employee healthcare decisions survey (2008) summary report

Transcription

1 Patients, families and professionals view reliable information on: Advance Care Planning Health Care Proxies Medical Orders for Life-Sustaining Treatment (MOLST) Life-Sustaining Treatment Feeding Tubes Pain Management Hospice & Palliative Care Death & Dying Spiritual Information Pediatrics En Espanol employee healthcare decisions survey (2008) summary report MOLST Video Visit CompassionandSupport to view our MOLST video. Learn how a new program for seriously ill patients improves care at the end-of-life Created by the Community-wide End-of-life/Palliative Care Initiative UN-442/

2 employee healthcare decisions survey (2008) A Report on Overall Knowledge, Motivation, Behavioral Readiness & Self-Reported Completion Rates Regarding Health Care Proxies and Living Wills summary report april 2008 Dr. Patricia Bomba Vice President & Medical Director, Geriatrics Julian Puretz Management Consultant

3 executive summary Over the last several years, Univera Healthcare has made a significant commitment to help its employees and people in the community become more aware of the importance of completing advance directives, including the designation of a Health Care Proxy, the completion of a Living Will and the importance of sharing wishes through conversations among families, close friends and trusted individuals, including the individual s personal physician. An advance care planning employee campaign held in October through November 2007 was initiated by an message from CEO David Klein followed by a series of s from Dr. Patricia Bomba, a national expert on advance care planning. Interventions utilized were developed in response to information derived from the 2006 Employee Healthcare Decisions Survey and included educational sessions, web-based information, the Community Conversations on Compassionate Care video and financial incentives. In 2002 and 2006, Univera Healthcare conducted surveys of all its employees to assess their knowledge and actions regarding two key advance directives, Health Care Proxies and Living Wills. During the fouryear period extending from , the completion rates for Health Care Proxies rose from to 34% among employees, while completion of Living Wills remained essentially unchanged (18% in 2002 vs. 17% in 2006). i ii Few studies on advance directives have been conducted nationally. A nationwide poll conducted by the AARP Bulletin in 2007 found that more than 9 of adults 35 or older are aware of Health Care Proxies and Living Wills, but less than have actually completed these forms (37% reported completing a Health Care Proxy and 36% a Living Will).iii Similarly, a nationwide poll conducted by the Pew Research Center in 2005 found that 95% of adults had awareness but only 29% of Americans had completed an advance directive, specifically a living will; Health Care Proxy completion rates were not assessed. iv In February 2008, Univera Healthcare conducted a third wave of the Employee Healthcare Decisions Survey (Employee Survey) to see whether employee knowledge and behavior regarding advance directives had changed over the past two years. The survey instrument and methodology were nearly identical to that used in the previous, 2006 Employee Survey. In both studies, an online methodology was used. On February 8th, all 4,343 Univera Healthcare employees were sent an inviting them to participate in the survey. Two follow-up s were sent to non-respondents within two weeks of the initial mailing to help improve the response rate. Of the over 4,300 surveys sent to employees, 2,314 or 53% responded, about the same response rate reported in 2006 (52%). The response rate obtained in the 2002 Survey was significantly lower (only 35%), even though the survey tool used in that survey was much shorter (only 6 questions, compared with 23 questions in the 2006 and 2008 Surveys). However, the 2002 Survey was conducted by mail (not online) and only one survey was mailed to employees. survey response rate % 53% 35%

