Transcription:
CARE Act and Advanced Directives

Melanie Cole (Host): The CARE Act, enacted in January of 2016 in Indiana has impacted those who can make a decision concerning a patient's healthcare choices, and many patients are easily confused by the number of patient designees they may be asked to designate to make healthcare choices for them should they become incapacitated or unable to communicate their wishes. My guest today is Rhonda Conrad. She's the director of transitions of care at Hendricks Regional Health. Welcome to the show, Rhonda. So, let's speak about some information for people who may need to stay in the hospital, and what is the CARE Act?

Rhonda Conrad, MSW, LCSW (Guest): Well, the CARE Act which again was enacted at the first of last year in January is known as the Caregiver Advise, Record and Enable Act, and what the CARE Act does is allows a person in the hospital to identify a caregiver who will be providing some care for them after they get out of the hospital or generally just looking after that person. The CARE Act allows a patient to identify this person which in turn the hospital's requirements are to provide the identification of this person in the medical record, and then we also will work with that person, reach out to them to provide general information on the patient's aftercare needs which could include anything from medication management, injections, how to operate medical equipment, things like that. It's to promote and support caregivers of patients.

Melanie: Can your healthcare representative also be your lay caregiver?

Rhonda: Absolutely. The healthcare representative can be the same as the lay caregiver. If a patient is unable to appoint a lay caregiver because they are not able to speak for themselves when they come into the hospital, then the healthcare representative can also designate a lay caregiver, but it does not have to be the same person.

Melanie: So that's where some of the confusion comes in -- is the healthcare representative designating somebody to be the lay caregiver, can they designate more than one person? Speak about that a little bit.

Rhonda: They can designate more than one person, but certainly the CARE Act only requires that we engage with one person that is identified as the lay caregiver, which again is generally a person who's going to provide aftercare or just look after the person after they get home during their recovery period. The healthcare representative or the designated healthcare rep can be somebody that's not even in the general area or even the state, and we've some that aren't in the country whereas the lay caregiver certainly needs to be somebody that's going to be in direct contact with the patient frequently after they are discharged.

Melanie: So how does the hospital that you have to notify the lay caregiver before they're discharged -- the patient is discharged from the hospital. Explain a little bit about the educational aspect of this explanation, the instructions for the post-hospital care, and what do you tell this caregiver?

Rhonda: Well, the CARE Act what it indicates that it's the regulation for hospitals in the state of Indiana is that we have to make every effort to make contact with the identified lay caregiver. Certainly, our goal is to be patient-centered, and we want to support that caregiver in being able to provide optimal assistance to that patient after they get out of the hospital. We find when we adhere to patient's wishes and preferences, our outcomes are more optimal. The type of things that we would be working with a lay caregiver on would be things like managing wound care. Again, assisting with administering medications, we would help them with learning how to operate medical equipment and just transfers between maybe a bed to a bedside commode if necessary -- those sorts of things. Those sorts of daily activities that a patient needs during their recovery.

Melanie: So, how does the healthcare representative pick or whether the patient does it themselves and based on this CARE Act, how do they pick somebody to be the lay caregiver and is there sort of a check as to whether or not this person knows how to be a caregiver?

Rhonda: Well, the lay caregiver -- the CARE Act in and of itself does not indicate that a person who is identified by the patient as a lay caregiver is obligated to take on that role. So, certainly we would ask that the lay caregiver confirm to us that they feel capable of providing care for this patient after they leave the hospital, but again that is not an obligation on their part just because they are identified. Generally most patients -- particularly for planned admissions -- that would be for surgeries -- know who is going to provide care for them when they get home. For those acute care episodes that happen that aren't planned a lot of our patients do have somebody that reasonably they know will be either looking after them or providing some direct care services when they get home.

Melanie: So, then there's been some confusion, Rhonda, between advance directives and the CARE Act. So, speak about advanced directives a little bit, and what types are recognized in Indiana and sort of why are these two things sometimes connected?

