The Effectiveness of Employing Exclusive Advance Care Planning

(ACP) Clinicians

Kasey Wallis, Karen Detering, Kathy Whiteside, Daveena Mawren, Rebekah Sjanta, Dorothy Campbell, William Silvester

What Does Austin Health Do?

97,501 inpatient admissions

170,497 outpatients

69,923 emergency presentations

Networked across 3 sites

>400 acute beds

$686M budget

> 900 beds

=Lots of ACP activity

A Large Health Care Provider

Primary catchment area 118km2

Extended catchment area 1800km2

Under Here

A Timely Review of the RPC Service

• Austin Health has a well established Respecting Patient Choices program since 2002

• Period of service development 2007-2012

• Equivalent of 2 full-time clinicians (1.6 acute / 0.4 sub-acute)

• Prospective audit of all patients referred to RPC program during 2010-2011

– Evaluate service effectiveness & inform service development

• Utilised RPC database & electronic hospital systems– Referral characteristics– Demographics of patients seen– ACP clinician activity & – frequency of Advance Care Directives (ACD)

An Overview of ‘Our’ ACP Process

Hi I’m Kathy

Supported by hospital policy

Patients referred to

RPC

Consultation with ACP Clinician

ACP outcome

Conversation no ACD doc

Completed≥1 ACD doc

Not completed

RTCSOC SDM (MEPOA)

Patient identified by

ACP Clinician Via EHR

The statistics: 2010-2011 Service Delivery

1580 referred 1463 (93%) had ACP• 79% acute hospital

• 20% sub-acute hospital

• 1% other

454 (31%) died

Are Patients Referred to ACP Clinicians Representative of Austin Inpatients?

Patients referred to RPC 2010-2011 Austin Hospital inpatients admitted in 2011

Median age (range) years 76 (18-102) 61 (0-105)

Male n (%): Female n(%) 801 (51%): 779(49%) 30,576 (53%): 26,843 (47%)

Referred Patients: Primary Admission Diagnosis

23%

10%

18%12%9%

28%

Primary Admission DiagnosisCancer Cardiac Renal Respiratory Orthopaedic Other

Designation of referrer n %Nursing staff 530 36Medical staff 109 7Allied health staff 56 4RPC initiated 541 37Other 228 16

Relationship Between Visits and ACD Completion

• Mean time for consultation 3 days (SD 11, range 0-236)

• Median (range) ACP visits: 2 (1-11)

• ACP clinician vists/discussions significant association with ACD completion (p<0.001).

ACP Activity: Total time vs. ACD Completion

Chi square = 129.752, p<0.001

Mean SD Median RangeTotal time (minutes) all patients 89 65 65 0,570Total time no ACD completed (minutes 67 47 47 0,360Total time ACD completed (minutes) 117 73 73 0,570

Proportion of Clinician Facilitated ACDsExisting ACD at time of referral n(%) Clinician facilitated ACD n(%) Total

Appointed a SDM 179 (11%) 408(26%) 587 (37%)SOC - competent 79(5.4%) 335 (22.9%) 514 (28.3%)SOC- non-competent 3 (0.2%) 35 (2.4%) 38 (2.6%)SOC total 82 (5.6%) 370 (25.3%) 452 (31%)RTC 9 (0.6%) 48 (3%) 57 (3.6%)

Resuscitation Preferences by Primary Diagnosis

Life Prolonging Treatment Preferences by Primary Diagnosis

Want LPT Want LPT if reasonable outcome Don't want LPT Delegate to SDM Missing/NA Total no of SOC'sAll SOC's 14(3%) 195(43%) 184(41%) 23(5%) 36(8%) 452(100%)Cancer 3(3%) 41(45%) 34(37%) 9(10%) 4(4%) 91(20%)Cardiac 1(3%) 9(26%) 15(44%) 4(12%) 5(15%) 34(8%)Renal 3(2%) 77(64%) 37(31%) 1(1%) 3(2%) 121(27%)Respiratory 2(4%) 22(39%) 24(43%) 3(5%) 5(9%) 56(12%)Orthopaedic 2(6%) 9(27%) 16(48%) 2(6%) 4(12%) 33(7%_Other 3(3%) 37(32%) 58(50%) 4(3%) 15(13%) 117(26%)

SOC: Undesired Medical Treatment Indicated

Clinician facilitated SOC n=370

Quality audit of 98 (26%) of these SOC’s

• 71 (72%) indicated undesired medical treatment

Are we targeting the right patients?RPC sample (2010/2011) Austin Health patients (2011)

n (%) 454 (31%) 1174 (1.2%)Male : Female 248(55%):206(45%) 674(57%):500(43%)Median age (range) years 79 (25-102) 79Median time ACP consult to death (range) weeks 6 (0-97) NAMedian time b/w selecting NFR -death (range) weeks 6 (0-79) NA

What makes Austin’s Service Model Effective?

• Dedicated and supported ACP clinicians

• ACP clinicians devoted to particular specialty areas

• Patient-centred approach

• Multi-staged approach across the continuum of care

• Processes and policy for recording/alerting clinicians to ACDs & executive support

• Systematic education of medical, nursing & allied health staff

Many thanks for your time today and to the

Austin Health RPC Team