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.

Hammes, B.J., Rooney, B.L., Gundrum, J.D., Hickman, S.E., & Hager, N. (2012). The POLST program: A retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. Journal of Palliative Medicine, 15(1), 77-85. doi:10.1089/jpm.2011.0178. Epub 2012 Jan 10.

A retrospective review of medical record and death certificate data of 400 adults who died in 2007/08 in the La Crosse County, Wisconsin, community. Information about POAHC, POLST forms, and medical treatments provided in the last 30 days of life were abstracted from decedents’ medical records;67% of decedents had a POLST form, whereas 22% had POAHC alone. In comparison with decedents with POAHC alone, decedents with a POLST form were significantly older (83 versus 77 years, p<0.001), more likely to die in a nursing home than in a hospital (p<0.001), and more likely to die from a terminal or chronic illnesses (97%). Decedents with POLST orders for higher levels of medical treatment received more treatment, and in only 2 cases was there evidence that treatment was discrepant with POLST orders. In 31% of all POLST forms, the person appointed in the POAHC consented to the POLST orders. POLST can be a highly effective program to ensure that patient preferences are known and honored in all settings.