University of South Dakota
What has been most instrumental to your progress?
1. Coalition building was the first step for which we utilized community processes concepts like inclusivity, collaboration and resourcefulness that are highlighted by the Community Innovation Process model provided by the Bush Foundation. The Advance Care Planning: Quality Conversations coalition was first convened by nurse educators and has been operating since 2015. The coalition is composed of an interprofessional, multi-institutional team that implemented a Practice Improvement initiative to provide Advance Care Planning (ACP) training to community practice partners according to the Respecting Choices® model. The coalition is divided into a decision-making leadership and a membership team. The leadership team meets once a month. The membership team provides advice and human resources; it meets every two months by teleconference with an option for face-to-face meetings.
2. At a grassroots level the ACP: Quality Conversations coalition identified the need for improved communication about end-of-life issues in rural South Dakota. Literature searches in combination with customer surveys statewide, showed that end-of-life (EOL) discussions are essential for person-centered care, improved care transitions across practice settings and for reducing the cost of healthcare. The primary purpose of the ACP: Quality Conversations coalition became to educate, expand and maintain a pipeline of interprofessional ACP educators (instructors and facilitators) in appropriate methodologies and provide tools to start ACP conversations in local communities. The Respecting Choices ®(RC) model of ACP was chosen by the coalition because RC has developed organizational policies and patient engagement tools that are guided by quality improvement principles. Thus far, the funds provided by Bush CI have been used to certify 7 RC Instructors (see Figure 1) and 150 facilitators that are working in communities throughout South Dakota. Their acquired skills and knowledge in ACP is utilized to start conversations to identify patients' wishes regarding EOL issues.
3. The community innovation introduced statewide with funding from the Bush Foundation Community Innovation grant, was to educate, expand and maintain a pipeline of interprofessional ACP educators (Instructors and Facilitators) in appropriate methodologies and provide tools to start ACP conversations in the community. The coalition provided the funds for training and certification of ACP instructors and facilitators. ACP training occurs at three major levels: 1. First Steps® ACP Instructors are certified in Respecting Choices® methods. 2. Certified Respecting Choices ® Instructors are qualified to train ACP First Steps® Facilitators in a setting of their choice. 3. The First Steps® Facilitators amplify ACP knowledge by directly interacting with clients across the state. This approach will amplify knowledge in ACP methods among all South Dakota citizens. All major health care providers were given access to this program and many have participated as partners in the coalition.
Key lessons learned
Professional representation on the Leadership and Membership Teams included the following credentials or professions: Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Nursing faculty member, Chair of Nursing, nursing researcher (Ph.D.), Director of Tribal Relations, emergency medical services coordinator, pastor, and senior Vice President (VP) Public Policy of a hospital, care coordinator, tribal patient navigator, hospice volunteer coordinator, gerontology field specialist, president of non-profit, owner of a senior care facility, clinical nurse leader, magnet program director at a hospital, director adult programming at a care center, program coordinator, cancer control program coordinator, and medical student. Participants were employed by academia, hospital systems, senior care facilities, adult daycare, SD Department of Health (SDDOH), SDAHO, a church, and Great Plains Quality Innovation Network (GPQIN). From this, we learned that partnership building is more time consuming than any of us anticipated and the landscape is constantly changing. Maintaining contact with community partners requires dedicated leadership, constant attention, and flexibility.
Reflections on the community innovation process
The coalition identified the need for ACP training among health professionals by responding to a request made by one of its many community partners. Monthly conferencing provided the forum for discussions, finding solutions to common problems and coming up with new ideas. Communally, the group decided to use the Respecting Choices model for ACP instructor and facilitator training. The partner organizations have the opportunity to put in requests for speakers in their communities, which leads to Community Innovation. A website supports communication among coalition partners and events are posted for everyone. The coalition is forward looking and discusses future projects. There are monthly reminders to be inclusive and ideas are floated how to best involve under represented partners. The most important element may have been the needs assessment because the coalition directly responds to needs as soon as they are expressed.
Progress toward an innovation
The ACP: Quality Conversations coalition based their work on an existing evidence-based approach, Respecting Choices (RC) that had previously been adopted by other rural Midwestern states. The coalition provided training according to RC for a statewide network of ACP Instructors and Facilitators to identify and honor an individual’s wishes at the end-of-life (EOL) through direct dialog. This approach was innovative in the state of South Dakota (SD). Previously, in SD, healthcare providers used unstructured methods for ACP and specific training was not provided. Our coalition achieved buy-in from all major healthcare providers in South Dakota. Specifically, the ACP: Quality Conversations coalition has trained RC Instructors and Facilitators from all the major providers (Avera Health, Sanford Health, Regional Health/Monument Health, IHS) and many smaller organizations. The Instructors and Facilitators are now in a position to amplify their knowledge by interacting with their organizations and with clients across the entire state. ACP RC training is now uniformly spread across the state, although it is not mandatory as we are not involved in policy-making.
We have firm plans for moving the project forward. So far, the work was focused on identifying and respecting the patients’ goals of care at the end of life. In the future, the coalition will begin to integrate other aspects of palliative care by providing structure to our existing network of partners through implementation of the evidence-based Extension for Community Healthcare outcomes (ECHO) model. In the future, the coalition plans to support its existing network of providers in palliative care through Project ECHO. Project ECHO links the expertise of distant specialty with primary care providers in local communities through regular teleECHO™ clinics. Subject or content experts located at designated “hub sites” are connected through technology with practitioners in local community “spoke sites”. The hub and spokes become part of a learning community through tele-mentoring and shared learning. This effectively amplifies specialized knowledge, increasing the capacity to help those in underserved areas.
If you could do it all over again...
The most unexpected part about this project were the difficulties we encountered in trying to get funds to our community partners. It took several months to work out how to satisfy and handle all the state requirements for contractors. We were very lucky that we have a committed staff member in accounting who showed great personal initiative in making the project work. Accounting staff members are now much more familiar with handling community funds, and this is the result of our constant interaction and patient communications that involved faculty, accounting, community partners and administration.
One last thought
For the project leaders at USD the project was very time-consuming but also very rewarding. It gave our students the opportunity to directly interact with rural communities and it also provided valuable training experiences for them that they would not have had otherwise. In addition, we gained a lot of new practice partners with whom we are now sharing other ideas. They come to us for networking and to find out about different training opportunities.