Podcast Host 2 (3:51)

That's great, Krista. And we all know how these conversations are very important and especially making those end of life of care decisions. I just went through it recently and if you're not a healthcare provider, I can see how this can be very difficult. Even as a healthcare provider, until you go through it yourself, you don't realize how difficult it is to make those decisions and to make it make sense to other people who are non medical professionals. It is a lot and I totally. And your work is very important. I totally understand the importance of this and we should really push for more engaged, dedicated time for advent care planning, especially education. I would say educate the family and patients on what it entails and what the importance is. So with that said, can you tell us in what type of setting the study was conducted and give us a brief description of the methodology that you used as well?

Podcast Host 1 (4:50)

Yeah.

Krista Cooper (4:50)

So I worked in a academic medical setting when I conducted this research and specifically in a movement disorder program in a Huntington's Disease center of Excellence clinic. So it was an outpatient clinic setting. The methodology for the research was a randomized control trial with an optional crossover open label. Crossover. So participants enrolled as patient caregiver diets because in order to have a conversation we need the patient there. But also whoever their healthcare problem attorney, they planned on for making their end of life decision. So they, the caregiver was also informed. So they enrolled as dyads and were either randomized to receive the telemedicine intervention or what we determined was kind of typical care for our clinic. And so prior to this intervention, unfortunately, typical care in our clinic was just providing healthcare power of attorney documents and five wishes paperwork which also kind of can help with discussions for patients and caregivers to have at home. And so we would provide these documents and say, like, let Us know, if you have questions, go through them and bring them back to us. Well, I, before I did this intervention study, I did a review of our clinic and found that only about 24% of patients in our clinic had any mention of having had advance care planning discussions or having a power of attorney. And only 10% had documented advance care planning documents in the EMR. So either POLST or healthcare power of attorney paperwork. So I saw there was a really big need and our typical care was really failing our patient population. So after they were randomized to either get the typical care or the intervention, which was the telemedicine, the typical care group were asked to review paperwork at home and send and have discussions on their own at home and send paperwork, the healthcare power of attorney paperwork back to us. And then at that, after two weeks of having time to fill out this paperwork and these discussions, they were then given the option to receive the telemedicine intervention. And that was one of the measurements that I used for acceptability to see how many of these dyads that they didn't have to do the telemedicine, how many actually wanted to have these conversations and opted in to receive a telemedicine advanced care planning visit.

Podcast Host 3 (7:37)

I that's very interesting. And just the fact that, you know, you were able to identify that need and I think obviously, and we'll talk about it later, just the fact that you'll be able to apply this in so many different settings in the future. So I saw in your paper that you talked about the recruitment process and you had several different criteria for your recruitment. How difficult was this task for meeting those goals of recruitment?

Krista Cooper (8:07)

Well, I chose a population that I had access to, so recruitment was not difficult. Actually, I think nearly everyone I invited to participate agreed to participate. And often I heard, oh great, we've been meaning to do this, I've been wanting to have these conversations and this gives us an opportunity because I worked in a Huntington's disease clinic. Obviously it's a rare disease, but I had access to that patient population, so recruitment was not too difficult.

Podcast Host 3 (8:42)

Good. So what were the main outcome measures used in the design study and or the study design? Excuse me. And what was the profile of the PA that was leading your tele ACP intervention?

Krista Cooper (8:55)

Yeah, so the three kind of outcomes that I was looking at was engagement in advanced care planning, how that changed after the intervention, if it changed, and in what direction, how feasible advanced care planning via telemedicine is, and acceptability of having these really emotional discussions throughout telemedicine so for engagement, I use the advanced Care Planning engagement survey. And it is a 15 to 17 question survey. It's different for patients versus caregivers. And it's really looking at like how well informed you are, how ready are you, how confident are you on various aspects of advanced care planning. And it's on a Likert scale. So that was my main outcome. For engagement, yes. For feasibility, my main outcome was the number of telemedicine medicine advanced care planning discussions that were successfully completed. So they were scheduled, completed, not running into technical difficulties that required kind of to abandon the telemedicine visit. And then for acceptability, I used the telehealth usability questionnaire. And that really asked participants how they liked having the discussion, how comfortable they were, various questions about the telemedicine visit specifically. And then the PA that was performing all of these advanced care planning discussions was me. So I had been a PA for over 10 years. I had worked in a Huntington's clinic for over six years. I had relationships with all of these participants. They were my patients. And I also had actually completed a specific palliative medicine training course that talked about advanced end of life discussions and advanced care planning documents.

Podcast Host 3 (10:52)

Okay, great. So in the article it was mentioned that satisfaction with PA led tele ACP was extremely high, with 100% of participants stating they agreed or strongly agreed that they were overall satisfied and could express themselves effectively to the PA. Nearly 96% stated that they felt comfortable communicating with the PA through telemedicine. What do you think influenced that positive response from the patients and their caregivers? Is it the PA's experience, your experience, for example, knowledge, compassion, or just a combination of factors?