4 The number of surveys completed by region is summarized in the table below. The margin of error for the overall sample (n = 2,314) is approximately ±2%. Margin of errors for specific regions varied with from ±3% for Rochester to ±22% for the Southern Tier. key findings The key findings from the 2008 Employee Survey are summarized below. Where appropriate, wave-towave comparisons are also discussed (2006 or 2002 results), as are certain findings from the Community Survey and certain national surveys. Regional results are also presented, with the exception of the Southern Tier, where the number of respondents was too small to be considered meaningful. 2 Surveys Margin of Region Returned Error Rochester 1,029 ±3% CNY 675 ±4% Utica 286 ±6% Southern Tier 19 ±22% WNY 299 ±6% Total 2,314 ±2% Specific issues explored on the survey included: Awareness and knowledge of Health Care Proxies and Living Wills Completion rates for Health Care Proxies and Living Wills Factors influencing the completion of Health Care Proxy forms Barriers to completion Discussions of Health Care Proxies and Living Wills with personal doctor Awareness and knowledge of the term, advance directives Note: Results from the Southern Tier are based on very few respondents (n=19), and therefore are not considered reliable. Specific results from this regional segment have not been included or discussed in this report. In addition to the 2008 Employee Healthcare Decisions Survey, Univera Healthcare also conducted a similar community-wide survey in March and April The End-of-Life Care Survey of Upstate New Yorkers: Advance Care Planning Values and Actions (Community Survey) examined knowledge, actions, as well attitudes of upstate New Yorkers toward Health Care Proxies and Living Wills. A number of questions from the Employee Survey were also included in the Community Survey. The Community Survey was conducted by telephone with a random sample of 2,000 adults (18 and over) living in the 39-county upstate area served by Univera Healthcare. The findings from the Community Survey are presented in a separate report (End-of-Life Care Survey of Upstate New Yorkers: Advance Care Planning Values and Actions).v For comparative purposes, selected results from that study are included in this report as well (e.g., knowledge and completion rates for Health Care Proxies and Living Wills). To help make these employee-community comparisons more meaningful, the community results that are used in this report included only respondents who were under the age of 65 and employed (n = 1,138). In addition, the community data was also adjusted (weighted) by region, age, and gender, so that demographic differences between the employee and community samples would be minimized. Rochester Central NY Southern Tier Utica Western NY Livingston Cayuga Broome Clinton Allegany Monroe Cortland Chemung Delaware Cattaraugus Ontario Jefferson Chenango Essex Chautauqua Seneca Lewis Schuyler Franklin Erie Wayne Onondaga Steuben Fulton Genesee Yates Oswego Tioga Hamilton Niagara St. Lawrence Herkimer Orleans Tompkins Madison Wyoming Montgomery Oneida Otsego awareness and knowledge of health care proxies knowledge of health care proxies by region awareness/knowledge of health care proxies Univera Healthcare employees appear to be very aware of and knowledgeable about Health Care Proxies. Nearly all (99%) said they had heard of the term, Health Care Proxy, and 97% have both heard of the term and knew what it meant (i.e., were able to identify its correct definition from a list of 5 choices). In 2006, a slightly smaller percentage said they had heard of the term (96%) and knew its definition (95%) % Awareness 99% Knowledge Knowledge of Health Care Proxies varied to some extent by age and gender, with young adults (18-24) and men being the least knowledgeable segments (9 and 95% respectively), a finding that was true in 2006 as well. However, during the last two years, both of these segments showed significant improvement in their level of knowledge of Health Care Proxies. For young adults, knowledge of Health Care Proxies rose from 67% in 2006 to 9 in For men, knowledge of Health Care Proxies rose from 89% in 2006 to 95% in the latest wave. Among women, knowledge of Health Care Proxies has been consistently high (97% in 2006, 98% in 2008) % 97% 94% 97% 95% 97% 94% 98% 97% 97% 97% 98% 3

5 Knowledge of Health Care Proxies varied little across regions (97%-98%). Significant improvements were observed in all regions, and across most age and education segments. knowledge of advance directive among Univera Healthcare employees and upstate residents Univera Healthcare employees appear to be more aware and knowledgeable about Health Care Proxies than their upstate New York counterparts. In the Community Survey, 83% of upstate residents said that they had heard of the term, Health Care Proxy, compared with 99% of Univera Healthcare employees % 78% 88% 74% completion rate for health care proxies by region % 34% 37% 45% 42% 33% 31% 51% 36% 18% Health Care Proxy Living Will Completion rates among Univera Healthcare employees were slightly higher than their counterparts living in the 39-county upstate New York area, after adjusting for differences in demographic characteristics between the two segments (43% vs. 41% for upstate residents). completion rate for health care proxies Overall, 43% of employees surveyed said they had designated a Health Care Proxy and completed a Health Care Proxy form, up significantly from 2006 (34%). completion rates for employees and upstate residents health care proxies and living wills 7 43% 41% 23% completion rate for health care proxies Health Care Proxy Living Will 43% 34%

