What is Advance Care Planning

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What is Advance Care Planning?

• Advance Care Planning is the process of thinking
  about, talking about and writing down your health
  care wishes.
• Advance Care Planning is the best way to ensure
  that your wishes are known, understood and
  respected.

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The importance of advance care planning

• Most people will die while under care of health
  care professionals after experiencing a chronic
  or life-threatening illness
• Up to 50 of persons will not be able to make
  their own decisions at the end of life
• When patient wishes are unknown, health care
  professionals typically treat if it can be done
  it will be done
• Without conversation in advance, family and loved
  ones may not know a person's wishes

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Sharing Your Wishes TM
Give them peace of mind, not tough choices. Plan
ahead for your health care
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Why the Foundation Funded this Project

• The Community Health Foundation of Western and
  Central New York resulted from the merger of
  Univera with Excellus health plan
• The endowment exceeds 100 million
• Mission Improve the health and health care of
  people and communities of Western and Central New
  York
• Funding Priorities
• Frail Elders
• Children in Communities of Poverty
• Funding Regions
• Eight counties in CNY, Eight counties in WNY

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CHFWCNY Vision for Frail Elders

• Frail elders live out their lives in keeping with
  their wishes with supportive family and community
  systems and high quality, appropriate healthcare

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Initial Goals of Project

• Improve health-care decision-making for frail
  elders in order to improve quality of care and
  quality of life
• Strengthen community coalitions with a project
  that would bring them together around a goal
• Community Engagement
• Professional Education
• System Change

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Original 7 Participating Coalitions in Western
and Central New York

• Allegany County
• Community Partnership on Aging
• Cayuga County
• Human Services Coalition of Cayuga County
• Erie County
• Coalition for Health Care Decision-Making
• Genesee County
• Long Term Care Task Force

• Niagara County
• Niagara Caregivers Network
• Onondaga County
• Sharing Your Wishes Community Coalition
• Tompkins County
• Health Planning Council of the Human Services
  Coalition
• Additional 6 Counties
• Cattaraugus, Chautauqua, Orleans, Wyoming Steuben
  Schuyler

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Coalition Project

• A Shared Learning Adventure
• Coalition representatives met for workshops,
  training, discussion, and sharing several times a
  year
• Each step of the way was supported by the
  Foundation and included the input of the
  coalition representatives
• Resources were developed to support these
  communities and to share with other communities
  interested in improving advance care planning

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Principles of the SYW Message

• Step One Plan ahead for health care needs by
  starting with thinking about what is important to
  you
• Step Two Select the best person to speak for
  you if you are unable to speak for yourself
• Step Three Talk with this person about your
  health care wishes
• Step Four Formally designate this person as
  your health care agent

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SYW Community Tool Kit

• www.sharingyourwishes.org
• Summary of the SYW coalition project with brief
  case scenarios on each of seven county coalitions
  and highlighting lessons learned
• Collection of resources organized for easy use,
  including          o media resource binder of
  materials          o op-ed pieces          o
  community meeting agendas, invitations,
  recognition          o facilitator tools,
  starting the conversation, etc          o
  surveys and focus group guidelines          o
  bookmarks, placemats, etc.          o
  promotional materials for events

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Sharing SYW Learnings Genesee County LTC Task
Force
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Importance of Coalition Structure Genesee County

• Long Term Care Task Force convened
• in June 2003
• Past History of Cooperatively Working on
  Projects
• Organized Sub-Committees to Complete SYW Tasks

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Three Sub-Committees Formed

• Heightened Awareness
• Facilitation
• Systems Development

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Heightened Awareness Sub-Committee

• Community Engagement
• Public Education
• Senior Group Presentations
• One on one visitation to area churches
• Media Releases

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Facilitation Sub-Committee

• Facilitation Training Plan
• Recruitment
• Physicians Referral
• LTC Agency Buy-In for Facilitation

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Systems Development Sub-Committee

• Integrated all facets of SYW Program
• Focus on long term systems change
• Primarily attended by decision- makers

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Broadening the Coalition

• Expansion of membership on Sub-Committees
• Bringing additional partner agencies on board
• Getting the right people at the table

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Reaching out into the Community Genesee County

• Goal Community Engagement
• Helping the Community understand what it
  means to do good Advance Care Planning.

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Methods

• Senior Group Presentations
• One on one visitation to area churches
• Health Files
• Newsletter Articles and Media Releases

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Community Presentations

• Senior Groups
• Church Groups
• Community and Civic Organizations
• 193 presentations with 2,492 in
  attendance

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Finding

• Most people want to talk about advance care
  planning when given the opportunity and
  information on understanding their options for
• sharing their wishes.

