Palliative Care and SNF physicians are currently seeing patients at their most vulnerable  time; at new diagnosis of a life limiting disease, advancement of their life limiting disease or at the end of their life when there is no hope for cure. Patients and families are struggle with naming a Designated Decision Maker or doing any life care planning including completing a POLST. The physicians require highly developed skills to facilitate these often very difficult conversations. 
The NSA shows 28% of eligible patients have completed a POLST. The NSA has a one Certified Advanced Steps Physician Facilitator with a total of 43 conversations completed by Non-MD (40 conversations) & MD (2 conversations) Facilitators in December 2016. 
Often these difficult conversations require advanced skills in how to approach conflict through demonstrating empathy and eliciting the patients perspective, investing in the interactions, work with conflict effectively and communicate clearly. This ultimately impact HCAPS scores and patient satisfactions.

Best practices for care for patients with life limiting diseases is to understand the patients and families goals of care and to fulfill these requests.  This prevents the confusion and implementation of aggressive care when it is unwanted or unnecessary based on the patients wishes.  The goal for 2017 for Life Care Planning-Advanced Steps conversation and completion of POLSTS is 100 conversations a month putting the NSA as having 58% of the eligible population having had an Advanced Steps conversation.  By the end of 2018 the goal is for 80% of eligible members will have had an Advanced Steps conversation or POLST completed. This 4-Habits Model will facilitate successful engagement by our palliative care and SNF physicians and assist in meeting these goals, advancing the conversation, clarifying goals of care and effectively managing conflict.