Systems Of Care Initiative

ADVANCED CARE PLANNING: SYSTEMS OF CARE INITIATIVE, INC. (SOCI) HAS 5 INITIATIVES FOCUSED AROUND ADVANCE CARE PLANNING. 1) SOCI PROVIDES ADVANCE CARE PLANNING (ACP) SERVICES TO PEOPLE IN NORTHERN COLORADO UTILIZING ITS COACHES. 2) SOCI TRAINS VOLUNTEERS TO HELP PEOPLE COMPLETE THEIR ADVANCE CARE DIRECTIVE AND TO HAVE THE CONVERSATION ABOUT THEIR END OF LIFE WISHES. 3) SOCI IS DEVELOPING A EDUCATIONAL VIDEO ABOUT ACP FOR COLORADO PHYSICIANS AND THEIR HEALTH TEAMS (NURSE PRACTITIONER, PHYSICIAN ASSISTANTS, SOCIAL WORKERS, ETC.) AND A SEPARATE VIDEO FOR PATIENTS TO VIEW PRIOR TO THEIR CONVERSATION WITH THEIR PRIMARY CARE PROVIDER THAT IS IPAD AND SMART PHONE COMPATIBLE. 4) SOCI FORMED A MULTI-STAKEHOLDER WORKGROUP WITH REPRESENTATIVES FROM THE COMMUNITY TO SET COMMUNITY GOALS FOR ADVANCE CARE DIRECTIVES. SOCI LEAD A MULTI-STAKEHOLDER COMMUNITY COLLABORATION AND ASSISTED IN DEVELOPING COMMUNITY GOALS FOR ADVANCE CARE DIRECTIVES. 5) SOCI IS LAUNCHING A PROGRAM TO ENCOURAGE AND ASSIST PHYSICIANS AND THEIR STAFFS IN HAVING CONVERSATIONS WITH THEIR PATIENTS ABOUT END OF LIFE WISHES AND ADVANCE CARE DIRECTIVES. THE GOAL IS TO ENSURE THAT ALL MEMBERS OF THE HEALTHCARE TEAM IN PRIMARY CARE PRACTICES HAVE TRAINING TO ENGAGE IN MEANINGFUL CONVERSATIONS WITH PATIENTS, HAVE KNOWLEDGE OF FORMS TO COMPLETE WITH PATIENTS AND CAN APPROPRIATELY UPDATE THE PERSON'S MEDICAL RECORD. DURING 2017 SOCI COACHES ENGAGED 1,306 PEOPLE IN CONVERSATIONS ABOUT ADVANCE DIRECTIVES. THERE WERE 510 ADVANCE CARE DIRECTIVES COMPLETED. THE CONVERSATION OCCURRED IN THE FOLLOWING TYPES OF SETTINGS: 1) ONE ON ONE HOME VISITS: 130 PEOPLE WITH 110 COMPLETED DIRECTIVES: 85% COMPLETED THEIR ADVANCE DIRECTIVES. 2) VISITS AT PLACE OF EMPLOYMENT: 685 PEOPLE WITH 354 COMPLETED DIRECTIVES: 52% COMPLETED THEIR ADVANCE DIRECTIVES. 3) COMMUNITY FORUMS (PRESENTATIONS OR BOOTHS NOT RELATED TO PLACE OF EMPLOYMENT): 491 PEOPLE WITH 46 COMPLETED DIRECTIVES: 9% COMPLETED THEIR ADVANCE DIRECTIVES. 23 MEDICAL PRACTICES RECEIVED TRAINING ON ADVANCE DIRECTIVES IN FACE TO FACE MEETINGS WITH TRAINED INSTRUCTORS. SOCI CONTINUED TO WORK ON TRAINING VIDEOS ON ADVANCE CARE PLANNING FOR TEACHING VOLUNTEERS AND STAFF AND FOR MEDICAL PRACTICES. SOCI HAS UTILIZED ITS SERIES OF ADVANCE CARE PLANNING (ACP) TRAINING VIDEOS FOR THE PRACTICES AS WELL AS IN SOCI'S VOLUNTEER CLASSES.