A Health System's Approach to Improve Care for Advancing Age and Advanced Illness

Using a collaborative structure, 17 teams from inpatient and outpatient settings developed reliable processes to identify an advanced illness population, conduct conversations with patients and families in order to clarify understanding of health condition and develop goals of care, and ensure that the services align with patients’ needs and preferences and are properly communicated throughout  the health care continuum.  This initiative to address a growing health care population took several steps to achieve progress.  Firstly, support by the leadership at the involved settings along with health system level direction allowed for staff buy-in and attentive participation of this project.  A definition of advanced illness was developed and adopted throughout the healthcare system.  Using the Model for Improvement as the transformational methodology, tools were developed to assist in identifying this population.  A need for educational programs in holding conversations with patients and families was identified and, therefore, developed. Once identified, goals of care were documented in the medical record, tools were used to ensure congruence to the next level of care throughout the healthcare continuum.  Evaluation measures being tracked include:  number of patients identified, number of conversations conducted with documented goals of care, geriatric/ palliative care and hospice referrals as well as goals of care handoffs at the transitions of care.  One of the 17 teams projects will be presented as an example of how the health system approach.  The process will be discussed, identification and documentation tools will be presented, and transitional handoffs to community services will be shared.