Medical Manuscript

The Relationship Between Organizational Characteristics and Advance Care Planning Practices

American Journal of Hospice & Palliative Medicine® 1-6 ª The Author(s) 2014 Reprints and permission: DOI: 10.1177/1049909114530039

Kristin R. Baughman, PhD1, Ruth Ludwick, PhD, RN-BC, CNS2, Barbara Palmisano, MA1, Susan Hazelett, RN, MS3, and Margaret Sanders, MA, LSW1

Abstract Organizational characteristics may impede the uniform adoption of advance care planning (ACP) best practices. We conducted telephone interviews with site directors of a Midwestern state’s Medicaid waiver program administered by the Area Agencies on Aging and surveyed the 433 care managers (registered nurses and social workers) employed within these 9 agencies. Care managers at 2 agencies reported more frequent ACP discussions and higher levels of confidence. Both sites had ACP training programs, follow-up protocols, and informational packets available for consumers that were not consistently available at the other agencies. The findings point to the need for consistent educational programs and policies on ACP and more in depth examination of the values, beliefs, and resources that account for organizational differences in ACP. Keywords advance care planning, organizational characteristics, care management, area agency on aging, community-based long-term care, nurses, social workers

Introduction An opportunity exists for home health care agencies to engage more consumers in advance care planning (ACP) as indicated by the low rate of advance directives documented by these agencies.1,2 Often health care providers do only what is required by regulatory agencies, such as documenting the existence of advance directives, but do not engage fully in the process of ACP. In the realities of practice settings, there is a ‘‘check box mentality’’ that is a tendency to check off a box on intake to verify that the requisite questions on the topic have been asked but not go further in discussing the topic. The ACP process is much more encompassing and includes ongoing discussions among health care providers, patients, and their families about disease pathways, treatment choices, and the goals and preferences of the patients.3 In moving past the check box mentality of advance directives and more completely integrating the ACP process into usual care, it is important to examine more closely those in position to initiate the ACP process. The attitudes of both the providers and the organization are important for transforming practice.4 For wide adoption of ACP best practices, the culture of organizations must support those responsible for initiating ACP discussions. An organization’s culture, that is its shared norms, values, and beliefs, can support or block the adoption of best practices.4 Although a provider can act independently within an

organization, for widespread adoption, a true cultural shift is needed. Numerous dissemination researchers emphasize the critical nature of organizational culture and the characteristics of an organization in adopting best practices.5-8 Expectations, both explicitly through policies and implicitly through norms, along with available resources set the necessary organizational climate for changing practice. Advance care planning is one of those best practices in need of more widespread adoption. Recently, a project team funded by the Agency for Healthcare Research and Quality (AHRQ) included ACP in their list of the top 20 safety practices for health care providers.9 Specifically, the team recommended that patient preferences for life-sustaining treatments to be documented. This recommendation was included because the scope of the


Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, OH, USA 2 Robinson Memorial Hospital, Ravenna, OH, USA 3 Health Services Research and Education Institute, Summa Health System, Akron, OH, USA Corresponding Author: Kristin R. Baughman, PhD, Department of Family and Community Medicine, Northeast Ohio Medical University, 4209 State Route 44, PO Box 95, Rootstown, OH 44272, USA. Email: [email protected]

Downloaded from at TULANE UNIV on January 27, 2015

American Journal of Hospice & Palliative Medicine®

2 problem is common, the evidence for its effectiveness is moderate, and the cost for intervening is low.9 Advance care planning provides an avenue for better communication with patients, incorporating patient preferences into care plans and reducing unwanted, questionable, and costly procedures.10 Thus, the potential impact on costs and quality of life is great. Lack of ACP has far reaching effects on quality of life and contributes to the annual high Medicare costs accrued in the final year of life.11-13 However, the AHRQ-funded project team states that the implementation issues of ACP practice are of moderate difficulty.9 As with many new practices, there needs to be a cultural shift in health care organizations. The team warns that changes in practice, even simple changes, require cultural changes in organizations and the local environment. Community-based care management organizations are in a key position to encourage ACP among older noninstitutionalized adults. As key players on the health care team, care managers are on the front lines explaining to patients and families what options are available for end-of-life care.11 Since many states have care management organizations, implementing their Medicaid waiver programs that provide services to help nursing-home-eligible older adults remains in their homes as long as possible, it is an opportunity for care managers to take a greater role in implementing ACP best practices. To fully realize this opportunity, it is important to look at possible barriers such as beliefs about ACP and facilitators of change such as policies and training within these organizations. The purpose of this article is to explore how the organizational characteristics of agencies, a necessary component of ACP implementation, may influence the use of ACP by community-based long-term care providers.

