April 3, 2023
Discussing end-of-life care with your Medicare and Medicare Advantage patients can be a difficult and time-intensive process, yet it is a necessary process that enables patients to explore their future health care wishes, giving them a comfortable space for these sensitive discussions and allowing them to feel heard.
Advance care planning (ACP) is beneficial to individuals and families, physicians and total cost of care. In-office ACP conversations can be time-intensive and filled with strong emotions and potential conflict. Getting documents created and executed is timely, burdensome, and in most places, not legal without independent witnesses.
What is CACP?
Comprehensive Advance Care Planning (CACP), a program offered by Aledade Care Solutions, includes an in-depth telephone conversation with patients and their families. Those conversations lead to the creation of state-specific advance directive and legal documents, which can include a living will, medical power of attorney and do not resuscitate orders.
Once executed by the patient, these documents are distributed to the patient, caregivers, family and physicians. This way, physicians can plan ahead and provide the care preferences outlined by the patient. Overall, the CACP process can involve a lot of time, people and expertise.
CACP helps patients feel empowered, respected.
Patients who participate in CACP are able to make, document and have their future health care decisions respected by clinicians and family members.
CACP does this by:
- helping patients live better. They will have a plan and clear goals that can improve quality of life and satisfaction with care.
- reducing stress and conflict. Patient health care planning discussions and written advance directives make their preferences clear to everyone on their care team, lifting the burden from family members, doctors and hospital staff if they are ever unable to discuss your wishes during treatment.
- reducing unwanted care. Patients who plan are more likely to have their wishes followed, especially in a crisis.
Health care planning involves conversations about important issues, such as treatment options, quality-of-care goals, preferences for care and who would speak for patients in a crisis. By having these discussions now, patients can make informed decisions about their future care.
CACP prioritizes the wishes of the patient.
Dr. Deb Dittberner, a regional medical director for Aledade, conducted ACP in her own North Carolina practice for almost a decade. Because of her years of experience, she is thankful that Aledade is committed to bringing CACP to patients across the nation. She recently started offering CACP to her patients and encourages others to learn more about the in-depth and personalized process.
“It has been a learning experience and a beautiful experience for my patients. I highly endorse CACP for the right patients,” she said, adding that once you have a patient go through this process, and really see what is done in CACP, you realize that there is no way you can do it easily in-house.
If you are in one of our ACOs, or are interested in joining Aledade, our app will identify and recommend which patients can be referred to the CACP program. However, we also support your choice to introduce CACP when you feel it is in the best interest of the patient.
“I have a patient who was diagnosed with advanced stage cancer. She wasn’t on an advance care planning list, but she was obviously at a point where she needed to think about CACP and decide what she wanted for her care,” Dittberner said. “She was young, but what surprised me in her comprehensive advanced care plan was her desire to be at home or in the clinic for as much of her care as we could manage. That was her idea and it really changed how we took care of her in the clinic. We surrounded her with care coordination and prioritized her care with activities we could do with our nursing team to prevent hospitalization. That’s the beauty of comprehensive advance care planning.”
CACP is good for doctors
CACP helps physicians understand and connect with their patient and their wishes during a time that is difficult and possibly painful.
Without a clearly documented plan, physicians may inadvertently give a patient unwanted care. This can be frustrating for the patient and their family. It may even cause conflict during a crisis, which can escalate an already difficult situation.
Implementing CACP gives physicians and their patients access to a detailed plan before a medical crisis occurs. Therefore, physicians can feel confident that they are following the wishes of their patients.
Clinicians may also work more efficiently and avoid giving/ordering unwanted care, leading to less stress and confusion for the patient, their family and the physician.
A recent study shows that enrolling patients in a CACP program can lead to 16% lower hospital admissions. Patients in a CACP program have 24% lower costs by reduction in unnecessary care.*
Completing CACP conversations at the right time, with the right patients, keeps your practice team focused on the delivery of excellent care while providing your patients the opportunity to advocate for their future care, enabling better care coordination, an enhanced patient experience and improving outcomes.
Discover Aledade’s CACP solution.
Aledade’s CACP program connects high-cost, high-need patients to an extra layer of support that complements existing CACP efforts. CACP includes through in-depth personalized facilitations, state specific documentation generation, review and distribution of completed documents to your care team. This program is completely free to your practice and patients.
If you are in one of our ACOs, or are interested in joining Aledade, our app will identify and recommend which patients can be referred to the CACP program. However, we also support your choice to introduce CACP when you feel it is in the best interest of the patient.
Watch our on-demand webinar to learn more about CACP.
Listen as Iris’s Chief Medical Officer Dr. Stephen Bekanich and Dr. Deb Dittberner, MD, MBA, a Regional Medical Director for Aledade in North Carolina, explore real-life CACP experiences in our recent webinar, and then take a moment to explore the four key elements in a CACP program.
Ready to take the next step? Book a meeting to explore how Aledade can meet your practice’s unique goals.
* MILLIMAN REPORT: Advanced Care Planning – Estimated Savings Analysis. Iris Healthcare. April 2019