Title: CNS as Health Coach: Advanced Care Planning to Promote Effective Care Transitions
1CNS as Health Coach Advanced Care Planning to
Promote Effective Care Transitions
Minnesota NACNS Annual Conference October 26, 2012
- Ann Loth, RN, MS, ACNS-BC
2Advance Care Planning 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
3Advanced Care Planning Who is it For?
- EVERYONE!
- Especially those living with chronic disease
- Advance Care Planning http//depts.washington.edu/
bioethx/topics/adcare.html - AHRQ Research in Action 2003
4Advanced Care Planning 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
5Quality 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-Pa
tient-Assessment-Instruments/hospital-value-based-
purchasing/index.html - http//www.cms.gov/Outreach-and-Education/Medicare
-Learning-Network-MLN/MLNProducts/downloads/Hospit
al_VBPurchasing_Fact_Sheet_ICN907664.pdf
6Chronic Disease in Minnesota
7(No Transcript)
8Advanced 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
9Advanced 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
10Spheres of Influence
11Advanced Care Planning
- Of the health care team, the CNS/Nurse is well
suited to lead this discussion - CNS interacts directly with patient and their
families - CNS develops processes to assist the Nurse at
Point of Care to lead this discussion - 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
12Key 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
13Key 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
14Motivational Interviewing
- Integrates relationship building
- Readiness assessment
- Open Ended Questions
- Affirmation
- Reflective Listening
- Summarizing
- Patient leads - Nurse facilitates the
conversation
Newnham-Kanas et al. 2010
15Appreciative Inquiry
Discovery
Dream
- What might life be like?
- Rooted in reality of health
- Hopes
- Patient Values
- What is going right
- What brings peace,
- joy and happiness
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
16Appreciative Inquiry
Discovery
- 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 Values
- What is going right
- What brings peace,
- joy and happiness
Patient and Family Values Care connected to
Values brings more meaning and purpose to life
and closure of live
Richer, Ritchie, Marchionni, 2009 Gordon,
2008 Moore Charvat, 2007 Sullivan Havens,
Woods, Leeman, 2006
17Appreciative Inquiry
Dream
- 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?
- What might life be like?
- Rooted in reality of health
- Hopes
Patient and Familys 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
Richer, Ritchie, Marchionni, 2009 Gordon,
2008 Moore Charvat, 2007 Sullivan Havens,
Woods, Leeman, 2006
18Appreciative Inquiry
What Does IT Look Like? What Where With
Whom With What Resources
- 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?
Design
- Discernment rooted
- in values
- Who else may need
- to be in the plan to
- make the dream a
- reality?
Richer, Ritchie, Marchionni, 2009 Gordon,
2008 Moore Charvat, 2007 Sullivan Havens,
Woods, Leeman, 2006
19Appreciative 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.
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.
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
20Appreciative Inquiry
Discovery
Dream
- What might life be like?
- Rooted in reality of health
- Hopes
- Patient Values
- What is going right
- What brings peace,
- joy and happiness
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
21Advance Care Planning
- Patient focused
- Family and health care team recognize and affirm
patient wishes - Promotion of self-determination
- Within the Art of Nursing
- The CNS has the advance practice expertise to
initiate, develop, promote Advance Care Planning
22Clinical 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
23Advance Care Planning
- The CNS shifts the nurses purpose from
objective problem-solver to sojourner in
discovery, interpretation, and revelation. - Newman et al. 2008 p. E23