6 completion rates for employees and upstate residents by region health care proxies Completion rates for Health Care Proxy forms varied significantly across regions, being highest in WNY (51%) and Rochester (45%), and lowest in Utica (31%). In CNY, 42% reported completing a Healthy Care Proxy form. In the Community Survey, the lowest completion rate was also observed in Utica (). 7 43% 41% 45% 46% 42% 41% 31% 51% 43% completion rates for employees and upstate residents by age health care proxies After the age of 25, the completion rate among employees increased by about 8- for every 10 years of age. Completion rates among young adult (ages 18 to 24) employees (25%) were noticeably higher than young adults in the community (9%). 7 43% 41% 39% 46% 49% 44% 51% 25% 31% 29% 9% Total Compared with results from a 2007 national poll (AARP Bulletin), the completion rate among Univera Healthcare employees is higher (43% vs. 37% of Americans 35 or older). demographic factors that influence completion rates for health care proxies Age is clearly the most important demographic factor influencing completion rates for Health Care Proxies. Among employees, completion rates ranged from a low of 25% for young adults (18-24) to a high of among those 55 or older. Steady growth in completion rates was observed among all age groups from two years ago. Other demographic factors that appear to influence completion rates for Health Care Proxies include: Gender women were significantly more likely than men to report completing Health Care Proxies (46% vs. 35%) and accounted for most of the observed improvement, with 46% saying they have completed a Health Care Proxy form, up from 34% two years ago. Among men, the completion rate showed only a modest, and not statistically significant, improvement over the last two years (from 32% to 35%). Influence of age on completion rates for health care proxies % 31% 24% 39% 31% 49% 37% 48% completion rates for health care proxies among men and women 7 32% 35% 34% 46% 6 17% Men Women 7

7 Education those with advanced college degrees were more likely to report completing a Health Care Proxy form (54% vs. 38% of those without any college education). other factors that influence the decision to complete a health care proxy form who had completed a Health Care Proxy were asked how important various factors were in their decision to complete the form. Psychological factors topped the list; however, personal experience and the influence of physicians and family members also played a significant role in many cases: 87% said that peace of mind knowing that their wishes would be honored 8 did not want to create problems for loved ones 48% mentioned a personal experience with the end-of-life care of others 15% said their physician recommending it played a significant role 14% mentioned the influence of their spouse or other relatives 13% said the Terri Schiavo case had a significant impact on them Similar responses were observed in when health care proxy was first completed timing of completion One of every five Health Care Proxy completions reportedly occurred within six months prior to the survey (), up from only 7% in This finding suggests that the advance care planning employee campaign conducted in the fall of 2007 had a significant impact on Health Care Proxy completions, perhaps accounting for two-thirds of the overall increase in the completion rate observed since As previously described, the advance care planning employee campaign involved a series of employee interventions, including an incentive program. 14% 27% 21% 28% 24% 28% 21% which of these factors played a significant role in your decision to complete a health care proxy form? Peace of mind knowing I would receive care consistent with my wishes Did not want to create problems for family/loved ones Personal experience with end-of-life care of others My physician recommended it My spouse/relatives recommended it The Terry Schiavo case 88% 8 48% 15% 14% 13% % Less than months ago months ago years ago years ago years ago behavioral readiness to complete a health care proxy While 43% of employees surveyed completed a Health Care Proxy, determining the stage of readiness to complete a Health Care Proxy generates reliable information for future interventions. Among all employees surveyed, only 5% see no need for a Health Care Proxy, Just over one-fourth (27%) are ready to complete their Health Care Proxy, a segment that requires some additional motivation and incentives to encourage them to act. An additional 27% of employees have identified barriers that need to be addressed. Overall, the percentage of employees needing motivation and having barriers has declined during the past couple of years. stages of behavioral readiness for completion of health care proxies No Need 5% 6% See no need to fill out a health care proxy Barriers Exist 27% See the need, but barriers exist Motivation Needed 27% 33% Ready to complete the form, or have actually started Form Completion 37% Completed form and it reflects my wishes Form Completion with changes needed 4% 5% Completed form, but needs to be changed 8 9

