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CNS as Health Coach: Advanced Care Planning to Promote Effective Care Transitions

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Appreciative Inquiry ... Slide 7 Advanced Care Planning Advanced Care Planning Spheres of Influence Advanced Care Planning Key Concepts of Nursing as a ... – PowerPoint PPT presentation

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Title: CNS as Health Coach: Advanced Care Planning to Promote Effective Care Transitions


1
CNS as Health Coach Advanced Care Planning to
Promote Effective Care Transitions
Minnesota NACNS Annual Conference October 26, 2012
  • Ann Loth, RN, MS, ACNS-BC

2
Advance 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

3
Advanced 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

4
Advanced 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

5
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-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

6
Chronic Disease in Minnesota
7
(No Transcript)
8
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

9
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

10
Spheres of Influence
11
Advanced 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

12
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
13
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
14
Motivational Interviewing
  • Integrates relationship building
  • Readiness assessment
  • Open Ended Questions
  • Affirmation
  • Reflective Listening
  • Summarizing
  • Patient leads - Nurse facilitates the
    conversation

Newnham-Kanas et al. 2010
15
Appreciative 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
16
Appreciative 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
17
Appreciative 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
18
Appreciative 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
19
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.

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
20
Appreciative 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
21
Advance 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

22
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
23
Advance 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
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