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Capstone project: Project prepare, plan, and provide

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Capstone project: Project prepare, plan, and provide

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Content Running head: CAPSTONE PROJECT: PROJECT PREPARE, PLAN 1
Capstone Project: Project Prepare, Plan, and Provide
Sarah Bartzen
University of Southern California
Doctor of Social Work
December 2019
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 2
Table of Contents
Area 1. Executive Summary……………………………………………………………………………….
4
Linkage Between Project and Grand Challenge……………………………………………………
4
Conceptual Framework………………………………………………………………………..........
4
Problem in Practice Setting…………………………………………………………………………
5
Project Methodology………………………………………………………………………………...
6
Project Implementation and Action Steps……………………………………………………….......
7
Area 2. Conceptual Framework…………………………………………………………………………...
7
Statement of Problem………………………………………………………………………………..
7
Literature and Practice Review of Problem and Innovation……………………………………......
9
Social Significance………………………………………………………………………………….
10
Conceptual Framework with Logic Model Showing Theory of Change……………………………
11
Area 3. Problem(s) of Practice and Innovative Solution(s)………………………………………………
12
Proposed Innovation and Its Effects on the Grand Challenge……………………………………...
12
Proposed Innovation………………………………………………………………………..
12
Innovation Defense…………………………………………………………………………
15
Continuum of Innovation………………………………………………………………….
16
Feasibility…………………………………………………………………………………
16
Views of Key Stakeholders………………………………………………………………………...
17
Evidence and Current Context for Proposed Innovation…………………………………………
18
Comparative Assessment of Other Opportunities for Innovation…………………………………..
19
Local Efforts……………………………………………………………………………….
19
State Efforts………………………………………………………………………………...
20
National Efforts…………………………………………………………………………….
20
How Innovation Links to Proposed Logic Model and Theory of Change……………………….....
21
Area 4. Project Structure, Methodology, and Action Components……………………………………..
22
Description of Capstone Deliverable/Artifact………………………………………………………
22
Comparative Market Analysis………………………………………………………………………
22
Project Implementation Methods……………………………………………………………………
23
Barriers and Facilitators………………………………………………………………........
24
Key Challenges and Alternative Solutions…………………………………………………
24
Plan Development………………………………………………………………………….
25
Exploration……………………………………………………………………………........
25
Preparation…………………………………………………………………………….......
26
Implementation…………………………………………………………………………….
26
Sustainment………………………………………………………………………………..
27
Financial Plans and Staging……………………………………………………………………….
27
Project Impact Assessment Methods……………………………………………………………….
29
Output Measures…………………………………………………………………………..
30
Outcome Measures……………………………………………………………………......
31
Stakeholder Engagement Plan…………………………………………………………………….
32
Communication Strategies and Products…………………………………………………………..
33
Ethical Considerations……………………………………………………………………………...
34
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 3
Area 5. Conclusions, Actions and Implications…………………………………………………………...
35
Current Practice Context for Project Conclusions………………………………………………….
35
Project Implications for Practice and Further Action………………………………………………
37
Project Limitations……………………………………………………………………………….....
39
Participant Sample…………………………………………………………………….........
39
Participants Receptivity…………………………………………………………………….
39
Funding Resources………………………………………………………………………….
40
Appendix…………………………………………………………………………………………………….
41
Appendix A: Bibliography