Rhonda: Well, I think there is some confusion about that. I think that it's mostly related to the fact that they do include -- some advance directives include a designation and so does the CARE Act; it includes a designation of a caregiver. Advanced directives are legal documents that allow an individual to make known their wishes if they were unable to communicate for themselves. There are several advanced directives that are recognized in Indiana. Some of them include a document that a patient fills out that puts in writing what their wishes are for future medical care if they were unable to speak for themselves. Other documents -- other advanced directives allow for a patient to designate someone to make those decisions for them. The recognized advanced directives in Indiana are -- there's an advanced directive for organ and tissue donation. There's a healthcare representative form where you can designate someone to make healthcare decisions for you. Most people are familiar with the living will declaration which allows a patient to put in writing what their wishes are should they be terminally -- deemed terminally ill. There are psychiatric advanced directives which are a little less known in healthcare, but does allow for somebody who has a psychiatric condition that may lead them to have incapacity to appoint someone to make decisions for them in that regard. There's also an out-of-hospital "Do Not Resuscitate" declaration. A lot of in the hospital, we have what we call DNRs which people are generally familiar with, but once the patient leaves the hospital -- even in an ambulance -- that does not apply so this advanced directive, the out-of-hospital "Do Not Resuscitate" order allows that to continue.
Certainly most people have heard of a power of attorney form and then there's the physician orders for scope of treatment which is the newest advanced directive we have, which is a post form, which is a doctor's order that includes a conversation between the patient and the doctor of what kind of medical provisions they want as they progress through their illness, and the provisions that they don't want and so the doctor goes ahead and writes out an order and this advanced directive – a post form -- stays with the patient, and it is enforced in every healthcare arena that they may find themselves.

Melanie: Are they required?

Rhonda: Advanced directives are not required. No. Highly recommended, certainly for people, particularly people with chronic illnesses or illnesses that could eventually result in death, but they are not required.

Melanie: And what happens in Indiana if you do not have an advanced directive?

Rhonda: Indiana law states that if you do not have an advanced directive, and you are unable to speak for yourself that the hospital will make every effort to contact what is a reasonable next of kin, and that's somebody that would know your wishes well. We have to use clinical judgement on our side that we have determined that the person we're speaking to is the patient's next of kin, and either lives in their home or is around them enough and would have this kind of knowledge that this is what the patient wants. In an emergency situation, certainly, we have to go with who we can contact first, but in Indiana, it's kind of the next of kin. We do not follow -- Indiana does not follow a strategy of it has to be a spouse, adult children, things like that, but that again, we have to use our clinical judgement on who we think would be the most likely person to have the information on what the patient's wishes would be.

Melanie: So, Rhonda, wrap it up for us what you would like listeners to know about the CARE Act in Indiana and designees and healthcare representatives. Give your best advice so that people can understand what this means for them.

Rhonda: Well, I think it's important for people to know that they -- the rights that they have as far as their healthcare and there are designees that they can make to make decisions for them if they would like, and in the advanced directive arena, certainly we can get those things in writing, and we can help to get patients in the right direction to execute advanced directives in that regard and when patients come to Hendricks Regional Health, we do encourage them to sign a form -- assigning a healthcare representative in case something would happen where they were unable to speak for themselves during their hospitalization. On the other side with the CARE Act, we certainly want to empower and encourage caregivers to be confident and capable of taking care of their loved one when they are discharged from the hospital, and so we do want patients to also designate and identify who that person is so that we can work with them. At Hendricks, we apply the principles of patient-centered care, and we believe strongly in patient rights, and we know that this is going to have a valuable and positive impact on the outcome.

Melanie: Thank you so much, Rhonda for being with us today. You're listening to Health Talks with HRH -- Hendricks Regional Health, and for more information, you can go to hendricks.org. That's hendricks.org. This is Melanie Cole. Thanks so much for listening.