April 2020 Communication Tips

April 2020 Communication Tips

 

 

 

 

COVID Specific Advance Care Planning

COVID has changed all of our lives and the way we work.

One important thing that many clinicians are talking about with patients at high risk for bad outcomes from COVID (i.e. many of our patients in the cancer center) is what they might expect and what care they would want if they were to get a severe case of COVID.  This is COVID-specific Advance Care Planning (ACP).

This may be a difficult conversation to have, but… it is likely that nearly every one of your patients is already thinking about it and will very much appreciate the discussion.

Below is an example of how I’ve been introducing these discussions (as a part of my regular patient visits)

Here’s how I start (based on various suggestions from our UCSF colleagues and those across the country)…

 

I can imagine that when you are dealing with cancer already, hearing about COVID must be really worrisome.

I am hoping that you are not affected directly by COVID. But I also want to make sure that I, my team, and UCSF can do as much as possible to provide you the best care possible and the type of care you want. Could we talk about that briefly today as part of our regular visit?

Planning is hard but it can be so helpful to you and your family during these confusing times.  I’d like to check-in with you about 3 important things. 

1.     If you got very ill and were unable to speak for yourself, who would you like to speak on your behalf?

2.     So I can be most helpful in your care now and if you were ever to get sick with COVID-19, can you share with me your biggest priorities, the things that are most important and meaningful to you in your life?

3.     Do you have an up-to-date advance directive scanned in the UCSF system (APEX)?

 

If patients need to make or update an advance directive, I think the “PREPARE for your Care” website is a great place to send them, especially in the midst of COVID:

Please remember also, as part of your regular in-person or tele visit note:

(1)   You should document your discussion in the ACP Navigator (bookmark the ACP discuss in your note with .ACPBEGIN at the start of the ACP discussion documentation and then .ACPEND after the text and that text will be pasted into the ACP Navigator for all providers on APEX to find quickly and easily)

(2)   You can bill for ACP discussions of at least 16 minutes, on top of your regular visit billing (add .ACPTIMESPENT to your note and then add the additional E/M code 99497 to the billing section)

This is just a start-- the very basic information from patients that may really help during a crisis.

Next week, I’ll be able to share a 1-page COVID ACP tip-sheet and a brief training video that we are preparing here at UCSF.   It will include language about hospitalization and ventilation preferences.  Please stay tuned.

All feedback is encouraged as we try to keep improving this.  Please email me, call my cell (415-215-4904), or Voalte me.

All My Best to You and Yours,

mike

 

 

 

 

POLST Forms

 

As you work on COVID-specific Advance Care Planning, POLST forms are ideal for patients who want to avoid hospitalization and/or intubation.

Below are 3 options for how to get it completed remotely:

  1. Mailing forms back and forth
  2. Verbal patient consent
  3. Docusign

Please note that these strategies are all being used during social distancing in COVID times.

#1 Mailing: is closest to the in-person workflow

#2 Verbal Consent: is most convenient and is allowable during COVID times.

#3 Docusign: can work for patients who can handle docusign. 

Regardless of which method you choose, the key is to make sure to document all patient preferences documented in the POLST form in your note (using the ACP Navigator)… just in case the form doesn’t make it back to us.

 

Best

mike

Option 1:

  1. Pull up the CA POLST form in a browser: https://capolst.org/wp-content/uploads/2017/09/POLST_2017_Final.pdf
  2. Share your screen with the pt/family
  3. Talk through each section of the POLST together
  4. You complete and sign a hard-copy POLST form (pink card stock.  If you don’t have a pink one, you can draw on it with pink highlighter.  If you don’t have pink highlighter, don’t worry… it’s still legal, just harder to see/recognize)
  5. Send the POLST form to the patient to review and sign
  6. Ask the patient to mail a copy or fax/scan the original back to us to put in our EHR.
  7. The patient can put the pink form on their refrigerator (where 911 can easily find it)

Option 2:

If the decisionmaker cannot be physically present to sign the POLST, verbal consent from the patient/decisionmaker is permissible in accordance with community policy. Best practice is to carefully document the conversation with the patient/decisionmaker, and write something similar to "Verbal Consent of (patient/decisionmaker)" on the Patient/Decisionmaker signature line with an annotation by the MD/NP /PA which says "discussed via phone on (date)” and “physical signature pending post COVID," then initial. 

 

Option 3:

We now have a version of the POLST form that can be signed using Docusign (thanks Tom Reid).   You can use it by following the below instructions.

  1. Log in to MyAccess
  2. Navigate to DocuSign. You may need to click “Manage Favorites” if you can’t see the whole list
  3. Click on “Templates”
  4. Search for “POLST” under Templates
  5. Click “Use” for “California POLST – Blank”
  6. Fill out the information for the Provider and Patient/DPOA and click “Send”

The finalized POLST form will be sent to you by e-mail after the patient completes it and you can forward it to your practice coordinator to put it in the appropriate section of the medical record.

The only tricky part is that the patients also needs to be able to print the form on their end and I’d recommend that they also draw a border around the document using a pink highlighter to make it easier to find in the setting of an emergency.