Appendix B: Concept Definitions

Appendix C: Logic Model

Appendix D: EPIS Framework

Appendix E: Project Prepare, Plan, and Provide Gantt Chart

Appendix F: Line Item Budget

Appendix G: Assessment Instruments

Appendix H: Prototype

CAPSTONE PROJECT: PROJECT PREPARE, PLAN 4
Capstone Project: Project Prepare, Plan, and Provide
Area 1. Executive Summary
Linkage Between Project and Grand Challenge
The identified Grand Challenge for this capstone project is to Close the Health Gap. This
Grand Challenge aims to address the issues plaguing the health care system through developing
and implementing innovative programming. The lack of conversations about death, dying, and
end of life care for those with chronic conditions are one of the issues plaguing health care. To
address this issue within the Grand Challenge the proposed innovation, Project Prepare, Plan,
and Provide, has been created. This pilot project offers training to health care providers to begin
and have consistent conversations about end of life care with 35- 64 year old patients who have
multiple chronic health conditions. With this training, health care providers can begin end of life
conversations with these individuals earlier on in their health care journey. With the increase in
the number of Baby Boomers rapidly rising by the year 2030, the increase in multiple chronic
health conditions for those in the middle age group and older, and increasing technological
advances, the time to begin discussing end of life care with patients is more present that ever
before (Lee, Daugherty, & Hamelin, 2018; Sopcheck, 2016).
Conceptual Framework
Research literature has consistently demonstrated providers feel unprepared to begin end
of life conversations with their patients, even those who have life ending illness, largely due to a
lack of education on the topic (Gillan, van der Riet, & Jeong, 2014; Shaw & Abbot, 2017).
Health care professionals report wanting to learn strategies to address end of life but report
barriers such as time and scope of practice. Instead, providers working with individuals who
have chronic illnesses often focus on their role in treating the disorder, so they do not see having
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 5
end of life conversations as part of their responsibilities. They largely expect patients and
families to understand that it is part of the illness and aim to have the conversation when
everyone is ready. However, in many instances the conversation goes unaddressed and patients
are referred to hospice or palliative care when they are terminally ill or actively dying (Alonso,
Hupcey, & Kitko, 2017; Bergman, Fink, Kwan, Maliski, & Litwin, 2011; McRee & Reed, 2016;
Nedjat-Haiem, Cadet, Amatya, & Mishra, 2018).
Innovative programming like Project Prepare, Plan, and Provide is needed to help bridge
this gap between provider knowledge and end of life conversations. The purpose of the pilot
project is to equip providers with the knowledge and skills needed to approach end of life
conversations with patients confidently and competently. In this pilot, providers from varying
disciplines (social workers, nurses, physicians, and physician’s assistants) will come together to
increase their knowledge of end of life resources, increase communication skills, and be better
equipped to walk through the process of discussing and documenting end of life plans with
midlife patients with chronic health conditions. Providers will go through this pilot training in a
mid-size health system in Jackson, Michigan. Social learning theory is the program model being
used to explain the relationship between the activities and outcomes of the project.
Problem in Practice Setting
The Kaiser Family Foundation has reported nine out of ten individuals want to have
conversations about end of life care with their providers, yet less than 20 percent actually do
(DiJulio, Firth, & Brodie, 2015). This is largely due to the culture of the health care system that
focuses on treatment and life sustaining measures. This often results in end of life conversations
being avoided or minimized by health care providers (Proulx & Jacelon, 2004; Soodalter,
Siegle, Klein-Fedyshin, Arnold, & Schenker, 2018; Turner & Kelly, 2000). However,
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 6
patients want their health care providers to ask them about planning for the end of life (Dobbs,
Parsons Emmett, Hammarth, & Daaleman, 2012; Kumar et al., 2010). If health care providers
embraced this conversation, patients and families could be having discussions about end of life
care long before a patient enters the hospital for the last time, is admitted to hospice, or is very
close to death. When decisions are made at the end of life and patients cannot communicate their
wishes, this can result in medical decisions made by families that may not be what the patient
wanted. Much of this happens because they are unaware of other options available earlier on in
care. Patients and families need guidance when deciding end of life care treatment. Without this
guidance and end of life care plans in place when someone is dying, options are usually
aggressive treatments (McRee & Reed, 2016; Sonenberg & Sepulveda-Pasci, 2018). If
conversations about end of life were started earlier, this could change how chronic diseases are
monitored, and how death is viewed and cared for by different professionals in the health care
system. Individuals with chronic illness should be invited to discuss end of life, what it means,
and how they want to die with their loved ones and health care providers (Proulx & Jacelon,
2004).
Project Methodology
The components of the project will take place over a 12 month period of time. The
project includes three phases; the training series, patient visits, and the evaluation component
that will be used to measure the success of the pilot project. Twenty four health care providers
and 50 of their 35-64 year old patients with chronic health conditions will be recruited to
participate in the program. In the first phase, the training series will take place over a six month
period of time using a one hour training, a four hour half day training, and an eight hour full day
training. In the second phase, patients of the trained health care providers will attend two visits at
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 7
three and six months post-training. Phase three is the evaluation component where program data
from providers and patients will be collected and analyzed. Three assessment tools will be used
to measure outputs and outcomes through the program evaluation. These tools are the Health
Care Provider Questionnaire, the Quality of Communication Questionnaire (QOC), and the
Canadian Health Care Evaluation Project (CANHELP) Patient Questionnaire.
Project Implementation and Action Steps
Using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, an
implementation plan has been developed to guide the implementation of the pilot of Project
Prepare, Plan, and Provide in Jackson, Michigan. The target start date is July 2020. Currently,
the program is in the Exploration phase, moving towards Preparation. A series of activities have
been completed to move towards Preparation, such as the completion of a needs assessment,
facilitated patient and family focus groups, and the development of a program manual, which can
be found as the capstone prototype. Securing funding and participant recruitment are some of the
next steps in the project implementation process. After the implementation of the pilot, the
program will be scaled to increase the number of trainings provided at the health system and to
different providers, and then to other health systems in the state of Michigan. Over time, the
project will be modified to be provided in other formats, such as webinars and online modules
and to include the creation of a legislative campaign, with the goal of scaling nationally.
Area 2. Conceptual Framework
Statement of Problem
The problem statement guiding the innovation is individuals with multiple chronic health
conditions, like diabetes or heart disease, lack awareness and understanding of the importance of
having discussions earlier on in treatment on the services and care they want when they are
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 8
dying. As a result, end of life services like palliative and hospice care are underutilized and crisis
decisions are made at the end of life that may not be in the best interest of the patient. Medical
professionals report being uneducated and uncomfortable about these issues and do not have
these discussions with patients when the time comes, let alone after diagnosis. Aggressive
treatment, being kept on a ventilator, or put in the intensive care unit are costly and likely
outcomes for those who do not have end of life care plans in place. Much of this occurs while
patients are dying or near death, as patients and providers are not aware of or are uncomfortable
discussing end of life options available earlier on in care. This problem is housed with the Grand
Challenge to Close the Health Gap.
The focus of the Grand Challenge to Close the Health Gap is to increase equity and
access to health care, improve and develop the health care workforce, and address social
determinants of health (Fong, Lubben, & Barth, 2018). This Grand Challenge addresses
complexities in the health care system through creating new approaches to improve individual
and community health. The lack of end of life conversations for those with chronic health
conditions are one of the complexities prevailing in health care. The purpose of the capstone
innovation, increasing training and continuing education for health care providers across
disciplines, is linked to the Grand Challenge’s aim of strengthening health care systems. This
goal is described in the working paper for the American Academy of Social Work and Social
Welfare, Strengthening Health Care Systems: Better Health Across America, that describes the
importance of creating interprofessional education opportunities to develop new care models and
improve those that currently exist. The new and updated care models promote provider
collaboration, patient-centered care, and emphasize social determinants of health. Health care
professionals need to collaborate and provide patient-centered care when addressing end of life
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 9
care for patients, particularly those with chronic health conditions, as they often receive
fragmented care for their differing health conditions (Browne et al., 2017; Spencer, Walters, &
Clapp, 2016). To provide a collective understanding of the important and relevant concepts used
in this document, a list of concept definitions can be found in Appendix B.
Literature and Practice Review of Problem and Innovation
Chronic health conditions are increasing due to the growing Baby Boomer population and
advances in medical technologies. These health conditions do increase with age, but what is
currently happening in the United States is that more middle aged adults, 35-64 years old, are
living with chronic conditions. Currently, four in ten adults have multiple chronic conditions
(Centers for Disease Control and Prevention [CDC], 2017). Most of these individuals will
succumb to their illnesses, as chronic conditions are seven of the top ten leading causes of death
in the United States each year (Cacioppo & Hawkley, 2003; CDC, 2017; Whittemore & Dixon,
2007). Addressing and caring for chronic health conditions impacts health care delivery and
utilization and costs, placing a strain on the health care system (CDC, 2013, McRee & Reed,
2016). With the increase in significant care needs and mortality from chronic disease, end of life
discussions must be addressed in the health care system.
The identified problem of the lack of conversations on end of life care has varied causes.
Some of these causes include patients underestimating the severity and trajectory of their
illnesses and lacking the understanding of the length and course of their conditions, creating
reluctance to having end of life discussions. Additionally, the structure and culture of the health
care system to cure and promote wellness greatly influences how and when end of life is
discussed with patients. Yet, the literature repeatedly focuses on one of the main causes of this
issue; health care providers outside of palliative and hospice care are unprepared and
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 10
uncomfortable addressing end of life with patients (Alonso et al., 2017; Bergman et al., 2011;
McRee & Reed, 2016; Proulx & Jacelon, 2004; Soodalter et al., 2018; Turner & Kelly, 2000).
Health care provider reluctance in having conversations about what care looks like at the
end of life has resulted in more than two-thirds of Americans not having end of life care plans in
place (Crist, 2017). Largely, providers report feeling unprepared and uncomfortable beginning
end of life conversations with their patients. They report significant concerns in addressing end
of life with patients. There is a limited focus on end of life content during their educational
programs, yet accrediting bodies and professional associations strongly recommend this content
for health professionals. Often, providers are more exposed to end of life in the field setting and
have to learn while they interact with patients and do not have the foundational knowledge to
provide appropriate care (Chung, Oczkowski, Hanvey, Mbuagbaw, & You, 2016; Gillan et al.,
2014; Healy, Chappell, Lee, Ross, & Sanchez-Reilly, 2017; Kim, Chakravarthy, Anderson, &
Liao, 2017; Shaw & Abbot, 2017; Stuart & Berry, 2017).
Social Significance
As a result of provider reluctance and unpreparedness in addressing end of life
conversations, many of these discussions occur when someone is terminally ill or actively dying,
and are often too late for patients to receive holistic end of life services (McRee & Reed, 2016;
Sonenberg & Sepulveda-Pasci, 2018; Sorensen & Iedema, 2011). These discussions are held in
hospices, hospitals, nursing facilities, and long-term care facilities, yet many individuals express
a desire to die in their own homes. However, the reality is that almost 50 percent of individuals
die in hospitals and one in five end up passing in intensive care units (Saboo, 2015). This has
caused costs of end of life care to soar. In 2014, 22.6 million Americans died, and of those who
had passed, 80 percent were on Medicare. A quarter of total Medicare spending goes towards
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 11
care for individuals in their last year of life. Given most of the individuals on Medicare have
chronic health conditions and poor health, they end up using expensive end of life care such as
frequent hospitalizations, hospice, long-term care or skilled nursing facilities, creating an
unequal disproportion of Medicare funds to prolong life (Cubanski, Neuman, Griffin, & Damico,
2016). Though feeling uncomfortable, unprepared, or unwilling, many health care providers are
tasked with having these conversations when patients are in these settings rather than earlier on
in their care when they are not dying and can make better informed and less costly decisions on
treatment (Soodalter et al., 2018).
Preemptive planning and discussions about what a person wants at the end of their life
could prevent loneliness, increase autonomy and connectedness, reduce unwanted medical care,
stop prolonged suffering, increase preparation for death, and support dignity in death. Additional
benefits are reduced hospitalizations, increased patient quality of life, reduced mental health
issues, and patients choosing less invasive and costly medical care like being discharged to die at
home (Proulx & Jacelon, 2004; Soodalter et al., 2018; Sonenberg & Sepulveda-Pasci, 2018).
These outcomes are what health care should support in end of life care, but it is not happening
consistently or nearly enough (Institute of Medicine, 2014). As result, the wicked problem being
addressed is that there are not enough conversations about death, dying and end of life care. The
lack of these conversations and resulting unplanned deaths are negatively impacting patient care,
quality of life, and the healthcare system.
Conceptual Framework with Logic Model Showing Theory of Change
Social learning theory has been chosen as the theory of change to describe the
relationship between the activities and outcomes of the proposed pilot program. This change is
explained and supported by this program model, which is demonstrated in the program logic
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 12
model in Appendix C. The logic model is a visual representation of how the solution of Project
Prepare, Plan, and Provide for health care providers will lead to change in how end of life care is
discussed with patients and in the health care system. Social learning theory describes how
learning and behavior change occur through observation, imitation, and modeling of new
behaviors. By using this model, it explains how if providers change their knowledge and skills
through engaging in Project Prepare, Plan, and Provide, they will then change their behaviors in
how they address end of life with their patients in the field (Bethards, 2014; Dewitt, 2003;
Sternszus & Cruess, 2016).
Area 3. Problem(s) of Practice and Innovative Solution(s)
Proposed Innovation and Its Effects on the Grand Challenge
Proposed Innovation. To increase end of life conversations earlier on in patient care, the
innovation being proposed is a pilot training series for health care providers called Project
Prepare, Plan, and Provide. The purpose of these trainings are to educate and increase the skill
levels of providers in discussing end of life with patients between the ages of 35-64 who have
chronic health conditions. Patients aged 35-4 years old have been chosen as they are increasingly
being diagnosed with multiple chronic health conditions and by being able to reach this
population earlier on in care can work towards preventing negative outcomes at the end of life.
The pilot training will utilize the reflective learning model and the curriculum will include
content on end of life communication skills, end of life resources and referrals, identifying and
processing provider individual feelings (fears, concerns, apathy) about end of life, and
supporting patients and families (Gillan et al., 2014; Jors et al., 2015; Shaw & Abbot, 2017).
Given the subject matter of the pilot training, it will be facilitated by a licensed clinical social
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 13
worker to address triggered feelings and thoughts associated with death and dying that may arise
from participants engaged in the training.
There are three phases of intervention for Project Prepare, Plan, and Provide. Though the
aim of the program is to target health care provider behavior change, patients will also be
included in two of the intervention phases. This will help determine if providers are integrating
the knowledge and skills they learned in the training series into practice with patients. The first
phase of Project Prepare, Plan, and Provide pilot in Jackson, Michigan will include 24 health
care providers with six providers each from the following disciplines; physicians, social workers,
physician’s assistants, and nurses, from the local area. This cohort of providers will go through a
training series that includes a one hour training, one four hour half day training, and one eight
hour full day training over a six month period. For the pilot, the providers will attend the same
trainings and receive the same content as a cohort. During this phase, providers will complete a
pretest before the training and a posttest upon completion of the training. To increase
participation in trainings, 12 continuing education units (CEU) and continuing medical education
(CME) credits will be provided. Continuing education units will be a key part of the training
series, as they are required for all health care providers to maintain licensure in the state where
they practice.
The structure of providing the trainings over a six month period of time allows providers
to take what they have learned from each of the training sessions and apply it in their respective
practices in between sessions. With this staging, providers are able to incrementally incorporate
the skills they are learning from Project Prepare, Plan, and Provide and reflect on their
experiences before attending the next training session. In the training sessions, providers are
asked to do “homework” between sessions and are expected to share and reflect on their
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 14
experiences with the training content in practice through small and large group discussions. This
structure was also designed so providers do not have to give up large blocks of their time to
accommodate the training such as would be required if the training was provided in a two or
three consecutive day training format.
Asking providers to attend and complete four and eight hour training sessions in light of
their intensive work schedule and load, is a big request. However, health systems are
increasingly providing continuing education programming for providers in and outside of their
organizations. More health systems are providing opportunities for their providers to engage in
continuing education opportunities to meet their professional development and licensing
requirement needs. For health systems across the state of Michigan there is an expectation that
their providers regularly participate in and present on a wide range of topics and research to their
colleagues. They provide a full range of continuing education opportunities for their providers to
attend, including physicians, physician’s assistants, nurses, social workers, and other allied
health professionals. Project Prepare, Plan, and Provide would be included as one of these
offerings available through the chosen partnering health system. This amount of time also allows
providers to get a number of their CEU and CME licensing requirements met through two
trainings sessions, as opposed to having to attend shorter, additional trainings to gather an
equivalent amount of credits.
The second phase of the project will be patient visits. Fifty 35-64 year old patients with
two or more chronic health conditions of the trained health care providers will also be
participants in the pilot. Three and six months after the training series patients will schedule and
attend visits with their health care providers who have participated in the training. This will
equate to two visits during this time period. During these visits providers are expected to begin,
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 15
continue, and document end of life care plans. Patients will complete two assessments after each
of the visits. The third phase will be the evaluation. Data collected from the provider and patient
assessments will be analyzed and compared. The evaluation will assess the program outcomes
and determine if the knowledge and skills gained during the training series has been incorporated
into practice, based on the data collected.
This innovative project is connected to the Grand Challenge to Close the Health Gap, as
it addresses the complex problem of the lack of end of life conversations for those with multiple
chronic health conditions. Not addressing this problem has created multiple burdens to the health
care system, such as increased costs, and is negatively impacting patient care and the provision
of health care services. These burdens to the health care system will continue to increase, and an
innovative solution like Project Prepare, Plan, and Provide needs to be implemented to tackle the
large scale impacts of these challenges. Increasing end of life care conversations earlier on in
patient care has the potential to transform different parts of the health care system that continue
to widen the health gap. This intervention would close the health gap by reducing the number of
unnecessary medical interventions for those with chronic health conditions, improve patient
quality of care and life, reduce health care costs, change how death and dying is discussed by
patients, families and medical professionals, and enhance health workforce education.
Ultimately, it is hoped that this intervention will create a paradigm shift in the health care system
around discussing death, dying, and end of life (Alonso et al., 2017; Lee et al., 2018; McRee &
Reed, 2016; Proulx & Jacelon, 2004; Sonenberg & Sepulveda-Pasci, 2018; Sopcheck, 2016).
Innovation Defense. The capstone project is innovative because it will train health care
providers to begin end of life conversations with 35-64 year old patients who have multiple
chronic health conditions. This is innovative because training health care providers to begin
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 16
conversations with this population has the potential to disrupt how end of life is discussed in the
health care system outside of palliative, hospice, and chapel and spiritual care. With this
capstone project, health care providers that are trained to have these conversations with patients
can begin these discussions earlier on in the lifespan and in care, and continue to have these
discussions throughout a patient’s life. This innovation will directly address the problem of
individuals with multiple chronic health conditions lacking awareness and understanding of the
importance of discussing end of life treatment and care. This will be done by educating providers
on how to address and discuss end of life options and resources to inform and help patients
choose and document the care they want when they are dying.
Continuum of Innovation. Currently, this innovation is on the transformational level on
the innovation continuum. With this innovation, end of life planning for chronic health patients
will be transformed. Presently, younger patients with chronic health conditions may or may not
be asked about end of life plans, though many will succumb to their conditions over time. Being
asked to plan for end of life earlier in care can increase awareness and knowledge of end of life
options and change how interventions are considered and planned at the end of life.
Feasibility. The innovation pilot has a target implementation date of July 2020. It is
politically feasible to implement the pilot in Jackson, Michigan. Over the past three years, the
local health system, Henry Ford Allegiance Health (HFAH), has increased efforts to help the
community understand the importance of discussing end of life care with health care providers.
The focus has largely been on the aging population of the community but they have shown
interest in looking into other ways to address end of life conversations. The innovation is
financially feasible, as the preliminary budget and financial plan has been developed, and as the
innovator will be the training facilitator and has developed a program manual to get the pilot up
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 17
and running. Through the partnership with the innovator’s employer, Spring Arbor University
(SAU), development resources, training space, and professional connections to implement the
pilot will be accessible.
Views of Key Stakeholders
A variety of stakeholders will be impacted by this innovation and it was crucial to have
their perspectives reflected throughout the development of the program. Not only did research
literature inform and provide insight into how the innovation would be developed, different
engagement strategies were implemented so stakeholder perspectives were represented in Project
Prepare, Plan, and Provide. These activities have been occurring since May 2018. Stakeholders
involved in project development have included end of life and non-end of life health care
professionals (physicians, nurses, social workers, and physician’s assistants), elderly individuals
living in long-term care facilities and retirement communities, individuals with chronic health
conditions, individuals in hospice care and their families, individuals who have lost family
members to chronic conditions, and experts in serious illness and end of life care.
Beginning in summer 2018, extensive interviews were completed with individuals who
were involved with or work with end of life care. These interviews provided important insight
into the training curriculum and further project research. Focus groups were held with elderly
individuals, family members, and those at the end of life. Themes of familial and community
influence helped determine how, when, and if end of life care decisions are made and how to
incorporate this into the project. Additionally, it was found that these influences can help
promote cultural or religious traditions in end of life and death, and this was included in the
prototype.
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 18
In 2019, table top exercises were conducted with two groups of stakeholders to obtain
feedback on the prototype and to assess program processes. This testing took place with two
small stakeholder groups, chronically ill patients (February 2019) and social work providers
(May 2019). Feedback garnered from these experiences informed the training curriculum to
include information on supporting families of patients, using a guest speaker who has utilized
end of life services, and billing for end of life visits. The participant recruitment process was also
modified as a result of the table top exercises.
Evidence and Current Context for Proposed Innovation
The evidence supporting the program model and the linkage between the activities and
outcomes in the logic model are classic research literature and actual innovation in the field.
These are two of the eight types of evidence used to demonstrate the link between the activities
and outcomes being predicted in the innovation pilot. Statistical data and preliminary findings
provided by classic research literature illustrate the link between health care provider trainings
and resulting behavior change in how providers approach end of life care with patients. Using
data collection methods with providers and patients, and the subsequent data analysis described
in the research literature, have further supported how the activity of providing health care
professional training increases end of life care conversations and documentation of end of life
plans (MacKenzie, Smith-Howell, Bomba, & Meghani, 2018). Actual innovations in the field are
being conducted by organizations such as Respecting Choices and Alive Hospice to demonstrate
how providing end of life training to health care providers can change their behaviors and
attitudes towards addressing end of life care with patients. Some of the resulting behavior
changes include having more end of life conversations, referring patients to end of life services
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 19
like palliative care and hospice, and assisting in the documentation of advance directives (Alive
Hospice, 2017; Blau, 2017; Respecting Choices, 2018).
Additionally, there is a need to address end of life conversations with the growing
population affected by this problem, the individuals with multiple chronic health conditions.
Forty percent of individuals in the United States have multiple chronic health conditions
(National Center for Chronic Disease Prevention and Health Promotion [NCCDPHP], 2019).
Within the state of Michigan, where the innovation will be implemented, an estimated four
million individuals have multiple chronic health conditions (Michigan Department of Health and
Human Services [MDHHS], 2019). The target population is health care providers who deliver
care to individuals with multiple chronic health conditions. There are roughly 426,210 health
care providers in the state of Michigan that could be connected to the innovation over time
(Bureau of Labor Statistics, 2019). Given the large number of individuals with chronic illness
and providers in the state of Michigan, there is evidence that a number of users and beneficiaries
would benefit from the pilot and future implementations of Project Prepare, Plan, and Provide.
Comparative Assessment of Other Opportunities for Innovation
Additional support and evidence for the pilot project is what is happening at the local,
state, and national levels. In assessing what is currently being done at each of these levels, much
of the work on end of life care is being developed and targeted toward the aging population. This
has resulted in service gaps for younger individuals with multiple chronic health conditions.
Local Efforts. In Jackson, Michigan, there have been efforts to address end of life care
with community members. One of these efforts by the local health care system, HFAH,
addresses advance directives for patients. During patient visits, as part of the intake assessment,
adult patients are asked if they have an advance directive. If not, they are asked if they would
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 20
like more information and assistance with creating one. The health system provides a free
advance directive form on their website and upon completion, this is entered into a patient’s
electronic health record and sent to their primary care doctor. With each hospitalization, this
form is used to plan treatment (D. Moore, personal communication, May 23, 2018).
State Efforts. The state of Michigan has addressed end of life care through the efforts of
different organizations. Making Choices Michigan is an organization located in Grand Rapids,
Michigan, dedicated to increasing community conversations about end of life plans. They
advocate for making these plans known through advance directives and at any age. They provide
trainings for the public and train facilitators to help promote end of life care planning in health
care settings (Making Choices Michigan, 2018). The Michigan Commission on End of Life Care
was created in 2000 to address end of life issues and make recommendations to the governor in
order to provide quality end of life care across the state (MDHHS, 2018). The Michigan
Physician Guide to End-of-Life Care was created by Michigan physicians, Blue Cross Blue
Shield and the Department of Community Health to guide doctors, patients and their families in
navigating end of life care (Michigan State Medical Society, 2018). Hospice of Michigan has
been a leader in education, training, and community resources. With outreach to each county in
Michigan, they have been a leader in discussions and referrals to end of life care options
(Hospice of Michigan, 2018).
National Efforts. Organizations with a national reach that focus on health care like the
CDC, The Conversation Project, the Hospice Foundation of America, and the American
Association of Retired Persons (AARP) have created trainings, guides, toolkits and programming
to address end of life care, mostly targeted toward the aging population and programs and
providers serving the population. Organizations like Sutter Health and Ariadne Labs, train health
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 21
care providers on having and increasing their skills to have end of life conversations with their
aging patients who have serious illness (Lakin, Bernacki, & Cunningham, 2016; Sutter Health,
2018; Stuart & Berry, 2017). National legislative efforts to address end of life care conversations
include the passing of the 2016 Medicare reimbursement for health care professionals to
incentivize increasing end of life care discussions with their patients. Additionally, the Palliative
Care and Hospice Education and Training Act, introduced into the Energy and Commerce
Committee of the House, addresses the need to increase professionals in palliative care and
increase end of life care topics in schools training medical professionals (Center to Advance
Palliative Care, 2018). The efforts at each of these levels further help open the door to increasing
educational curriculum and professional development trainings on end of life care, supporting
the work of Project Prepare, Plan, and Provide.
How Innovation Links to Proposed Logic Model and Theory of Change
The proposed innovation links to the program logic model and theory of change, social
learning theory. Social learning theory explains how knowledge and behavior change occurs
after exposure to, and imitation of new behaviors. With the content of the Project Prepare, Plan,
and Provide training series, program participants will gain new skills to address end of life
through a combination of lecture, guest speakers, and experiential activities. The series will
largely consist of opportunities for providers to engage in experiential learning such as role plays
and interactive case studies to help integrate the material they are learning throughout the
training, as explained by the theory of change. These opportunities are provided through the
interaction of the program inputs, activities, and outputs identified in the program logic model in
Appendix C. By utilizing these components, it is hoped providers will be able to observe and
model new behaviors in the training sessions and then adopt the new behaviors in their practice.
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 22
These new behaviors are reflected in the outcomes of the logic model. The relationships between
the inputs, activities, outputs, and outcomes are found in the program logic model in Appendix C
and demonstrate how the program will effect change using the identified program model.
Area 4. Project Structure, Methodology, and Action Components
Description of Capstone Deliverable/Artifact
To address the identified problem and put Project Prepare, Plan, and Provide into
practice, the capstone prototype is a program manual. The program manual is the
operationalization of Project Prepare, Plan, and Provide. This program manual was created as a
guide for health organizations or systems who want to administer Project Prepare, Plan and
Provide, and train their health care providers to address end of life care and planning earlier on in
care. The contents of the manual include a description of the Project Prepare, Plan, and Provide
innovation, how to administer the program, program components, a training curriculum for the
three training sessions, tools to assess the program, applications to apply for social work and
nursing CEUs, and program evaluation guidelines. The prototype can be found attached to this
paper in Appendix H.
Comparative Market Analysis
Currently, hospice, palliative, and chapel and spiritual care departments within a health
care system have largely been charged with preparing patients for the end of life. Unfortunately,
this results in many end of life plans being created when someone is dying and end of life
services cannot be utilized. To increase end of life service utilization and increase end of life
conversations, other innovative programs such as Respecting Choices (LaCrosse, Wisconsin),
Alive SHARE (Nashville, Tennessee), the University of Washington School of Medicine End of
Life Care Research Program (Seattle, Washington), the Coalition to Transform Advanced Care
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 23
(C-TAC) (Washington, D.C.), and Ariadne Labs (Boston, Massachusetts) have taken charge of
creating interventions to begin end of life conversations with patients (Alive Hospice, n.d.;
Ariadne Labs, 2018; Coalition to Transform Advanced Care, 2018; Heyland, et al., 2012;
Respecting Choices, 2018). While these interventions have been useful in starting conversations,
their efforts largely focus on aging or advanced illness patients. While this is a necessary and
important focus given the increasing number of Baby Boomers, there needs to be an equal focus
on end of life discussions for midlife patients with chronic conditions (NCCDPHP, 2018). After
conducting a comparative market analysis of the current available programming and research on
end of life for younger patients, it was determined that there are no existing programs targeting
health care providers to increase end of life discussions with 35-64 year olds who have multiple
chronic health conditions.
Project Implementation Methods
The proposed strategy to facilitate the implementation of Project Prepare, Plan, and
Provide was developed by utilizing the Exploration, Preparation, Implementation, and
Sustainment (EPIS) framework. When planning and executing program implementation, it is
also necessary to identify contextual barriers and facilitators to the program. To identify and
thoroughly examine the barriers and facilitators and to structure the implementation process,
EPIS was also used. This framework has four stages and is used to examine how an evidence-
based or innovative program (EBP) fits into and then is integrated into an organization. This
framework was chosen because it has been used to guide other health care innovations aimed at
changing provider behavior and practice culture through education and training, much like the
aims of Project Prepare, Plan, and Provide. This was influential in choosing an implementation
framework, as provider behavior change is necessary for the pilot program to be successful and
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 24
for future diffusion (Aarons, Hurlburt, & Horwitz, 2011; Becan et al., 2018; Beidas, Barmish, &
Kendall, 2009; Dimeff et al., 2009; Moulin, Dickson, Stadnick, Rabin, & Aarons, 2019;
Weersing, Weisz, & Donenberg, 2002; Willging, Green, & Ramos, 2016; Williams et al., 2014).
Barriers and Facilitators. With the health care system being set up to sustain and
preserve life, EPIS was used to look at what could present as barriers and facilitators to
implementation of this program. Some of the major barriers to implementing the program
include societal perceptions of death, innovative program fit, individual adopter characteristics,
funding, staffing and staff characteristics, and patient receptivity. However, there are end of life
training programs that currently exist, demonstrating that facilitators can help pave the way for
implementation of the program. These facilitators include organizational characteristics, inter-
organizational networks, health and sociodemographic trends, leadership, provider incentivizing,
and public-academic collaboration (Aarons et al., 2011; Melnyk, Fineout-Overholt, Giggleman,
& Cruz, 2010; Soydan & Palinkas, 2014; Sredl et al., 2011). Additional barriers and facilitators
have been included in the EPIS chart in Appendix D.
Key Challenges and Alternative Solutions. Two key challenges the project is likely to
encounter during implementation have been identified. The first challenge is provider resistance
to the training content. Providers could argue their goals in the health care system are to sustain
and preserve life, and this content is inconsistent with these aims. Addressing this contradiction
could result in challenges for providers in identifying and reconciling their feelings about end of
life and result in refusing to participate in trainings where they have to wrestle with this paradox.
This challenge would be addressed by having focus groups with health care providers to identify
and address strategies to reduce provider resistance to the training and incorporating this
feedback into the training model. The second challenge that may present is the discourse that end
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 25
of life is already being addressed by palliative and hospice care, so other health care providers
may believe they do not need to address it. To address this challenge, a research study would be
completed by the innovator with Michigan health systems on when and how patients are referred
to and receive end of life services. The gathered data and subsequent report would be
disseminated to providers to begin discussions on other end of life interventions that could be
done earlier on in care.
Plan Development. To put the identified implementation strategy into place, an
implementation plan was developed for Project Prepare, Plan, and Provide using EPIS and is
demonstrated in a Gantt chart. This chart displays how and when the different program activities
will occur as the program is being implemented. The initial timeline has been built out over four
years. The attached Gantt chart in Appendix E displays the EPIS stages, activities within each of
the stages, and a timeline for when these activities will be implemented.
Exploration. During the Exploration stage of implementation, which Project Prepare,
Plan, and Provide is currently in, the activities have focused on fully developing and completing
the program components and manual, and determining if the program was a fit for a health
system where it could be implemented. This stage began in January 2019 and will continue
through December 2019. The program has already undergone some of the activities listed in this
stage such as examining which health system to partner with, interviewing and holding focus
groups with patients, families, and providers, applying for Institutional Review Board (IRB)
approval, and securing a training location through the innovator’s employer, SAU. Additional
work needs to be done to address potential challenges such as strengthening patient and provider
support and leveraging health system facilitators to champion the program during 2020 and
2021. A needs assessment has been completed to determine where and how the program will fit
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 26
to meet provider and patient needs. Currently, the innovator is working to secure an official
implementation date. This has been an ongoing process since February 2019. Once this date is
approved, the program will be able to move onto the next stage of EPIS, Preparation. If the
implementation date of July 2020 is not secured, the training will be postponed to late 2020.
Preparation. The Preparation stage will take place from December 2019 through June
2020. The major activities during this stage will center on seeking and obtaining funding,
preparing the health system for program implementation, obtaining guest speakers for the
training, and securing approval to provide CEU/CME credits. For Project Prepare, Plan, and
Provide’s pilot, applications will be submitted in December 2019 to the Michigan Social Work
Continuing Education (CE) Collaborative and the American Nurses Credentialing Center
Commission on Accreditation to obtain approval for social work and nursing CEUs. For the
physician and physician’s assistant CMEs, the facilitator will need to partner with the chosen
health system to provide these credits.
Seeking and securing funding for implementation will begin in December 2019 and
continue through to right before the anticipated program start date of July 2020. It will be
important to explore and secure funds early on in this stage. If funding is not secured this will
create a challenge in implementing the pilot. The strategies that will be completed to prepare the
health system in early 2020 include identifying early program adopters and program champions,
engaging executive boards, facilitating educational meetings with providers, preparing patients
for the program, and participant recruitment.
Implementation. The Implementation stage is expected to take place from June 2020
through September 2021. This stage will consist of strategies used to implement and deliver the
Project Prepare, Plan, and Provide pilot. The major activities during this stage will include
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 27
providing the training, patient visits, implementing the evaluation to collect program data to
measure outputs and outcomes, and using evaluation and participant data to inform future
program iterations. A mass media campaign will be implemented three months prior to the
program (April 2020) to inform providers and patients about the program and how and when
they can participate. The pilot training series will begin July 2020. The evaluation plan will
begin to be conducted in June 2020, right before the training series begins. During this phase, the
innovator will evaluate the implementation process and outcomes to determine if output and
outcome measures were met and where program improvements need to be made for future
implementation.
Sustainment. To further expand Project Prepare, Plan, and Provide, it is anticipated the
Sustainment stage will begin in November 2021 and continue through the end of 2022. It is
hoped that Sustainment will continue beyond 2022, but the pilot needs to be implemented and
evaluated before future planning and strategies can be determined. The aim of the activities
during this stage are to expand and scale the program. A further discussion of sustainability is
discussed in Area 5 under the Project Implications for Practice and Further Action, found
below.
Financial Plans and Staging
See Appendix F for the line item budget of Project Prepare, Plan, and Provide. The
budget specifies the projected revenues and expenses during the program’s pilot year of
operation. The total program cost is $43,600. For the pilot program, the projected revenue will
come from three sources: philanthropic foundation grants, in-kind donations, and program fees.
It will be necessary to utilize varied revenue sources to diversify revenue streams for the pilot. A
majority of the revenue is expected to come from philanthropic foundation grants, making up 80
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 28
percent of the total revenue, $35,500. It is expected that 50 percent ($17,750) of the foundation
revenue will come from the Gordon and Betty Moore Foundation, while the other 50 percent
($17,750) will come from the David and Lura Lovell Foundation. Six thousand dollars of
revenue (13 percent) will be provided by program fees. Health care provider participants in the
program will pay a reduced rate of $250 for a total of 12 CEU/CME credits provided by the
program. The cost of 12 credits was decided upon by the completion of a comparative analysis
with similar health professional training series providers in mid-Michigan such as Michigan
State University and the Michigan Public Health Institute, where 12 CEUs are provided for
around $350. The reduced rate of the credits is to increase provider buy-in and engagement in the
training.
Seven percent of the total revenue ($3,000) will come from in-kind donations. This
revenue source will be in the form of training facility and facility related costs provided by the
innovator’s employer, SAU. The training space, along with the cost of its utilities and insurance,
are being provided in-kind by the university. The university is willing to provide additional in-
kind assistance with registering and processing the social work CEUs for the training series. The
university is authorized to provide CEUs for social workers, but not for nurses, physicians or
physician’s assistants. The cost of providing accredited CEUs to these providers will be covered
with other funds.
During the pilot year of operation there will be two staff members, the facilitator and a
master of social work (MSW) intern. The facilitator is a licensed social worker with ten years of
experience in social work, with extensive experience in end of life programming and program
evaluation. The MSW intern will be in their specialized/advanced standing year of a MSW
program, have an interest in healthcare and workforce development, and be able to commit to a
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 29
year of program involvement. The cost of the facilitator will be $18,750. A $1,000 stipend will
be provided to the MSW over the fiscal year, with one payment of $500 being provided during
the first half of the year (first semester), and the second half ($500) being provided at the end of
the year and second semester.
Other spending plans and costs are delineated in the program budget under the Operating
Expenses category in Appendix F. These items are necessary for program operation. Supplies
and printing costs will cost a total of $1,500. Marketing is necessary to promote the program and
will take the form of printed flyers and brochures, emails, and social media activity. The cost to
implement the marketing strategy will be $1,500. Technology costs include fees for the use of
data analysis software and Adobe licensing. Data analysis software will be used when
conducting the evaluations and Adobe will be used to create program materials. Three
assessment tools will be used to as pre- and posttests to collect output and outcome data
throughout the year. The cost for initially purchasing the assessment tools and to cover ongoing
fees that include consultation and scoring will be $1,500. Refreshments such as water, tea,
coffee, and snacks will be provided at each of the trainings. The estimated cost for this is $500,
to be used over the year. At the eight hour training, light meals will be provided to participants.
This cost will be $1,000. A larger expenditure for the program will be for the accreditation to
provide CEU/CMEs to providers at $10,500.
Project Impact Assessment Methods
As part of the program scope and implementation, an evaluation will be conducted. The
evaluation will begin two weeks prior to the beginning of the training series. It will be important
to conduct an evaluation, as it will determine if the program was effective and successful in what
it was intending to do by examining output and outcome measures. The pilot will be evaluated
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 30
for effectiveness and impact using three assessment tools found in Appendix G. The first
assessment tool is the Health Care Provider Questionnaire developed by the Centre for Health
Service Development at the University of Wollongong in Australia, which will be used to assess
provider knowledge, awareness, attitude, and skill level in addressing end of life care pre- and
post-trainings. The second is the QOC, developed by the University of Washington School of
Medicine End of Life Care Research Program, that will determine the quality of end of life
conversations with providers. The third is the CANHELP Patient Questionnaire, developed by
the Canadian Researchers at the End of Life Network (CARENET), which will be used to
determine if end of life plans were documented. Each of the instruments have been tested and
were found to be reliable and valid (Eagar et al., 2003; Engelberg, Downey, & Curtis, 2006;
Heyland et al., 2012).
Output Measures. The output measures to be collected during implementation are
number of health care providers trained, number of trainings held, number of patient visits where
end of life is discussed, and number of documented end of life plans. These measures will
determine if key activities have been delivered for the intervention, during implementation. If the
activities are not provided, the program will not be able to be delivered in accordance with the
program design. The first two measures, the number of providers trained and trainings held, will
be collected using sign in and out sheets that are required for CEU/CMEs to be conferred to
providers for participation in the training during months one, three, and six. These measures
will indicate if the desired sample of trained providers are participating and finishing the
training, and if the required number of trainings were held to meet program fidelity. The last two
measures, number of visits where end of life was discussed and documented end of life plans,
will be collected using the QOC and the CANHELP Patient Questionnaire. These measures will
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 31
determine if providers are discussing end of life with patients during their visits in accordance
with the training they received. The number of end of life plans documented will indicate
whether or not this training component has been integrated into provider practice. These
measures will determine whether or not the implementation process is going as planned and if
changes need to be made to meet program outcomes and fidelity. These are reflected in the
program logic model as outputs in Appendix C. The output data collection process can be found
in Section 2: Program Assessment Instruments, under the Data Collection Schedule, in the
capstone prototype in Appendix H.
Outcome Measures. Outcome measures will be also be collected during program
implementation. The outcome measures that will be collected are health care providers have
increased knowledge of end of life care and resources, health care providers have increased end
of life communication skills, and increased documentation of end of life care plans. These
measures will determine if the program was successful in what it was intending to do, train
health care providers to have end of life conversations with 35-64 year old patients with chronic
health conditions through providing training and subsequently changing provider behavior and
practice. Each of these outcomes will be measured by the instruments completed by providers
and patients, the Health Care Provider Questionnaire, QOC, and the CANHELP Patient
Questionnaire. These instruments will provide the program with the data necessary to determine
if these outcomes were met, and if not, what needs to be modified to help reach these outcomes
in future training iterations. Additional outcome measures will be considered after pilot
implementation and depend on what improvements need to be made in future training iterations.
The outcome measures are identified in the logic model (Appendix C) as Short-Term Outcomes.
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 32
The outcome data collection process can be found in Section 2: Program Assessment
Instruments, under the Data Collection Schedule, in the capstone prototype in Appendix H.
Stakeholder Engagement Plan
As stakeholders were involved in the development of Project Prepare, Plan, and Provide,
they will continue to be engaged in the pilot implementation, future program iterations, and in
scaling the project. First, an advisory board will be created to provide guidance and feedback on
Project Prepare, Plan, and Provide. The board will be made up of health care providers (from
hospice, palliative, and other care departments), health system administrators, university
department chairs, patients, health care navigators, and family members of patients. Next, with
the pilot implementation, three sets of training evaluations will be developed and collected from
the participating providers, patients, and health system engaged in the training series. A summary
of the data and feedback will be drafted and reviewed by the advisory board. Using the feedback
from each of these instruments and advisory board input, changes will be made to inform the
next iteration of the training. This stakeholder involvement process will continue and be
incorporated into future training iterations as a feedback loop. Stakeholder input is important to
include in the pilot and as the program grows it makes the program a product that is meaningful
for users and beneficiaries. Without this input there could be significant gaps in knowledge,
program feasibility, and delivery.
As the program is scaled locally and statewide, additional stakeholder input will be
sought via needs assessments in different communities to determine where and how Project
Prepare, Plan, and Provide can be implemented. The advisory board will be key in determining if
and what type of additional programming can be provided in conjunction with the training series.
Their input will be necessary to develop different formats of the training and to reach other
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 33
stakeholders beyond Jackson and the state of Michigan. Stakeholders will also play active role
in a future legislative advocacy campaign through campaign development and providing
testimony. The project will implement the legislative campaign after three to five years of
program sustainability.
Communication Strategies and Products
Different communication products and strategies will be used to spread awareness of, and
to inform stakeholders of the impact of Project Prepare, Plan, and Provide. The communication
products that will be developed include reports, executive summaries, proposals to present, live
and poster conference presentations, articles for publication in peer-reviewed journals, and social
media campaign components. These products will be developed over time and with multiple
iterations of the project.
After the implementation of the pilot project, multiple products will be developed to
communicate the results. The first product will be a report to the funding bodies to describe the
activities and outcomes of the project. This document will be important for the funding bodies to
see how their funds were utilized, how outcomes were met, and to potentially secure future
funding. The second product will be an executive summary and presentation of the program and
outcomes to contributing partners of the pilot project. The executive summary will also be used
to develop proposals to present the results of the pilot at conferences. The initial conferences
where proposals will be submitted for either a live or poster presentation will be the National
Association of Social Workers’ (NASW) Michigan Chapter 2022 Annual Conference, the
Society for Social Work and Research (SSWR) 2022 Conference, and the Council on Social
Work Education (CSWE) 2022 Annual Program Meeting. Lastly, pilot outcomes will be posted
to Project Prepare, Plan, and Provide’s website to inform stakeholders about pilot program
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 34
outcomes. These strategies and products will be replicated for the first three and four iterations
after the initial pilot. The social media campaign will continue to be revised with new iterations
of the program and to meet the demands of new technology.
After future iterations of the project (five to seven years), additional products and
strategies will be used. These endeavors will be pursued after the program has reached scale in
the state of Michigan. The aim of these products and strategies will be to increase visibility of the
Project Prepare, Plan, and Provide nationwide. They will also be used to gain support, develop
funding opportunities, and network with potential partners to expand the program. Proposals will
be submitted to present at conferences such as the Michigan Home Care & Hospice Association
(MHHA) Annual Conference, the International Conference on Social Work in Health and Mental
Health Annual Conference, the National Summit on Advanced Illness Care by the Coalition to
Transform Advanced Care (C-TAC), and the Center to Advance Palliative Care (CAPC)
National Seminar. Articles on program process and outcomes will be written and proposals will
be submitted to peer-reviewed journal publications for article submission. The journals where
proposals will be submitted to publish articles include Journal of Social Work, Research on
Social Work Practice, BMC Palliative Medicine, American Journal of Hospice and Palliative
Medicine, Journal of Palliative Care and Medicine, OMEGA- Journal of Death and Dying,
Journal of Nursing and Healthcare of Chronic Illness, and Health and Social Care in the
Community.
Ethical Considerations
To ensure the pilot project is being conducted ethically, IRB approval will be sought
before pilot implementation as it will be relying on human subjects to obtain data and to ensure
the rights of human subjects are being protected. Informed consents have been created and will
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 35
be given to the providers and patients pre-pilot program. The informed consents outline the
expectations of the participants, the purpose of the study, how confidentiality will be maintained,
that participation is voluntary, and the contact information of the facilitator. The IRB application
for the project has already been submitted to SAU and is pending approval. The project will
comply with the NASW Code of Ethics throughout implementation of the pilot.
Though the pilot will go through an IRB process, there are still potential negative
consequences that could result from participation in the project. The subject matter of the
training, death and dying, could potentially trigger negative thoughts that may lead to anxiety or
fear in participants. With the program facilitator being a clinical social worker, their experience
and knowledge can help with addressing these thoughts, and if needed, referrals to additional
services can be provided. Another issue could be maintaining patient participant confidentiality.
As patient participants will be referred to the program through the providers participating in the
training, this reduces the level of anonymity of these participants. It will be important for the
facilitator to put processes in place to maintain the confidentiality of the participant responses,
such as assigning identification (ID) numbers to patient participant responses and aggregating the
results when writing program reports for funders and any publications. These issues have been
identified in the IRB application and feedback from the IRB will be incorporated to reduce any
harm to program participants that may result from these potential ethical concerns.
Area 5. Conclusions, Actions and Implications
Current Practice Context for Project Conclusions
Due to the increase of the aging population and incidence of chronic health conditions,
the United States health care system will be facing new challenges over the coming decades. It is
anticipated that by 2030, the number of those over 65 years old will account for 20 percent of the
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 36
population. In 2050, this is expected to be 89 million people (CDC, 2016). As individuals age,
the number of chronic illnesses increase. As this trend continues, these increases are going to
place a heavier burden on health services and costs to Medicare. Much of these costs are
associated with chronic health conditions and the growing population of the elderly that need
more intensive health services, particularly at the end of life (CDC, 2013). Over-diagnosis of
ailments, excessive procedures, and redundant treatments have been reported to add to these
costs as well. Adding to this, a desire to prolong life using all available medical technologies by
patients, families, and physicians contribute to more patients dying in hospitals rather than in
home. Deaths in hospitals are more expensive and medically invasive, and remove patient
autonomy in choosing how and where they die (Aldridge et al., 2015; Chen, Kuo, Huang, & Fan,
2018; Chen & Miller, 2016; Copeland, 2018; Freedman & Lin, 2018; Gawande, 2015; Lee et al.,
2018).
Additionally, there is already a great need for nurses and physicians to provide care, and
according to the Association of American Medical Colleges, there is an expected shortage of at
least 40,800 physicians by 2030 (Dixon, 2017). The impending “Silver Tsunami” not only
presents a challenge related to the amplified number of patients that will be needing continuous
and comprehensive care, but it also presents issues in maintaining the health care workforce. As
Baby Boomers begin retiring from the health care system, this presents additional issues in
providing affordable care and service delivery. These seasoned professionals with institutional
knowledge and skills cannot pass on these skills and knowledge quickly enough to the new
professionals coming into the field. This is projected to impact health care delivery and could
result in a reduction in quality of care. However, this new environment has implications for how
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 37
to educate incoming health care professionals to work with the aging, chronically ill, and those
who will die from their chronic conditions (Heflin, 2016; Lee et al., 2018).
By implementing Project Prepare, Plan, and Provide now, this has the potential to
transform how the health care system approaches end of life care, and to help patients make
informed decisions about care at the end of life. By connecting patients to resources earlier in
care, this can help them decide which options best meet their needs at different stages of life, and
potentially reduce the number of unnecessary medical treatments. Increasing the knowledge and
skills of health care providers through a training series can help new and seasoned providers feel
confident and prepared to address end of life earlier on in care. Being able to critically and
thoughtfully plan for end of life will leave patients, families, providers, and the healthcare
system with better care outcomes and work to help close the health gap nationally.
Project Implications for Practice and Further Action
To further Project Prepare, Plan, and Provide, the project will use different components
of sustainability to move forward and increase scale. After the implementation of the pilot
training, the results of the evaluation will be used to demonstrate program effectiveness to
current and future funders. After the pilot implementation, two additional training series’ will be
conducted at the chosen health system, increasing the number of providers trained and patients
served at each iteration. To do this, the innovator will develop and implement a train the trainer
model to prepare additional program facilitators employed by the health system. The innovator
will provide ongoing consultation and supervision to the individuals who have been trained to
deliver Project Prepare, Plan, and Provide. Additional funding will be sought for these iterations
from current or new funding bodies. The cost to scale the program to the next level through these
two trainings will be $120,000 to cover the costs of additional participants and program
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 38
facilitators. Program evaluations will be conducted after each training iteration for program
improvement and revisions, and to demonstrate program efficacy to additional funders. Revenue
from CEU/CME fees paid by participating providers will be used to help fund the training
program and to solicit matching funds from foundations.
Three years after the pilot, additional partnerships will be sought with other mid-
Michigan hospitals to implement the training, and eventually the training will be marketed to
health systems across the state of Michigan to bring the project to scale on a statewide level. To
do this, the innovator will build a learning collaborative with other health systems in the mid-
Michigan area, and local universities to enhance the program through sharing ideas and seeking
feedback from outside providers, patients, and end of life experts. Creating a learning
collaborative can help pave the way to develop academic partnerships, promote network
weaving, and begin discussions on planning how to scale to other health systems in the state of
Michigan. Given the training content and focus, political champions will continually be sought
for support and advocacy inside and outside the health systems where the trainings will be
implemented. Matching funds from federal grant-making organizations will be sought at this
level of implementation to enhance financial stability.
When the program is scaled to other health systems and is proven to be effective and
successful (five to six years), the next step will be to deliver the training in in alternative formats
such as through webinars and online courses that could be available nationwide. As more
trainings and certifications are being delivered in alternative formats and using different
technologies, this will be important to help scale and diffuse Project Prepare, Plan, and Provide.
At this time, another sustainability effort will be to increase the number of insurance providers
who reimburse for end of life visits through legislative advocacy. A legislative campaign
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 39
spearheaded by the advisory council and other stakeholders will be developed and could begin as
early as 2027.
Project Limitations
Participant Sample. The potential limitations and risks of the program are varied. The
first limitation involves the participant sample. Given the study is quasi-experimental, random
assignment will not be done in the pilot project. Though this may affect the internal and external
validity of the study, particularly in regards to history, selection bias, and reactive effects, it is
important that the pilot uses an availability sampling in order to obtain willing participants in the
pilot. This pilot will be challenging to implement in the health care setting, as there is largely an
aversion to this topic for providers and patients outside of palliative and hospice care. It will be
important to go through one training iteration to identify implementation challenges before
moving onto an experimental research design to compare providers who went through the
training to control groups of providers who did not attend the training and the resulting impact on
patients.
Participants Receptivity. The second category of limitations could present themselves
through the program participants. Though more health systems are asking patients if they have
advance directives in place, for some of these patients it may be the first time their provider has
taken the time to have an in-depth discussion with them about end of life. This may create
unanticipated fear, confusion, and uncomfortableness for these patients who may be hesitant to
discuss the end of their lives with their health care providers. This may cause them to provide
negative feedback to their providers, not continue to see their providers, or withdraw from the
program. Another limitation could be the response from provider participants who may respond
negatively and not want to participant in the program. To address these issues, focus groups will
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 40
continue to be held with patients, families, and providers throughout the program development
and implementation to help inform the training and to respond to concerns from these
stakeholders.
Funding Resources. Lastly, the final category of limitations involves financial
implications of the program. Foundation giving will be a large source of revenue for the program
during the pilot. Their decisions to fund the program will drastically influence if the program is
able to operate. If the funders decide to allot a smaller amount of grant funding than requested or
do not award funding to the program, the planned revenue for the program will significantly
change. If this happens, other sources of revenue such as funding from the Blue Cross Blue
Shield of Michigan Foundation would need to be sought, or the cost of the CEU and CMEs
would need to be increased to support program operations during the pilot.

