Education is first step in end-of-life initiative

Insurer’s goal is to make sure wishes are respected

Educating the internal staff was the first step in Highmark Blue Cross Blue Shield’s Advance Care Planning/End-of-Life Care program.

"In order to think about what we needed to do for our members, we needed to be educated, ourselves," says Judith Black, MD, senior products medical director for Highmark.

The insurer, with headquarters in Pittsburgh, started its advanced care planning initiatives in summer 2000. A committee guided the process with representatives from all segments of the health plan, including case management and care management.

"We felt we could do a better job of increasing members’ awareness of advanced care processes so they could talk to their physicians. We knew that an essential part of it was to have a staff that is knowledgeable about advanced care planning," Black says.

Advanced care planning is a process that guides people through thinking about what kind of care they want in end-of-life situations.

Documents necessary for advanced care planning include advance directives, a written plan that lets health care providers know what kind of care the person wants, a health care power of attorney that designates a surrogate to make treatment decisions if the patient can’t make them for him- or herself, and a living will (an advanced directive that goes into effect only if the patient has a terminal condition or a state of permanent unconsciousness).

"Advanced care planning is a process which allows people to make choices if they are terminally ill. One of our first concerns was to make sure that care managers and case managers realized that advanced care planning is not the same thing as having advance directives," Black says.

The committee decided on a comprehensive plan to increase awareness of advanced care planning through working with community groups, educating health care providers, and guiding members through the process, she says.

But first, the internal staff needed to be comfortable with end-of-life issues before they could discuss the issues with the members or their families, she adds.

Training was provided for case managers in Highmark’s SeniorCareBlue, a case management program specifically for the frail elderly in nursing homes; the Blues on Call staff (the insurer’s disease management vendor), and general case management staff.

Community organizations that helped educate the staff about advanced care planning included palliative care organizations, hospices, the Pennsylvania Bar Association, the End-of-Life Partnership of Western Pennsylvania, the Allegheny County Medical Society, and the Allegheny County Bar Association.

The Allegheny County Medical Society and Allegheny County Bar Association provided information about advanced care planning, living wills, and health care power of attorney that case managers can give to members.

Highmark developed a training video for case managers and care managers to help them talk to members about advanced care planning and the difference between comprehensive planning and just having advance directives in place.

The video includes role-playing by staff members showing scenarios between case managers and their clients when end-of-life issues are discussed.

The Highmark web site includes educational tools for physicians and case managers including information about end-of-life issues, such as palliative care and pain management.