Providence St. Joseph Health is developing an easy-to-follow framework to help clinicians talk to patients about their goals and preferences.
Older adults routinely receive care they do not want or that is discordant with their goals and wishes. A key reason is that providers do not consistently ask patients what matters to them. Clinicians are very good at problem-based discussions with patients, which focus on assessing symptoms and identifying treatments. But many of us need additional training in how to have conversations with patients about what matters to them versus what’s wrong with them.
What We Tried
As one of five pilot organizations in the Creating Age-Friendly Health Systems (AFHS) initiative, Providence St. Joseph Health is committed to improving health care for seniors and their families focused on the 4Ms:
- Identify and pursue what mattersto patients.
- Maintain mobility by encouraging patients to be active.
- Determine any unnecessary or potentially harmful
- Ensure mentation by ensuring proper hydration and nutrition and managing dementia, delirium and depression.
To address “what matters” to patients, we formed a multidisciplinary team that includes a physician, physician assistant, nurse, social worker, and chaplain. As team members thought about how to better understand and address older patients’ goals and preferences, we found inspiration in a tool called “The Serious Illness Conversation Guide,” which helps clinicians talk with patients about end-of-life care. The guide gives providers language to use or adapt, including a series of questions that can help uncover a patient’s goals, worries, and wishes.
We decided to use the “Serious Illness Conversation Guide” as a template for developing a “What Matters Conversation Guide” that providers can use for our general patient population ages 65 and older who are not near the end of life. We are designing the guide as a template that can be used and adapted by staff across different care sites at Providence St. Joseph Health, including acute, ambulatory, and home care.
First, we identified six key steps to follow before, during, and after these conversations with patients:
- Set up: Invite the appropriate people to the conversation and check the electronic health record (EHR) for notes from previous discussions with the patient.
- Invite the patient to the conversation: Explain the reason for the discussion and request permission to ask the patient a few questions.
- Ask the questions: Learn what matters to the patient by posing a few questions
- Summarize and action planning: Confirm what the patient said and invite the patient to help determine how to best fulfill his or her goals and preferences.
- Next steps: Acknowledge that this will be an ongoing process.
- Document: Add or update the patient-stated goals in the longitudinal plan of care in EHR.
Identifying the right questions to ask patients has been an ongoing process. We have been testing different questions and phrasing in our outpatient clinic and through our Elder at Home program, which provides multidisciplinary support to fragile seniors in their homes. Using the Plan-Do-Study-Act process improvement model, we test the questions on at least five patients and log the interaction. One of the things we’re looking at is whether the patient appears comfortable answering the question.
We plan to finalize the “What Matters Conversation Guide” by the end of 2018. The guide will be a one-page sheet that can be read quickly by clinicians and easily adapted to fit their populations and settings.
Because we are still in the testing phase for the guide, we do not yet have quantitative results. We anticipate that the guide will help improve patient experience and may reduce the use of unwanted treatments and services. Research has shown that addressing what matters to patients in an integrated, coordinated manner can lower inpatient utilization by 54 percent and ICU stays by 80 percent.
We are also hoping that this intervention will help promote the development of advance directives. Anecdotally, in our pilot tests, we have noticed that asking patients about their goals and wishes tends to lead to discussions about these legal documents.
Getting clinicians to buy into the “what matters to patients” vision has been an easy sell. On a small scale (e.g., a single inpatient unit), leaders might simply encourage staff to talk to patients about their goals and care preferences and suggest one or two questions to use during these conversations. We went with a more comprehensive approach because we plan to scale this initiative across Providence St. Joseph and wanted to promote a standardized approach across the system.
The Creating Age-Friendly Health Systems initiative is sponsored by the John A. Hartford Foundation, the American Hospital Association, and the Institute for Healthcare Improvement.