CAPSTONE PROJECT: PROJECT PREPARE, PLAN 41
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Appendix B
Concept Definitions
Advance directive- A written document that describes the type of care and treatment a patient
wants at the EOL if they are unable to communicate their preferences. It can take the form of a
living will, health care power of attorney, provider orders for life-sustaining treatment, or do not
resuscitate, or all of these.
Aggressive treatment- the treatment provided to address a serious illness or condition. All
forms of medication, treatment, and technology are provided to fight the illness and sustain life.
Chronic health conditions- “…conditions that last 1 year or more and require ongoing medical
attention or limit activities of daily living or both” (NCCDPHP, 2019, para. 1).
Continuing education- professional development opportunity provided to individuals who have
completed formal education to increase knowledge and skills in their area of practice.
End of life- The stage where a person is actively dying and there is no cure or treatment to
prevent death.
Health care workforce-“…refers to all of the people who deliver or assist in the delivery of
health services, or help operate health care facilities” (Center for Health Workforce Studies,
2019, para. 1).
Hospice care- Team based care approach that is provided when a patient has a terminal or
advanced illness that no longer responds to curative treatment. Interventions focuses on symptom
and pain management. They are not curative, but palliative. Hospice care can be provided in-
home, at a hospice facility, in nursing facilities and in the hospital. Provides services to patients
and their families/caregivers. Care can include emotional, spiritual, and medical services.
Hospice may or may not be covered by insurance.
Intensive care unit- hospital unit where patients with life-threatening illness are admitted for
constant observation and care provision.
Interprofessional education- opportunities where participants from different disciplines (health
and social sciences) learn together to provide collaborative care.
Medical professionals/health care providers- for the context of this paper this definition
includes physicians, nurses, social workers, and physician’s assistants.
Palliative care-A team based care approach provided to patients who have serious or advanced
illness. Care is focused on improving quality of life by symptom alleviation and addressing other
areas of life that are impacted by the illness. Services provided to patients and families include
emotional, spiritual, and medical support. Patients can receive palliative care in conjunction with
care from their primary care doctors. Care can be provided in-home, in hospitals, in nursing
homes, or in palliative care clinics. Insurance may or may not cover palliative care services.
Patient centered care- A treatment approach that allows patients to take an active role in their
health care by partnering with their health care providers to make decisions to meet their health
care needs.
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 55
Social determinants of health- According to the Artiga and Hinton, “Social determinants of
health include factors like socioeconomic status, education, neighborhood and physical
environment, employment, and social support networks, as well as access to health care.
Addressing social determinants of health is important for improving health and reducing
longstanding disparities in health and health care” (2019, para. 1).
Ventilator- a machine that helps patients breathe when they are unable to do so on their own.

CAPSTONE PROJECT: PROJECT PREPARE, PLAN 56
Appendix C
Logic Model
Project Prepare, Plan, and Provide Pilot Logic Model
Inputs Activities Outputs Short-term
Outcomes
Intermediate
Outcomes
Long-term Outcomes
 24 health care providers
(6 physicians, 6 nurses,
6 physician assistants, 6
social workers) for the
pilot
 50 patients, 35-64 years
old with chronic health
conditions, for pilot
 1 trained facilitator
 1 master of social work
(MSW) intern
 Training/classroom
space- Spring Arbor
University
 Training curriculum for
all providers focusing
on end of life
communication skills,
end of life resources
and referrals, and
supporting patients and
families
 Funding
 Training materials
 3 assessment tools
 Provide end
of life
training
series
focused on
middle age
adults, 35-64
years old, to
health care
providers

 Patients
attend visits
with trained
providers

 Complete
data
collection
with
providers and
patients

 Conduct
process and
outcome
evaluations
 Number of
trainings
held

 Number of
health care
providers
trained

 Number of
patient
visits where
end of life
is discussed

 Number of
documented
end of life
plans

 Health care
providers have
increased
knowledge of
end of life care
and resources

 Health care
providers have
increased end
of life
communication
skills

 Health care
providers
increase
documentation
of end of life
care plans

 Health care
providers
have end of
life
conversations
with patients
during health
care visits
 Patients have
documented
end of life
care plans
 Health care
providers
provide
referrals to
palliative
care, hospice
care, and
other end of
life resources
 Conversations
about end of
life increase
across
disciplines
and
departments
in a health
care system

 End of life
care is
discussed and
documented
across
condition and
lifespan by
patients and
providers
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 57
Appendix D
EPIS Framework

Exploration
Preparation Implementation Sustainment
Outer Context
Barriers
Sociopolitical
Funding
Societal perceptions of death
Innovative program fit

Facilitators
Interorganizational networks
Health and sociodemographic
changes
Client advocacy
Outer Context
Barriers
Funding

Facilitators
Sociopolitical
Interorganizational networks
Outer Context
Barriers
Sociopolitical
Funding

Facilitators
Interorganizational networks
Health professional continuing
education approval
Innovation developer
Leadership

Outer Context
Barriers
Sociopolitical
Funding

Facilitators
Public-academic collaboration
Leadership

Inner Context
Barriers
Individual adopter
characteristics
Leadership

Facilitators
Organizational characteristics
Fit with client characteristics

Inner Context
Barriers
Staffing and staff
characteristics
Facilitator fit
Training availability and
scheduling

Facilitators
Organizational characteristics
Leadership

Inner Context
Barriers
Innovation-values fit
Individual adopter characteristics
Patient receptivity
Service delivery
Provider workload

Facilitators
Organizational characteristics
Provider incentivizing
Training facility
Client advocacy
Inner Context
Barriers
Staffing
Fidelity monitoring/support

Facilitators
Organizational characteristics
Ongoing training
Ongoing supervision
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 58

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Assess for readiness and identify barriers and facilitators
Secure training location through SAU
Develop training curriculum and program manual
Conduct needs assessment
Submit IRB application to SAU IRB
Determine and leverage facilitators
Involve and garner support from patients, family members, and
providers through interviews and focus groups
Secure program start date
Access new funding and fund innovation with private foundations
(Gordon & Betty Moore Foundation, David and Lura Lovell
Foundation)
Identify early adopters at health system
Involve executive boards within health system
Conduct educational meetings with providers from varied disciplines
Identify and prepare champions to promote training series
Prepare participants for training
Obtain approval to provide professional continuing education credits
Recruit guest speakers for training
Recruit participants
Implement mass media campaign to increase awareness of training and
to encourage provider and patient buy-in
Program evaluation begins with pretest data collection from providers
using Health Care Provider Questionnaire
Conduct pilot training
Intervene with providers and patients to enhance uptake and
adherence
Posttest data collection from providers using Health Care Provider
Questionnaire
Patient visits and posttest data collection from patients using Quality
of Communication and Advanced Care Questionnaire
Patient visits and posttest data collection from patients using Quality
of Communication and Advanced Care Questionnaire
Obtain and use patient, family, and provider feedback for program
improvement
Evaluate implementation process, output and outcome measures using
evaluation methods
Use train the trainer strategies to provide additional trainings
Conduct additional iterations of Project Prepare, Plan, and Provide at
health system
Seek funding to support additional training iterations
Develop, organize and implement quality monitoring systems
Create a learning collaborative
Present at conferences and submit journal proposals
Seek champions to continue to support program
Discuss planning to scale up to other Michigan health systems
2022
Sustainment
Preparation
Appendix E
Project Prepare, Plan, and Provide Gantt Chart
Implementation Activities
2019 2020 2021
E PIS Stages
Exploration
Implementation
CAPSTONE PROJECT: PROJECT PREPARE, PLAN 59
Appendix F
Line Item Budget

In-kind donations 3,000.00 $ Provided by Spring Arbor University (SAU)
Program fees 6,000.00 $ $250 for 13 CEUs per 24 providers
Foundation grants 35,500.00 $
Gordon & Betty Moore Foundation @50%, David & Lura Lovell
Foundation @ 50%
TOTAL REVENUE 44,500.00 $
CEO 18,750.00 $ 25% effort of salary
MSW Intern 1,000.00 $ 1, $500 stipend provided per semester (x2)
Subtotal Personnel 19,750.00 $
CEO 3,750.00 $ 20 % of salary
Subtotal Benefits 3,750.00 $
TOTAL PERSONNEL 23,500.00 $
Supplies/printing 1,500.00 $ $125/month
Marketing 1,500.00 $ $125/month
Technology fees 600.00 $ Data analysis software and Adobe licensing
Assessment tools 1,500.00 $ Initial purchase and ongoing fees to use and score
Refreshments 500.00 $ Provided at all 3 trainings
Meals 1,000.00 $ Provided at 4 hour and 8 hour trainings
Registration with accrediting bodies to provide CEUs 10,500.00 $ One time registration and ongoing fees to provide CEUs
Training space rent 1,000.00 $ $83.33/month, provided in-kind SAU
Training space utilities 500.00 $ $42/month, provided in-kind SAU
Training space insurance 1,500.00 $ $125/month, provided-in-kind SAU
Subtotal Operating Expenses 20,100.00 $
TOTAL EXPENSES 43,600.00 $
SURPLUS/DEFICIT 900.00 $ Contingency/Reserve
01/01/2020-12/31/2020
FY 2020 Line Item Operating Budget, Project Prepare, Plan & Provide
Operating Expenses
EXPENSES
Personnel Expenses
REVENUE
Benefits

PROGRAM MANUAL
PROJECT PREPARE, PLAN, AND PROVIDE

Project Prepare, Plan, and
Provide

Email:
projectprepareplanprovide@gmail.
com

Company website:
www.projectprepareplanprovide.we
ebly.com

Ph: 517-745-3512

PROJECT PREPARE, PLAN, AND PROVIDE PROGRAM MANUAL

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Table of Contents
Introduction………………………………………………………………………………………………..
4
What is Project Prepare, Plan, and Provide…………………………………………………….
4
Purpose of intervention……………………………………………………………………….......
5
Purpose of manual………………………………………………………………………………...
5
Intended audience…………………………………………………………………………………
5
How is the manual organized?………………………………………………………..................
5
Section 1: Project Prepare, Plan, and Provide Intervention………………………………………
7
Program model- Social Learning Theory……………………………………………………….
7
Staffing……………………………………..............................................................................
7
Program administration…………………………………………………………………………..
7
Funding…………………………………………………………………………………….
7
Health organization or system partnership…………………………………………….
7
Provider time………………………………………………………………………………
8
Location……………………………………………………………………………………
8
CEU and CME approval………………………………………………………………….
9
Institutional review board approval……………………………………………………..
10
Guest speakers…………………………………………………………………………...
10
Refreshments and food…………………………………………………………………..
10
Recruitment………………………………………………………………………………………...
11
Project Prepare, Plan, and Provide process map……………………………………………..
12
Prototype testing………………………………………………………………………………….
12
Section 2: Program Assessment Instruments………………………………………………………
13
Assessment instruments………………………………………………………………………….
13
Proposed outputs and outcomes for intervention……………………………………………...
13
Data collection schedule………………………………………………………………………….
13
How to use instruments to measure process and outcomes…………………………………
14
Section 3: Pre-Intervention Evaluation Components………………………………………………
15
Section 4: Training Session 1- One Hour Training…………………………………………………
16
Learning Objectives……………………………………………………………………………….
16
Session 1 Training Syllabus……………………………………………………………………...
16
Section 5: Training Session 2- Four Hour Half Day Training……………………………………..
22
Learning Objectives……………………………………………………………………………….
22
Session 2 Training Syllabus……………………………………………………………………..
22
Section 6: Training Session 3- Eight Hour Full Day Training……………………………………
31
Learning Objectives……………………………………………………………………………...
31
Session 3 Training Session………………………………………………………………………
31
Section 7: Post-Intervention Evaluation Component………………………………………………
38
Appendix…………………………………………………………………………………………………...
39
Appendix A: Resources

Appendix B: Bibliography

Appendix C: Informed Consents

Appendix D: Project Prepare, Plan, and Provide Process Map

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Appendix E: CEU Provider Applications

Applications

Sign in/out sheet

Appendix F: Letter of Support for Training

Appendix G: Assessment Instruments

Health Care Provider Questionnaire

Quality of Communication Questionnaire (QOC)

Canadian Health Care Evaluation Project (CANHELP) Patient Questionnaire

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Introduction
Chronic health conditions are increasing due to the rapidly growing Baby Boomer
population and advances in medical technologies. Chronic conditions are defined by the
National Center for Chronic Disease Prevention and Health Promotion as “…conditions
that last 1 year or more and require ongoing medical attention or limit activities of daily
living or both” (National Center for Chronic Disease Prevention and Health Promotion
[NCCDPHP], 2019, para. 1).
Although more of these conditions appear in the aging population, the United States is
witnessing an increase in the number of individuals 35-64 years old who have multiple
chronic health diseases. Forty percent of adults in the country have 2 or more of these
diseases (NCCDPHP, 2019). Chronic conditions include disorders such as heart
disease, diabetes, cancer, and asthma.
Most of these individuals will succumb to their illnesses, as chronic conditions are a
leading cause of death in the United States (Cacioppo & Hawkley, 2003; Whittemore &
Dixon, 2007). Many of these adults will die after undergoing intensive, expensive,
unnecessary, and at times, unwanted care to prolong their lives as they are dying or
near death. These situations have created a need for quality end of life (EOL)
conversations to prevent medical interventions and treatment that may not be wanted
by patients at the end of their lives (Chung, Oczkowski, Hanvey, Mbuagbaw, & You,
2016). However, there is a reluctance by health care providers to address end of life
earlier on in patient care, and as a result, families end up making unwanted care
decisions or patients feel pressured to undergo more treatment. To equip patients,
families, and providers with the knowledge necessary to address EOL earlier on in care,
new interventions focused on increasing end of life conversations must be developed
and integrated into patient care. Project Prepare, Plan and Provide is a program that
aims to do just that.
What is Project Prepare, Plan, and Provide?
Project Prepare, Plan, and Provide is an innovative program for health care providers
that aims to increase the number of EOL conversations with patients 35-64 years old
with multiple chronic conditions. Continuing education units (CEU) and continuing
medical education (CME) are issued to providers who participate in the training. The 12
month program has 3 phases: the training series, patient visits, and the program
evaluation.

