Respecting Choices

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Linda Briggs, M.S., M.A., R.N.³ (2014).
¹Spectrum Health Medical Group, Byron Center, Michigan
²Medical Affairs Department, Priority Health, Holland, Michigan
³Respecting Choices, Gundersen Health System, La Crosse, Wisconsin


The insurance plan case managers (CMs) of Priority Health, part of a regional healthcare system located in Michigan, work telephonically with frail patients who have multiple comorbidities. However, these CMs have lacked facilitation skills for advance care planning (ACP) discussions in this vulnerable population. In 2012, the findings of a six-month pilot study of telephonic ACP (TACP) with some of the plan’s Medicare population were implemented with Medicare members under case management.


Case mangers were trained and certified by Respecting Choices® to introduce and facilitate ACP discussions telephonically utilizing both First Steps and Last Steps protocols. The CMs identified appropriate patients using hospitalization and emergency room utilization data, severity of illness, and diagnostic criteria. The primary goal was to complete both the ACP discussion and the documentation for each protocol on identified patients. They also attempted to schedule facilitated conversations with the patients’ healthcare advocates present.


During a 12-month period, 576 health plan members were offered First Steps discussions, with 198 interested in engaging in further ACP. Some 152 members were identified for Last Steps TACP using established criteria; discussions occurred with 56 members. TACP implementation resulted in 55 new or updated First Steps documents and 4 Last Steps documents. A total of 50 discussions included the designated healthcare advocate.

Significance of results:

Following TACP implementation with the Medicare CM team and evaluation of the results, processes and methods were instituted to increase engagement and completion of discussions and documents. These included enhancements to the electronic assessment and ongoing support of the CM team to increase the engagement of patients and advocates. Dissemination of the project to the entire Medicare CM team demonstrated opportunities and lessons learned for facilitated TACP discussions. The TACP model has the potential to be successfully utilized by other health insurance companies.

This prospective, inter-regionally controlled trial focusing on German nursing homes, compared the number, relevance and validity of new ADs completed in the intervention region versus the control region.  Intervention nursing home residents and their families were offered professional facilitation (based on the Respecting Choices® model) including standardized documentation. Data from 136 residents of three intervention nursing homes were compared with data from 439 residents of 10 control nursing homes over a study period of 16.5 months.The implementation of an ACP program in German nursing homes led, much more frequently than previously reported, to the creation of advance directives with potential relevance to medical decision-making.

Models of advance care planning such as Respecting Choices® have shown that a coordinated, systematic, patient-centered approach to advance care planning by trained non-medical facilitators can improve outcomes for patients. Evidence also showed that advance care planning and end of life discussions reduce stress, anxiety, and depression in surviving relatives.

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