8 Further analysis of employees who have not completed a Health Care Proxy reveals that 45% are ready to fill out a form or have already started, 47% said they see a need to fill out the form but there are reasons or barriers preventing them from doing so, while the remaining 9% saw no need to complete the form. Similar results were observed in 2006, although at that time a slightly higher percentage indicated that they were ready to complete the form (48% vs. 45% in 2008). awareness/knowledge of living wills Nearly all Univera Healthcare employees (99%) said they had heard of the term, Living Will, and 88% have both heard of the term and know what it means (i.e., were able to identify its correct definition from a list of 5 choices). In 2006, about the same percentage said they had heard of the term (98%) and knew its definition (89%). Not surprisingly, young adults (18-24) were much more likely to say that they did not see a need to complete a Health Care Proxy form (33% vs. 9% overall). Similar results were reported in barriers to completing a health care proxy awareness and knowledge of living wills % 99% 89% 88% The most common reasons employees gave for not completing a Health Care Proxy form included: 7 Not knowing who to designate as a Health Care Proxy (mentioned by 16% of those who did not complete the form) Not having enough time (16%) Not knowing where to get the forms (15%) Being uncomfortable thinking about the topic (13%) Not knowing enough about it (8%) Too young to be concerned about it (6%) Similar responses were reported in 2006 Awareness Knowledge top reasons for not completing health care proxy Don t know who to designate Don t have enough time Don t know where to get forms 16% 16% 15% Knowledge of Living Wills varied little across regions (87-89%). Age and education level appeared to have some impact, with college graduates and employees over the age of 35 being somewhat more knowledgeable about Living Wills than other segments. Uncormfortable with topic 13% knowledge of living wills by region % 88% 88% 88% 91% 87% 87% 88% 89% 89% Don t know enough about it 8% 8 Too young to be concerned 6% 7 5% 15% 25% 35% A very similar pattern of results was observed in Univera Healthcare employees were found to be significantly more likely to be knowledgeable about Living Wills when compared with the general upstate community (88% of employees vs. 79% of upstate New Yorkers)

9 knowledge of advance directives among Univera Healthcare employees and upstate residents % 78% 88% 74% completion rate for living wills by region Completion rates for Living Wills varied significantly across regions, the differences being similar to those already reported for Health Care Proxies. Highest completion rates were observed in Rochester () and WNY (28%), while the lowest rate was reported in Utica (17%). In the Community Survey, the lowest completion rate was also observed in Utica (). Health Care Proxy Living Will 17% 14% 23% 11% 17% 17% 28% completion rate for living wills completion rate for living wills Overall, of employees said they had completed a Living Will, up significantly from 2006 (17%). Significant improvements were observed in most regions, and across most demographic segments. While completion rates for both men and women improved over the past two years, the increase was much larger for women than for men (from 17% to 27% for women, and from 18% to 23% for men). In fact, the change in the completion rates for men was not statistically significant. completion rate for employees and upstate residents by region living wills 7 23% 25% 23% 22% 21% 17% 28% 21% 18% 17% 2002 After adjusting for differences in demographic characteristics, completion rates among Univera Healthcare employees were found to be somewhat, but not significantly higher than residents living in the 39-county upstate New York area ( vs. 23% for upstate residents)

10 completion rates for employees and upstate residents health care proxies and living wills 7 43% 41% Other demographic factors that appear to influence completion rates for Living Wills include: Education those with advanced college degrees were more likely to report completing a Living Will (37% vs. 22% of those without a four-year college degree). Marital Status married employees were significantly more likely to report completing a Living Will (29% vs. of single employees). discussions with doctors 23% Just over a third of respondents said that their doctor had talked to them about Health Care Proxies and Living Wills (36%), up from 34% in 2006 (a difference that was not significant). The figure was significantly higher in Rochester (44%) than in other regions (Utica, 19%; WNY, 27%; and CNY, 34%). Health Care Proxy Living Will has a doctor ever talked to you about health care proxies or living wills? (% Yes) 34% 36% 43% 44% 34% 31% 19% 19% 27% demographic factors that influence completion rates for living wills As with Health Care Proxies, age is the most important demographic factor influencing completion rates for Living Wills. Among employees, completion rates ranged from a low of 11% for young adults (18-24) to a high of 35% among those 55 or older. completion rates for employees and upstate residents by age living wills Completion rates among young adult (ages 18 to 24) employees (11%) were noticeably higher than young adults in the community (3%). 7 Interestingly, these regional differences in discussions with doctors were observed in the Community Survey as well, and may help explain some of the rate differences observed among regions. Women also were much more likely than men to report that their doctor had spoken to them about advance directives (39% vs. 24% of men), a finding that was observed in the Community Survey as well. 23% 11% 3% 15% 17% 24% 22% 32% 28% 35% Total % 14 15

