Hospital
O Do Not Transfer to Hospital O Transfer to Hospital (unless needed for comfort)
DPatient or patient’s representative signature
Required – Fill in every line for valid orders
Select one circle below to indicate who is signing Section D:O Patient O Health Care Agent O Guardian O Parent/Guardian* of minorSignature of patient confirms this form was signed of patient's own free will and reflects his/her wishes and goals of care as expressed in the Section E signer. Signature by the patient’s representative (indicated above) confirms that this form reflects his/her assessment of the patient’s wishes and goals of care, or if those wishes are unknown, his/her assessment of the patient’s best interests. *A guardian can sign to the extent permitted by MA law. Consult legal counsel with questions about guardian’s authority. Signature____________________________ Date________________________Legible Printed Name of Signer______________________ Date _______________________
Massachusetts Medical Orders for Lift-Sustaining Treatment (MOLST)
Clinician signatureERequiredFill in every line for valid orders
Signature of Physician, Nurse Practitioner or Physician Assistant confirms that this form accurately reflects his/her discussion(s) with the signer in Section D.
Health Care Agent Printed Name___________________ ___________ Telephone Number ______
Primary Care Physician Printer Name___________________________ Telephone Number_______OptionalExpiration date and other patient care contacts
This form does not expire unless expressly stated. (Expiration date (if any) of this form:__________Health Care Agent Printed Name ____________________________________ Telephone Number ________Primary Care Printed Name _________________________________________ Telephone Number ________
SEND THIS FORM WITH THE PATIENT AT ALL TIMES.HIPAA permits disclosure of MOLST to health care providers as necessary for treatment.
Massachusetts Medical Orders for Lift-Sustaining Treatment (MOLST)
Statement of Patient Preferences for Other Medically-Indicated Treatment
F INTUBATION AND VENTILATIONSelect one circle
Refer to Section B on Page 1 O Use intubation and ventilation as checked O Undecided in Section B, but short term only O Did not discuss
NON-INVASIVE VENTILATION (e.g. Continuous Positive Airway Pressure – CPAP
Select one circle
Refer to Section B on Page 1 O Use intubation and ventilation as checked O Undecided in Section B, but short term only O Did not discuss
DIALYSIS
Select one circle
O No dialysis O Use dialysis O Undecided O Use artificial nutrition, but short term only O Did not discuss
ARTIFICIAL NUTRITION
Select one circle
O No artificial nutrition O Use artificial nutrition O Undecided O Use artificial nutrition, but short term only O Did not discuss
ARTIFICIAL NUTRITION
Select one circle
O No artificial nutrition O Use artificial nutrition O Undecided O Use artificial nutrition, but short term only O Did not discuss Other treatment preferences specific to the patient’s medical condition and care _____________________________________________________________________________________________
Massachusetts Medical Orders for Lift-Sustaining Treatment (MOLST)
PATIENT orPatient’s representative signatureGRequiredFill in every line for valid orders
Select one circle below to indicate who is signing Section G:O Patient O Health Care Agent O Guardian* O Parent/Guardian* of minorSignature of patient confirms this form was signed of patient’s representative (indicated above) confirms that this form reflects his/her assessment of the patient’s wishes and goals of care, or if those wishes are unknown, his/her assessment of the patient’s best interests. *A guardian can sign to the extent permitted by MA law. Consult legal counsel with questions about guardian’s authority.
______________________________________________________________ ___________________________Signature of Patient (or Person Representing the Patient) Date of Signature
_____________________________________________________ _______________________Legible Printed Name of Signer Telephone of Signer
CLINCIANsignature
HRequired Fill in every line for valid orders.
Signature of physician, nurse practitioner or physician assistant confirms that this form accurately reflects his/her discussion(s) with the signer in Section G.
____________________________________________________ ________________________ Signature of Physician, Nurse Practitioner, Or Physician Assistant Date of Signature
_____________________________________________________ _______________________Legible Printed Name of Signer Telephone of Signer
Additional Instructions For Health Care ProfessionalsFollow orders listed in A, B and C and honor preferences listed in F until there is an opportunity for a clinician to review as described below. Any change to this form requires the form to be voided and a new form to be signed. To void the form, write VOID in large letters across both sides of the form. If no new form is completed, no limitations on treatment are documented and full treatment may be provided. Re-discuss the patient’s goals for care and treatment preference as clinically appropriate to disease progression, at transfer to a new care setting or level of care, or if preferences change. Revise the form when needed to accurately reflect treatment preferences. The patient or health care agent (if the patient lacks capacity), guardian*, or parent/guardian* of a minor can revoke the MOLST form at any time and/or request and receive previously refused medically-indicated treatment.