The first phase is where health care providers from varying disciplines (medicine,
nursing, social work) go through the live, in-person training series that includes 3
sessions over a 6-month period. These trainings include a 1 hour training, a 4 hour half
day training, and an 8 hour full day training. The training utilizes the reflective learning
model and the curriculum includes content on EOL communication skills, end of life
resources and referrals, patient engagement, engaging 35-64 year olds in EOL care,
and supporting patients and their families.
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The structure of providing the trainings over a 6 month period of time allows providers to
take what they have learned from each of the training sessions and apply it in their
respective practices in between sessions. With this staging, providers are able to
incrementally incorporate the skills they are learning from Project Prepare, Plan, and
Provide and reflect on their experiences before attending the next training session. In
the training sessions, providers are asked to do “homework” between sessions and are
expected to share and reflect on their experiences with the training content in practice
through small and large group discussions. This structure was also designed so
providers do not have to give up large blocks of their time to accommodate the training
such as would be required if the training was provided in a 2 or 3 consecutive day
training format.

The second phase occurs 3 and 6 months post-training series. Here, patients, of the
trained health care providers will complete 2 visits with their providers. During these
visits, the trained health care providers will discuss EOL plans with their patients. After
these visits, patients will be provided with assessments to determine if there have been
changes in provider behavior as a result of participating in the training series.

The third phase will be the program evaluation. Data collected from the provider and
patient assessments will be analyzed and compared during this phase. The evaluation
will assess the program outcomes and determine if the knowledge and skills gained
during the training series has been incorporated into practice, based on the data
collected.
Purpose of the intervention
The purpose of the Project Prepare, Plan, and Provide intervention is to increase
awareness, and to educate and build the skill level of health care providers in being able
to address EOL care with chronically ill patients ages 35- 64 years old. Project Prepare,
Plan, and Provide is intended to change the behavior of health care providers in
discussing EOL conversations in their practice.
Purpose of the manual
This program manual was created as a guide for health organizations or systems who
want to administer Project Prepare, Plan and Provide and train their health care
providers to address EOL care and planning earlier on in care. This manual provides
the information for how to put the program into practice.
Intended audience
The intended audience of this program manual are health care providers who deliver
care to individuals with multiple chronic health conditions and are able to bill health
insurance companies for EOL visits. Within this group, the target audience of Project
Prepare, Plan, and Provide are physicians, nurses, social workers, and physician’s
assistants.
How is the manual organized?
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The manual is organized into 7 sections. Section 1 provides background information on
the context and purpose of Project Prepare, Plan, and Provide, and how to use the
program manual. Section 2 describes how and when the assessment tools will be used
to collect program data. Section 3 details the evaluation procedures that need to be
completed prior to the intervention. Section 4 is a detailed outline and agenda for the 1
hour training session. Section 5 is a detailed outline and agenda for the 4 hour training
session. Section 6 is the outline and agenda for the 8 hour training session. Section 7
describes the evaluation procedures that need to be accomplished post-intervention.
Lastly, the Appendix contains examples of materials needed to administer the program
such as CEU applications, assessment tools, letters of support, resources for the state
of Michigan and nationally, and other items.

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Section 1: Project Prepare, Plan, and Provide Intervention
Program model- Social Learning Theory
The program model underlying Project Prepare, Plan, and Provide is Social Learning
Theory. This model has been chosen as it describes how learning and behavior change
occur through observation, imitation, and modeling of a new behavior. By using this
program model, it will examine how if health care providers change their knowledge and
skills through participating in the training series, they will then change their behaviors in
how they address EOL with their patients in practice.
Staffing
Two staff members are needed to implement Project Prepare, Plan, and Provide. One
staff member must be a licensed master’s level social worker with extensive experience
in clinical practice, end of life programming, and program evaluation. This will be the
program facilitator. Given the subject matter of the training, it should be facilitated by a
licensed clinical social worker to address triggered feelings and thoughts associated
with death and dying that may arise from participants engaged in the training. The other
staff member must be a MSW intern. The intern must be in their advanced
standing/specialized year of a MSW program, have an interest in healthcare and
workforce development, and be able to commit to a year of program involvement. Both
of the staff members will be involved in delivery of the intervention from participant
recruitment in Month 1 through final data collection and analysis in Month 12. The pilot
program implemented in Jackson, Michigan will use this staffing model.
Program administration
To be able to administer Project Prepare, Plan and Provide, there are key components
that need to be completed to deliver the intervention in accordance with the program
model. The following areas need to be planned for and solidified to administer Project
Prepare, Plan, and Provide.
Funding
The total cost to implement Project Prepare, Plan, and Provide is $43,600. This funding
must be sought before proceeding with implementation to cover program expenses.
Funding will cover the cost of staff, CEU and CME provider accreditation fees, and other
operating expenses such as marketing, printing, food and refreshments, and technology
fees. Funding can be sought from foundations or grant funding. The pilot program in
Michigan will be seeking funds from the Gordon and Betty Moore Foundation, David
and Lura Lovell Foundation, in-kind contributions from the partnering university, Spring
Arbor University, and program fees.
Health Organization or System Partnership
To be able to administer the program and obtain program participants, a partnership
must be entered into between the program facilitator and a health system or
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organization. This can be done in a few ways. First, a needs assessment can be
conducted to determine which geographic location has a significant number of patients
who are chronically ill and ages 35-64. Using the needs assessment data, a proposal
can be made to the health system or organization in the geographic location to
implement Project Prepare, Plan, and Provide. For the pilot program of Project Prepare,
Plan, and Provide in Michigan, the facilitator completed a needs assessment. Second, a
formal meeting can be had with administrators or board of a local health system or
organization to determine if there is interest in providing the Project Prepare, Plan, and
Provide training. Third, a partnership could be entered into with a local university and
health care professional alumni could be invited to attend. Lastly, presenting on Project
Prepare, Plan, and Provide at state and national health care professional conferences
can help garner support for the program and make connections with potential partners
who would want to administer the program. These attempts will need to be made a year
in advance before the program is held as these relationships and partnerships may take
some time to build.
Provider Time
Asking providers to attend and complete four and eight hour training sessions in light of
their intensive work schedule and load, is a big request. However, health systems are
increasingly providing continuing education programming for providers in and outside of
their organizations. More health systems are providing opportunities for their providers
to engage in continuing education opportunities to meet their professional development
and licensing requirement needs. For health systems across the state of Michigan there
is an expectation that their providers regularly participate in and present on a wide
range of topics and research to their colleagues. They provide a full range of continuing
education opportunities for their providers to attend, including physicians, physician’s
assistants, nurses, social workers, and other allied health professionals. Project
Prepare, Plan, and Provide would be included as one of these offerings available
through the chosen partnering health system. This amount of time also allows providers
to get a number of their CEU and CME licensing requirements met through two trainings
sessions, as opposed to having to attend shorter, additional trainings to gather an
equivalent amount of credits.
Location
A training location needs to be secured to be able to provide the training. In the training
location, there needs to be classroom or conference room space available to
accommodate more than 20 participants and space for role plays and small group work.
The partnering organization may be willing to provide training space. It will be important
to get a letter of support, memorandum of understanding, or contract to secure space.
For the pilot program, classroom space at Spring Arbor University was provided to
deliver the training series in-kind. Two letters of support from nursing and social work
department chairs can be found in the Appendix F as examples.

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CEU and CME Approval
A crucial component of the training is the provision of CEU and CME credits for
participating health care providers. Approval to provide these credits must be gained in
the state where the training series is being delivered. To be able to provide CEU and
CMEs, facilitators or health care organizations/systems need to first seek approval from
CEU and CME accrediting bodies. For example, in the state of Michigan, approval must
be sought from the following accrediting bodies:
 Social Workers
o Michigan Social Work CE Collaborative- Continuing Education Provider
Application and Fees
 https://www.socialworkcec.com/provider-application-fees
 Nurses
o American Nurses Credentialing Center Commission on
Accreditation- Nursing Continuing Professional Development
 https://www.nursingworld.org/organizational-
programs/accreditation/primary-accreditation/
 National center
 Physicians & Physician’s Assistants
o Accreditation Council for Continuing Medical Education (ACCME)
o https://www.accme.org/become-accredited
o National council
Depending on which state the training is being implemented, the facilitator will need to
submit their CEU and CME provider applications well in advance of the training dates.
For example, in the state of Michigan, social work CEU applications are due 45 days
before the training date. If the facilitator is first time provider of CEU or CMEs,
accrediting bodies require self-studies or self-assessment tools to move forward with
the provider application. Another way to provide CEU or CMEs would be to utilize the
partnership where the training will be provided (health system or organization), if they
are a current accredited provider. If they are not an accredited provider, the facilitator
will need to become the accredited provider to be able to provide the credits.
Certificates of participation are needed to verify a health care provider has attended the
training. To send certificates of participation that document the number of CEU or CME
credits the provider earned, a sign in and out sheet is required for each training session.
This sheet verifies the provider attended the full training session and can receive the
designated number of CEU or CME credits. A template sign in and out sheet can be
found in the Appendix E.
Participating providers will be paying for the 12 CEU/CME credits they will receive from
the training series and can submit payment via Spring Arbor University’s training
registration payment portal at www.arbor.edu.
Example applications for social work CEU credits and nursing CEU credits for the state
of Michigan are provided in Appendix E. For Project Prepare, Plan, and Provide’s pilot,
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applications will be submitted in December 2019 to the Michigan Social Work CE
Collaborative and American Nurses Credentialing Center Commission on Accreditation
to obtain approval for social work and nursing CEUs. For the physician and physician’s
assistant CMEs, the facilitator will be partnering with the health system to provide these
credits, as they are an ACCME approved provider.
Institutional Review Board (IRB) Approval
After the preceding steps have been taken, and before participant recruitment, the
program needs to go through IRB approval as it will be collecting data from human
subjects. For the pilot project, the IRB application has been submitted to Spring Arbor
University’s IRB and is pending approval. Potential facilitators of the program need to
determine if the partnering health organization or system has an IRB where they can
submit program materials and application or if they need to have a university partner in
order to get the appropriate IRB approval.
An example of the program’s informed consent form can be found in Appendix C.
Guest Speakers
An important component of the training series is to have guest speakers present during
Session 2 and Session 3 of the training series. The program facilitator needs to reach
out to the health system or organization’s hospice and palliative care departments 3
months prior to the beginning of the training series. The facilitator needs to coordinate to
have a representative from hospice care and a representative from palliative care come
speak at Session 2. They need to speak for 30 minutes each and need to share
resources and the referral process to their respective services. They can also bring
additional information they see as valuable for participants to know about.
For Session 3, the facilitator needs to find a person with a terminal illness and/or is
dying or near death and is willing to speak about their experiences with EOL services
and care for 75 minutes. Additionally, the facilitator needs to ask them if they have
family members who are willing to come and speak along with them. These guest
speakers can come to the training location or they can use a software platform like
Skype or Zoom to present. Potential speakers can be sought from hospice, speakers’
bureaus, or through referrals from palliative and hospice care departments. These guest
speakers should be arranged 6 months prior to Session 3, if possible.
Refreshments and Food
For Session 2, the facilitator needs to provide refreshments such as coffee, water, and
light snacks. For Session 3, in addition to the refreshments, lunch needs to be provided.
The facilitator needs to arrange for a lunch to be delivered at the training location.
Funding for the refreshments and food will come out of the funding supporting the
program and has been allotted for in the program budget.

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Recruitment
Two groups of participants need to be recruited for the pilot, 24 health care providers
and 50 patients of these health care providers.
Providers
The following providers need to be recruited for the training series:
 Physicians (medical doctor (M.D.) or doctor of osteopathic medicine (D.O.))
 Nurses (registered nurse (R.N.), or nurse practitioner (N.P.))
 Physician’s assistants
 Social workers (master’s level prepared (MSW))
The other requirements for recruitment of providers include:
 Not currently practicing in hospice or palliative care
 Are paneled and credentialed with health insurance companies
Patients
Patients meeting the following characteristics need to be recruited to assess program
outcomes.
 Be an established patient of one of the health care providers participating in the
training series
 Be between the ages of 35-64 years old
 Have 2 or more of the following chronic conditions for 12 months or more
o Chronic conditions include:
 Diabetes
 Cancer
 Chronic obstructive pulmonary disease
 Arthritis
 Alzheimer disease or dementia
 Heart disease
 Chronic kidney disease
 Chronic lung disease
 Stroke
 Human immunodeficiency virus (HIV)/acquired immunodeficiency
syndrome (AIDS)
 Multiple sclerosis (MS)
 Parkinson’s disease
 Asthma
 Epilepsy
 Huntington’s disease
All participants need to have access to a computer and internet service and a valid
email address for which they can be sent assessments previous to and after the
training. Participants can also be provided with paper copies of the instruments if
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requested. All participants must read and sign the informed consent forms to participate
in the program.
To recruit health care provider and patient participants, the facilitator must work with the
partnering health system or organization. The partnering organization can provide a list
of potential providers to recruit that meet the eligibility criteria outlined above. Provider
participants need to be recruited using a marketing campaign and email list-service
circulated within the health care system or organization. An email message and flyers
need to be created to promote the program and to gain participants. These documents
will describe the purpose of the intervention, cost of CEU and CMEs, duration of
program participation, and what is expected of participants. The email and flyers will be
sent to all eligible providers. Flyers will also be distributed and put up in the partnering
organization. Once providers have been recruited, they will recruit patient participants
meeting the eligibility criteria above. Providers should recruit at least 4 patients who
could participate in the study. Providers will be given printed material to recruit potential
patient participants. The printed material will include the following information; purpose
of the intervention, duration of the program participation, and what is expected of
participants.
Project Prepare, Plan, and Provide process map
See Appendix D for the program process map.
Prototype testing
This prototype, the Project Prepare, Plan, and Provide Program Manual, has been
tested twice in table top exercises with 2 small stakeholder groups, chronically ill
patients (February 2019) and social work providers (May 2019). Feedback garnered
from these experiences have informed the training curriculum to include information on
supporting patient families, using a guest speaker who has utilized EOL services, and
billing for EOL visits. The participant recruitment process was also modified as a result
of the table top exercises.

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Section 2: Program Assessment Instruments
Assessment instruments
Three assessment instruments will be used to monitor implementation and determine
whether or not the program has been successful. The assessment tools can be found in
Appendix G. Data will be collected using these instruments over the 12 month program
period. The following instruments found in Appendix G need to be used for the
evaluation component of the program:
 Health Care Provider Questionnaire
 Quality of Communication Questionnaire (QOC)
 Canadian Health Care Evaluation Project (CANHELP) Patient Questionnaire
Proposed outputs and outcomes for intervention
Project Prepare, Plan, and Provide’s program consists of a program evaluation. The
evaluation aims to reach the following outputs and outcome measures:
Outputs
1. Number of health care providers trained
2. Number of trainings held
3. Number of patient visits where end of life is discussed
4. Number of documented end of life plans
Outcomes
1. Health care providers have increased knowledge of end of life care and
resources
2. Health care providers have increased end of life communication skills
3. Increased documentation of end of life care plans
A detailed description of how the assessment instruments will be used during the
program to measure outputs and outcomes can be found below.
Data collection schedule
The following is the schedule for when data needs to be collected over the course of the
program.
 Month 1
o Email link sent to providers to complete the Health Care Provider
Questionnaire as pretest
o Sign in and out sheets collected from Training Session 1
 Month 2
 Month 3
o Sign in and out sheets collected from Training Session 2
 Month 4
 Month 5
 Month 6
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o Sign in and out sheets collected from Training Session 3
o Email link sent to providers to complete the Health Care Provider
Questionnaire
 Month 7
 Month 8
 Month 9
o Email links sent to patients to complete the QOC and CANHELP
 Month 10
 Month 11
 Month 12
o Email links sent to patients to complete the QOC and CANHELP
How to use instruments to measure outputs and outcomes
To measure success for the project, outputs and outcome will be collected and
measured. Data on 4 program outputs will be collected by program staff. These
measures will determine if key activities have been delivered for the intervention. The
first 2 outputs, the number of providers trained and trainings held, will be collected using
sign in and out sheets that are required for CEU/CMEs to be conferred to providers for
participation in the training. These measures will indicate if the desired sample of
trained providers are participating and finishing the training, and if the required number
of trainings were held to meet program fidelity. The last 2 outputs, number of visits
where end of life was discussed and documented end of life plans, will be collected
using the QOC and CANHELP. These outputs will determine if providers are discussing
end of life with patients during their visits in accordance with the training they received.

Data on 3 outcome measures will be collected. These measures will determine if the
program was successful in what it was intending to do, train health care providers to
have end of life conversations with midlife patients with chronic health conditions
through providing training and subsequently changing provider behavior and practice.
Each of these outcomes will be measured by the instruments completed by providers
and patients, the Health Care Provider Questionnaire, QOC, and CANHELP. These
instruments will provide the program with the data necessary to determine if these
outcomes were met.

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Section 3: Pre-Intervention Evaluation Components
The program evaluation component of Project Prepare, Plan, and Provide will begin 2
weeks prior to the beginning of the training series. At this time, health care providers will
be asked to complete the Health Care Provider Questionnaire (Appendix G) as a
pretest. Provider participants need to complete the assessment within 1 week of
receiving an email link via SurveyMonkey that contains a hyperlink to an electronic
version of the identified assessment tool.
Sign in and out sheets need to be created previous to the beginning of training as it will
keep track of outputs and to be in compliance with CEU and CME provider
requirements.

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Section 4: Session 1- One Hour Training
The training curriculum draws on research and recommendations for increasing end of
life communication from organizations and researchers that can be found in the
Bibliography in Appendix B.
The first training to be provided as part of the Project Prepare, Plan, and Provide
training series is Session 1. This is a 1 hour training session.
*Two weeks previous to this training session, providers need to be sent the Health Care
Provider Questionnaire, found in Appendix G of this program manual. This assessment
needs to be sent to participants emails via SurveyMonkey, unless a printed copy of the
assessment tool is requested.
Learning Objectives
The learning objectives for the first training session are:
1. Participants will explain the importance of discussing end of life planning earlier
on in patient care.
2. Participants will identify and describe EOL options with patients in practice.
Training Syllabus
The following is a syllabus/outline of the 1 hour training.
Throughout the training series, facilitators should work on creating a safe, welcoming
space for participants to share their experiences and to be able to ask questions about
this challenging topic.
Overview of session/purpose of training session (5 minutes)
Provide an introduction of Project Prepare, Plan, and Provide by describing the
following components to participants:
 Purpose of the Project Prepare, Plan, and Provide
 Structure of Project Prepare, Plan, and Provide
o Three trainings over a 6-month period of time
o Patient visits at 3 and 6 months post-intervention
o Data collection process
 Expected learning objectives for the training
 Brief overview of the training series content
o Describe the topics, activities, and expectations of the program
o Mention that the training content and structure was set up with the variety
of activities. Research has found that health care providers want certain
learning strategies to help facilitate learning about end of life. This
includes interactions with patients who are dying or at the end of their
lives, simulations, and practical experiences. They also described a need
to learn more about end of life resources like hospice and palliative care,
end of life communication skills, and how to support family members of
patients
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Remind providers that they need to sign in and sign out on the sign in/out sheet in order
to receive their CEU or CME credits.
 It is crucial that the sign in/out sheet is the completed by each provider and
collected to be able to provide CEU/CME credits and to measure the program
outputs. A template sign in/out sheet can be found in Appendix E.
Introductions (10 minutes)
Have participants introduce themselves to the group by sharing the following
information:
 Name
 Position and department
 Role
 Rate themselves on a scale of 1-5 on how comfortable they feel discussing end
of life plans with patients. One being very uncomfortable and 5 being very
comfortable.
Why is end of life important to discuss? (10 minutes)
Start out this section by describing the three trends that are increasing the need for
consistent and quality EOL conversations
1. Increasing number of Baby Boomers
o By 2030, those over 65 will be the largest age group in the U.S.; 89 million
by 2050 (Centers for Disease Control and Prevention [CDC], 2013)
o This demographic shift will increase the need for medical interventions
and service delivery
o Ninety-five percent of health care costs are attributed to care for chronic
conditions in older adults (CDC, 2013)
2. Advancing medical technologies
o Individuals are living longer due to available medications and equipment
o Additional treatments do not always equate to better quality of life and the
question becomes quantity versus quality of life
3. Increasing chronic illnesses
o Advancing technologies and longer life expectancies contributing to
increase chronic disease in the older population (CDC, 2013)
o The number of chronic conditions in younger population is growing too, 40
percent of adults (under 65) have 2 or more chronic conditions (CDC,
2016)
Describe the following to participants:

These trends combined have created a need for quality end of life conversations to
prevent intensive medical interventions that may not be wanted by patients at the end of
life their lives. Not all patients want extreme treatment measures when they are dying or
near death. However, health care professionals are not having these conversations with
patients nearly enough. If they do, some of the decisions that are made are not
documented in the patient record. As a result, families end up making unwanted care
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decisions or patients feel pressured to undergo more treatment. This unwanted care at
the end of life has been linked to a reduction in life quality and creates psychological
and emotional impacts on the patient and their family members. These decisions, or
lack thereof, are why conversations need to be had, and to shift how death, dying, and
end of life are perceived by health care system to improve patient care and service
delivery. To do this, health care providers need to take an active role in discussing end
of life care with patients and families earlier on in treatment (Alonso, Hupcey, & Kitko,
2017; Chung et al., 2016 McRee & Reed, 2016; Proulx & Jacelon, 2004; Sonenberg &
Sepulveda-Pasci, 2018).