11 conclusions During the past two years, the completion rates for Health Care Proxies and Living Wills have risen significantly within the Univera Healthcare employee population. Overall, the completion rate for Health Care Proxies now stands at about 43% for employees, up from 34% in For Living Wills, the completion rate is, up from 17% two years ago. Improvements were seen across all regions for both advance directives. A discrepancy exists in completion rates between Health Care Proxies and Living Wills, presumably because the Health Care Proxy is the legal document in New York State. Community education in the state has focused on the importance of completing a Health Care Proxy and on having a conversation with family, close friends and personal physician. references i ii Last accessed April 11, FINAL.pdf Last accessed April 11, 2008 iii Last accessed April 11, 2008 iv Last accessed April 11, 2008 v vi Guest/Contact+Us/Health+Policy+%26+Research/GLO-Contact+Us-Health+Policy+and+Research Last accessed April 23, 2008 Ott B. B. Advance Directives: The Emerging Body of Research. American Journal of Critical Care. 1999; 8(1) www. Last accessed February 11, Significant regional differences exist in completion rates for Health Care Proxies, a finding that was observed in the Community Survey as well. Completion rates among employees are highest in WNY (51%) and Rochester (45%) and lowest in Utica (31%). Similar regional differences exist in the completion rates for Living Wills. vii Dexter P. R., Wolinsky F. D. Gramelspacher G. P., Zhou Z. H., Eckert G. J., Waisburd M., Tierney W. M. Effectiveness of Computer-Generated Reminders for Increasing Discussions about Advance Directives and Completion of Advance Directive Forms. Annals Intern Med.1998; 128(2): viii Wenger N. S., Kanouse D. E., Collins R. L., et al. End-of-life discussions and preferences among persons with HIV. JAMA, 285:2880-7, The completion rates for employees are somewhat higher than those of the upstate community, after adjusting for differences on key demographic factors known to significantly impact completion rates (e.g., age, region, gender). ix x Emanuel L. L., Barry M. J., Stoeckle J. D., Ettelson L. M., Emanuel E. J. Advance directives for medical care a case for greater use. N Engl J Med. 1991; 324: Gordon N. P., Shade S. B. Advance Directives Are More Likely Among Seniors Asked About End-of-Life Care Preferences. Arch Intern Med. 1999; 159: Comparisons of the employee results with those obtained from recent national surveys (e.g., AARP Bulletin, Pew Research) are difficult to make, due to significant differences between the demographics of our employee population and the populations targeted in the national surveys. The demographics of the populations surveyed are quite different, particularly with regard to age which has been shown to be a key factor in driving completion rates. xi Hahn M. E. Advance Directives and Patient-Physician Communication. MSJAMA. 2003; 289:96. xii Morrison, R. S. and Meier, D. E. High rates of advance care planning in New York City s elderly population. Arch Intern Med Dec Dec 27; 164(22): Evidence from both the Employee and Community Surveys suggests that regional differences in completion rates may be driven, in part, by physician communications with patients. In both surveys, the highest rate of discussion with doctors occurred in Rochester while the lowest rate was observed in Utica. Studies in the medical literature have demonstrated that physician counseling markedly increases the completion rate of advance directives. vi vii viii ix x xi xii Further, evidence from the Employee and Community Surveys suggest community education makes a difference. Higher completion rates are present in regions where community education efforts have been initiated. While male employees showed some improvement in completion rates, women accounted for most of the improvement seen during the past two years, especially for Health Care Proxies. Age is the most important factor affecting completion rates for Health Care Proxies and Living Wills. As people grow older, they are much more likely to engage in advance care planning. Other demographic factors that may influence the decision to act include gender, level of education, and marital status. Some evidence suggests that young adults (ages 18 to 24) can respond to behavioral interventions and be motivated to take action and complete a Health Care Proxy. Personal experience with the end-of-life care of others appears to play a major role in the decision to designate a Health Care Proxy. Nearly half of those who had completed a Health Care Proxy form mentioned personal experience as playing a significant role in their decision to act. The results support the view that an advance care planning employee campaign that utilizes interventions that include incentives can motivate employees to take action to complete a Health Care Proxy. appear to be fairly knowledgeable about Health Care Proxies and Living Wills. Nearly all employees have heard of these terms, and the vast majority know what is meant by these terms (95% are knowledgeable about Health Care Proxies, 88% are knowledgeable about Living Wills). Univera Healthcare employees also appear to be more aware and knowledgeable about Health Care Proxies and Living Wills than their upstate New York counterparts. For more information on Advance Care Planning, view

12 five easy steps 1. Learn About Advance Directives NYS Health Care Proxy NYS Living Will 2. Remove Barriers 3. Motivate Yourself View Full CCCC Video 4. Complete your documents Have a conversation with your family Choose the right Health Care Agent Discuss what is important to you CCCC Video Learn why healthy individuals should complete their Advance Directive. Understand life-sustaining treatment Share copies of your directives 5. Review and Update For more information on Advance Care Planning, view 18