Telephonic advance care planning facilitated by health plan case managers.

OBJECTIVE: The insurance plan case managers (CMs) of Priority Health, part of a regional healthcare system located in Michigan, work telephonically with frail patients who have multiple comorbidities. However, these CMs have lacked facilitation skills for advance care planning (ACP) discussions in this vulnerable population. In 2012, the findings of a six-month pilot study of telephonic ACP (TACP) with some of the plan's Medicare population were implemented with Medicare members under case management. METHOD: Case mangers were trained and certified by Respecting Choices® to introduce and facilitate ACP discussions telephonically utilizing both First Steps and Last Steps protocols. The CMs identified appropriate patients using hospitalization and emergency room utilization data, severity of illness, and diagnostic criteria. The primary goal was to complete both the ACP discussion and the documentation for each protocol on identified patients. They also attempted to schedule facilitated conversations with the patients' healthcare advocates present. RESULTS: During a 12-month period, 576 health plan members were offered First Steps discussions, with 198 interested in engaging in further ACP. Some 152 members were identified for Last Steps TACP using established criteria; discussions occurred with 56 members. TACP implementation resulted in 55 new or updated First Steps documents and 4 Last Steps documents. A total of 50 discussions included the designated healthcare advocate. SIGNIFICANCE OF RESULTS: Following TACP implementation with the Medicare CM team and evaluation of the results, processes and methods were instituted to increase engagement and completion of discussions and documents. These included enhancements to the electronic assessment and ongoing support of the CM team to increase the engagement of patients and advocates. Dissemination of the project to the entire Medicare CM team demonstrated opportunities and lessons learned for facilitated TACP discussions. The TACP model has the potential to be successfully utilized by other health insurance companies.

Using experiential techniques for staff development: liking, learning, and doing.

Experiential techniques, such as role plays and simulations, are recommended to achieve nursing home staff training and development objectives. Experiential techniques can be customized to match the learning styles and preferences of all levels of nursing staff. Nursing staff's reactions to and benefits from such techniques are a necessary first step in the evaluation of a skills training program. Project RELATE (Research and Education for Living with Alzheimer's Disease: Therapeutic Eldercare) measured reactions to and knowledge gained by nursing staff using such techniques in training person-centered care. Findings suggest experiential techniques are efficacious as learning methods.

Predicting response to rehabilitation in elderly patients with stroke using the Orpington Prognostic Scale and selected clinical variables.

PURPOSE: Prediction of outcome and response to rehabilitation in patients with stroke can be difficult, especially in the elderly. The purpose of this study was to determine the ability of the Orpington Prognostic Scale (OPS) to predict outcome and response to subacute rehabilitation in older patients with stroke. METHODS: Twenty-two subjects in the subacute care setting diagnosed with acute stroke were prospectively studied. The OPS was scored within 2 weeks of stroke, and the Functional Independence Measure (FIM) motor subscale was scored at admission and discharge. RESULTS: Strong Spearman correlations with OPS scores were found for improvement in FIM score [rs = -.74, 95% CI: (-.88, -.45), p = .0007] and discharge FIM score [rs = -.81, 95% CI: (-.92, -.58), p = .0002]. CONCLUSIONS: The OPS scores were strong predictors of response to subacute rehabilitation and discharge FIM motor subscale scores. The OPS may warrant a broader application as a prognostic indicator for patients with stroke.

Postintervention focus groups: toward sustaining care.

This study examined whether effects of person-centered care and person-centered mentoring were sustained postintervention from the perspective of long-term care nursing staff. Separate focus groups for administration, nurse mentors, and certified nursing assistants (CNAs) were used to assess perception of change in behaviors. CNAs sustained person-centered care skills on the job while nurse mentors experienced less change. With regard to nurse-CNA relationships, a discrepancy in the perceptions of nurses and CNAs was evident. The non-threatening environment of focus groups allowed staff to share their perceptions of the barriers to behavior change needed to sustain the intervention over time.