C O L L A B O R A T I V E C A S E M A N A G E M E N T
Introducing Advance Care Planning: One Hospital’s Experience
by Linda Bierbach and Michelle Roy
St. Vincent Healthcare, a 250-bed acute care hospital in Billings, MT, has assumed a leadership position in the developing area of advance
care planning. Advance care planning is a system approach in which trained healthcare professionals assist individuals and their close family
members in planning proactively for end-of-life healthcare choices, based on personal values and beliefs. For maximum effectiveness, it requires
collaboration among case managers and various other professionals, including physicians, PA’s, nurses, social workers, and chaplains. Advance
care planning is a powerful force that has the potential to change the way end-of-life healthcare is delivered in this country.
Death has been called “the last taboo.” Many people are very ill at ease with
this subject and shrink from discussing it. But the philosophy and practice
of advance care planning calls for learning a special language and skill set to
overcome such reticence. This enables the healthcare professional to create a
sense of comfort in discussing death with patients and families and helping
them make their own plans for end-of-life care.
Advance care planning, for the patient, is much more than simply filling out
an advance directive. It’s making difficult decisions about which types of care,
under which conditions, are acceptable and which types are not. It’s speaking
candidly with loved ones who need to be aware of these decisions. And
perhaps most important, it’s making sure the healthcare advocate (also called
agent or proxy) named in the advance directive is able and willing to honor
one’s end-of-life wishes. Through all of this, a trained advance care planning
facilitator can offer invaluable support and practical assistance.
St. Vincent Healthcare’s involvement in advance care planning began
with participation in a national study funded by the Robert Wood Johnson
Foundation, with local support from Blue Cross Blue Shield of Montana. Titled
“Advanced Illness Care Coordination Program” (AICCP), the study involved 600
patients nationwide, and extended from December 2000 through September
2002. It was designed to determine whether patients’ values and goals for their
end-of-life care were being respected, and whether any changes occurred in
cost of care as a result of patients’ access to advance care planning.
A full-time registered nurse was hired by St. Vincent for a dedicated
position as local site interventionist. She had 25 years of experience in
oncology nursing, home hospice care, rehabilitation, community education,
and nursing management. This employee was integrated into the Care
Management Department and worked closely with its members.
Case managers, due to the nature of their responsibilities, are well
qualified to be the first line in advance care planning. They understand and
comprehensively manage the needs of patients. They can identify patients
who could benefit from advance care planning interventions, and they
communicate and collaborate with all members of the healthcare team such
as patients’ family members, physicians, nurses, chaplains, pharmacists, and
physical and occupational therapists.
In the course of the AICCP study, shifts occurred in the care of patient
participants at St. Vincent, most of whom had disease-specific considerations
such as chronic obstructive pulmonary disease, congestive heart failure, and
end-stage cancer or renal disease. These patients accessed hospice services
much sooner than non-participants, and they had fewer readmissions. It was
clear that advance care planning was welcomed by and beneficial for patients,
as well as being an important contributor to resource management.
When the study ended, St. Vincent decided to continue its commitment to
advance care planning and to adopt a standardized intervention model, rather
than the AICCP investigational approach. After research to determine what
was available, an advance care planning program developed by the Gundersen
Lutheran Clinic in LaCrosse, WI, nationally recognized for its work in this field,
was chosen.
The program uses a systems approach that includes three components:
• community engagement
• professional education
• and organization/community standards of practice.
3
It characterizes success in terms of the development and maintenance of
new routines of care by the health organization and its professionals. The
routines are described as a list of commitments to the patient and family,
promising to:
1 Initiate conversations about advance care planning
2 Skillfully facilitate planning with each individual
3 Make sure all advance care plans are clear to all involved and
specific to each person
4 Ensure that plans are available when needed
5 Follow plans in a thoughtful and respectful way
Gundersen’s assistant director for advance care planning came to St.
Vincent in November 2002 and taught a three-and-a-half-day training
session for facilitators. The initial group included the St. Vincent Healthcare
Advance Care Planning Leadership Team; St. Vincent nurses, social workers
and chaplains; and Billings community participants. They learned a standard
intervention process by which advance care planning conversations with
patients can be replicated through use of the same language, skill set, and
understanding of goals.
The Gundersen professional also assisted the Leadership Team in
identifying and developing strategies for system changes. One was adding
a full-time advance care planning coordinator to the Care Management
Department. The same person who had been site interventionist for the AICCP
study was hired for this position. Assistance with funding came from the St.
Vincent Healthcare Foundation. The philosophy of the advance care planning
program was incorporated into the department through the care managers.
At present, half of them (six) are trained facilitators, and the goal is to have the
other six certified by the end of 2004. Also, all members of the Pastoral Care
Department are trained facilitators.
St. Vincent offers advance care planning assistance not only to patients,
but also to others in the Billings Community. Even if a person has never been
a patient there, he or she may have an advance care directive placed on file in
the Medical Records Department, where it is given a hospital number. This can
be quickly checked when emergency room admissions occur.
In implementing an advance care planning program, St. Vincent had help
from a “physician champion” an MD who believes strongly in empowering
patients to make their own end-of-life choices, and is willing to spend time
talking to other physicians about this. Typically, physicians listen to physicians,
so she is a powerful ally. She began helping as a volunteer in late 2002, and on
June 1 this year joined the staff as full-time medical director of St. Vincent’s
new Palliative Care Services Department. Any hospital initiating an advance
care planning program would do well to enlist a physician champion, if
possible ideally, an established member of the medical community who has
good credibility with fellow physicians, excellent communication skills, and a
passion for helping patients in this capacity.
Three tiers of internal education are offered at St. Vincent. One is the
advance care planning facilitators course, two days of didactic and skills
training. It is taught by one of five certified facilitator trainers. At St. Vincent,
certified trainers may be registered nurses, social workers or physicians, as they
understand more thoroughly the clinical aspects of advance care planning.
 w w w . a c m a w e b . o r g

