Article Figures & Data
Tables
- Table 1.
Patient Demographics and Summary of Advance Care Planning Clinical Notes (n = 17)
ID Age (years) Provider Type Specialty Primary Diagnoses Code Status Documented Living Will DPOA IPOST Hospice Status 1 69 ARNP IM/PC HF, COPD, Afib, CKD, MI Yes Yes Yes Yes Yes 2 87 MD IM/PC Afib, CAD, CKD Yes Yes Yes Yes Yes 3 59 ARNP IM/PC Cholangiocarcinoma Yes No Yes Yes Yes 4 80 MD IM/GI CAD, CVD, perihepatic fistula No No No No No 5 49 MD IM/PC Renal failure No No Yes No No 6 55 MD IM/PC COPD Yes No Yes No No 7 70 MD IM/PC Lingual cancer No No Yes No No 8 70 MD IM/PC HF, CVA, DM1 Yes No Yes No No 9 63 MD IM/PC HF Yes Yes Yes No No 10 52 MD IM/PC HF No No Yes No No 11 58 DO IM/PC HF, CKD, DM2 Yes No Yes No Yes 12 75 ARNP IM/PC HF Yes No Yes No No 13 63 ARNP IM/PC HF Yes No Yes No No 14 35 ARNP IM/PC Melanoma with brain metastasis No No Yes No No 15 67 PA FM HTN, obesity No Yes No No No 16 58 MD FM HF, Afib, obesity No Yes No No No 17 84 MD FM CHF, CKD, HTN No Yes No No No Afib, atrial fibrillation; ARNP, advanced registered nurse practitioner; CAD, coronary artery disease; CVA, cerebral vascular accident; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CVD, cerebrovascular disease; DM1/2, diabetes type 1/2; DO, Doctor of Osteopathic Medicine; DPOA, durable power of attorney for health care; FM, Family Medicine; HF, heart failure; HTN, hypertension; IM/GI, Internal Medicine/Gastroenterology; IM/PC, Internal Medicine/ Palliative Care; IPOST, Iowa Physicians Orders for Scope of Treatment (legally binding document); MD, Doctor of Medicine; MI, myocardial ischemia or infarct; PA, Physician Assistant.
- Table 2.
An Example of Epic Advance Care Planning Checklist SmartPhrase, Adapted from the Serious Illness Care Conversation by Ariadne Labs12
Serious Illness Care Plan (.famacp) 1. Set up the conversation “I'd like to talk about what is ahead with your illness and do some thinking in advance about what is important to you so that I can make sure we provide you with the care you want — is this okay?” (The patient must give permission for this discussion, per Medicare guidelines. They can decline to discuss.) *Introduce purpose *Prepare for future decisions *Ask permission 2. Assess understanding and preferences “What is your understanding now of where you are with your illness?” “How much information about what is likely to be ahead with your illness would you like from me?” 3. Share concerns about the future
*Frame as a “wish … worry”, “hope … worry” statement
*Allow silence, explore emotion“I want to share with you my understanding of where things are with your illness …” Uncertain: “It can be difficult to predict what will happen with your illness. I hope you will continue to live well for a long time but I'm worried that you could get sick quickly, and I think it is important to prepare for that possibility.” OR Function: “I hope that this is not the case, but I'm worried that this may be as strong as you will feel, and things are likely to get more difficult.” OR Time: “I wish we were not in this situation, but I am worried that time may be as short as ____ (express as a range, e.g., days to weeks, weeks to months, months to a year).” 4. Explore key topics “What are your most important goals if your health situation worsens?” *Goals “What are you biggest fears and worries about the future with your health?” *Fears and worries “What gives you strength as you think about the future with your illness?” *Sources of strength “What abilities are so critical to your life that you can't imagine living without them?” *Critical abilities “If you become sicker, how much are you willing to go through for the possibility of gaining more time?” *Tradeoffs “How much does your family know about your priorities and wishes?”
“Do you want to make it more concrete?” Consider IPOST.*Family 5. Close the conversation
*Summarize
*Make a recommendation
*Check in with patient
*Affirm commitment“I've heard you say that ____ is really important to you. Keeping that in mind, and what we know about your illness, I recommend that we ____. This will help us make sure that your treatment plans reflect what's important to you.”
“How does this plan seem to you?”
“I will do everything I can to help you through this.”6. Document your conversation 7. Communicate with key clinicians IPOST, Iowa Physicians Orders for Scope of Treatment.
Statement of Patient Consent and Time Spent on Advance Care Planning: [Patient name] voluntarily consented to an advance care planning discussion to aid in considering and prioritizing their treatment goals. I spent *** minutes face-to-face with [patient's name] and [add any other participants (family, RN, MA, etc.) discussing Advance Care Planning.
ID Qualified Provider ACP Time (minutes) Spent RN ACP Time (minutes) Spent CPT 99497 Billed and Reimbursed Actual Reimbursed Dollars Payers*† 1 30 0 Yes $61.97 Medicare & Supplement 2 30 0 Yes $72.90 Medicare & Supplement 3 30 0 Yes $61.97 Medicare & Supplement 4 30 0 Yes $76.42 Medicare Replacement 5 0 16 No $0.00 Private 6 0 20 No $0.00 Medicare Replacement 7 0 25 No $0.00 Medicare & Supplement 8 0 25 No $0.00 Medicare & Supplement 9 0 25 No $0.00 Medicaid 10 0 25 No $0.00 Private 11 0 20 No $0.00 Medicare 12 0 20 No $0.00 Medicare 13 0 20 No $0.00 Medicare & Supplement 14 0 16 No $0.00 Medicare & Supplement 15 5 0 No $0.00 Medicare & Supplement 16 8 0 No $0.00 Medicare 17 25 0 No $0.00 Medicare ACP, advance care planning; CPT, current procedural terminology, RN, registered nurse.
↵* Medicare & Supplement: Medicare is primary insurance; secondary commercial insurance or Medicaid were supplemental to the Medicare coverage and may have paid a portion of the total payment amount that is billed.
↵† Medicare Replacement: also known as Medicare Part C; a plan offered by private health insurance companies that provide the same coverage as Medicare Part A and Part B, and may include other benefits not normally covered by standard Medicare (e.g., prescription, dental).
