SummaryAs part of an organization-wide initiative to reduce disparities, HealthPartners (an integrated health care financing and delivery system based in Minneapolis) employs a culturally sensitive, tailored approach to care-coordinator discussions about advance directives with seniors enrolled in Minnesota Senior Health Options (a managed care plan for those eligible for both Medicare and Medicaid). The quality-improvement initiative initially targeted low-income African Americans and black immigrants, primarily from Eastern Africa, with the goal of encouraging them to sign both a living will and durable power of attorney for health care. In a 6-month pilot test, the initiative increased the completion rate for advance directives in the targeted group, and reduced the gap in completion rates between African Americans/black immigrants and whites. Based on this success, HealthPartners rolled out the approach to members of all racial and ethnic groups served by care coordinators and enrolled in Senior Health Options or other insurance products offered by HealthPartners.Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of enrollees completing advance directives (including between African Americans/black immigrants and whites), along with post-implementation reports from care coordinators who participated in the program.
Developing OrganizationsHealthPartners Institute for Education and Research
Health Partners; Health Partners Institute for Education and Research
Date First Implemented2011
Age > Aged adult (80 + years); Race and Ethnicity > Black or african american; Vulnerable Populations > Frail elderly; Immigrants; Racial minorities; Age > Senior adult (65-79 years)
Problem AddressedThough advance directives can improve end-of-life care and reduce stress and anxiety for family members, African Americans are significantly less likely than whites to be knowledgeable about them or to have completed one.
- Less knowledgeable about advance directives: African Americans and black immigrants tend to be less knowledgeable about advance directives than whites, including their benefits, which include alleviating stress, anxiety, and depression among family members and making care more patient-centered.1 For example, in Los Angeles County, only 12 percent of African-American seniors reported being familiar with advance directives, compared with 69 percent of European Americans.2
- Less likely to possess them: Numerous studies have found that African Americans are less likely than whites to possess advance directives. For example, one recent study documented this gap in three different settings: home care (13 percent completion rate for African Americans, 32 percent for whites), nursing homes (35 percent vs. 70 percent), and hospice care (80 percent vs. 89 percent).3 Before implementation of this program at HealthPartners, only approximately one-quarter of African-American members of Minnesota Senior Health Options had completed advance directives, roughly one-half the completion rate of their white peers (50.49 percent). This gap exists even among those knowledgeable about advance directives. For example, the Los Angeles County survey mentioned above found that only 17 percent of African Americans familiar with advance directives possessed one, compared to 40 percent of European Americans.2
Description of the Innovative ActivityAs part of an organization-wide program to reduce disparities, HealthPartners employs a nontechnical, nonthreatening approach to care-coordinator discussions about advance directives. This approach was a result of a quality-improvement initiative targeted at low-income African Americans and black immigrants, primarily from Eastern Africa, enrolled in Minnesota Senior Health Options, with the goal of encouraging them to sign a living will and durable power of attorney for health care. HealthPartners later rolled out the approach to members of all racial and ethnic groups served by care coordinators and enrolled in Senior Health Options or other insurance products offered by the organization. Key program elements include the following:
Assignment to care coordinator: As a routine part of care, each of the more than 3,000 members of Minnesota Senior Health Options is assigned to 1 of 40 care coordinators (social workers or nurses) who help them navigate the health care system and learn to self-manage chronic medical conditions. As part of their duties, care coordinators routinely discuss end-of-life planning issues, including advance directives. (Another 60 care coordinators provide similar services to members of other insurance products.)
- Culturally tailored and nontechnical discussions: Care coordinators have nonthreatening, nontechnical discussions with members about advance directives and end-of-life planning. This approach was a result of a quality-improvement project originally targeted at African Americans and black immigrants enrolled in Minnesota Senior Health Options. During a 6-month pilot test involving 10 care coordinators working with elderly, low-income African-American and black immigrants, a culturally tailored approach was devised, including two key elements outlined below:
- Nonthreatening, nonclinical conversation starter: Before implementation of this initiative, care coordinators usually introduced the topic by asking members if they wanted life-support systems, such as ventilators and feeding tubes, as part of their end-of-life care. This approach was thought to be too impersonal and technical in nature. As part of this quality-improvement process, care coordinators adopted a new, less threatening way to introduce the topic by asking members if they had chosen someone to speak for them about medical issues should they become unable to speak for themselves.