Facilitators need excellent communication skills, including active listening and assessment, and
sensitivity to the two-way nature of the advance care planning process. The facilitators course,
which carries 14.2 CEUs, teaches participants:
• To facilitate thoughtful, skilled and specific conversations with patients about end-of-life issues,
• To work with both the patient and his/her advocate (health care proxy) in advance care planning, Five Wishes
• To assist the patient in completing an advance care document.
The second tier is a general, one-hour, voluntary education program (1.0 CEU) for all hospital for the
End of Life
staff members. It discusses the advance care planning philosophy and explains how it pertains to
employees and to patients. Participants learn how to contact Care Management to obtain advance
care planning consultation for patients. Employees can receive help, if they wish, in completing their
own advance directives.
The third education tier is a required self-teaching module for all St. Vincent nurses, which takes 60 Many advance directives for
to 90 minutes to complete. It gives an overview of the advance care planning program, with specifics healthcare have just one page, but
on how to access consultations for patients. Nurses are expected to be responsive when patients ask St. Vincent Healthcare offers Five
about advance care planning, and the module promotes both “the letter and the spirit of the law.” Wishes, a 12-page booklet that lets
St. Vincent Healthcare also places a strong emphasis on community education about advance care people be specific about what they
planning. This takes a wide variety of forms, including one-on-one advance care planning sessions for do and don’t want when terminally
patients and families with trained facilitators, presentations at senior meal sites, and public education ill. It’s published by Aging with
conferences. Currently, St. Vincent is involved in a major, grant-funded project to train parish nurses
Dignity in Tallahassee, FL.
and health ministers as advance care facilitators in six larger cities around Montana.
(www.agingwithdignity.org)
For hospitalized patients, St. Vincent does not do advance care planning facilitation in crisis
The American Bar Association’s
situations. In such cases, the family is consulted and a decision on DNR orders is made. A facilitation
Commission on the Legal Problems
session can then be scheduled after the patient has pulled through the crisis. Even so, in the average
workday of the care manager who is a certified facilitator, advance care planning does take extra of the Elderly and leading experts
time. But this helps to increase patient comfort and trust, and ultimately, St. Vincent Healthcare in end-of-life care helped write
believes that it will be offset by measurable benefits such as savings in resources, cost shifting, and it. This document meets legal
an anticipated decrease in length of stay and number of ICU admissions. requirements of 35 states and the
“Bottom-line” benefits, notwithstanding, St. Vincent is firmly committed to offering advance care District of Columbia.
planning because, simply put, “it’s the right thing to do.” Many people are not aware they have a
right to determine their end-of-life care, to say no to aggressive treatments if they don’t want them. The Five Wishes are:
Case managers can help them realize that they do have choices.

SOURCES OF INFORMATION ABOUT ADVANCE CARE PLANNING The person I want

• www.gundluth.org/eolprogram to make care decisions
Gundersen Lutheran Programs for Improving End-of-Life Care for me when I can’t
• www.capc.org
Center to Advance Palliative Care®
The kind of
• www.lastacts.org
Last Acts®
medical treatment I want
or don’t want
• www.rallyingpoints.org
Rallying Points: Improving Community End-of-Life Care through Coalitions
• www.growthhouse.org How comfortable
Growth House: Guide to Death, Dying, Grief, Bereavement, and End-of-Life Resources I want to be
• www.abcd-caring.org
Americans for Better Care of the Dying
How I want people
Michelle Roy has been a case manager and is now Director of Care Management at St. Vincent to treat me
Healthcare, Billings, MT. A BSN graduate of the University of Wyoming, she has 14 years of professional
experience. Michelle is a member of ACMA.
Linda Bierbach is the Advance Care Planning and Palliative Care Services Coordinator at St. What I want my
Vincent Healthcare. She holds a BS from Montana State University and an ADN from Miles City (MT)
Community College, and is a certified hospice palliative nurse. For 12 years, she has been an assistant
loved ones to know
instructor at Montana State University-Billings, teaching a class on the philosophy of death and dying
and medical ethics. Linda is a member of ACMA.