Methods We conducted a descriptive cross-sectional study to examine how the attitudes, experiences, and characteristics of care managers and organizational characteristics of the Area Agencies on Aging (AAAs) in which they worked influenced the practice of ACP. The study took place in a Midwestern state with 9 of the 12 possible agencies and subsequently with 433 (91%) of the 476 possible care managers. Of the 3 agencies that did not participate, 1 agency was excluded because staffs were involved in other research on palliative care14 and 2 agencies refused to participate citing time as a factor. Approval for the research was obtained by the institutional review boards at the 2 universities and the hospital system in which the researchers were employed. Then permission to carry out the study at each agency was obtained from the site’s Medicaid waiver program director at each of the 9 agencies. The procedures for data collection were 2-fold. First, structured telephone interviews were conducted with site directors for the state’s Medicaid Waiver program at each AAA. Next, we attended the last 15 minutes of the next scheduled staff meeting to describe the study and ask care managers to complete questionnaires at each agency. The telephone interviews and care

manager surveys were part of a larger study3,15 that included focus groups and hypothetical vignettes in the care manager surveys. In the current study, we focus only on the director telephone interviews and selected parts of the care manager survey.

Measures The structured telephone interviews with site directors for Medicaid waiver programs provided the following data on each organization: (1) location, whether the AAA was in a rural, urban, or Appalachian region of the state, (2) whether the AAA had policies on ACP and follow-up protocols, and (3) training opportunities on ACP. In addition to responses to the questions, comments by the directors were also recorded during the telephone interviews. From the questionnaires given in the larger study to the care managers, we used the following data: professional background, professional and personal experience with ACP, selfefficacy, and beliefs about ACP. The professional background data included greater than 5 years of experience working at the AAA, nursing or social work education, and whether or not the care manager had a graduate degree. Professional experience with ACP included discussing ACP with a consumer within the past month and discussing ACP with greater than 50% of one’s caseload. Personal experience with ACP included having completed one’s own advance directive and assisting family or friends with advance directives. Self-efficacy was measured by asking participants 2 questions. The first question was ‘‘To what extent do you agree or disagree with the following statement: I am confident that I can help consumers take a more active role in ACP.’’ A scale from 0 to 10 was used with 0 indicating strongly disagree and 10 indicating strongly agree. A second question was asked if the care manager had a recent ACP encounter, ‘‘Were you confident about your skills in discussing ACP with this consumer?’’ A scale from 0 to 10 was used (0 indicated not at all confident and 10 indicated strongly confident). Participants were also asked the extent to which they agreed or disagreed with several other beliefs about ACP: discussing ACP is too upsetting for consumers and their families, ACP is only for people with less than 6 months to live, ACP is appropriate when all other treatment options have been exhausted, it takes too much of my time to discuss ACP with consumers, I do not know enough about diseases and their progression to initiate ACP discussions, it is not the role of the AAA to lead discussions about ACP, physicians are primarily responsible for ACP discussions, and I am comfortable discussing ACP with consumers. Each of these items were rated on a scale from 0 to 10 with 0 indicating strongly disagree and 10 indicating strongly agree.

Analysis Descriptive statistics were used to describe each agency and the characteristics of their care managers. We then examined care manager characteristics by site. To test for differences in skills,

Downloaded from at TULANE UNIV on January 27, 2015

Baughman et al


Table 1. Responses From Area Agency on Aging Site Directors for Medicaid Waiver Programs About ACP Policies and Training. Variable

Site A

Site B

Site C

Site D

Site E

Site F

Site G

Site H

Site I

AAA policy to inquire about DPOA Living wills DNR orders Goal setting Advance directives documented Follow-up conducted ACP training

Yes Yes Yes Yes Yes Yes Yes

Yes Yes No No Yes Sometimes Yes

Yes Yes Yes No Yes Yes Yes

Yes No No No No Don’t know Yes

Yes Yes Yes No No No Yes

Yes No No No Yes Sometimes No

Yes Yes No No Yes Sometimes Yes

Yes Yes No No Yes Yes Yes

Yes No No No Yes No Yes

Abbreviations: ACP, advance care planning; AAA, area agency on aging; DPOA, durable power of attorney for health care; DNR, do not resuscitate.

