Page 181 - CHHA Binder 2.3.20

4/11/2019

Behind the Scenes on our Process-
What are the CHHA Clinicians Doing?

• If they are admitting a case that has already been identified by Intake as an “ACP” case
− The Clinician is having the initial Advance Care Planning conversation with the
patient and family and coordinating with the Social Worker to have more in-depth
conversations with the patient and family about Advance Care Planning (Advance
Directives, Goals of Care)
− They are performing an assessment of advanced disease using OASIS items and
the patient and family interview
• If admitting a case that has not yet been screened for Advance Care Planning,
palliative, or hospice care needs:
− The Clinician will have an initial Advance Care Planning conversation with patient
and family and determine if a more in depth conversation with a Social Worker is
needed
− The Clinician will perform an assessment of advanced disease using OASIS
items and the patient and family interview

• In both instances:
− The Clinician will communicate significant findings during team meetings to
develop plan of care recommendations
− The Clinician will communicate findings to supervising MD and communicate
recommendations (using SBAR format)

Assessment of Advanced Disease -
The Surprise Question

Would I be surprised if this patient lived
longer than one year?

Additional Questions to consider:

 Are this patient and his/her family in need of teaching
and support?
 Would a conversation about goals of care relieve
anxiety about the future and improve this patient’s
quality of life?

If you answer “yes” to any of these questions, then look
at the Core Indicators (next slide).

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