By BETSY TAYLOR
It may sound counterintuitive, but as part of a health incentive for its employees, Providence Health & Services asked them to plan for a time when they may be too sick to make medical decisions for themselves. The activity was designed to increase caregivers' comfort and skill in discussing end-of-life care for themselves and their loved ones, and ultimately with patients.
Each year, the Catholic health care system asks employees who are eligible for benefits to complete a health-related activity for which the employee receives a financial incentive. For the 2016 activity, the option that the overwhelming majority of employees chose was focused on advance care planning.
Renton, Wash.-based Providence Health & Services said only 23 percent of Americans have put their medical care wishes in writing. Prior to its advance care promotion for employees, only 27 percent of Providence Health & Services' staff said they had formally documented their care wishes. Of the 55,000 benefits-eligible Providence Health & Services employees who participated, roughly 51,000 employees, and in many cases their spouses or family members, pledged to complete a goal related to their advance care planning as part of their 2016 health activity.
Dr. Ira Byock, chief medical officer of the Providence Institute for Human Caring, right, explains the basics of advance care planning in this educational video that includes actors portraying a patient and the patient's family member.
Advance care planning is a process of communication between a person, the person's loved ones and the person's health care providers to discuss and put in writing health care preferences in case a time comes when the person is not able to voice or make decisions due to illness, injury or age-related decline. (See box.)
Tackling a tough topic
At the Catholic Health Assembly in June, Dr. Ira Byock, chief medical officer of the Providence Institute for Human Caring, and Keegan Fisher, Providence Health & Services' senior director of benefits, will explain the steps the system took to encourage its employees to engage in advance care planning.
The online activity, facilitated through a Minneapolis-based vendor called RedBrick Health, involved an employee watching a short video in which Byock explains the basics of advance care planning. Then the employee was asked to answer eight reflective questions and to commit to a goal related to the person's own advance care plan, by electronically selecting one of the goals. These included several options, such as: "I will talk to my health care provider about advance care planning, including advance directive documents, at my next visit." Or "I will learn more about advance directives (written statement of a person's wishes for medical treatment), palliative care or hospice services."
The advance care planning activity is part of a larger effort to "make highly personalized care routine," Byock said. For Providence Health & Services employees to provide the best patient care, they need to understand a patient's values, preferences and priorities. That allows them to understand a person's personal experience of illness, he said, which is certainly an important part of caring for a patient with an incurable disease.
"Our promise at Providence is to 'know me, care for me, ease my way,'" he said, referring to Providence Health & Services' vision statement. "We have to know who that 'me' is, to do this well."
He said the effort involves work to move from a problem-based medical model to one in which employees understand that quality of care requires good faith efforts to ask about and respect a patient's medical care preferences. Part of this effort includes work on employees' communication skills, so those providing care learn a different way to talk with patients, essentially asking patients and their families not "what's the matter with you?" but "what is it that matters most to you?"
Byock said Providence Health & Services has refined charting tools to make it easier to enter and retrieve a patient's medical preferences in the patient's medical record.
Providing an incentive
Providence Health & Services gave its employees who are eligible for benefits the choice to complete one of two activities by Dec. 1, 2015, to earn their 2016 health incentive. For an employee with a health insurance plan that uses a health reimbursement arrangement or a health savings account — which are both accounts for the reimbursement of medical expenses — an employee received up to $700 as an individual or up to $1,400 if that employee's spouse or immediate family members took part in the advance care planning or an alternate activity. Providence Health & Services contributed to the account associated with the medical plan. Some employees are part of a health maintenance organization. They earned up to $400 as an individual or up to $800 in a premium credit if their spouse or family participated in one of the two activity choices.
Fisher said 3,900 employees opted to complete a health assessment online. Providence Health & Services offered employees a choice in case some employees didn't want to delve into advance care planning.
Photo credit: Eric Taylor
Providence Health & Services' Communications Manager for Oregon Olivia Ramos took steps to complete her advance care plan after the health system encouraged employees to do so. She's shown here working at Providence Office Park in Portland, Ore.
Byock said Providence Health & Services recognizes that advance care planning is a sensitive topic for many people and the system wanted to "respect the sanctity of its relationships with employee caregivers." He added, "This is an incentive plan, not a mandate."
Fisher said the advance care planning activity got "far more positive feedback" than many past health incentive activities. He thinks that's in part because the topic showed the system wasn't focused just on wellness, but on overall well-being, including a person's spiritual and emotional needs.
Providence Health & Services will measure the impact of the advance care planning activity by again asking employees if they've documented their medical wishes in writing when employees take part in the 2017 incentive activity.
Olivia Ramos, communications manager for Providence Health & Services in Oregon, called the advance care planning initiative a strong motivation for moving ahead on a health care directive. "I knew it was something I wanted to do, but I kept putting it off." Ramos said she continues to work on her advance care plan, but she's confident she'll get her medical wishes legally documented. "I made a promise to Providence that I would do this," she said.
Ramos volunteers with a support group for families of cancer patients, a bereavement support group and a grief camp for children. She said engaging in the advance care planning activity made her confident she can ask questions and discuss the basics of these issues if they arise in the support groups she staffs. She'd then direct support group members to other professionals with Providence Health & Services who may be more expert on the finer points.
There are generally two types of advance care directives: durable power of attorneys for health care and living wills. Advance care planning could include the creation of both types of documents.
A durable power of attorney legally identifies a trusted person to make medical decisions when a patient can no longer make these decisions. A living will includes detailed or perfunctory instructions about whether or under what circumstances to withhold potentially life-prolonging interventions and treatments such as cardiopulmonary resuscitation, mechanical ventilation or even antibiotics. Both types of advance directives are legal documents; however, physicians usually do not face legal sanctions if they do not comply with the patient's documented wishes, said Fr. Tom Nairn, OFM, CHA's senior director of theology and ethics.
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