Many of the current efforts working to increase end of life conversations are focused on
the elderly population and those with advanced illness. While this is necessary given the
increasing number of Baby Boomers, there should be equal focus on end of life care
earlier in the life stage, beginning in middle age, to increase awareness and educate
patients on options at end of life. Patients who are able to make decisions earlier on in
care often choose less invasive and less expensive interventions at the end of life. This
also helps the bereavement and emotional outcomes of families who have lost a loved
one (Proulx & Jacelon, 2004).

Acknowledge why these conversations aren’t happening more frequently overall due to
the reluctance of discussing EOL plans by health care providers and patients using the
following information:

In 2015, The Kaiser Family Foundation reported 9 out of 10 individuals want to have
conversations about end of life care with their providers. But only 17 percent of those
interviewed actually had conversations with their providers (DiJulio, Firth, & Brodie,
2015). With the structure and culture of the health care system to cure and promote
wellness, end of life conversations are avoided by health care providers and patients.
This is due to a variety of reasons- time, strong emotions from patients, families, and
even providers themselves, patients and families not understanding the trajectory of
their illnesses, and providers feeling unprepared or unwilling to have EOL
conversations. However, research on end of life has found health care providers do
value learning about and gaining skills in addressing end of life with their patients, and
patients want their health care providers to ask them about end of life planning (Gillan,
van der Riet, & Jeong, 2014; Jors et al., 2015; Shaw & Abbot, 2017).

To address this desire to increase knowledge, learn skills, and begin EOL conversations
participants must know what options are available to patients at the EOL. Providers
must be able to expertly discuss and educate their patients about different options and
the next section of the training does just that.
End of life care terms and options (25 minutes)
To increase provider knowledge of EOL resources this section of the training will focus
on terminology of the options available at the end of life. Having a working knowledge of
these terms will help providers be better informed of what is available and be able to
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discuss these options with patients when beginning or continuing discussions about
EOL.
Since the provider will be making the treatment decisions, it is crucial participants
understand that their patients may have limited understanding of what is available for
end of life care. This will require providers to take on the role of educator as well as
provider. It will be important for the provider to help the patient understand what matters
most to them at the end of life and what they want to happen if their health reaches a
critical limit or if they are unable to make decisions for themselves. Part of the provider’s
job is to help empower patients to think through the options and work with them to
decide what they want at the end of life. The provider should NOT be making decisions
for the patient. Providers should discuss the trajectory of the patient’s illness and
potential outcomes and explain why it is necessary to make these decisions ahead of
time in lieu of the illness trajectory. If providers do not know the trajectory of the illness,
they need to be informed and learn about their patient’s illness so patients are able to
make informed decisions for care at the EOL.
End of life planning options
 Advance directive (AD)
o A written document that describes the type of care and treatment a patient
wants at the EOL if they are unable to communicate their preferences.
o It can take the form of a living will, health care power of attorney,
POLST/MOLST/POST/MOS, or DNR, or all of these.
 Advanced care planning (ACP)
o The process of learning about EOL options and planning for which options
a patient wants at the EOL. This is a continued conversation between the
patient, their family members, and health care providers.
 Artificial nutrition and hydration
o A medical intervention that provides fluids and nutrition through tubes in
the nose and throat, stomach, intestine, or a vein, rather than the mouth.
 Comfort care
o Care that focuses on relieving symptoms and keeping the patient
comfortable at the EOL. This is not curative treatment and other medical
interventions to treat the disease(s) have stopped.
 Cardiopulmonary resuscitation (CPR)
o A medical intervention used in emergency situations when breathing or
heartbeat have ceased. This intervention uses chest compressions and
artificial ventilation to restart breathing and blood flow.
 Do not resuscitate (DNR)
o A medical order that states a patient does not want CPR if they stop
breathing or their heartbeats cease. This must be written and signed off by
a physician.
 Health care proxy/health care agent/durable power of attorney for health care
o A written document where a patient designates another person to make
medical and associated personal care decisions for them.
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o Document must be signed by patient and witnesses.
o Can be referred to as any of the terms listed above.
 Hospice care
o Team based care approach that is provided when a patient has a terminal
or advanced illness that no longer responds to curative treatment.
Interventions focuses on symptom and pain management. They are not
curative, but palliative.
o Hospice care can be provided in-home, at a hospice facility, in nursing
facilities and in the hospital.
o Provides services to patients and their families/caregivers. Care can
include emotional, spiritual, and medical services.
o Hospice may or may not be covered by insurance.
 Intubation/mechanical ventilation
o A surgical intervention to insert a tube into a patient’s trachea (windpipe)
to open the airway and help them breathe. The tube can be attached to a
machine called a ventilator to help the patient breathe as they cannot do
so on their own.
 Living will
o A written document that describes the medical treatment a patient wants
at the EOL if they become unable to speak for themselves.
o May or may not be legally binding depending on the state.
o Not legally binding in Michigan.
 MOLST (Medical Orders for Life-Sustaining Treatment)/MOST (Medical Orders
for Scope of Treatment)/POLST (Physician Orders for Life-Sustaining
Treatment)/POST(Physician Orders for Scope of Treatment)
o A legally binding document that describes the EOL medical treatment a
patient wants to receive in an emergency medical situation.
o Depending on the state, it can be referred to as a MOLST, POLST,
MOST, POST.
o POST is used in the state of Michigan.
o To find the designation used in another state, go to National POLST
Paradigm- https://polst.org/programs-in-your-state/
 Palliative care
o A team based care approach provided to patients who have serious or
advanced illness. Care is focused on improving quality of life by symptom
alleviation and addressing other areas of life that are impacted by the
illness.
o Services provided to patients and families include emotional, spiritual, and
medical support. Patients can receive palliative care in conjunction with
care from their primary care doctors.
o Care can be provided in-home, in hospitals, in nursing homes, or in
palliative care clinics.
o Insurance may or may not cover palliative care services.
 Time limited trial of aggressive care
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o Physicians place patients in the ICU for a short amount of time to receive
aggressive treatment in order to determine if they will improve and
increase survival.
After explaining and reviewing the different end of life options with participants, have
them share their experiences with these different options. They can share personal or
professional experiences they have encountered involving the specific terms and
concepts that were discussed in the EOL options section.
Homework before next training (3 minutes)
 Ask providers the following questions:
o Have you engaged in any advance care planning or do you have an
advance directive?
o Why or why not?
o What encouraged or discouraged your decision? Personal or professional
experiences?
 To respond to these questions, have them write a one page summary they can
share in the next training session in small groups
 Make sure they bring this summary with them to the next training session
Summary and Questions (7 minutes)
 Take this time to summarize the session’s content.
 Allow providers time to ask questions about the content discussed and the
activities in Session 1.
Additional Information
Be sure to provide time for participants to come to you if they need to process feelings
or emotions around today’s content. If additional time is needed you will need to
determine how you want to address this with participants so they are able to discuss
material or their reactions to the content.

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Section 5: Session 2- Four Hour Half Day Training
This training session will take place 3 months after the first training session over a 4
hour period of time. Two 5 minute breaks will be provided during the session at the
facilitator’s discretion.
Learning Objectives
The learning objectives for this training session are:
1. Participants will report on their personal and professional experiences with
advance care planning.
2. Participants will be able to describe resources that are available for patients at
the EOL within their health system.
3. Participants will illustrate how to engage chronically ill 35-64 year old patients in
EOL care planning.
4. Participants will apply the SPIKES and NURSE models communication strategies
to discuss EOL with patients in practice.
Training Syllabus
Overview of session/purpose of training session (5 minutes)
 Provide an overview of today’s training session. Make sure to include:
o Expected learning objectives for this training session
o Provide a brief overview of the content for this training session
 Describe the topics, activities, and expectations of the session
 Remind providers that they need to sign in and sign out on the sign in/out sheet
in order to receive their CEU or CME credits
o It is crucial that the sign in/out sheet is the completed by each provider
and collected to be able to provide CEU/CME credits and to measure the
program outputs. A template sign in/out sheet can be found in Appendix
E.
Homework and debrief (30 minutes)
Start out this section by asking the group if they have any questions or thoughts since
the last training session. It has been 3 months since the last training so it will be
important to check in with them on questions or thoughts they had since the last time
you met. Allot 5-8 minutes for this exercise.
Next, shift to a small group discussion on the homework that was assigned in Session
1. Break participants into groups of 6, for a total of 4 groups. Have participants share
their responses from the 1 page summary they completed for their homework
assignment. If there is time available have each group report out to the larger group.
 As a reminder, the homework assignment question were:
o Have you engaged in any advance care planning or do you have an
advance directive?
o Why or why not?
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o What encouraged or discouraged your decision? Personal or professional
experiences?
Guest speaker: Palliative and hospice resources within the health system (60
minutes)
Have a representative from palliative and hospice care come in to describe what their
respective services look like at the health system. Ask the representatives to share
available resources in and outside of the health system for patients, families, and
providers, the referral process to their services, contact information for providers, and
any other additional information they want to share to help providers better understand
their services.
After the representatives have shared the information, allow providers to ask questions
for 10 minutes.
Suggested break time- (5 minutes)
Engaging 35-64 year old patients to discuss end of life planning (45 minutes)
During this component of the training, the discussion should address the unique focus
of this training series, addressing EOL with 35-64 year olds with chronic conditions. This
time should focus on how to engage patients in discussing this topic.
Describe the following to participants:
Given the increasing number of multiple chronic conditions in adults 35-64 years old, it
is important to begin discussing EOL of plans earlier on in care. It is suggested that
these discussions begin after the second or third chronic illness diagnosis. With the
young age of this group, it can be a challenge to begin these conversations. Some
barriers include patients not willing to discuss EOL as they are “too young” or “will do
better”, patient and provider reluctance and delaying EOL conversations, and patients
not understanding what EOL planning or options are. Unfortunately, there is a gap in the
research on how to engage and discuss EOL with specifically with this age group,
except for younger patients with terminal or late stage cancer or HIV/AIDS. As a result,
not only do these barriers impact this age group but they tend to mirror barriers to
conversations for older adults as well. This population needs to be approached
differently as they are younger than the typical patient discussing and completing EOL
plans, and a majority are healthier, as many EOL plans are made when a patient is
terminally ill or dying. This can be done as the research on 1) engaging younger
patients with terminal illness, and 2) 35- 64 year old patient engagement in their overall
medical care, has been helpful in informing some strategies that providers can use in
practice to discuss EOL with this population.
There are some values and characteristics impacting the medical decisions and care of
this age group that can help facilitate EOL conversations:
 Prevention- Preventive measures are valued by those who are in the older end of
this group. For example, they are increasingly asking their providers for services
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like mammograms earlier on in care (Majors, 2018). This can help build a case
for beginning EOL conversations now, before they are terminally ill or
incapacitated, and cannot make decisions for themselves

 Information- They are information seeking. They want to know about what
options are available to them before making a health care decision. This group is
more likely to use information to help inform and make health care decisions than
younger or older age groups (Cantata Health, 2019; Chambers, 2019; Majors,
2018). A common issue in addressing EOL care is that patients and families do
not understand their illness trajectories or that they may lead to their deaths, thus
avoiding the conversation around EOL. Given the multitude of information online
on chronic illness and EOL care and planning, providers can direct these patients
to do research on what they want or can expect at the EOL and their illnesses.
They can then bring what they have found into a consultation or visit with a
provider. Providers must be open and willing to learn from and hear about what
patients have found on this topic and how they want to incorporate this into their
plan of care.

 Technology- This age group frequently uses online resources like web search
sites like Google or Bing, social media like Facebook or Instagram, and reviews
online to find information and learn from others’ experiences (Cantata Health,
2019). Many use digital patient portals and fitness technologies like FitBits so
they are comfortable with using new technologies to improve their health
(Chambers, 2016). There are now many digital platforms to help patients and
families begin and document EOL conversations, such as Cake
(https://www.joincake.com/); SafeBeyond (https://www.safebeyond.com/); Once
I’ve Gone (https://onceivegone.com/); Final Wish (https://www.finalwish.ca/); and
MyDirectives (https://mydirectives.com/). Having patients use these platforms
could be a great way for patients and families to continue the conversation about
EOL and then bring it into conversations with their providers.

 Providers- A majority of this age group (78 percent) have a primary care provider.
However, they have a challenging time trusting providers and the health care
system. They see the health care system as more of a way to make money,
rather than provide quality care to patients. This can cause them to switch
providers if they are not happy with the care they are receiving. To help curb this
cynicism, being open and honest about medical treatments, care and costs,
working on building a relationship and gaining trust with patients in this age
group, is recommended (Byers, n.d; Chambers, 2016; Hayhurst, 2017).

 Shared decision making- This population sees medical care as a collaborative,
team effort. To better engage this patients it is recommended using a shared
decision making approach where providers partner with the patient to make
decisions about medical interventions and treatments. Providers should be able
to provide information on best practices, pros and cons of interventions and
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treatments, and outcomes so patients are able to make the best decision based
on evidence and their beliefs and choice (Hayhurst, 2017; Kumar et al., 2010).
Large group discussion
To end this section of the training, take 20 minutes and give the group some time to
discuss the strategies described and/or their experiences having EOL conversations
with patients in the 35-64 year old age group. Have them briefly describe the case and
what worked or didn’t work when addressing this topic with the patient. Also, ask the
group what recommendations they have as a result of their experiences.
End of life communication skill building (45 minutes)
This section is devoted to discussing communication strategies and accompanying skills
needed to discuss EOL with patients. Skilled communication is needed when discussing
EOL. In a study by Trovo de Araujo and de Silva (2011), they determined that length of
provider experience did not make an impact but additional training and skill building are
what made providers better EOL communicators. Additional training also made nurses
more responsive to the emotional aspect of EOL care. To help increase communication
skill level, the first discussion should cover verbal and non-verbal communication health
care providers use with patients.
Verbal and non-verbal communication
So every participant has a common understanding, define two types of communication
as the following:
 Verbal communication is the spoken or written expression of words
 Non-verbal communication are the physical actions that may or may not
accompany verbal communication. This can include gestures, tone of voice,
affect, and physical contact or distance
Both of these factors influence how EOL communications are held and perceived. When
having EOL conversations providers need to consider the importance of what is said in
connection with what is done. Research has found that specific communication
practices allow providers to be more confident and empathetic, and patients feel more
understood in EOL conversations. These practices elicit emotional responses by
creating and stimulating connections in the brain. They are especially impactful when
patients are overwhelmed, upset, sad, or in pain. They help continue conversations and
increase trust in the patient-provider relationship (Trovo de Araujo & Paes de Silva,
2011). These practices include:
 Affectionate touch such as a hug, touching hands or arms, handshake, or
greeting with physical contact
 Facial expressions (ex. smiling)
 Continued eye contact
 Maintaining a personal distance between patients and families of 17 to 49 inches
 Active listening (including affirmative nodding, body directly facing patient, using
short phrases to affirm what the patient is saying
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It is necessary to underscore the importance of using these practices with patients when
discussing EOL. Tell participants they will have a chance to practice these skills later in
the training series through use of role plays.
Empathy
There is no one size fits all in discussing end of life plans. Research has found patients
who have completed advance directives are more likely to be older, women, have
higher education, and higher socioeconomic status (Marco et al., 2018; Rao, Anderson,
Lin, & Laux, 2014). However, the aim of Project Prepare, Plan, and Provide is to
inclusively reach patients outside of these demographics. To be able to do this,
providers have to build relationships and trust with their patients to be able to provide
compassionate and individualized EOL conversations. To do this, empathy must be
discussed.
Using empathy has been documented as an important aid in patient engagement and
confidence, and in discussing EOL with patients and families. It is particularly important
to have empathy when discussing challenging topics like poor medical news, chronic
illness trajectory, or EOL issues. Using empathy in patient-provider conversations can
increase satisfaction in the therapeutic relationship, increased patient coping
mechanisms, and improve overall health outcomes such as lower A1C or cholesterol
levels. It can be a challenge for providers to balance between too much empathy and
not enough, as being less empathetic can help provider increase neutrality in making
medical decisions and help to avoid burnout. To be able to manage this dichotomy and
increase empathy in patient-provider relationships, the following strategies are
recommended (as the facilitator feel free to include examples from your own experience
using these strategies in practice):
 Being open and transparent about patient and family questions and concerns
about their illness and EOL to help increase safety in discussing hard to discuss
issues
 Creating a non-judgmental and compassionate environment
 Increasing the level of personalized care for patients
 Building trust and safety in the relationship
 Maintaining hope while being honest in conversations about illness trajectory and
EOL
 Provide multiple, ongoing opportunities for patients and families to ask questions,
voice concerns and preferences
 Ask patients about beliefs and fears about death and dying, which may include
cultural, spiritual, and religious beliefs
 Continued training and supervision on empathy
 Ask patients about other factors that are related to and impact their illness
 Using the SPIKES and NURSE model help address EOL
(Brighton & Bristowe, 2016; Dehning et al., 2014; Derksen et al., 2017; Monden, Genry,
& Cox, 2016)
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Using SPIKES and NURSE communication models for EOL conversations
To help health care providers begin, facilitate, and continue EOL conversations with
patients and their families, the adapted SPIKES and NURSE models can be used. The
SPIKES (Setting, Perception, Invitation, Knowledge, Emotion, Summary) model was
developed by Robert Buckman to help health care providers deliver bad news to
patients in palliative care settings (Buckman & Kason, 1992; Hauser, 2017; Monden et
al, 2016; Rosenbaum, Ferguson, & Lobas, 2004). This model has been used as a
framework and adapted for this training to discuss EOL with patients as it has been
used universally in working with diverse patients. The NURSE (Name the emotion;
Understand the emotion; Respect the patient; Support the patient; Explore the emotion)
framework can be used to help providers provide empathy and react to strong emotions
provided by patients and families in response to EOL conversations.
To use the SPIKES model, it is recommended to use it more as an outline to direct the
conversation rather than a formal step by step process. Your patients want you to ask
them about EOL and using SPIKES can help facilitate this conversation (Dobbs,
Parsons Emmett, Hammarth, & Daaleman, 2012; Kumar et al., 2010). This adapted
model can be repeated in future visits to help patients and families retain and gain
further understanding of EOL options, planning, and care. The following are
recommendations for how to use SPIKES with patients and families (adapted from
Buckman & Kason, 1992 and Hauser, 2017).
 Phase 1- Set the Stage
o This phase takes place prior to the actual conversation with the patient.
These are the steps that need to be taken prior to the provider meeting
with the patient. The provider should have an outline of what will be
discussed with the patient, review the medical history, and ensure
additional pieces of information are accessible if needed. They also need
to ensure if other providers are part of a patient’s care, they are available
to take part in the visit.
o The provider should take a look at the environment where the
conversation will be held. Is there privacy? Will there be interruptions? Is
there enough time to address the conversation fully? Is there enough
seating? The provider will need to address the answers to these questions
and make accommodations to ensure the patient will receive quality care.
o Who else needs to attend? Make sure the patient knows they will be able
to have any supportive persons in the room with them.
 Phase 2- Perception. What does the patient know?
o As mentioned previously, some patients and families may not understand
the trajectory of their illness or that it can lead to death. It is important for
the provider to assess what the patient and family knows about their
illness and EOL. Questions that can be asked to assess what patients
know include “What do you know about your illness?” “Do you know what
will happen in 5 years, 10 years, or 15 years with your conditions?” What
do you know about EOL?”
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o This will give the provider a reference point for understanding what the
patient and family knows and is feeling, and where to start with providing
information and education.
 Phase 3- Invitation. How much does the patient want to know?
o Providers need to assess how much the patient and family want to know
about illness trajectory and EOL. Each patient will be different in their
capacity to understand and take in information about this challenging
topic. Providers need to ask what type of information patients want about
EOL, how they want it, and how much they want, when. This will help
provide concrete information that can be managed over time so patients
are able to make informed decisions about EOL. Further, this can help the
provider know how to best provide individualized care, communicate to
patients about EOL, and approach EOL planning.
o Providers needs to be willing to write down information and provide
resources such as statistics and links to resources.
 Phase 4- Knowledge. Share the information.
o During this phase, providers will share information about EOL with their
patients and their families. This information sharing should be empathetic
and compassionate, but candid. Providers should avoid using medical
jargon and use easy to understand information. Providers should not rush
through the information and allow for brief silences. It will be important to
pay attention to non-verbal communication, and to implement
communication practices that will convey empathy and understanding,
which was discussed earlier (eye contact, active listening, facing towards
patients, etc.).
o Providers need to create an environment of safety and openness. They
must be willing and able to answer questions, provide clarification, and
provide summaries of the EOL information being shared with patients.
 Phase 5-Emotion. Respond to feelings.
o Providers should be aware that these conversations might evoke strong
emotions from patients and families. This can result in evoking emotions
from providers as well. Providers need to be aware of their external and
internal responses and how this is perceived by others. Emotional
regulation and self-awareness is key in handling strong emotions in this
phase.
o Providers need to let patients and families react to what is being
discussed. Providers need to be aware of their tendencies to rush in,
discuss solutions, and avoid silence, and avoid these tendencies. Space
should be given to patients and families to talk.
o Providers need to be present with patients and family members, and ask
them to name their feelings and define them. Providers can ask questions
like “What are you feeling right now?” “What are you afraid of”, “Can you
tell me more about that feeling?” They need to make sure to support and
validate these feelings without pitying or feeling sorry for patients.
o Even though there may not be displays of emotions, providers need to
make sure to ask how patients and family members are feeling.
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o Further strategies to utilize in Phase 5 is the NURSE model:
 N- Name the emotion
 U- Understand the emotion
 R- Respect the patient
 S- Support the patient
 E- Explore the emotion
 Phase 6- Summary. Plan next steps and follow up
o The provider needs to summarize what was discussed during the visit and
provide the patient with next steps. The next steps can involve further
information on their chronic condition trajectory, EOL resources, other
supports, and referrals to other services. Providers should encourage
patients and families to engage in their own research of EOL options and
planning, and bring the information they have learned to the next visit.
Suggested break time (5 minutes)
Small group discussions- Case vignettes (30 minutes)
Break the participants into 6 groups of 4, try to vary the groups so each participant will
have a variety of interactions with fellow participants. Assign each group 1 of the short
vignettes found below. Have each of the participants discuss how they would address
EOL using SPIKES and NURSE with their “patient” in their small groups. Encourage
participants to ask one another questions about their responses. After 20 minutes in
their small group discussions, have the groups report out to the larger group by giving a
brief summary of their vignette and sharing their ideas for how to address EOL with their
“patient”.
1. Sam is a 42 year old high school teacher, married with 3 children under the age
of 12. He is African American and identifies as a Christian. Sam has multiple
chronic health conditions. He has been diagnosed with Type II diabetes and high
blood pressure over the past 7 years. He is showing symptoms of kidney
disease. How would you approach end of life planning with Sam?

