How Advance Care Planning Can Benefit Post-Acute Care

May 25, 2022 | Written by: Cindy Kreider, RN, BC RAC-CT, Clinical Executive Account Specialist

As more and more aging seniors accelerate towards the later stages of life, the number of decisions both they and their family’s face, can often become insurmountable. Although they may be presented with an onslaught of decisions, it is imperative to ensure they are able to maintain the same quality of life they are accustomed to.

While these sensitive conversations can often be difficult, initiating discussions with the patient and their family members/loved ones are often mutually beneficial in helping to prepare for where they are in their biological life cycle. With all these factors and potentially challenging discussions, what can be done to ease the process for both the patient, their family, and the caregivers?


What is Advance Care Planning?

Regardless of whether someone is facing an acute or long-term chronic illness, advance care planning (ACP) can help alleviate unnecessary suffering, improve quality of life, and provide better understanding of the complex decisions faced by the patient and their family/loved ones. ACP provides a greater understanding regarding the types of decisions that might need to be made, considering those decisions ahead of time, and then discussing the patient’s preferences with the family/loved ones and health providers.

With the numerous decisions which arise within ACP, how can this process be leveraged by skilled nursing facility (SNFs) within post-acute care?


The Importance of Advance Care Planning with Post-Acute Care Facilities

Value based care (VBC) continues to be a prevalent topic within the healthcare industry, and post-acute care facilities are no exception. Within the VBC model, it is important for the post-acute settings to have an appropriate balance of both the patient’s goals, as well as ensuring the care provided is meeting the patient’s needs.

As more and more patients are discharged to post-acute facilities with a multitude of chronic medical issues and co-morbidities, the utilization of ACP initiatives enables them to digest the complex information more easily. This allows facilities to assess more accurately, as well as process coding associated with patient care. The information within the advance care initiatives help to guide the clinical teams in making the appropriate decisions to ensure that patients receive medical care that is consistent with their values, goals, and preferences – while also aligning with VBC outcomes.

ACP is an integral aspect of the facility’s comprehensive care planning process and assures re-evaluation of the patient’s desires on a routine basis and when there is a significant or progressive change/decline in the patient’s condition. The process can help the patient, family and interdisciplinary teams prepare for the time when a patient becomes unable to make decisions, ensuring their wishes are honored. Additionally, it enables providers to support families’ and patients’ expectations and avert the emotional decision making that may lead to inappropriate or unwanted care. Clinical staff can accurately assess the care the patient is receiving and ensure that it has an appropriate emphasis on areas inclusive of pain management, depression management, and what is most important to the resident in supporting their quality of life.


How Post-Acute Care Facilities can Achieve Value-Based Care Goals

Value-based care improves quality outcomes for patients and reduces overall cost of care by providing overall wellness and preventative treatments. Through the right implications, post-acute facilities can implement value-based and patient centered care goals while not sacrificing the patient’s care or their end-of-life decisions.

All in all, there are various benefits in utilizing ACP analytics. One of these gains is the opportunity for more productive conversations relating to palliative or end of life care with patients and their families. By adding value to these discussions, care providers can maximize quality of care while simultaneously taking patient choice into consideration. The integration of information from the ACP analysis continually helps facilities to not only provide VBC, but also helps them to maximize efficiency when caring for patients with differing ACP scores and prioritize accordingly.

With the Real Time Medical Systems ACP Alert, a measurable score utilizing clinical data is provided, as well as risk factors modeled after the personal severity index (PSI). Patients who receive an ACP score of 9 or greater are more likely to be moving through another phase of their life cycle. As facilities are often tasked with attending to a variety of patients, the predictive capabilities embedded within the ACP score enable them to prioritize patients who have a score of 9 or greater, as well as obtain information as to what is triggering that score.

The ACP score is modeled after the PSI and clinical data from the EHR, or once the MDS is completed. The ACP identifier, including ACP alerts, ACP reports, and ACP tagging, provide a comprehensive view of the patient. This score includes metrics relating to functionality, as well as clinical and mood status. This compilation aids facilities to provide the patient with the best quality of life care. The predicative score card within ACP enables the care teams to discuss and respect the patient’s choices while they are of sound mind.

With this prognosis, this may require changes to current care plans, as well as advance directives. Ultimately, this provides post-acute facilities the opportunity to initiate code status discussions, as well as what is important to the patient and their loved ones around advance directives and the associated decision-making processes. It is important to keep in mind, that although the ACP is a predictive tool, patients may still require further clinical investigation before reaching a proper diagnosis.

To learn more about Real Time’s ACP alerting, contact us today.

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