Abstract

Priority Health Case Managers (CMs) work telephonically with members that are frail and have multiple co-morbidities, yet little or no Advance Care Planning (ACP) has occurred. Face-to-face ACP facilitation is successful, but it is unknown whether ACP can be successfully facilitated telephonically. In consultation with Respecting Choices©, a six-month Telephonic Advance Care Planning (TACP) pilot was developed and implemented to test the feasibility of a telephonic model of ACP facilitation by health plan case managers. Secondary goals of the TACP pilot were to provide a standard TACP facilitation skill set to CMs; to evaluate the integration of ACP facilitation into CM workflow; to facilitate ACP discussion and completion of documents for both First Steps© and Last Steps© protocol; to engage members' physicians in TACP plan; to provide pilot CMs support, and document their skill development; and to create a TACP dissemination plan for all health plan CMs. TACP facilitation protocols were developed and integrated into the electronic assessment tool, CMs were trained, member eligibility criteria were developed, frequent meetings were held for pilot staff, and CM skill assessment was documented. The TACP pilot demonstrated the feasibility of telephonic ACP facilitation for frail elders with advanced disease. There was acceptance of the telephonic model by CMs, members, primary care physicians and health plan staff. The successes and lessons learned allowed TACP dissemination to all CMs.