2. Christina is a 38 year old single hairdresser. She is biracial and has no religious
affiliation. She is the sole caregiver for her disabled 65 year old mother. Christina
has had a history of asthma and was recently diagnosed with stage 3 breast
cancer 6 months ago. How would you approach end of life planning with
Christina?

3. James is 35 years old and underemployed. He is Caucasian. He lives with 3
roommates and has not talked to his immediate family in 5 years. He has been
diagnosed with hepatitis C and a pulmonary condition. How would you approach
end of life planning with James?

4. Diane is 58 years old. She has been married for 30 years, has 2 children, and
four grandchildren. She is a Caucasian college professor close to retirement. Her
husband has been living with MS for the past 15 years and her children live
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across the country. Diane has had Type I diabetes since she was 11 years old,
has high blood pressure, and arthritis. How would you approach end of life
planning with Diane?
Summary and Questions (15 minutes)
 Take this time to summarize the session’s content and activities.
 Allow providers time to ask questions about the content discussed and the
activities in Session 2.
Additional Information
Be sure to provide time for participants to come to you if they need to process feelings
or emotions around today’s content. If additional time is needed, you will need to
determine how you want to address this with participants who need additional time to
discuss material or their own reactions to the content.

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Section 6: Session 3- Eight Hour Full Day Training
Learning Objectives
The learning objectives for this training session are:
1. Participants will share their experiences with attempting to initiate EOL
conversations with patients.
2. Participants will describe how to use the SPIKES and NURSE models as
strategies to engage patients in EOL discussions.
3. Participants will describe the importance of involving families in EOL discussions.
4. Participants will be able to explain how to use the CPT codes to document patient
EOL visits for reimbursement.
5. Participants will demonstrate an understanding of questions to ask to begin EOL
conversations with patients.
6. Participants will integrate cultural competency practices to better serve their target
populations.
7. Participants will listen and respond to the EOL experiences of a terminally ill
patient and their family members.

Training Syllabus
Overview of session/purpose of training session (5 minutes)
 Provide an overview of today’s training session. Make sure to include:
o Expected learning objectives for this training session
o Provide a brief overview of the content for this training session
 Describe the topics, activities, and expectations of the session
 Remind providers that they need to sign in and sign out on the sign in/out sheet
in order to receive their CEU or CME credits
o It is crucial that the sign in/out sheet is the completed by each provider
and collected to be able to provide CEU/CME credits and to measure the
program outputs. A template sign in/out sheet can be found in Appendix
E.
Debrief (45 minutes)
 Start out this section by asking the group if they have any questions or thoughts
since the last training session. It has been 3 months since the last training so it
will be important to check in with them on questions or thoughts they had since
the last time you met.
 Check in on two specific areas:
o Using EOL strategies learned from the training in practice
 Have they had a chance to discuss EOL with patients? What
prompted the conversation? How did the conversation go? Has
there been an opportunity and you missed it? Why?
o How are they processing and working through feelings associated with
discussing EOL?
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 Take time to identify and process provider individual feelings (fears,
concerns, apathy) about end of life, theirs or their patients.
 Has it made them think differently about death and EOL? Why or
why not?
 Have they shared this information with anyone? Why or Why not?
Revisit communication techniques (35 minutes)
Take time to recap the SPIKES and NURSE communication strategies. This section will
involve knowledge recall and role play. For the knowledge recall, ask participants to
describe what they remember and how they would deliver the adapted model to
patients.
 Phase 1- Set the Stage
 Phase 2- Perception. What does the patient know?
 Phase 3- Invitation. How much does the patient want to know?
 Phase 4- Knowledge. Share the information.
 Phase 5-Emotion. Respond to feelings.
o Further strategies to utilize in Phase 5 is the NURSE model:
 N- Name the emotion
 U- Understand the emotion
 R- Respect the patient
 S- Support the patient
 E- Explore the emotion
 Phase 6- Summary. Plan next steps and follow up
Role play
To provide a refresher on these strategies, break up participants into 12 groups of 2.
Have them practice using SPIKES and NURSE with one another and encourage them
to provide feedback to one another. Have one partner be the provider and one be the
patient for 8-10 minutes, and then have them reverse roles for an additional 8-10
minutes.
Other information to consider (80 minutes)
Why do patients create advance directives?
To help providers better understand why some patients choose to engage in EOL
planning, go over the following reasons. Studies have found range of motivations and
reasons for why some patients complete advance directives (Genewick, Lipski,
Schupack, Buffington, 2018; Levi, Dellasega, Whitehead, & Green, 2010; Lynn, Curtis,
& Lagerway, 2016; van Wijmen, Pasman, Widdershoven, & Onwuteaka-Philipsen,
2014).
Reasons for filling out advance directives
 Don’t want certain things to happen to them at EOL
 What they have witnessed happen to loved ones when they were ill and dying
 No direct motivation
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 Terminal illness
 Serious illness
 Didn’t want to die too soon
 Prevent suffering and pain
 Want more treatment to extend life
 Achieve dignity and peace at death
 Family issues
 Control at end of life
 Spiritual beliefs
Ask participants if this is something they have come across in their practice as well. Are
there other motivations they have heard or experienced that are not listed? Do any
reasons surprise them? Why?
By having this information, providers should feel better equipped to knowing why
patients complete advance directives. The facilitator needs to reinforce that patients
want to be asked by their providers about EOL. Patients often do not ask because they
are waiting for their provider to ask them. Keep repeating this as a reminder throughout
the training session (Dobbs et al., 2012).
Questions to guide EOL conversations
This is a list of example questions to help facilitate EOL discussions. Providers can
encourage patients to discuss and document their responses with family members,
friends, and providers themselves. This list is from Dr. Angelo E. Volandes book, The
Conversation: A Revolutionary Plan for End-of-Life Care (2016, p. 7).
 What kinds of things are important to you in your life?
 If you were not able to do the activities you enjoy, are there any medical
treatments that would be too much?
 What fears do you have about getting sick or medical care?
 Do you have any spiritual, religious, philosophical, or cultural beliefs that guide
you when you make medical decisions?
 If you had to choose between living longer or having a higher quality of life, which
would you pick?
 How important is it for you to be at home when you die?
Ask participants the following questions in response to the list:
 What else could be added to this list?
 How would you respond to these questions?
 In your experience, would your patients respond to these questions? Why or why
not?
 Would you feel comfortable asking these questions to patients? Why or why not?
Encouraging patients to speak with families
Participants need to understand the importance of telling patients to share their EOL
wishes with their family members and close friends. Providers may suggest to patients
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to invite their family members or close friends to visits so they are aware of the
conversation being had. This can help family members understand why certain
decisions are being made by patients and their preferences. Patients and providers
need to be aware of how family members may react to the conversations. This may be
the first time they have thought about their family member having a condition that could
result in their death. Family member reactions have been found to be a barrier to having
EOL conversations so it will be important for participants to decide how they will
respond if these reactions occur and how they will respond to family members (Proulx &
Jacelon, 2004).
Documentation and reimbursement for EOL
One of the biggest barriers cited by providers in addressing EOL care is the lack of time
to discuss such an important topic. To address this barrier, recent legislation has been
implemented for providers to bill for EOL planning, or as it is referred to for insurance
reimbursement, advance care planning (ACP). The push for this policy began in 2015 to
address the lack of EOL conversations with patients who have significant health needs,
to discuss end of life care early on in diagnosis, and to support planning for the end of
life before terminal illness or health crises that lead to death (Francouer et al., 2016).
Physicians and other medical professionals such as nurse practitioners, social workers,
and physician assistants are now able to bill for of end of life conversations with
patients. This reimbursement allows for providers to have lengthy and purposeful
conversations with their patients to discuss end of life care. One study (Proulx &
Jacelon, 2004) mentioned that a barrier to having these discussions with patients was
the length of time it takes to have these conversations. Providers reported not having
enough time to have thorough discussions about these topics previous to the
reimbursement policy. Now, with this policy, providers are able to bill for the time to
have these important conversations. The CPT ACP reimbursement codes are 99497
and 99498. There does not need to be a specific diagnosis to have these conversations
and no training is required for providers previous to using this code. There are no limits
as to the number of times this code can be used for the same patient in the calendar
year.
Lunch break (60 minutes)
Allow 60 minutes for lunch. This lunch needs to be ordered by the facilitator ahead of
time and delivered to the training location.
Guest speaker- patient and family panel on end of life (75 minutes)
During this time, have a speaker who has a terminal illness and/or is near death or
dying and one or more of their family members speak to the group in a panel format.
The speakers can come to the training location or use a software platform like Skype or
Zoom. The purpose of having these guest speakers is for them to share their
experiences with EOL care and services. Providers have reported that they learn more
from having guest speakers who have had experiences with the training topic.
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After the speakers have shared the information, allow providers to ask questions for 10
minutes or with whatever the speakers are comfortable with.
Cultural competency in EOL (60 minutes)
Providers must understand the importance of being aware of the impact of culture on
EOL discussions. The facilitator needs to discuss the importance of not only considering
race and ethnicity, which is usually thought of when discussing cultural competency, but
other aspects of culture. These include religion affiliation, gender, age, socioeconomic
status, sexual orientation, language spoken, where the patient lives, family structure,
spirituality, ability, and mental health.
Providers need to gain cultural awareness of the patients they serve to be able to
respond appropriately in addressing EOL. Careful consideration needs to be taken
when learning and asking about a patient’s values, beliefs, traditions, and cultural
environments. This will help build trust between the patient and provider and encourage
open communication in the relationship (Dobbs et al., 2012).
This training session is not meant to provide an in-depth discussion on all potential
cultural groups providers may in encounter, as it will vary greatly. Rather, this
discussion should be focused on the importance of recognizing culture and the impact it
has on patients and discussing EOL, and what providers can do to increase their
cultural awareness and understanding.
Strategies to help increase cultural awareness and understanding include (adapted from
Duke Health, 2009):
 Reflecting and examining one’s own self-awareness
 Be aware of how the patient and family perceives and discusses EOL
 If necessary, use interpreters during office visits
 Learn who is making the decisions for the patient’s care
 Being open to new experiences with patients and colleagues
 Engage in research about the patients you serve through reading journal articles
and books and attending trainings/conferences
 Ask patients and families about their beliefs, values, traditions, and cultural
environments
 Be open to learning about and respecting cultural beliefs and values different
than yours
 Being willing to acknowledge and question personal beliefs and assumptions
Role play- Working with families/ supporting patients and families (85 minutes)
 Break participants into 6 groups of 4. Have the group assign themselves the
following roles:
o Provider
o Patient
o 2 family members (examples: spouse, friends, children, grandchildren,
siblings)
 They will have 2 rounds of the role play.
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o In the first role play, the patient will ask the provider to discuss their end of
life wishes. The group member playing the provider should use terms,
resources, referrals, cultural competency, and communication strategies
learned in previous training sessions. Give the groups 25 minutes for this
role play and to process responses from this role play.
o In the second role play, have group members switch roles. In this
scenario, the provider will ask the patient about their end of life plans. The
group member playing the provider should use terms, resources, referrals,
cultural competency, and communication strategies learned in previous
training sessions. Give the groups 25 minutes for this role play and to
process responses from this role play.
o As the groups are role playing, the facilitator needs to go around to the
different groups to be able to coach and provide feedback to participants.
 Have the groups briefly report out on their experiences to the larger group by
answering these questions.
o Was it easy or hard to have these conversations?
o Was it easier to ask a patient or provider?
o How did family members respond? How did the patient react? How did the
provider react?
o What feelings were evoked during this process?
o What did they learn from this experience?
o How will they take what they used in the role play and apply it to future
patients and families?
Next steps- patient visits (20 minutes)
The facilitator needs to describe what is required from participants in the next phase of
Project Prepare, Plan, and Provide. Inform the providers that the patients they referred
to the program will be contacted to be reminded to set up 2 appointments within the
next 6 months to meet and discuss EOL with them. Patients will schedule appointments
at 3 and 6 months post-training. The purpose of these visits will be to discuss EOL care
and planning. Providers need to use the ACP CPT codes to reimburse for these visits.
Providers need to be encouraged to help patients document their planning or give them
resources to do it on their own.
The facilitator needs to answer any questions providers may have about the next steps
in the program and what is expected of them.
Summary and Questions (15 minutes)
 Take this time to summarize this session’s content and activities.
 Allow providers time to ask questions about the content discussed and the
activities in Session 3.
Additional Information
Be sure to provide time for participants to come to you if they need to process feelings
or emotions around today’s content. If additional time is needed you will need to
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determine how you want to address this with participants so they are able to discuss
material or their own reactions to the content.
*The facilitator needs to make sure that the Health Care Provider Questionnaire posttest
is sent to participants via SurveyMonkey 1 week after the full day training.

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Section 7: Post-Intervention Evaluation Component
The post-intervention evaluation component of the program is to collect post-
intervention assessment data. Beginning in Month 6, 1 week after the completion of the
training series, health care providers will be asked to complete the Health Care Provider
Questionnaire (Appendix G) as a posttest. Provider participants need to complete the
assessment within 1 week of receiving an email link via SurveyMonkey that contains a
hyperlink to an electronic version of the identified assessment tool. Data analysis of the
provider assessments will need to be completed in Month 7.
The remaining evaluation data needs to be collected during patient participant visits with
their trained health care providers. Three and six months after the training series have
completed, month 9 and month 12 respectively, patients will schedule and attend visits
with their health care providers who have participated in the training. This will equate to
two visits during this time period. During these visits providers are expected to begin or
continue conversations on end of life plans and/or document end of life care plans with
their patients. Patients will complete the QOC and the CANHELP after the month 9 visit
with their provider and after the month 12 visit with their provider. Patients need to
complete the questionnaires 1 week post visit. Data analysis of the patient
questionnaires will need to be completed in Month 12. Patient participants need to
complete the questionnaires within 1 week of receiving an email link via SurveyMonkey
that contains a hyperlink to electronic versions of the identified questionnaires.

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Appendix
Appendix A
Resources
To learn more about communication and end of life planning the following lists are
resources that can be provided to participants.
Resources for Michigan
*If you are implementing this training outside the state of Michigan you will need to
provide a list of resources for your state*
 ACP Michigan, https://www.acpmich.org/
 Blue Cross Blue Shield of Michigan, https://www.bcbsm.com/index/health-
insurance-help/faqs/topics/other-topics/advance-directive-faq/advance-
directive.html
 Hospice of Michigan, https://www.hom.org/advance-directives/
 Making Choices Michigan, https://makingchoicesmichigan.org/
 Michigan Care Management Resources Center, https://micmrc.org/
 Michigan Department of Health and Human Services, Services for Seniors,
https://www.michigan.gov/mdhhs/0,5885,7-339-73971_7122_3183_4895---
,00.html
 Michigan Department of Health and Human Services, Michigan Commission
on End of Life Care, https://www.michigan.gov/mdhhs/0,5885,7-339-
73971_7122_3183-14145--,00.html
 Michigan- Five Wishes, https://fivewishes.org/five-wishes/state-detail/michigan
 Michigan State Medical Society, https://www.msms.org/
National Resources
 Advance Care Planning, http://www.cms.gov
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 Alive Hospice, https://www.alivehospice.org/
 Ariadne Labs, https://www.ariadnelabs.org/
 AARP, https://www.aarp.org/
 Centers for Disease Control and Prevention,
https://www.cdc.gov/aging/advancecareplanning/index.htm
 Coalition to Transform Advanced Care, https://www.thectac.org/
 Dying Matters, https://www.dyingmatters.org/
 Hospice Foundation of America, https://hospicefoundation.org/End-of-Life-
Support-and-Resources
 Medicare.gov, https://www.medicare.gov/
 National Center for Chronic Disease Prevention and Health Promotion,
About Chronic Disease., https://www.cdc.gov/chronicdisease/about/index.htm
 National Institute on Aging, https://www.nia.nih.gov/
 Respecting Choices, https://respectingchoices.org/
 The California State University, Shiley Institute for Palliative Care,
https://csupalliativecare.org/programs/
 University of Washington, End of Life Care Research Program,
https://depts.washington.edu/eolcare/
Books/Reports
Advice for Future Corpses, Sallie Tisdale
Being Mortal: Medicine and What Matters in the End, Atul Gawande
Dying in America: Improving Quality and Honoring Individual Preferences Near the End
of Life, National Institutes of Medicine,
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http://www.nationalacademies.org/hmd/Reports/2014/Dying-In-America-
Improving-Quality-and-Honoring-Individual-Preferences-Near-the-End-of-
Life.aspx
Extreme Measures: Finding a Better Path to the End of Life, Jessica Nutick Zitter
How We Die: Reflections of Life’s Final Chapter, Sherwin B. Nuland
Modern Death, Haider Warraich
Talking About Death Won’t Kill You: The Essential Guide to End-of-Life Conversations,
Kathy Kortes-Miller
The Best Care Possible: A Physician’s Quest to Transform Care Through the End of
Life, Ira Byock
The Conversation: A Revolutionary Plan for End-of-Life Care, Angelo E. Volandes

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Appendix B
Bibliography

Alonso, W., Hupcey, J.E., & Kitko, L. (2017). Caregivers’ perceptions of illness severity
and end of life service utilization in advanced heart failure. Heart & Lung, 46(1),
35-39.
Brighton, L.J. & Bristowe, K. (2016). Communication in palliative care: Talking about the
end of life, before the end of life. Postgraduate Medical Journal, 92, 466-470.
Buckman, R., & Kason, Y. (1992). How to break bad news: A guide for health care
professionals. Baltimore, MD: Johns Hopkins University Press.
Byers, M. (n.d.). Health care engagement varies by generation. Retrieved from
https://www.marybyers.com/12462-2/
Cacioppo, J.T., & Hawkley, L.C. (2003). Social isolation and health, with an emphasis
on underlying mechanisms. Perspectives in Biology and Medicine, 46(3), S39-
S52
Cantata Health (2019, January 22). Shifting generations of decision makers and how to
prepare. Retrieved from https://cantatahealth.com/blog/shifting-generations-of-
decision-makers-and-how-to-prepare/
Centers for Disease Control and Prevention. (2013). The state of aging and health in
America 2013. Atlanta, GA: Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention. (2016, January 20). Multiple chronic
conditions. Retrieved from https://www.cdc.gov/chronicdisease/about/multiple-
chronic.htm
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43 | P a g e

Chambers, B. (2016, July 12). The generational differences in healthcare technology.
Physician’s Weekly. Retrieved from https://www.physiciansweekly.com/the-
generational-differences-in-healthcare-technology/
Chung, H., Oczkowski, S.J., Hanvey, L., Mbuagbaw, L., & You, J.J. (2016). Educational
interventions to train health care professionals in end-of-life communication: A
systematic review and meta-analysis. BMC Medical Education, 16(131), 1-13.
doi: https://doi.org/10.1186/s12909-016-0653-x
Dehning, S., Rei , E., Krause, D., Gasperi, S., Meyer, S., Dargel, S., Muller, N., &
Siebeck, M. (2014). Empathy in high-tech and high-touch medicine. Patient
Education and Counseling, 95(2), 259-264.
https://doi.org/10.1016/j.pec.2014.01.013
Derksen, F., Olde Hartman, T.C., van Dijk, A., Plouvier, A., Bensing, J., & Lagro-
Janssen, A. (2017).Consequences of the presence and absence of empathy
during consultation in primary care: A focus group study with patients. Patient
Education and Counseling 100(5), 987-993.
DiJulio, B., Firth, J., & Brodie, M. (2015, September 30). Kaiser health tracking poll:
September 2015. Retrieved from https://www.kff.org/health-costs/poll-
finding/kaiser-health-tracking-poll-september-2015/
Dobbs, D., Parsons Emmett, C., Hammarth, A., & Daaleman, T.P. (2012). Religiosity
and death attitudes and engagement of advance care planning among
chronically ill older adults. Research on Aging, 34(2), 113-130. DOI:
10.1177/0164027511423259
PROJECT PREPARE, PLAN, AND PROVIDE PROGRAM MANUAL

44 | P a g e

Duke Health. (2009). Cultural competency at end of life. Retrieved from
https://www.dukehealth.org › sites › default › files › cultural_competence
Eagar, K., Senior, K., Fildes, D., Quinsey, K., Owen, A., Yeatman, H., Gordon, R. &
Posner, N. (2003). Palliative care evaluation tool kit: A compendium of tools to
aid in the evaluation of palliative care projects. Centre for Health Service
Development, University of Wollongong.
Francoeur, R.B., Burke, N., & Wilson, A.M. (2016). The role of social workers in spiritual
care to facilitate coping with chronic illness and self-determination in advance
care planning. Social Work in Public Health, 31(5), 453-466. doi:
10.1080/19371918.2016.1146199
Genewick, J.E., Lipski, D.M., Schupack, K.M., & Buffington, A.L.H. (2018).
Characteristics of patients with existing advance directives: Evaluating
motivations around advance care planning. American Journal of Hospice and
Palliative Medicine, 35(4), 664-668.
Gillan, P.C., van der Riet, P.J., & Jeong, S. (2014). End of life care education, past and
present: A review of the literature. Nurse Education Today, 34(3), 331-342.
Hauser, J. (2017). Communication in heart failure and palliative care. Heart Failure
Review, 22,535-542. DOI:10.1007/s10741-017-9643-2
Hayhurst, C. (2017, July 26). How to tailor the patient experience for different
generations (Part 2: Gen X). Retrieved from
https://www.cardinalhealth.com/en/essential-insights/what-do-gen-xers-want-
from-their-patient-experience.html
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45 | P a g e

