Advance care planning (ACP) is defined as a process that supports individuals in understanding and sharing their values, goals and preferences for future medical care. These care decisions are then formally documented in an Advance Directive, a forward-thinking legal document that empowers individuals, their loved ones and their care teams to make the right healthcare decisions moving forward. ACP facilitates physicians providing patients with the right care, at the right time, in the appropriate setting. Download a patient-facing handout here.
By providing education about disease progression and the risks and benefits of different treatment options, individuals can create a care plan that truly enables them to achieve their quality-of-life goals. Likewise, by documenting and distributing these care decisions, ACP ensures that individuals’ care preferences are understood and followed throughout their healthcare journey, creating a higher quality care experience overall. ACP is associated with reduced hospitalization, receipt of less intensive treatments, increased utilization of hospice services.
The Iris Premier program is a service that is offered to UHA Members at higher risk. It is an enhanced ACP service that is fully facilitated by healthcare professionals via phone or video conference. Iris’ highly trained ACP experts have in-depth conversations with each patient and their loved ones, taking the time to listen, counsel and provide support to tailor a plan to the patient’s unique and disease-specific care needs. The resulting documented plans are then distributed by Iris to all care teams for future use. Enrolled patients receive two years of support.
Who is Iris Healthcare?
Iris Healthcare is our partner for providing advance care planning (ACP) services to patients dealing with serious illness. Their specially trained health experts facilitate these crucial conversations with the patient, and their loved ones / caregivers, help resolve any conflict that arises, and ultimately complete a full set of advance directives. The service is offered daytime, evenings and weekends and provided through phone or video conference.
Why is ACP important?
ACP is important because it has been shown to improve patient and family satisfaction, help get patients the care they want while avoiding unwanted treatments, decrease the total cost of care, and support the physicians in their work.
How are patients chosen to go through ACP with Iris?
The patients are identified by Umpqua Health. All of these patients have a serious illness (ex. CHF or late-stage malignancy). Patients you identify as having a need for ACP can also be referred to Iris through Umpqua Health care coordination.
How does Iris contact my patient?
Patients are initially contacted through phone to offer the service, answer questions, and enroll them in the program.
What does the service cost my patient?
The service is FREE to UHA Members.
Who facilitates these conversations with my patients from Iris?
Iris uses licensed healthcare professionals to facilitate ACP discussions (typically nurses or social workers). Their backgrounds are such that they’ve had long-time exposure to the situations the patients are experiencing. The facilitators go through a rigorous ACP training program with Iris before they are permitted to facilitate, and they receive extensive ongoing quality reviews and coaching.
What does Iris do to assure quality control?
The facilitators receive regular feedback and trainings on ACP. All conversations with patients,whether it is through phone or video, are recorded. Iris supervisors review these and provide structured, focused feedback. The technology Iris has built allows measurement of everything the facilitators do. Quality is monitored on a continued basis for the purpose of creating master facilitators.
How does Iris communicate with the physician and practice?
Iris sends communications to the physician and practice after the initial set of ACP
conversations are held. This information reflects what is happening with your patient – which advance directives are being generated, what the patients understand about their disease or situation, and more. If there is something urgent that we uncover or observe, we call the practice directly to convey this information.
What happens after the initial ACP discussions are over and the documents are generated?
The Iris ACP process is a longitudinal one. As a disease progresses, often times patient
preferences evolve. We hold follow up conversations, update the documents based on new goals, and then re-distribute them to the family, hospital and physician(s).
Does Iris change the physician plan?
No – they do not make diagnoses, give advice, or alter your treatment plan. Iris is not in the corporate practice of medicine.
Do they use CPT codes to bill?
Iris does not use CPT codes. Patients and families do not pay for this service. However, we do make it easy for the physician and practice to utilize the two ACP CPT codes by having someone from the office review with the patient the advance directives Iris has created.
Does this create a billing opportunity for me?
Yes. Iris has prepared a memo to provide details on how you can bill for time you
and/or your staff (including RNs) spends reviewing the advance directives and following-up with your patient on the ACP discussions that they’ve already had with Iris.
Where do I send referrals?
If you think this service would benefit your patient, please contact our Care Coordination team at CaseManagement@umpquahealth.com