- Offering option for multiple spokespeople: Before implementation of this program, care coordinators typically insisted that members name only one person as their durable power of attorney for health care. In response to feedback from African-American members of a quality improvement team (see the Planning and Development Process section for more details), care coordinators abandoned this approach, as it had a tendency to upset African-American and black immigrant members, who often prefer to grant decisionmaking authority to multiple family members. As a result, care coordinators began to highlight this option during their discussions.
- Approach replicated for all racial/ethnic groups: After the pilot test with African Americans and black immigrants ended in December 2011, those involved in the quality-improvement committee realized that the nontechnical, nonthreatening approach to discussions about advance directives and the option to name multiple spokespeople would work with members from all racial and ethnic backgrounds. In 2012, the new approach was rolled out to members of Minnesota Senior Health Options as well as members of other insurance products who are also enrolled in care-coordination programs.
Context of the InnovationA nonprofit, consumer-governed, integrated health care financing and delivery system based in Minneapolis, HealthPartners provides care to 1.4 million members through a network of five hospitals, more than 1,700 physicians, 52 primary-care clinics, 22 urgent care locations, and numerous specialty medical practices throughout Minnesota and Western Wisconsin. The Case and Disease Management Department at HealthPartners employs roughly 100 individuals, primarily care coordinators who work on numerous care coordination programs serving various members of HealthPartners' many insurance products. These coordinators help members maintain an independent lifestyle and use health care resources appropriately.
The advance directives program came out of the EBAN Experience™ equitable health collaborative, a structured year-long education and quality improvement program launched in 2011 by the HealthPartners Institute for Education and Research, with the goal of improving the cultural intelligence of HealthPartners' providers and reducing disparities in health outcomes among racial and ethnic minorities in Minnesota. (EBAN is a symbol from the Asanti people in Ghana that represents security, safety, and trust.) The project on advance directives was one of nine inaugural initiatives launched as part of the EBAN Experience™, with each targeting a specific disparity. It was chosen after an analysis of Minnesota Senior Health Options members found that African Americans completed advance directives at a significantly lower rate than did whites.
ResultsIn a 6-month pilot test, the program increased the completion rate for advance directives among African Americans and black immigrants, and reduced the gap in completion rates between these groups and whites.
Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of enrollees completing advance directives (including between African Americans/black immigrants and whites), along with post-implementation reports from care coordinators who participated in the program.
- Higher completion rate: In a pilot test with 62 African Americans and black immigrants between June and December 2011, the completion rate for advance directives rose from 24.76 percent to 32.03 percent. (This figure includes those completing and signing one or both of two documents—a living will and a durable power of attorney for health care.) Since the end of the pilot test, completion rates among African Americans and black immigrants have risen further, reaching 44.74 percent in June 2013.
- Fewer disparities: The gap in completion rates between African Americans/black immigrants and whites narrowed from 25.73 percentage points in June 2011 (when completion rates were 24.76 percent for African Americans and black immigrants and 50.49 percent for whites) to 19.90 percentage points in December 2011 (32.03 percent for African Americans and black immigrants, compared with 51.93 percent for whites). As of June 2013, the gap in the completion rate between African Americans/black immigrants and whites was 15.94 (44.74 percent for African Americans and black immigrants versus 60.68 percent for whites).
- Greater comfort among staff: The 10 care coordinators who participated in the 2011 pilot project reported that the new approach made them feel more comfortable discussing advance directives and end-of-life planning with health plan members.
Planning and Development ProcessKey steps included the following:
- Forming the team: Led by the head of the Disease and Case Management Department (who has extensive training in quality-improvement methods), HealthPartners formed a 14-member team to participate in the EBAN Experience™ that comprised staff from the department and two members of the African-American community in Minneapolis. (Three staff members on the committee were also African American.)
- Training in quality improvement and cultural intelligence: As one of nine teams involved in the EBAN Experience™, team members attended four all-day meetings (held quarterly throughout 2011) during which they learned how to conduct quality improvement projects using techniques taught by the Institute for Healthcare Improvement. Team members listened to patients, listened to community panels, and viewed videos (produced for the EBAN Experience™ equitable health collaborative) in which professional actors portrayed patients from African-American, Somali, Hmong, and Latino cultures interacting with the health care system. The listening sessions and videos served as a springboard for group discussions on how to provide culturally intelligent care to members and patients of each of these minority groups.
