Tufts Health Plan began developing the Voice Your Choice program in 2015 after reviewing both internal data sources and the literature on improving the end-of-life experience. Nora Buckley, Tufts Health Plan’s Senior Manager of Clinical Programs, talks about the role health plans can play in improving the quality of end-of-life care.
The Voice Your Choice program teaches clinicians how to have end-of-life care discussions with their patients. Why focus on clinicians and not your members?
A literature review and our own data validated what we heard anecdotally: clinicians frequently felt ill-prepared to begin end-of-life care conversations, and often didn’t ask members for this important information. Also, we learned that our members didn’t have a standardized way to communicate with their health care providers that gave them confidence that their wishes would be honored.
We know doctors and nurses haven’t always received training in end-of-life care or conversations. That’s true for me. I learned about this topic through my own professional growth as a nurse and from personal experiences.
In 2016, we conducted focus groups with our members. They clearly stated they wanted to have these conversations with their PCPs, and while they were happy to hear from their health plan about available resources, they did not want their health plan to get too involved.
Based on that feedback, we now share information through care managers — clinicians who work with high-risk members — and physicians. Our member and caregiver web portals also have information about advance care directives, health care proxies, and The Conversation Project Starter Kit.
As part of the foundational strategy for our Voice Your Choice model, we trained our care managers and introduced doctors and other providers in our network to The Conversation Project Starter Kit. We promote the idea that early conversations — before someone is seriously ill — can include questions like, “What would be most important to you if something unforeseen happens?” or “Who would be your spokesperson if you were ever unable to speak for yourself?” The Conversation Starter Kit is a great guide to encourage and support early conversations. It helps people understand that, even though they’re not sick now, they need to be ready for the “unexpected.”
Why did members want to limit their health plan’s involvement in the conversation?
Our members expressed concern that insurance companies only care about costs. It’s a predictable response, but we’re not doing it for the money. We’re doing it because people’s end-of-life wishes are not routinely being discussed and honored. We’re in a unique position to help.
Members may not fully grasp how many nurses and doctors work at Tufts Health Plan whose primary goal is to provide quality care for our members with geriatric conditions. We have strong relationships with our provider network, and all our Medicare products make improving care for the elderly a priority.
What members did ask for from their insurance company was an advance directive checklist, so we created a Voice Your Choice brochure that we’ve begun to share with PCPs and care managers. Doctors can place the brochure in their office and waiting areas along with Conversation Project Starter Kits. We’ve also begun to introduce the Ariadne Lab Serious Illness Conversation Guide to the providers. It’s a prognosis-driven tool to guide clinicians as they ask patients about their goals and values, especially after delivering a serious diagnosis or if a chronic disease worsens.
What are you trying to achieve with Voice Your Choice?
We want to:
- Help providers and care managers get more comfortable having end-of-life conversations, and then master those skills.
- Promote more shared decision making between providers and members.
- Ensure that members’ wishes are expressed, documented in the providers’ medical records, and honored.
- Give the support hospice care can offer for longer periods of time for those who want to be at home when the time comes.
- Encourage more members to talk with their loved ones about their end-of-life care wishes.
What feedback are you getting so far?
Many of the case managers and physicians we’re training are excited. One physician, for example, started having these conversations with his patients, and said, “It was great, and it wasn’t as hard as I thought it would be.” Several months later, he said, “I’ve enjoyed being a doctor more in the last two months than I have in a very long time because of this.”
This kind of reaction is what we hope for. We want doctors to understand that end-of-life care conversations can be professionally satisfying and possibly not as hard as they imagine.
The Conversation Project encourages organizations to run Conversation Starter Kit workshops with their employees as well as their customers. What has been the response at Tufts Health Plan?
It’s been great. In 2013, when [Conversation Project founder] Ellen Goodman brought the conversation to Tufts Health Plan, some of us volunteered to become coaches, and took up the mantle of bringing this important message to employees. We’ve coached a couple of hundred clinicians and non-clinicians. Some are getting ready to retire, while others are younger people who had experienced the deaths of friends or family members. Some wanted to have the conversation with their parents.
People seemed to get a lot out of attending session one, coming back to the group, and sharing how their conversations went with their families. They, of course, had varying degrees of success, but they all had the realization that initiating the conversation was just a beginning. They learned it’s something to keep working at.
The idea of it being a process has had a big impact on clinicians. It’s a relationship-building conversation, and it doesn’t have to take an hour and a half. If, on the other hand, you wait until someone’s in crisis, it’s definitely going to be a long conversation. There will always be discussions that are more difficult than others, but if you take time to build the relationship first, it’s going to be easier for both sides when it’s time to make difficult decisions.
A lot of case managers said using the Starter Kit themselves changed them. They said things like, “I’ve changed the way I talk to patients about this.” When you have the conversation for yourself, you reach a deeper level of empathy.
I’ve had people tell me they used the Starter Kit with their husband. They say things like, “We’ve been together 20 years. We thought we knew what each of us wanted, but we found out we didn’t know.”
Do you have advice for health plans that may be thinking of using The Conversation Starter Kit?
Health plans could consider making advance care planning an annual health goal for members and support employees with some sort of incentive like they do for weight loss or smoking cessation. At the very least, they could offer “lunch and learns” to inform employees about The Conversation Project as we did. From that event, we got people to sign up to participate in The Conversation Project workshops.
For the sessions we do with clinicians, we tell them, “No patient stories allowed.” They don’t have to share personal stories as long as they’re actively listening, but we want them to at least think about the process personally and not just professionally.
Improving end-of-life care is something I truly care about. I got the chills when that doctor said he enjoyed being a doctor again. Moments like that keep me going.
Note: This conversation was edited for length and clarity.