By:
Scott Brown, President & CEO | MyDirectives
Joanne Eason, Senior States and Partnerships Strategist | MyDirectives
How statewide ecosystems focused on improving advance care planning engage and align champions, organizations, and technology to create solutions with greater value than any single stakeholder could achieve alone.
The benefits of high-quality advance care planning (ACP) for patients, families, providers, and payers are well-documented. The U.S. is experiencing a convergence of policy changes, payment incentives, and consumer demand that supports broader adoption. CMS continues to focus on expanding ACP in reimbursement models, and it is now a mandatory measure in most healthcare quality reporting requirements. Providers are increasingly incentivized to reduce unwanted and low-value care by aligning treatment with patient goals recorded as the result of good and effective ACP.
Yet, despite growing recognition of ACP’s value, challenges remain. One persistent issue is ensuring that treatment preferences documented in advance directives, mental health advance directives, and portable medical orders like POLST are accessible to treating providers at all critical points of care, especially in emergency settings and transitions of care.[1] Currently, most ACP documents are stored in siloed electronic health record (EHR) or electronic medical record (EMR) databases, file cabinets, safe deposit boxes, or even sock drawers, which means they may not be available when they’re needed most. While efforts to leverage health information exchanges (HIEs) to share documents have helped, many HIEs have limited access and significant issues with ACP document portability and interoperability between different care settings.
The result is a missed opportunity. Despite best intentions, patients sometimes receive medical treatments and interventions inconsistent with their values and goals, while providers face avoidable moral distress and system inefficiencies. Providers and payers may have developed intentional processes for completing ACP documentation, but when the documents are unavailable to be reviewed as care is delivered, the benefits aren’t actualized. To fulfill the promise of ACP, we must address both the human and technical dimensions of document access by ensuring that clearly written, legally and medically valid ACP documents are available across care settings locally, statewide, and nationally.
Why a Statewide Approach Matters
Much of the work needed to leverage resources and ensure proper access to ACP documentation is linked to state policy. Statutory document execution requirements and formats, as well as processes for recognizing ACP documents, vary by state. Likewise, the structure and accessibility of state ACP document registries and the systems used to share documents differ — some states operate robust statewide HIEs, while others rely on regional or private networks, and still others use toll-free numbers, mail, and fax machines. Given these considerations, a statewide approach offers the best opportunity to align policies, stakeholders, and technical systems. By coordinating efforts across public health agencies, healthcare provider and payer organizations, HIEs, and community coalitions, states can create an integrated ACP ecosystem that meets the unique needs of their residents and fulfills the promise of ACP.
Building Statewide ACP Ecosystems
A statewide ACP ecosystem brings a network of interconnected champions, organizations, and technologies that work together to develop state-specific ACP solutions. Essential components typically include:
- Public-facing tools that empower individuals to create, store, update, and share their advance directives.
- ACP training and education adapted to the appropriate clinical and community settings.
- Integration of ACP workflows and documentation within EHR and EMR platforms.
- Secure registry and data exchange services,including state HIEs, that enable query and retrieval of ACP documents across care settings, including EMS and other first responders, emergency departments, acute care, and others.
- Equitable support for smaller or resource-limited organizations to participate in the ACP ecosystem.
- First responder real-time access to POLST and other portable medical order forms directly in their electronic patient care record (ePCR) systems during transport.
MyDirectives partners with states to build these connected systems. Through its collaborations, MyDirectives works with healthcare and community stakeholders to establish comprehensive ACP ecosystems tailored to each state’s unique policy, demographic, and infrastructure landscape.
Tools & Resources
C-TAC offers several resources that can guide coalition members interested in advancing statewide ACP initiatives:
- The C-TAC Advanced Care Transformation Index (ACT Index) has state-specific data and trends that provide objective data to understand the landscape and develop a local plan. The Communication Domain of the ACT Index includes a measure for Medicare fee-for-service beneficiaries with ACP, and the Cost Domain of the ACT Index includes several measures that are positively influenced by high-quality advance care planning, including 30-day hospital readmissions, hospice length of stay, hospital days in the last two years of life, and ICU days in the last six months of life.
- C-TAC’s Community Engagement Toolkit for State Coalitions guides individuals and groups through the process of developing and strengthening partnerships at the state and local level. The Community Engagement Toolkit Companion Guide provides detailed, step-by-step guidance, and outlines key strategies and tasks that help ensure success in establishing and working within statewide initiatives.
Getting Involved
The first step in developing a robust statewide ACP ecosystem is to reach out to your state’s ACP decision-makers and influencers, which typically include governmental healthcare authorities, the state’s HIEs, POLST collaboratives, palliative care advisory councils, and major healthcare providers. MyDirectives can work with you to begin these outreach efforts to build a coalition that supports ACP and is willing to champion the program.
If you are passionate about keeping the promise of ACP in your state, get started now. Explore the ACP access gaps in your current environment. Communicate the possibilities to your colleagues. Engage other stakeholders.
If you’re ready to build a strong ACP ecosystem in your state, reach out to us at MyDirectives. Contact Scott Brown, president and CEO, at sbrown@mydirectives.com or Joanne Eason, Senior States and Partnerships Strategist, at jeason@mydirectives.com.
[1] Although advance directives, psychiatric or mental health advance directives, and portable medical order forms like out-of-hospital do-not-resuscitate orders and POLST forms serve markedly different purposes, in the interest of brevity, we refer to all of these documents collectively as ACP documents in this article.