- Team-led development and testing: The committee met on a biweekly basis to design a new approach to obtaining completed advance directives from members. As part of this process, the committee used flow charts and cause-and-effect diagrams to illustrate the process through which discussions on end-of-life planning occur with members of Minnesota Senior Health Options.
- Pilot testing new approach: Five committee members (all care coordinators) tested the new conversation starter with two clients each over a 2-week period and reported back to the full committee about the results of those conversations. They subsequently rolled out the new approach to all their clients over time. Around the same time, the committee added five other care coordinators to test the revamped approach with African Americans and black immigrants in their caseload. These 10 coordinators tested the program for a 6-month period beginning in June 2011.
- Expansion to all care coordinators: To expand the new approach to discussions about advance directives to all health-plan members in care-coordination programs, members of the quality-improvement committee trained all care coordinators in 2012.
Resources Used and Skills Needed
- Staffing: The program required no incremental hiring of staff, as the 17 HealthPartners employees who participated in the quality improvement committee did so as part of their regular duties. On an ongoing basis, care coordinators engage in program-related activities as part of their regular duties. The two community members who participated on the committee did so as volunteers.
- Costs: Although data on the specific costs of the quality-improvement initiative are not available, they were fairly low, consisting primarily of staff time taken away from other activities during the upfront development phase. In 2011, the entire EBAN Experience™ collaborative cost roughly $500,000 for all nine teams, including the costs of developing and producing the videos and other materials, creating and maintaining a Web site, and shifting staff time away from their regular jobs.
Funding SourcesPfizer Independent Grants for Learning & Change
Tools and Other ResourcesMore information on the EBAN Experience™ collaborative can be found on the HealthPartners Institute for Education and Research Web site, available at: http://www.ebanexperience.com.
The Institute for Healthcare Improvement offers practical information on quality improvement, including videos, white papers, and worksheets, available at: http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx.
Getting Started with This Innovation
- Have experienced quality-improvement practitioners lead project: If possible, assign an employee with previous quality-improvement experience to lead the team.
- Take small steps forward: Do not overwhelm members of an improvement team by implementing a lot of changes at once; instead, start with a small change designed to have a big impact. Success will foster enthusiasm among team members, who will then embrace more changes.
- Leverage available data: Set up an evaluation system that relies on data already collected by the organization and avoid resource-intensive processes such as chart reviews.
- Teach as change in mindset: Approach training as a change in mindset or philosophy rather than an exercise in memorizing scripted conversations. If care coordinators change their overall approach to discussions about advance directives (emphasizing nontechnical and jargon-free communication skills and beginning the conversation with a discussion about spokespeople) they will be more likely to feel comfortable initiating such conversations and responding to whatever concerns individual members may have about completing the documents.
Sustaining This Innovation
- Monitor and report on project impact over time: Monitor metrics over time to gauge the impact of the initiative, and then share information with care coordinators and other relevant staff to remind them of the importance of the changes and encourage them to continue to improve their performance.
- Focus on initial conversation: Although it usually takes more than one conversation about advance directives to obtain completed documents from health-plan members, the initial conversation is the most important. If the the initial conversation does not go well, members may be unwilling to address the topic again.
- Employ a nonclinical approach: Health-plan members may be put off if the approach to discussions about advance directives is overly technical and involves a lot of medical jargon.
Contact the InnovatorDebra Bryan
Director, Collaborative Learning
HealthPartners Institute for Education and Research
P.O. Box 1309, Mailstop 21101B
Minneapolis, MN 55440-1309
Vice President Disease and Case Management
P.O. Box 1309, Mailstop 21106H
Minneapolis, MN 55440-1309
Innovator DisclosuresMs. Bryan reported that Pfizer Independent Grants for Learning and Change made a professional education grant to HealthPartners Institute for Education and Research to partially fund The Equitable Health Collaborative—Leading System Change Through PI-CME, which later was renamed The EBAN Experience™, An Equitable Health Collaborative; in addition, information on funders is available in the Funding Sources section.
Detering K, Hancock A, Reade M, et al. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345. [PubMed]
Murphy T, Palmer J, Azen S, et al. Ethnicity and advance care directives. J Law Med Ethics. 1996;24(2):108-17. [PubMed]
Jones A, Moss A, Harris-Kojetin L. Use of advance care directives in long-term-care populations. NCHS Data Brief. 2011;(54):1-8. [PubMed]
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Original publication: December 18, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.