Programs and Communities
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- All Subjects: Advance Care Planning
- All Subjects: Food Systems
Disease burden is higher in the United States than in comparable countries. The Patient Self Determination Act of 1990 requires healthcare facilities to provide Advance Care Planning (ACP) information to all Medicare patients. The healthcare staffs’ (n=7) commitment to 3-days of ACP training increase ACP rates in the primary care setting. The Medicare Incentive Program is the platform for this initiative. This quantitative project used a valid and reliable pre and posttest design that consisted of 27 items on a Likert-scale. A 3.5-month chart audit (n=91) was conducted to assess the completion rate. Descriptive statistics was used to describe the demographic data.
The results of the two-tailed Wilcoxon signed rank test were significant based on an alpha value of 0.05, V = 0.00, z = -2.37, p = .018. There was a significant increase in the post-readiness to change average scores. A Mann Whitney test was used to analyze the statistically significant difference between the averages in two ACP types and electronic health record documentation (EHR). Staff did not always code (Mdn = 0.00) but they documented in the EHR (Mdn =1.00; 512.00, p = 0.003). ACP discussion was performed 63% of the time during Annual Wellness Visits (AWV), and there was a 49% increase in the EHR documentation. Trained staff are key stakeholders in guiding ACP conversations. They understand the barriers, impact, and consequences related to the lack of advance directives.
Interview with Ashley Schimke, Farm to School Specialist for Arizona Department of Education
Ashley Schimke is the Farm to School Specialist for the Arizona Department of Education. Her experience working in the Phoenix community gave her an introduction to the struggles of the less fortunate within the Valley. Working with the Arizona Department of Education Ashley had the opportunity to bridge the gap between the education system and local producers. She seeks to give students the nutrition to focus and learn as well as the education to make healthy choices. Understanding food systems become more of an experience for students, which promotes a continual interest. Her work engages the next generation in an effort to change how they understand their environment and their food.
The original intent of the project was to attempt to mitigate the complex sustainability issue of systematic food waste via creating a guide that would educate users how to create a food saving organization that prevents edible food from ending up in landfills. The guide was going to be based on a nonprofit organization my family and I founded called Epic Cure, that has activated programs that serve to relieve community food insecurity, encourage community connectedness, support environmental health, and empower youth with entrepreneurial opportunity. The development of the guide was going to be based on my personal experience developing and running the organization, as well as my understanding of sustainable systems and frameworks. However, the original scope and plan of this project has shifted considerably since the outbreak of the COVID-19 virus. I have decided to put the guide on hold so that I can step into a space of agency via working in real time, to adapt my organization so that we can continue to operate when we are most needed. This shift is a response to the health and economic crisis that continues to unfold daily. In order to sustain the wellbeing of communities, the adaptation of a food aid service in the time of the crisis is an imminent need. This project shift not only serves to provide emergency relief, but also to identify gaps in the food distribution system and the supply chains that NGOs like Epic-Cure rely on so that we might be more resilient in the face of future shocks to the systems.
Background and Significance: National regulations mandate that patients are provided information about advance directives in the healthcare setting, but completion rates are not monitored and continue to be low. ACP is now a billable service for healthcare providers, but it has not provided enough incentive to increase completion rates. Barriers for healthcare providers in the outpatient setting include lack of time, protocols, and lack of education on how to initiate and foster advance care planning discussions.
Methods: Healthcare providers in a primary care office attended a 15-minute structured educational session with and a toolkit was provided on the importance of ACP, how to initiate conversations with patients, and bill for the service. Participants completed a portion of the Knowledge, Attitudinal, and Experiential Survey on Advance Directives (KAESAD) survey assessing their confidence in ACP before and three months post intervention. Participant confidence (N = 6) in ACP was analyzed using the Wilcoxin test and descriptive statistics. The number of billed ACP services for the office was collected for four months post intervention and compared to the previous four months. Outcomes: A significant increase in provider confidence after participating in a multimodality education program was found in the results (Z = -2.21, p = .03). There was a 42.1% increase in the number of billed ACP discussions for the office in the four months post intervention.
Conclusion: The future desired state is that ACP discussions become standard practice in primary care leading to the completion of advance directives. This can be accomplished through formalized education sessions and resources for providers in order to increase their confidence in initiating ACP discussions with patients. The ultimate goal is to decrease unnecessary spending at end-of-life while improving patient and family satisfaction with the quality of care received at end-of-life.
The project used a mixed method design. Participants were recruited from a primary care practice. Descriptive statistics described the sample and outcome variable. An independent t- test measured if there were significant changes in the participant responses for the ACP survey.
The average age (standard deviation) of the chart review sample was 72.22 (SD=9.47). The ages ranged from 60 to 100 years of age. Most of the sample in the chart audit were female with 105 (53%) participants and 95 (48%) were male. Most of the sample, 183 (92.5%) reported having a chronic health condition and 17 (7.5%) of the sample reported having no chronic condition. Overall, the results were inclined towards a significant difference in participants who did the ACP discussions and those who did not when comparing completed AD forms.
As Baby Boomers age, the number of older homeless patients facing end of life is increasing. Homeless individuals die of the same diseases as their domiciled counterparts, but they have distinct barriers to equitable end-of-life care, such as lack of regular medical care, a higher likelihood of comorbid serious mental illness and substance abuse, alienation from potential healthcare proxies, and specific fears related to dying. Completion of an advance directive (AD) would address many of these barriers, as well as national goals of reducing medical costs associated with end of life care. A review of the literature indicates that homeless individuals, once educated on the purpose and significance of ADs, complete them at a higher rate than non-homeless people. Further, racial and ethnic disparities in document completion are minimized with educational interventions about an AD’s purpose.
King’s Theory of Goal Attainment provides the theoretical basis for the application of such an intervention in the setting of a medical respite center and a day resource center that both serve the homeless. Thirty-seven clients of the two sites and 14 staff members were administered a pre-and post-test measuring attitudes and knowledge relating to ADs on a Likert scale, resulting in an increase in knowledge about one of the two documents that traditionally comprise an AD, while not significantly affecting attitudes. Implications for practice include an inexpensive intervention that does not require a medically trained individual to deliver, enabling a broad application to a variety of settings with the goal of empowering a traditionally disenfranchised population to make health decisions related to the most vulnerable of life passages.
For the community engagement piece of the project, existing community engagement protocols and frameworks were compared. The most effective strategies were then selected and combined into a single adaptive framework. Assets Based Community Development, the Sustainable Neighborhood for Happiness Index, and the six types of capital are used as the foundational structure of the Community System Map. A Community Food System map was then organized using a “hub” approach, and the Residential Edible Landscaping map was organized based off of field experience. The nested systems illustrate just how complex the community food system really is. The outcome of the project is the first iteration of an adaptive tool that can be used by for-profit or non-profit organizations to co-create and interdependently manage local community food systems.