Goals of Care Conversations - PowerPoint Presentation

Slide1

Goals of Care ConversationsStrategies and Tools to Help Proactively Identify High-Risk Patients

To successfully honor patients’ goals and decisions, we must:

Why?Conducting a goals of care conversation BEFORE the patient experiences a medical crisis helps ensure that treatment near the end of life matches the patients goals and preferences. It is difficult for patients and families to absorb information and make carefully-considered decisions in the midst of a health crisis.

When the patient has lost decision-making capacity, it is very stressful for family members to make decisions about life-sustaining treatment.

Clear information about the patient’s goals and decisions helps reduce the risk of uncertainty and conflict among family members and staff during a health crisis.

How?Use Clinical Judgment Ask yourself the “surprise” question:

Ask yourself:

Would I be surprised if this patient had a life-threatening clinical event in the next 1-2 years?

Who are my sickest patients?

Advanced

Lung Disease/Heart Disease/Liver Disease/ Kidney Disease/ Cerebrovascular Disease/Cancer

Frail with Multiple Comorbidities

Dementia

Use Clinical Judgment Clues:Multiple hospitalizations in the last yearNew or progressing diseaseAt risk for loss of decision-making capacityDependent on others for careDaily symptoms affecting quality of life or function

LAST FOUR SYNDROME:

When you know the last four digits of the patient’s SSN without having to look it up, the patient is probably at high risk

Use objective screening tools Indicates risk of hospitalization or death90-day CAN score1-year CAN score

Available to

Primary Care Teams

through the

Primary Care Almanac

and the

Patient Care Assessment System

CAN Scores: Care Assessment Need Score

Patient Care Assessment SystemNational web-based application designed to optimize the health care that VA’s Patient-Aligned Care Teams (PACT) provide patients, especially high-risk patients. PCAS helps PACT care managers and

teamlets

:

Identify

patients who require focused

attentionManage the services and care their patients receive and the tasks required for patient

care

Coordinate

care for their patients

Lists patients on the primary care team’s panel by CAN scores

Lists potential candidates for Goals of Care Conversations – patients with CAN scores

>

95 and those who have been manually added to the list

Allows Primary Care Teams to Identify Patients Who Meet Specific

Risk Characteristics

Allows Primary Care Teams to Identify Patients Who Meet Specific Risk Characteristics

This filter will be made available

to your team when your

VA facility begins to use the LST Progress Note to document goals of care conversations

Goals of Care Conversations Filter

Automatically lists patients with high CAN scores; others can be added manually

YES

NO

YES

= GoCC conducted

NO

= GoCC not conducted

TASK

= A GoCC-related task has been assigned to one or more team members

Lists patients who may be appropriate for goals of care conversations (

GoCCs

)

Sample High-Risk Indicators Page

for an Individual Patient

This shows that a

task related to a goals of care conversation has been assigned to a primary care team

member.

How Primary Care Teams Can Access PCASLink to the Patient Care Assessment System https

://secure.vssc.med.va.gov/PCAS/

Will automatically import the list of patients that are assigned to you/your team through the Primary Care Management Module (PCMM). Talk to your Primary Care administrator if your panel of patients does not appear when you click the link.

Fact Sheet

Includes an overview of the program, answers to frequently asked questions, and a link to an educational

module about PCAS.