Long-term Care Costs and Home Care vs. Nursing Home Care
Part 6 & 7
Private Home Healthcare vs. Nursing Home Care
In-home care has risen at less than (1) one percent annually during the past five years
according to Genworth Financials 2013 annual Cost of Care Survey. Average hourly rates
($19 to $21) for HHA/CNA will vary depending on location and skills required. Also, LPN and RN rates will be higher and vary depending on
care level required. Assisted Living, Nursing home, costs have increased by more than (4) four percent a year
based on Genworth Financials 2013 Cost of Care survey. Rates
($108 to $230 per day) vary depending on location and type
of facility. Adult day center averages $67 per day.
Over the past 10 years there has been a steady move away from traditional nursing home care to
less-expensive options that include in-home care and adult day care.
Planning for long-term care should take place long before
need arises because youth is not a guarantee that long term care
will not be required.
Majority of people over age 65 will require some type of
long-term care, and 40 percent will require a period
of care in a nursing home according to Centers for Medicare and Medicaid
Services.
Long-term Care Funding Fundamentals
Seniors and families facing nursing home decisions should first
determine if Medicare is an option; however, it
only pays for “approved” agencies (VNA, etc).
Many long-term care insurances have limits
on what they will pay (2-5 years) while others will pay as long as you live.
Health and Disability Insurance often only
covers very limited and specific types of long-
term care, and disability policies don’t cover any
at all.
Even if you or your loved one does not need care
today, it’s wise to look at the costs now and in five years to gauge what the financial impact would
be.
Life Insurance options for long-term care
coverage. *Combination (life/long-
term care) products*Accelerated Death
Benefits (ABDs)*Life Settlements
*Viatical Settlements
Most forms of insurance (Private/HMO) follow
same rules as Medicare. If Insurance covers long-term care, it’s typically only for skilled, short-
term medically necessary care.
If you are in poor health or already receiving
long-term care services, you may not quality for
long-term care insurance. However, coverage at a higher
“non-standard” rate may be purchased.
Long-term Care Funding Fundamentals
Paying Privately through * reverse mortgages
* annuities*trusts
Deferred Long-term Care Annuity available for
those up to 85 years old. In exchange for a single premium payment, one
receives a stream of monthly income for a
specified period of time.
Reverse Mortgage provides cash (lump-sum
payment, monthly payment, or line of credit) against one’s home value without
selling the home. Many pros and cons to this
option; seek professional advise.
Deferred Long-term Care Annuity creates two funds (one-term care
expenses and separate fund to be used as one
desires).
If long-term care fund is not used it can be passed onto heirs.
Annuity may not be enough to pay for long-
term care expenses.Annuity can affect your eligibility for Medicaid. Speak with a specialist
about your options.
Annuities are provided by insurance company to pay for long-term care.* Immediate annuity*Deferred long-term
care annuity
Immediate annuity is available for purchase
regardless of your current health status.
Single premium payment is turned into a monthly
income for a specific period of time or the
rest of your life.
Long-term Care Funding Fundamentals
Trusts are legal entities that allows a person
(the trustor) to transfer assets to another person
(trustee).
Charitable Remainder Trust value will only payout the amount
based on your donation. When you pass the
funds in the trust go to the charity you selected.
Donation may affect your Medicaid eligibility.
Trusts are used to provide flexible
control of assets for the benefit of minor
children or older adults or a person with
a disability.
Medicaid Disability Trusts are limited to
those with disabilities who are younger than 65
and qualify for public benefits. This type of trust is exempt from rules regarding trusts
and Medicaid eligibility.
If beneficiary with disability receives
Medicaid Disability Trust, the state can recover any amount
remaining in the trust when he or she dies. See a specialist advice
prior to setting up a trust.
Two types of trusts can help pay for long-term
care.*Charitable Remainder
Trusts*Medicaid Disability
Trusts
Charitable Remainder Trusts allow you to use your assets to pay for
long-term care services (while you are alive)
and also contribute to a charity of your
choice and reduce your tax burden at the
same time.
QuestionsEnd