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Finding

• Most people have not spoken with their
  physician, spiritual advisor, family members or
• health care agent, often because they find it
  uncomfortable to begin the discussion or they
  believe that others do not want talk about it.

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One on One Visit to Area Churches

• Individually contacted over 50 churches
  offered presentation to church group provided
  material on SYW for Bulletin
• Encouraged Pastor or Lay Person to be trained
  as ACP Facilitator
• Encouraged Participation on a Sub-Committee
• Encouraged Pastor or Lay Person to be
  trained as ACP Facilitator
• Encouraged Participation on a Sub-Committee
  

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Health File Distribution

• Encourage Use of Health File as Discussion
  Tool
• Presented Health Files to local Medical
  Society
• Health Files Available at 55 Physicians Office
• Distributed through local hospital and
  ambulance service and to senior groups throughout
  the county
• In past year, distributed 10,000 Health Files

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Newsletter Articles and Media Releases

• SYW articles placed monthly in Office for
  the Aging newsletter for the past 3 years.
• Several Daily News newspaper articles to
  highlight SYW activities
• The Morning Show radio talk show
• Press Releases on SYW events
• Insure that partner agencies are included in
  media coverage

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Professional Education Genesee County

• Professional Education is Key to
  Sustainability
• Respecting Choices Facilitation
• Basic ACP Facilitation Skill Training
• GCC Nursing Program BOCES LPN Training
• NY Connects/Caregiver Counseling/ OFA Case
  Management

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Respecting Choices Facilitation

• Chosen as training program for Certified Advance
  Care Planning Facilitators
• Philosophy Firmly supports consideration of a
  persons values and beliefs along with
  conversation with their family and physician to
  work hand in hand with a completed and updated
  health care proxy form. Advance care planning
  process is so much more than completing a health
  care proxy form.

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GCC RN Nursing Program BOCES LPN Training

• Genesee Community College RN Nursing Program
  adopts Respecting Choices Advanced Care Planning
  Facilitation program in their core curriculum
• 3 GCC Nursing Instructors and 2 United Memorial
  Medical Center Nurses Trained as Respecting
  Choices trainers
• BOCES LPN Training Course includes Basic ACP
  Facilitation into curriculum

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Result

• Nursing Students in
• Genesee
• Livingston
• Orleans
• Wyoming
• GLOW Region becoming well trained
• in Advanced Care Planning

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Result SYW Basic Certified Facilitation
Skills Training Completed

• 218 Genesee Community College (GCC) RN
  Students (Certified)
• 3 GCC Nursing Program Instructors (Certified)
• 72 BOCES LPN Nursing Students (Basic)
• 8 Office for the Aging/NY Connects
  Information Assistance, Case Management,
  Assessment and Caregiver Counseling staff
  (Basic)
• 2 Nurses ACP Instructors (Certified) and 10
  Nursing staff from the local hospital (Basic)
• 6 Caseworker or Nursing staff from County DSS
  and Health Dept. (Basic)

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Result

• 5 Nursing/social work staff from local home
  care/hospice agencies (Basic)
• 4 Social workers/admissions coordinators for
  local nursing home/adult care facilities (Basic)
• 8 Pastors or lay leaders in local churches
  (Basic)
• 2 Legal service providers (Basic)
• Other representatives of other long term care
  related agencies (Basic)

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Systems Change Genesee County

• How have we changed the Advanced Care Planning
  culture
• by integrating Sharing Your Wishes into the way
  people do business in Genesee County?

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Systems Change Central Registry

• Central Registry System
• www.sharingyourwishes.org
• Free, secure on-line storage of advance directive
  documents
• CHFWCNY led an effort to link
• to an electronic registry system established
  by Hospice of Rockland County

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How the Registry Works

• Share copies of advance directives
• Send a copy with authorization form to SYW
  partner
• Scanned into registry
• Wallet card personal pass code
• Providers either register or access individual
  information using pass code

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Systems Change Health Files
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Systems Change GCC RN Nursing Program Lifespan
Curriculum

• Lifespan Curriculum approved by NYS Education
  Department incorporating Respecting Choices
  Facilitation Training.
• 218 RNs graduated with ACP Facilitation Training
• 150 RN students to be trained each year as part
  of core requirements!

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OFA/New York Connects

• Integration of Advance Care Planning Facilitation
  into
• NY Connects Information, Screening Referral
• OFA Caregiver Counseling
• OFA Case Management Assessment

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Evidence of Systems ChangeOFA Outcome
Measurement

• HCP Documents Completed
• Number of Clients
• Time Frame Assessed Clients w/HCP
  w/ HCP
• 7/05 9/05 223 34
  15.2
• 7/06 9/06 204 105
  51.4
• 10/06 3/07 246 136
  55.2
• 4/07 3/08 333 213
  63.9