Krista Cooper (11:29)

I think it was a combination of factors, one being my, my prior relationship with these participants. Ideally, in medical settings, it is a health care provider, whether that's a PA or a different type of healthcare provider that's having these kind of emotional discussions that has already built trust with the patient, with the caregiver, and already has an established relationship that's ideal. I know that doesn't always happen, but I think that really helped with the positive outcome of my, of my research. And I really tried to use nurse statements to provide empathy. So like naming emotions, providing understanding, respect, support and kind of exploring. I was able to do these telemedicine advanced care planning discussions outside of my clinic time, so I also was not rushed, so I could kind of give them just time to discuss. And I had time to kind of ask these questions, exploring questions. But actually on average the Visits only lasted about 45 minutes, and I had a whole discussion with the dyad and we also completed healthcare power of attorney paperwork. So I could imagine splitting those into two separate visits to better fit into a typical clinical workflow.

Podcast Host 1 (12:54)

Krista, you must have been reading our minds because I think the next question is all about how do you operationalize this? You know, it sounds like you had a very impactful relationship with these patients and they're very engaged. But do you think that this same intervention could be used in other care settings or health systems?

Krista Cooper (13:10)

I do. I think it is a really simple to implement at this point in the healthcare landscape. Probably most clinics have already implemented telemedicine and use telemedicine visits. So it would be kind of a similar scheduling process and you could use the same telemedicine platform that are used for clinical visits for these types of discussions. I did the scheduling myself since it was part of research, but it was kind of a quick process. So I just identified participants, consented them, and scheduled them. So that could easily be done within a clinical workflow. In addition, because of the time, so the short, the range of time was somewhere between 30 minutes to 60 minutes about. But if you broke the different topics into two sections, so having more of just a discussion versus actually filling out healthcare power of attorney paperwork, you could split it over two clinical visits and they could more easily fit into a typical clinical appointment time. There are reimbursement codes as well for advance care planning discussions. So that's something that PAs should be aware of. If this is actual clinic time, then you should be billing for your time. Obviously in research, I was not billing for my time, but that's something particularly if you're interested in implementing this, to talk with administration about that. It can be billed.

Podcast Host 1 (14:49)

Yeah, that's really important. So outside of time and reimbursement, what are some other factors that should be identified before implementing a PA led tele advanced care plan planning program that may influence acceptability and program success?

Krista Cooper (15:02)

I think probably the first thing that is most important is the comfort of the PA having these discussions. They're not easy discussions to have. I know there's research showing that a lot of healthcare providers kind of avoid having them because of their own discomfort with not knowing how to bring them up with feeling like patients might think you're giving up on them. So being comfortable framing these conversations in a way that is just, just supportive and just providing total care of the patient, including thinking ahead to end of life, is important. If a PA is not knowledgeable of the disease state that could play a role. So obviously I worked in a Huntington's clinic, so I'm very knowledgeable of end of life care and Huntington's disease. So having a PA that is comfortable with what typically comes up in end of life would be important. And then this intervention could certainly be used in a wide variety of disease states. Huntington's disease is a little unique because we really need to have these discussions early on in the disease course. People tend to not even tend to kind of universally late stage Huntington's, you have dementia and often mutism. So you really cannot consent or even let your wishes be known. So if we wait too long into the disease course, we've lost our opportunity. So when applying this type of intervention to different patient populations, I think that those kind of considerations also need to be thought of ahead of time before implementing.

Podcast Host 1 (16:50)

You know, I'm so impressed with your work with this population in particular. It is pretty empowering. So our last question, you know, you proved through your research that teleadvanced care planning interventions led by a PA autonomously was feasible, acceptable and improved engagement. How does this finding positively impact the role of PAS on medical teams dealing with life limited illnesses? And what does the future look like for PAS and palliative care, in your opinion?

Krista Cooper (17:17)

I think this research really shows the tremendous value and impact PAs can have on medical teams. So PAs really can have a bal of medical knowledge that's needed in order to have these types of discussions, time in their schedule and being able to build for this and the empathy that's really required to have these types of emotional end of life discussions with different patient populations, palliative care in General. I think PAs would be very valuable to those teams, not only in end of life life discussions, but kind of general palliative medicine and caregiving for a variety of patient populations. I'm not sure what else to say about that.

Podcast Host 1 (18:09)

I love it. Very wise. All right, Well, I think before we wrap up, any last thoughts or comments?

Krista Cooper (18:17)

I think my, my kind of last thoughts are this is real. I really, really was wanting to make an intervention that would be very easily adaptable to different patient populations and very feasible. I didn't want it to be a burden on patients and caregivers. I didn't want to have to have them come in. I work in a urban setting, so they have to pay for parking. They often drive very long distances. So I wanted it to be as little burden on patients and caregivers as possible because there's already so many barriers to advance care planning. I wanted to try to eliminate as many barriers as possible and then to show that you can have these discussions over telemedicine and that a PA really can can do it. With absolutely no physician involvement and our education and training, we are definitely very capable of implementing this type of intervention on our own. Well said, Krista.

Podcast Host 1 (19:22)

Thank you for leading the way on this. I was already thinking through all the different ways that we could use this in my own clinic. So thank you. And to our listeners, don't forget, you can now earn CME by listening to the podcast. To receive your CME credit and access your certificate, you just listen to the podcast and then complete the post test and evaluation in AAPA's learning central@cme.aapa.org it.