Advance Directives – Entry 2

Dear Diary:

Based on a conversation I had with Carol, Hattie’s daughter, as well as conversations with our team related to our work to reduce avoidable hospitalizations, our QAPI team decided to review our systems around advance directives.  We do a great job completing advance directives upon admission and reviewing them annually, but we don’t have a good system in place to ensure that:

  • Residents and their families have good information to help make these important decisions, and
  • Advance directives are always current and easy to find in the health record.

Rhonda, our social worker,  has agreed to lead a team to work on these areas. Since we use a lot of the INTERACT tools, we thought this would be a good time to look at the INTERACT Advance Care Planning tools to see if they can help us out. As we reviewed the tools, we all agreed that the place to start is to make sure staff are comfortable having end-of-life conversations with residents and families. The INTERACT Advance Care Planning Communication Guide is a great tool to help with this.

Rhonda volunteered to lead educational sessions using this tool with all of our nurses on the Elm neighborhood. She has a wonderful idea of role playing these conversations as part of the training. Some volunteers from our QAPI team even agreed to help her out! Once everyone is trained on how to use the communication guide, we’ll introduce the rest of the INTERACT Advance Care Planning tools to the Elm neighborhood.

Rhonda’s team will be involved with the training and then work on systems to assure the advance directives are current and everyone knows where to find them.  She’ll report the progress back to the QAPI team. Our plan is to empower the staff on Elm neighborhood and test the education and strategies there. Once we figure out what works best, we’ll move ahead with the other neighborhoods. I’m excited about the possibilities here!

I wonder what other homes are doing to facilitate discussion and assure current advance directives are in place?

Signed, Donna

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