Jors, K., Seibel, K., Bardenheuer, H., Buchheidt, D., Mayer-Steinacker, R., Viehrig, M.,
Xander, C., & Becker, G. (2015). Education in end-of-life care: What do
experienced professionals find important? Journal of Cancer Education, 31(2),
272-278.
Kumar, R., Korthuis, P.T., Saha, S., Changer, G., Sharp, V., Cohn, J., Moore, R., &
Beach, M.C. (2010). Decision-making role preferences among patients with HIV:
Associations with patient and provider characteristics and communication
behaviors. Journal of General Internal Medicine, 25(6), 517-523. DOI:
10.1007/s11606-010-1275-3
Levi, B.H., Dellasega, C., Whitehead, M. & Green, M.J. (2010) What influences
individuals to engage in advance care planning? American Journal of Hospice
and Palliative Care, 27(5), 306-312. DOI: 10.1177/1049909109355280
Lynn, T., Curtis, A., & Lagerway, M.D. (2016). Association between attitude toward
death and completion of advance directives. OMEGA- Journal of Death and
Dying, 74(2), 193-211.
Monden, K.R., Genry, L., & Cox, T.R. (2016). Delivering bad news to patients. Baylor
University Medical Center Proceedings, 29(1), 101-102.
Marco, C.A., Mozeleski, E., Mann, D., Holbrook, M. B. ,Serpico, M.R., Holyoke, A.,
Ginting, K., & Ahmed, A. (2018). Advance directives in emergency medicine:
patient perspectives and application to clinical scenarios. The American Journal
of Emergency Medicine, 36(3), 516-618.
https://doi.org/10.1016/j.ajem.2017.08.002
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Majors, M., (2018, June 17). How to engage different generations with their healthcare
benefits. Retrieved from
https://www.managedhealthcareexecutive.com/article/how-engage-different-
generations-their-healthcare-benefits
McRee, L., & Reed, P.G. (2016). Nurse practitioners: Knowledge, skills, and
leadership for the end-of-life conversation in intensive care. Nursing
Science Quarterly, 29(1), 78-81.
Mulvany,C. & Gundling, R. (2017). Patient engagement: A missing piece to the value
puzzle. Healthcare Financial Management, 71(7), 26-29.
National Center for Chronic Disease Prevention and Health Promotion. (2019, July 30).
About chronic disease. Retrieved
fromhttps://www.cdc.gov/chronicdisease/about/index.htm
Proulx, K., & Jacelon, C. (2004). Dying with dignity: The good patient versus the good
death. American Journal of Hospice and Palliative Medicine, 21(2), 116-120.
Rao, J.K., Anderson, L.A., Lin, F., & Laux, J.P. (2014). Completion of advance
directives among U.S. consumers. American Journal of Preventive Medicine,
46(1), 65-70. DOI: 10.1016/j.amepre.2013.09.008
Rosenbaum, M.E., Ferguson, K.J., & Lobas, J.G.. (2004). Teaching medical students
and residents skills for delivering bad news: A review of strategies. Academic
Medicine, 79(2), 107-117. DOI: 10.1097/00001888-200402000-00002
Shaw, P.A., & Abbott, M.A. (2017). High-fidelity simulation: Teaching end-of-life
care. Nurse Education Today, 49, 8-11.
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Sonenberg, A., & Sepulveda-Pacsi, A.L. (2018). Medicare payment: Advanced
care planning. The Journal for Nurse Practitioners, 14(2), 112-116.
Trovo de Arajuo, M. M., & da Silva, M.J. (2012). Communication strategies used by
health care professionals in providing palliative care to patients. Revista da
Escola de Enfermgem da USP, 46(3), 626-632. DOI: 10.1590/S0080-
62342012000300014
van Wijmen, M.P.S., Pasman, R.W., Widdershoven, G.A.M., & Onwuteaka-Philipsen,
B.D. (2014). Motivations, aims and communication around advance directives: A
mixed-methods study into the perspective of their owners and the influence of a
current illness. Patient Education and Counseling, 95(3), 393-399.
https://doi.org/10.1016/j.pec.2014.03.009
Volandes, A.E. (2016). The conversations: A revolutionary plan for end-of-life care. New
York, NY: Bloomsbury.
Whittemore, R., & Dixon, J. (2007). Chronic illness: The process of integration. Journal
of Nursing and Healthcare of Chronic Illness, 17(7b), 177-18.

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Appendix C
Informed Consent Forms
Patient Informed Consent
Project Prepare, Plan, and Provide
Informed Consent Form
Patient

I _____________________________________________, understand that my health system is
PRINT NAME participating in a pilot program

called Project Prepare, Plan, and Provide and an evaluation will be conducted on the outcomes of
the pilot project. The research intends to evaluate the effectiveness of the pilot Project Prepare,
Plan, and Provide program.

I am being asked by the study’s principal investigator to grant permission to use my responses from
the Project Prepare, Plan, and Provide pilot project administered questionnaires and allow these
responses to be used in the research.

I understand that all information released will be coded, and that no names or identifying information
will be released. The researcher will keep all research information in a locked file cabinet in the
researcher’s secure office. You understand that this information will be compiled with information
about other Project Prepare, Plan, and Provide participants participating in the evaluation. This
compiled information will only be used for this research. The results of this research will be
presented at scientific conferences and in briefing papers and publications that will be distributed to
the funding bodies to encourage them to continue to fund this program so other individuals may
benefit from this program. There are no foreseeable risks to you to participating in this research, as
all results will be kept completely confidential.
I understand that you can revoke my consent to participate in this research at any time, without fear
of penalty by calling Sarah Bartzen, Project Prepare, Plan, and Provide Director and Principal
Investigator at (517) 745-3512 and you will still be able to receive services from the health system
now and in the future. If you choose not to participate in this research, you will still receive services
from your health care provider.
I understand that my records are protected under Federal privacy regulations provided by the Health
Insurance Portability and Accountability Act (HIPPA), 45 C.F.R., Parts 160 & 164.

I understand my participation in this study is completely voluntary. Should I feel uncomfortable about
this research, or if I simply want to discuss the research, I know I can call or Sarah Bartzen, at 517-
745-3512. You may also contact Mrs. Bartzen if you want a copy of the research.

You have read or had read to you all of the above information about the research, including the
research procedures, possible risks, side effects and the likelihood of any benefit to you. The content
and meaning of this information has been explained and you understand both the content and
meaning. All of your questions, at this time have been answered and you have been given a copy of
this form to keep. You hereby consent and do voluntarily offer to follow the research requirements
and take part in the research.

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__________________________________________ ____________________
(Signature) (Date)

__________________________________________ ____________________
(Investigator or Specified Designee) (Date)

Provider Informed Consent
Project Prepare, Plan, and Provide
Informed Consent Form
Provider

I _____________________________________________, understand that my health system is
PRINT NAME participating in a pilot program

called Project Prepare, Plan, and Provide and an evaluation will be conducted on the outcomes of
the pilot project. The research intends to evaluate the effectiveness of the pilot Project Prepare,
Plan, and Provide program.

I am being asked by the study’s principal investigator to grant permission to use my responses from
the Project Prepare, Plan, and Provide pilot project administered questionnaires and allow these
responses to be used in the research.

I understand that all information released will be coded, and that no names or identifying information
will be released. The researcher will keep all research information in a locked file cabinet in the
researcher’s secure office. You understand that this information will be compiled with information
about other Project Prepare, Plan, and Provide participants participating in the evaluation. This
compiled information will only be used for this research. The results of this research will be
presented at scientific conferences and in briefing papers and publications that will be distributed to
the funding bodies to encourage them to continue to fund this program so other individuals may
benefit from this program. There are no foreseeable risks to you to participating in this research, as
all results will be kept completely confidential.
I understand that you can revoke my consent to participate in this research at any time, without fear
of penalty by calling Sarah Bartzen, Project Prepare, Plan, and Provide Director and Principal
Investigator at (517) 745-3512 and you will still be able to be employed by the health system now
and in the future. If you choose not to participate in this research, you will still be employed by the
health system.

I understand that my records are protected under Federal privacy regulations provided by the Health
Insurance Portability and Accountability Act (HIPPA), 45 C.F.R., Parts 160 & 164.

I understand my participation in this study is completely voluntary. Should I feel uncomfortable about
this research, or if I simply want to discuss the research, I know I can call or Sarah Bartzen, at 517-
745-3512. You may also contact Mrs. Bartzen if you want a copy of the research.

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You have read or had read to you all of the above information about the research, including the
research procedures, possible risks, side effects and the likelihood of any benefit to you. The content
and meaning of this information has been explained and you understand both the content and
meaning. All of your questions, at this time have been answered and you have been given a copy of
this form to keep. You hereby consent and do voluntarily offer to follow the research requirements
and take part in the research.

__________________________________________ ____________________
(Signature) (Date)

__________________________________________ ____________________
(Investigator or Specified Designee) (Date)

Appendix D

Project Prepare, Plan, and Provide Process Map

Location
is secured
for
training
series
Provider participants
complete the Palliative
Care and End of Life
Care Competency
Assessment in Month
1, two weeks prior to
beginning of Session 1
of the training series
via email link

KEY
Document
Decision Process
Data
Program facilitator
recruits 24 health
care providers and
50 patient
participants for the
pilot
Program collects
informed consents
from pilot participants
Sign in and out sheets
collected from Training
Session 1
Facilitator creates
partnership with
health care
system or
organization
Facilitator obtains
CEU and CME
approval from
accrediting bodies
IRB approval is
sought from
health system or
university
Training Session 1
is conducted in
Month 1
Training Session 2
is conducted in
Month 3
Sign in and out sheets
collected from Training
Session 2 in Month 3
Training Session 3
is conducted in
Month 6
Sign in and out sheets
collected from Training
Session 3 in Month 6
Provider participants
complete the
Palliative Care and
End of Life Care
Competency
Assessment 1 week
post-intervention via
email link

Patient participants
schedule
appointments with
trained providers in
Month 9
Patient participants
complete the Quality
of Communication
Questionnaire and
Advanced Care
Questionnaire
Assessment 1 week
post visit via email
links

Data analysis of
provider
assessments
completed in
Month 7
Patient participants
schedule
appointments with
trained providers in
Month 12
Patient participants
complete the Quality
of Communication
Questionnaire and
CANHELP Patient
Questionnaire 1 week
post visit via email
links

Data analysis of
patient
questionnaires
completed in
Month 12
Program
facilitator
arranges for
guest speakers
to present at
training series
and food and
refreshments
Facilitator secures
$43,600 in
funding to
administer
program
Michigan Social Work Continuing
Education Application Packet
Michigan Social Work
Continuing Education
Collaborative
www.socialworkcec.com
swcollaborative@gmail.com
Appendix E
CEU Applications
Michigan Social Work Continuing Education
Collaborative Application Instructions, Content
Requirements & Fees Schedule
July 2017 v.1
1. Thank you for taking the time to complete and submit this application.
2. This application is a fillable PDF form.
3. Please read each question on the application carefully
4. The application is self-explanatory
5. Use the tab key on your keyboard to move from one field to the next, when your cursor is blinking on the field either enter your
answer or select from the drop down menu if one has been provided for that question. Use your mouse to move to the next page.
6. DO NOT under any circumstances change the format or questions on this application.
7. Red outlined fields are "required" fields. You will not be able to submit the application until all required fields are answered
8. Blue outlined fields are mostly optional depending on the type of CE event you are applying for
9. Remember to save the application periodically so as not to lose information, use the 'save file as' and name the file with the
workshop title.
10. After the application is complete save it one last time and then click on the "envelope" icon on the upper left corner and email the
application and all supporting documents to: swcollaborative@gmail.com
General Directions
What is Required for Application Submission (Use as a checklist)
If the application is incomplete or missing any of the required documentation your application will not be reviewed
A Completed Application
Presenter's Biography OR Resume OR CV (Limit of 5 pages) This is not required on conference applications as
the biography section is on the Breakout Form
A Sample of the Evaluation (evaluation questions must reflect the objectives of the training event )
A Sample of the Certificate of Attendance OR Participation/Conference Check in/out Form
Understanding of Payment Requirements/Make Payment Arrangements
Payments and Provider Status
Annual Fees
Annual fees must be renewed every year
Opting for the annual fees allows the Provider to submit an unlimited number of applications in a 12 month period.
$ 500.00 Only for CSWE Schools of Social Work
$ 800.00 Non-profits - all 501(c) Organizations
$1600.00 For-profits
Individual Application Fees-One and Two Day Event
$ 175.00 Non-profit: One-day Event
$ 350.00 For-profit: One-day Event
$ 225.00 Non-profit: Two-day Event
$ 425.00 For-profit: Two-day Event
Conference Application Fees
Three & Four Day Events
$425.00 Non-profit
$490.00 For-profit
Five + Days Event
$500.00 Non-profit
$600.00 For-profit
Additional Fees
Rush Fees The Rush fee is in addition to the application fee
$75.00 Applications submitted 45-15 days prior to the event date.
$100.00 Applications submitted 14 days or less prior to the event date.
We renew our annual dues on:
Amount :
Amount :
Is an "Unlimited" Provider
Will become an "Unlimited" Provider
Will pay for each application separately
Please complete the following:
Our Organization:
This is a rush application and I have enclosed an additional fee of:
Total Amount Due: Payment will be made by: Check Credit Card
Check Payment: Make Checks payable to: NASW-Michigan, 741 N. Cedar Street, Lansing, MI 48906
Credit Card Payment-complete the following information:
We only accept Visa or MasterCard for credit card payments
Credit Card Number:
Cardholder's Name
Organization's Name
Expire Date: Month
3 Digit SEC Code
Billing Address:
Street
City State Zip
Important Information
• Incomplete applications will not be reviewed, they will be returned to you.
• Do not send in partial applications, this means that all documentation must be sent in with the completed application. (see your
checklist)
• We accept and prefer to receive a digital copy of the application and documents however if you do not have access to a
scanner you can send in the application and documents via regular mail or fax them to 517-487-0675.
• Email the application and all documents to swcollaborative@gmail.com
• Applications are processed and reviewed on a first come, first serve basis unless they are marked as a "rush".
• We no longer accept post-dated applications.
• If your application is complete when you send it in then you can expect the review to take up to 5 business days, if it is a "rush"
we will review the application within 72 hours.
• Remember that all events/trainings/workshops etc... must be relevant to social work practice and this must be demonstrated
throughout the application. The content must meet at least one of the following:
 Theories & concepts of human behavior in the social environment
 Social work practice, knowledge and skills
 Social work research, program evaluation, or practice evaluation
 Social work agency management or administration
 Development, evaluation, or implementation of social policy
 Social work ethics and standards of professional practice
 Current issues in clinical or macro social work practice
 Cultural competence and diversity
 Pain/Pain Symptom Management-Psychology of Pain
Year
• CE Credit will not be given for general meetings or supervision.
• Attendance guidelines require that the first hour of presentation must be at least 60 full minutes. Partial attendance may be
granted if you believe that it is acceptable for the learning requirements.
A.
1 .
B.
D.
Michigan Social Work Continuing Education Collaborative
Application for CE Credit Approval
Applicant Application
Enter the contact information of the individual responsible for the submission of this
application: First, Last Name:
Job Title:
Primary Phone Number with Area Code:
Email Address:
Non-profit For-Profit
Organization Information
Enter the organization’s information that will be sponsoring this event:
Organization Name:
Address:
City, State and Zip:
Phone Number with Area Code:
Website Address :
Today's Date:
First and Last Name:
Job Title:
Phone number with area code:
Email Address:
Social Work Involvement
Name of social worker involved in the planning of this event (include all credentials):
Michigan Social Work License Number
Organization /FiduciaryStatus: Tax ID #
E. Explain social work involvement in the development of this event :
F. Is this social worker licensed in more than one state? If yes, list other states below
G. Is this social worker's license free of violations?
If no, please explain below:
EXT:
C. CE Contact Person: (person responsible for the completion of this application)
Provider Status This is a "RUSH"
This event is days long
Pricing will vary depending on the number of days and your organization's tax status. Refer to the fee section of this packet.

hours long
H.
1.
Education Event Details
This event is
Another State Board of SW - List State (s):
Type of Event
Check all that apply
2. This event was previously approved by the Collaborative (approval number)
3. This event has also been approved by or submitted for approval to:
Other Professional Organizations (List Them) :
Please complete corresponding application pages listed below for event type:
4.
5. How will social worker attendance be monitored?
6. Will this event be open to all licensed social workers?
7. Who is your audience?
LMSW MCBAP
Other
Case Manager
In-person (1-2 Day Event) Complete pages 1-7
Live Webinar Complete pages 1-7 and Addendum C
Multi-day Conference Complete pages 1-7, Skip Questions 17 & 19, Complete Addendum B for ea. breakout
Self-study/Home Study Complete pages 1-7 and Addendum C
Synchronous On-line Complete pages 1-7 and Addendum C
A-Synchronous On-line Complete pages 1-7 and Addendum C
Multi-week/Modules Complete pages 1-7, Skip Questions 17 & 19, Complete Addendum B for ea. module
Teleconference Recorded Complete pages 1-7 and Addendum C
Recorded webinar Complete pages 1-7 and Addendum C
Hybrid Complete pages 1-7 and Addendum C and Addendum B if there are modules .
Other-Please Explain
ASWB/ACE
LBSW
Event/Course/Workshop Title
Event Date (s) (list all known dates)
Event Date
Additional dates and locations may be listed on a separate piece of paper.
If the location information is incomplete then
the course will not be listed on the Collaborative website.
8.
9.
10. Course Description
11. Course Objectives (These objectives must be referenced on the evaluation form)
List one objective for each hour of presentation
(or mark if Webinar or Online)
Registration Phone
Location Name:
Location full address:
Location County:
Name of person who will handle registration:
Registration Email:
Registration Web Link:
Americans with Disabilities (ADA) Contact
ADA Phone Number: Event Time(s):
12.
Timed Agenda:
15. Please select all standards that apply:
Theories & concepts of human behavior in the social environment
Social work practice, knowledge and skills
Social work research, program evaluation, or practice evaluation
Social work agency management or administration
Development, evaluation, or implementation of social policy
Social work ethics and standards of professional practice
Current issues in clinical or macro social work practice
Cultural competence and diversity
Pain/Pain Symptom Management-Psychology of Pain
16. Methods of Presentation (check all that apply)
Textbook
Vignettes
Experiential
Lecture
PowerPoint
Video/Movie
Other (explain)
17. Presenters' Name(s) & Credentials (please include a short bio OR resume for each presenter max 5 pages)
Presenter #1 Name
Presenter #2 Name
Presenter #3 Name
13. How many CE Hours are you requesting?
One CE hour is equivalent to 1 clock hour. All events must be at least 1 hour. Events over 1 hour are calculated based on a
full 60 minutes for the first hour and then 50-60 minutes for every hour after the first.
14. Do you want this listed on the Collaborative website?
18. Explain the relevance this training has to social work practice?
Please list three bibliography references that are relative to the topic being
presented following these guidelines:
19.
1. References must be listed in the APA format
2. Two of three references must be from a peer reviewed book or journal
3. At least one reference must be from a peer reviewed book or journal that was published within the last five years.
4. Websites may be listed as a fourth reference only if it is the direct link to the topic being presented.
20.
Additional Information: (check all that apply)
I understand that I must issue certificates of attendance within 30 days after the event
I will verify all attendee CE hours before issuing certificates
Certificates will have all of the correct wording as provided by the Collaborative
I understand that evaluations must reflect the course objectives
I certify that all of the programs offered by my organization comply with the requirements for
social work continuing education as described in the 1978 PA 368 MCL 333.1101 to
333.25211
Signature / Digital Signature
Date
THIS IS A REQUIREMENT
Addendum A
Phone:
Co-Sponsorship Information
Is this event being co-sponsored?
Name of co-sponsoring organization:
Why is the event being co-sponsored?
Name of person for contact at co-sponsorship organization :
Email of co-sponsor contact:
Which organization will be responsible for all record keeping, attendance, evals, etc...?
The co-sponsoring organization is a:
Non-profit For-profit
Is the co-sponsoring organization paying you a fee or trading services to co-sponsor this event?
If yes, please explain:
In a co-sponsorship the primary organization (name on page one) must be an approved provider
and must assume all responsibility for compliance with the application standards.
Only complete this section if the event is being
co-sponsored with an "approved" provider.
Addendum B
Conference Breakout Sessions
Length of Breakout
Breakout/Keynote Title:
This presentation will be repeated how many
times at this event?
Please check the point of reference below for this presentation. (You may check more than one)
Brief overview of presentation:
Objectives:
Primary presenter's name & credentials:
Bibliography:
1. One reference for each hour of presentation. If citing one reference it must be current within the last 5 years
2. References must be listed in the APA format
3. References must be from a peer reviewed book or journal
4. Websites may be listed as a fourth reference only if it is the direct link to the topic being presented.
Primary presenter biography:
Complete one of these for each breakout session, keynote & plenary.
DO NOT complete this unless you have multiple speakers and topics.
Theories & concepts of human behavior in the social environment
Social work practice, knowledge and skills
Social work research, program evaluation, or practice evaluation
Social work agency management or administration
Development, evaluation, or implementation of social policy
Social work ethics and standards of professional practice
Current issues in clinical or macro social work practice
Cultural competence and diversity
Pain/Pain Symptom Management-Psychology of Pain
Type of Alternative Learning: Check all that apply
Other Learning
Addendum C
Synchronous On-line-Participants are on-line at the same site (web portal) at the same time of day using technology such as an assigned
chat room or blackboard etc...
Asynchronous On-line-Participants do not need to be on-line at the same time. Information is posted and available to course participants
on an “any time, anywhere basis”.
Hybrid or Blended Course– A class which combines traditional, face-to-face instruction with on-line, distance instruction. Classroom time
is split between meeting in person and meeting on-line. Any combination of the two forms of educational delivery is considered a hybrid
class.
Webinar-A specific type of web conference. It is typically one-way, from the speaker to the audience with limited audience interactions,
such as in a webcast. A webinar can be collaborative and include posting and question & answer sessions to allow full participation
between the audience and the presenter.
Web Conferencing-This is used to conduct live meetings or presentations via the Internet. In a web conference, each participant sits at
their computer and is connected to other participants via the Internet. This can either be a downloaded application on each of the
attendees computers or a web-based application where the attendees will simply enter an assigned web portal to enter the conference.
Video Conferencing-(also known as a live video teleconference) allows two or more locations to interact via two-way video
and audio transmissions simultaneously. It has also been called visual collaboration. It differs from videophone in that it is
designed to serve a conference rather than individuals.
Home Study-A course of study carried out at home rather than in a classroom. Mail correspondence.
Podcast-Is a series of audio or video digital media files which is distributed over the Internet by syndicated download, through Web feeds,
to portable media players and personal computers. Though the same content may also be made available by direct download or
streaming, a podcast is distinguished from most other digital media formats by it’s ability to be syndicated, subscribed to, and downloaded
automatically when new content is added.
Conference call-Is a telephone call in which the calling party wishes to have more than one called party listen in to the audio portion of the
call. The conference calls may be designed to allow the called party to participate during the call, or the call may be set up so that the
called party merely listens into the call and cannot speak. It is often referred to as an ATC (Audio Tele-conference). The call must be a
continuing education approved training.
Other Learning Questions:
2. How will you verify participation?
3. How will you monitor attendance?
4. Will there be a test?
5. If this is a hybrid course, how much "live" interaction will there be?
Note: 10,000 words is equal to one CE hour. This applies to reading an article or journal as a training method.
1. How did you determine the number of CE hours?