experience, self-efficacy, and beliefs by site, we used chi-square tests. Continuous variables were split at the median for these comparisons between sites. Based on that analysis, we split the AAAs into 2 groups, 1 with more than 50% of their care managers holding ACP discussions with more than half of their consumers and 1 group of AAAs with care managers who did less. These 2 groups of AAAs were compared in terms of the care managers’ self-efficacy and beliefs using t-tests. Finally, we conducted a multivariate analysis (logistic regression) predicting whether a care manager discusses ACP with more than half of the consumers in his or her caseload. The SAS 9.2 was used for the analysis.16


Table 2. Description of Care Managers From Care Manager Surveys.a Frequency (%) or mean (SD) Profession, n (%) Social worker Registered nurse Combination or other Female, n (%) Age, mean (SD) Race, n (%) White Black Other Graduate degree, n (%) Years of service at AAA, mean (SD)

286 125 12 404 46.1

(67.6) (29.6) (2.8) (95.3) (10.8)

363 38 17 149 7.7

(86.8) (9.1) (4.1) (35.7) (6.2)

Abbreviations: AAA, area agency on aging; SD, standard deviation. a n ¼ 433.

Site Characteristics The AAAs served a mix of rural and urban areas: 1 AAA served a predominantly rural area, 4 were from regions with a major urban center (population > 100 000), and 4 served Appalachian-designated counties. The number of care managers at each agency ranged from 19 to 92 (mean ¼ 56.4 and standard deviation [SD] ¼ 29.6) and the average caseload per care manager ranged from 62 to 75 (mean ¼ 66.8 and SD ¼ 4.2). The percentage of care managers with nursing backgrounds ranged from 14% to 70% (mean 40.5% and SD ¼ 20.6). Rural and Appalachian areas were more likely to have a greater percentage of care managers with nursing backgrounds. Other care managers had social work backgrounds or a combination of nursing and social work. All 9 agencies had operational policies to inquire about durable power of attorney for health care, 6 had specific policies for inquiring about living wills, and 3 for do not resuscitate orders. Only 1 agency had a policy for ACP goal setting (see Table 1). When asked if their care managers followed up on ACP discussions, 3 said yes, 3 said sometimes, 2 said no, and 1 was unsure. Nonetheless, ACP was included in either orientation or training for care managers at 8 of the 9 agencies.

Care Manager Surveys At each AAA, in addition to the interviews with site directors, we also surveyed the care managers. Table 2 shows the

percentage of nurses and social workers participating in the care manager questionnaires. Over two-thirds were social workers, and most were white females. Less than 15% identified themselves as African American, Hispanic, or Asian. We compared the agencies in terms of care managers’ professional backgrounds, experience with ACP, self-efficacy, and beliefs about ACP (see Table 3). There were statistically significant differences between sites for years of service, nursing backgrounds, graduate degrees, percentage of caseload in which ACP was discussed, time since last ACP discussion, and in their beliefs about ACP. Two sites (sites A and B) stood out in terms of the percentage of their care managers that discussed ACP with greater than 50% of their consumers. From the interviews with the site directors, we learned that both agencies had ACP training programs, informational packets available for consumers, and a leader who was instrumental in training the care managers about ACP. This difference in professional experience conducting ACP discussions became the basis of further analysis. Table 4 compares the self-efficacy and the beliefs about ACP of the care managers at these 2 agencies with those of the care managers from the other agencies. There are several small but statistically significant differences between the agencies. Care managers from sites A and B reported higher levels of overall self-efficacy and feeling comfortable discussing ACP

Downloaded from at TULANE UNIV on January 27, 2015

American Journal of Hospice & Palliative Medicine®


Table 3. Area Agency on Aging Site Differences in Care Managers’ Professional Background, Experience, and Self-Efficacy (Percentages). Variable

Site A Site B Site C Site D Site E Site F Site G Site H Site I

Professional background >5 years of service Nursing degree Graduate degree ACP professional experience Discuss ACP with >50% of consumers Last ACP within past month ACP personal experience CM has own advance directive CM assisted other ACP high self-efficacya During last encounterb Overall self-efficacy ACP beliefsa ACP is too upsetting for consumers ACP only for consumers with

The Relationship Between Organizational Characteristics and Advance Care Planning Practices.

Organizational characteristics may impede the uniform adoption of advance care planning (ACP) best practices. We conducted telephone interviews with s...
117KB Sizes 0 Downloads 4 Views