1
ANCC Primary Accreditation Organizational Self-Assessment Tool - Provider, 05.02.2017
ANCC Primary Accreditation Organizational Self-Assessment Tool - Provider
The first step in pursuing accreditation as an ANCC Accredited Provider is an organizational self-assessment. The self-assessment process is used
to evaluate organizational readiness to meet accreditation criteria, and to identify potential gaps that may need to be addressed within the
organization.
Current State
(Describe)
Compliant with Requirement
(Yes/No)
Gap
(Yes/No)
Action Plan to Address Gap
(Describe)
Eligibility Requirements
1. There has been a qualified Lead Nurse
Planner within the applicant
organization for at least 6 months
(currently licensed registered nurse with
a graduate degree, and either the
baccalaureate or graduate degree must
be in nursing).
The process is in place to
partner with a qualified
Lead Nurse Planner who
is employed by the
Nursing School at Spring
Arbor University
No Yes The Lead Nurse Planner will
be determined by January
2020
2. The Lead Nurse Planner has the
authority within the organization to
ensure adherence to ANCC accreditation
criteria.
Yes, the Lead Nurse
Planner will have the
authority
Yes No N/A
3. Nurse Planners (if any) within the
applicant organization are currently
licensed registered nurses with a
baccalaureate degree or higher in
nursing.
Yes, the Lead Nurse
Planner and other Nurse
Planners have a
minimum of a master
nurse practitioner (NP)
degree
Yes No N/A
4. The applicant organization has position
descriptions for the Lead Nurse Planner
(required) and Nurse Planner (if
applicable) that accurately reflect job
responsibilities according to ANCC
accreditation criteria.
Yes, the positon
descriptions are
available within the
Nursing School
Yes No N/A

2
ANCC Primary Accreditation Organizational Self-Assessment Tool - Provider, 05.02.2017

5. The applicant organization has planned,
implemented and evaluated at least 3
educational activities of at least one
hour in length using ANCC accreditation
criteria with active involvement of a
qualified Nurse Planner.
No No Yes This needs to be discussed
with the dean of the school
of nursing
6. The applicant organization has been
operational using ANCC accreditation
criteria for at least 6 months.
Yes, the applicant
organization is in
complicate with the
criteria
Yes No N/A
7. The applicant organization is not
classified as a commercial interest
organization, or is not owned or
operated by an organization classified as
a commercial interest organization.
This is a true statement
for the applicant
organizations
Yes No N/A
Criterion/Responsibility Requirements
1. The Lead Nurse Planner is responsible
for ensuring all members of the
applicant organization have been
oriented to the ANCC accreditation
criteria.
Yes, the Lead Nurse
Planner will have this
responsibility
Yes No N/A
2. A Nurse Planner has actively
participated in planning, implemented
and evaluating each educational activity
awarding or to award ANCC contact
hours.
The Lead Nurse Planner
will participate in the
planning, implementing
and evaluation of the
programming
Yes Yes When the Lead Nurse
Planner is decided on, they
will take an active role in
this process, potential
Planners are aware of this
expectation
3. Each educational activity has been
developed to address an identified gap
in knowledge, skills and/or practices for
registered nurse learners.
Yes, all educational
activities will meet this
requirement
Yes No N/A

3
ANCC Primary Accreditation Organizational Self-Assessment Tool - Provider, 05.02.2017
4. Content for educational activities has
been developed using best-available
evidence.
Yes, all programming
will be developing using
best practice and
evidence-based
practices
Yes No N/A

5. All educational activities have been
planned independently, free from the
influence of commercial interest
organizations.
Yes, the programming
will meet this
requirement
Yes No N/A
6. The Lead Nurse Planner and all Nurse
Planners are able to correctly calculate
contact hours (continuing education
credit) for live and enduring educational
activities.
Yes, the Lead Nurse
Planner and Nurse
Planners will be able to
calculate contact hours
for all activities
Yes No N/A
7. The Lead Nurse Planner and all Nurse
Planners are able to operationally define
the following:
a. commercial interest
organization
b. conflict of interest
c. commercial support
d. joint-providing
e. content integrity
Yes, they will be able to
operationally define
each of these
components
Yes No N/A
8. The Lead Nurse Planner and all Nurse
Planners are able to describe required
disclosures that must be provided to
learners prior to an educational activity:
a. purpose/objectives
b. criteria for successful
completion
Yes, the Lead Nurse
Planner and other Nurse
Planners will be able to
provide this information
to learners prior to any
educational activity
Yes No N/A

4
ANCC Primary Accreditation Organizational Self-Assessment Tool - Provider, 05.02.2017
c. presence or absence of conflict
of interest
d. commercial support
e. expiration date
9. The Lead Nurse Planner and all Nurse
Planners are able to identify and
evaluate appropriate outcome measures
at the individual activity level.
With help from the
applicant organization
and organization
partners, the Lead Nurse
Planner and other Nurse
planners will be able to
identify and evaluate
activity outcomes
Yes No N/A
10. The Lead Nurse Planner and all Nurse
Planners are able to identify the
requirements for a certificate of
completion provided to learners.
Yes, the Lead Nurse
Planner and other Nurse
Planners will be able to
meet this requirement
Yes No N/A
11. The Lead Nurse Planner ensures that the
applicant organization identifies and
evaluates appropriate strategic goals
and quality outcome measures related
to the organization as an entity.
In conjunction with the
other educational
activity organizers in the
applicant organization,
the Lead Nurse Planner
will be able to
accomplish this
requirement
Yes No N/A
12. The Lead Nurse Planner ensures that the
applicant organization identifies and
evaluates outcome measures related to
improving nursing professional
development and/or patient outcomes.
In conjunction with the
other educational
activity organizers in the
applicant organization,
the Lead Nurse Planner
will be able to
accomplish this
requirement
Yes No N/A
Other

5
ANCC Primary Accreditation Organizational Self-Assessment Tool - Provider, 05.02.2017
1. The applicant organization has the
resources to maintain records for 6
years.
Yes, the applicant
organization has the
capacity and available
software to maintain
records for 6 years
Yes No N/A
2. The applicant organization understands
and has the resources to pay all
accreditation-related expenses including
application, annual and other associated
fees.
No, funds are currently
being pursed in order to
be able to pay the
accreditation related
expenses
No Yes Funding is being actively
sought from private
foundations and grant-
making bodies to cover the
accreditation expenses
3. The applicant organization understands
and has the resources to submit all
required accreditation documents to
ANCC in a timely manner.
Yes, the applicant
organization will submit
all required documents
to ANCC in a timely
manner
Yes No N/A

Page 1 of 2
MEETING SIGN-IN SHEET
Training: Project Prepare, Plan, and Provide Meeting Date:
Facilitator: Sarah Bartzen Place/Room: Spring Arbor University

Name
Sign In
(Initials
with
Time)
Sign Out
(Initials
with
Time)
CEU
/CME
(Y/N)
Phone License # E-Mail

Page 2 of 2
Name
Sign In
(Initials
with
Time)
Sign Out
(Initials
with
Time)
CEU
/CME
(Y/N)
Phone License # E-Mail

Appendix F
Letters of Support

Health Care Provider Questionnaire (Evaluation Tool 2.1 Modified from ‘Promoting Excellence in End-of-Life Care’)
Eagar, K., Senior, K., Fildes, D., Quinsey, K., Owen, A., Yeatman, H., Gordon, R. & Posner.N. (2003). Palliative care evaluation tool kit: A compendium of tools to aid in the
evaluation of palliative care projects. Centre for Health Service Development, University of Wollongong.
Please rate your degree of confidence with the following patient / family interactions and patient management topics,
by ticking the relevant box below
1 = Need further basic instruction 2 = Confident to perform with close supervision / coaching
3 = Confident to perform with minimal consultation 4 = Confident to perform independently
No Patient/family interactions and clinical management 1 2 3 4
1 Answering patients questions about the dying process
2 Supporting the patient or family member when they become upset
3 Informing people of the support services available
4 Discussing different environmental options (eg hospital, home, family)
5 Discussing patients wishes for after their death
6 Answering queries about the effects of certain medications
7 Reacting to reports of pain from the patient
8 Reacting to and coping with terminal delirium
9 Reacting to and coping with terminal dyspnoea (breathlessness)
10 Reacting to and coping with nausea / vomiting
11 Reacting to and coping with reports of constipation
12 Reacting to and coping with limited patient decision-making capacity
Please indicate the importance of the issues below in terms of the problems they create for you in caring for a
dying patient by ticking the box that best describes your feelings. (There are no right or wrong answers).
No Statement
Very
important
Important Unsure Less
important
Not
important
1 Control of pain
2 Managing depression
3 Legal concerns
4 Ability to meet spiritual needs
5 The patient’s emotional needs
6 Communication with family
7 Communication with other palliative care staff
8 Communication with (other) doctor/s
9 Uncertainty about what is best care
10 Other (please describe)
Appendix G
Assessment Instruments

Please indicate how much you agree or disagree with each of the following statements, by ticking the box that best describes how
you feel. (There are no right or wrong answers).

Views about death and dying
No Statement
Agree
Strongly
Agree Unsure /
Mixed
Disagree Disagree
Strongly
1 The end of life is a time of great suffering.

2 Little can be done to help someone achieve a sense of peace at the end
of life.

3 The use of strong pain medication can cause the person to stop
breathing.

4 I am not comfortable caring for a dying patient.

5 I am not comfortable talking to families about death.

6 When a patient dies I feel that something went wrong.

7 Feeding tubes should be used to prevent starvation at the end of life.

8 Nursing homes/hospitals are not good places to die.

9 Families have the right to refuse a medical treatment, even if that
treatment prolongs life.

10 Dying patients should be referred to a hospice or acute care.

Attitudes towards Palliative and End of Life Care
No Statement
Strongly
Agree
Agree Neither
Agree nor
Disagree
Disagree Disagree
Strongly
1 Pain at the end of life is an inevitable part of the dying process

2 Pain medication should be given as needed to terminally ill patients

3 Spiritual care should include counselling the terminally ill patient

4 I do not like talking about death and dying with patients

5 Palliative care should be the standard medical treatment for patients
who are suffering from a terminal illness

6 Patients should have the right to determine their own degree of medical
intervention

7 Addiction to oral morphine is not a serious issue given that terminally ill
patients have a short time to live

8 Opening discussions of end-of-life care should be deferred until there is
no further effective curative treatment available

9 Estimation of pain by an MD or RN is a more valid measure of pain than
patient self-report

10 Complete pain relief is a reasonable goal even when the pain is not
caused by a terminal condition such as cancer

11 Patients have the right to determine their own degree of psychosocial
intervention

12 The most appropriate person to make end-of-life decisions is the
patient’s primary care provider

13 A patient should experience discomfort prior to receiving the next dose
of pain medications

14 Patients should be maintained in a pain-free state

15 As a rule, terminally ill patients prefer not to talk about death and dying

1
UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE
Quality of Communication Questionnaire
____ ____ ____ ____ RESPONDENT ID
DATE / /
Start time ____ ____ : ____ ____
Stop time ____ ____ : ____ ____
TOTAL TIME ____ ____ ____(minutes)
Copyright by the University of Washington. All rights reserved.
Do not duplicate without written permission.
2
PROVIDER COMMUNICATION
We would like to know, in as much detail as possible, how good the provider taking care of your
health problems is at talking with you about your illness and the types of care that you would
want if you became sicker or too sick to speak for yourself. We know that many people think
very highly of their providers. To help us improve communication between providers and their
patients, please be critical.
Using the following scale, where “0” is the worst you could imagine, and “10” is the best you
could imagine, please tell me the best number for each statement.
Interviewer: use response 888 when provider did not do
Turn to the response scale card and read response options
When talking with provider x______ about important issues like becoming very ill, how good is
he/she at:
The very worst
I could imagine
The very best
I could imagine
Didn’t
Do
Don’t
Know
1. Using words that you can
understand. 0 1 2 3 4 5 6 7 8 9 10 888 999
2. Looking you in the eye.
0 1 2 3 4 5 6 7 8 9 10 888 999
3. Including your loved ones
in decisions about your
illness and treatment.
0 1 2 3 4 5 6 7 8 9 10 888 999
4. Answering all your
questions about your
illness and treatment.
0 1 2 3 4 5 6 7 8 9 10 888 999
5. Listening to what you
have to say. 0 1 2 3 4 5 6 7 8 9 10 888 999
6. Caring about you as a
person. 0 1 2 3 4 5 6 7 8 9 10 888 999
7. Giving you his/her full
attention. 0 1 2 3 4 5 6 7 8 9 10 888 999
3
When talking with provider x______ about important issues like becoming very ill, how good
is he/she at:
The very worst
I could imagine
The very best
I could imagine
Didn’t
Do
Don’t
Know
8. Talking with you about
your feelings concerning
the possibility that you
might get sicker.
0 1 2 3 4 5 6 7 8 9 10 888 999
9. Talking to you about the
details concerning the
possibility that you might
get sicker.
0 1 2 3 4 5 6 7 8 9 10 888 999
10. Talking to you about how
long you might have to
live.
0 1 2 3 4 5 6 7 8 9 10 888 999
11. Talking to you about what
dying might be like. 0 1 2 3 4 5 6 7 8 9 10 888 999
12. Talking with your loved
ones about what your
dying might be like.
0 1 2 3 4 5 6 7 8 9 10 888 999
13. Involving you in the
decisions about the
treatments that you want
if you get too sick to
speak for yourself.
0 1 2 3 4 5 6 7 8 9 10 888 999
14. Asking about the things
in life that are important
to you.
0 1 2 3 4 5 6 7 8 9 10 888 999
15. Respecting the things in
your life that are
important to you.
0 1 2 3 4 5 6 7 8 9 10 888 999
16. Asking about your
spiritual or religious
beliefs.
0 1 2 3 4 5 6 7 8 9 10 888 999
17. Respecting your spiritual
or religious beliefs. 0 1 2 3 4 5 6 7 8 9 10 888 999
4
The next two questions ask you to rate how comfortable this provider is in talking about
dying and about how well this provider communicates with you.
18. How comfortable do you feel your provider is talking about dying? On the scale below,
0 = “not at all comfortable and 10 = “extremely comfortable” (Circle one number)
Not at all
comfortable
Extremely
comfortable
I do not
know
0 1 2 3 4 5 6 7 8 9 10
19. Overall, how would you rate this provider’s communication with you? On the scale below,
0 = “the very worst I could imagine” and 10 = “the very best I could imagine” (Circle one
number)
The very
worst I could
imagine
The very best
I could
imagine
0 1 2 3 4 5 6 7 8 9 10
Subject # : __________
CANHELP Patient Questionnaire 11 Nov 2014

Can

adian Health Care Evaluation Project
(CANHELP)

Patient Questionnaire

Date : ______ - _______ - ________
DD MMM YYYY

Subject # : __________
CANHELP Patient Questionnaire 11 Nov 2014 2

Instructions:

The following questionnaire includes items that are considered important in terms of
quality of care for people with serious, life threatening illnesses.

Please think about the health care that you have received during the past month
from doctors, nurses and other health care professionals. For each question you will
be asked to choose a number between 1 and 5 to indicate how satisfied you are with
that particular aspect of care -- the higher the number, the more satisfied you are. If
you choose option #1 “Not at all Satisfied”, for example, you will be indicating that
this aspect of the care you received did not meet any of your expectations of high
quality care. At the other end of the scale, your choice of option #5 “Completely
Satisfied” will indicate that this aspect of the care you received met or exceeded
your expectations of quality care.

All answers are confidential and will not be shown to doctors or other health care
professionals who are responsible for your care. There are no right or wrong
answers. Completely honest answers are most helpful!
Subject # : __________
CANHELP Patient Questionnaire 11 Nov 2014 3
The following questions concern the care you received during the past month
For each one, please indicate the degree to which you are satisfied.
.

1. In general

, how satisfied are you with the quality of care you received during the past
month?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Relationship with the Doctors

2. How satisfied are you that you knew the doctor(s) in charge of your care during the
past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

3. How satisfied are you that your doctor(s) took a personal interest in you during the
past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

4. How satisfied are you that your doctor(s) were available when you needed them (by
phone or in person) during the past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

5. How satisfied are you with the level of trust and confidence you had in the doctor(s)
who looked after you during the past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Illness Management

6. How satisfied are you with the level of trust and confidence you had in the nurses
who looked after you during the past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

7. How satisfied are you that the doctors and nurses

who looked after you during the
past month knew enough about your health problems to give you the best possible
care?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Subject # : __________
CANHELP Patient Questionnaire 11 Nov 2014 4
8. How satisfied are you that the doctors and nurses

looking after you during the past
month were compassionate and supportive?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

9. How satisfied are you that you were treated by those doctors and nurses

in a
manner that preserved your sense of dignity during the past month?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

10. How satisfied are you with the tests that were done and the treatments that were
given during the past month for your medical problems?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

11. How satisfied are you that physical symptoms you had during the past month (for
example: pain, shortness of breath, nausea) were adequately assessed and
controlled?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

12. How satisfied are you that emotional problems you had during the past month (for
example: depression, anxiety) were adequately assessed and controlled?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

13. How satisfied are you with the help you received with personal care during the past
month (for example: bathing, toileting, dressing, eating)?

Not At All Not Very Somewhat Very Completely Not Applicable
No Help Needed
1 2 3 4 5 6

14. How satisfied are you that, during the past month, you received good care when a
family member or friend was not able to be with you?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

15. How satisfied are you with the home care services you received during the past
month?

Not At All Not Very Somewhat Very Completely Not Applicable.
No home care needed
1 2 3 4 5 6

Subject # : __________
CANHELP Patient Questionnaire 11 Nov 2014 5
16. How satisfied are you that health care workers worked together as a team to look
after you during the past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

17. How satisfied are you that you were able to manage the financial costs associated
with your illness during the past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

18. How satisfied are you with the environment or the surroundings in which you were
cared for during the past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

19. How satisfied are you that the care and treatment you received during the past
month was consistent with your wishes?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Communication

20. How satisfied are you that the doctor(s) explained things relating to your illness in a
straightforward, honest

manner during the past month?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

21. How satisfied are you that the doctor(s) explained things relating to your illness in a
way you could understand

during the past month?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

22. How satisfied are you that you received consistent

information about your condition
from all doctors and nurses looking after you during the past month?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

23. How satisfied are you that the doctor(s) listened

to what you had to say during the
past month?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Subject # : __________
CANHELP Patient Questionnaire 11 Nov 2014 6
24. How satisfied are you that you received updates about your condition, treatments,
test results, etc. in a timely manner

during the past month?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Decision Making

25. How satisfied are you with discussions during the past month with your doctor(s)
about where you would be cared for (in hospital, at home, or elsewhere) if you were
to get worse?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

26. How satisfied are you with discussions during the past month with your doctor(s)
about the use of life sustaining technologies (for example: CPR or cardiopulmonary
resuscitation, breathing machines, dialysis)?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

27. How satisfied are you that, during the past month, you have come to understand
what to expect in the end stage of your illness (for example: in terms of symptoms
and comfort measures)?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

28. How satisfied are you with your role during the past month in decision making
regarding your medical care?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Role of the Family

29. How satisfied are you with the level of confidence you felt during the past month in
the ability of a family member or friend

to help you manage your illness?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

30. How satisfied are you with discussions during the past month, involving a family
member

or someone who would make decisions for you, about your wishes for
future care in the event you yourself are unable to make those decisions?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Subject # : __________
CANHELP Patient Questionnaire 11 Nov 2014 7
31. How satisfied are you that you were able during the past month to talk comfortably
about your illness, dying, and death with the people you care about?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

32. How satisfied are you that your relationships with family members and others you
care about were strengthened during the past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

33. How satisfied are you that during the past month you were not a burden on your
family or others you care about?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

34. How satisfied are you that you had family or friends to support you when you felt
lonely or isolated during the past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Your Well Being

35. How satisfied are you with the level of confidence you

felt during the past month in
your own ability to manage your illness?
Not At All Not Very Somewhat Very Completely
1 2 3 4 5

36. How satisfied are you that you were able during the past month to contribute to
others in a meaningful way?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

37. How satisfied are you that you did special things you wanted to do during the past
month (for example: resolve conflicts, complete projects, participate in special family
events, travel)?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

38. How satisfied are you that you were at peace during the past month?

Not At All Not Very Somewhat Very Completely
1 2 3 4 5

Abstract (if available)

Abstract In this capstone project the Grand Challenge being addressed is to Close the Health Gap. The lack of end of life conversations for patients with chronic health conditions is a problem that exists within this Grand Challenge. More individuals are being diagnosed with multiple chronic conditions in the United States. Most of these individuals will succumb to these illnesses, as chronic conditions are a leading cause of death. Though death is a reality for most with chronic conditions, it is still an uncomfortable topic for patients and health care providers to discuss. Though health care providers do receive content on end of life during their educational programs, providers are reluctant to discuss this topic with patients. To increase end of life conversations for this population, an end of life training series, Project Prepare, Plan, and Provide, will be piloted in Jackson County, Michigan to train health care providers. The pilot will include 24 health care providers from varying disciplines. This capstone project is innovative because it will train health care providers to begin end of life conversations with patients who have chronic health conditions, 35-64 years old, as opposed to focusing on those 65 years and older.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Bartzen, Sarah Lynn (author)

Core Title Capstone project: Project prepare, plan, and provide

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 12/03/2019

Defense Date 11/22/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag chronic health conditions,close the health gap,end of life,grand challenges for social work,health care provider,OAI-PMH Harvest,training and education

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Arriaran, Karla (committee chair), Manderscheid, Ronald (committee chair), Rank, Michael (committee chair)

Creator Email bartzen@usc.edu,slbartzen@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-243717

Unique identifier UC11673347

Identifier etd-BartzenSar-7966.pdf (filename),usctheses-c89-243717 (legacy record id)

Legacy Identifier etd-BartzenSar-7966.pdf

Dmrecord 243717

Document Type Capstone project

Rights Bartzen, Sarah Lynn

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA