Advanced Care Planning in Case Management | Comprehensive Case Management Certification

Hey there, everybody, and welcome to this presentation on advanced care planning in case management. I'm your host, Dr. Donnelly Snipes. Now, this class was one of my favorite classes when I was going through my master's program in rehabilitation counseling. Dr. Horace Sawyer was our professor, and he did a great job. So I'm hoping that I can communicate some of the finer points of this to you in this meager hour that we're going to be talking about advanced care planning or life care planning. You can find out more about life care planning for people with traumatic brain injury from Dr. Sawyer if you look online. He works for a company that now that does a specialized certificate in life care planning for people with traumatic brain injury. But today, we're just going to be talking about life care planning in general in terms of what a case manager might need, need to know. You're going to gain a general understanding of the purpose and procedures for advanced care planning and recognition, recognize that each person, family, and diagnosis is unique. And this presentation really only provides an introduction. So if you're working with one person with dementia or one person with Alzheimer's, their life care plan, their advanced care plan may look very different than another client of, you know, generally the same age, even that also has Alzheimer's or dementia. So we don't want to get into a rut where we're assuming that every person with X diagnosis needs XYZ services. We want to be very sensitive to the individualized needs of the person. Life care or advanced care planning empowers patients and their families by providing anticipatory guidance and developing a roadmap of services that may be needed and their cost. So when somebody gets a diagnosis like Alzheimer's disease or multiple sclerosis, a advanced care planner can go in and work with the person to understand, you know, what does the trajectory of this illness look like? You know, what can we expect in terms of progression of the illness, how fast, what will happen? That helps people understand and feel a little bit more comfortable about, you know, what they're probably going to be going through in the upcoming days, weeks, and years. But the advanced care planner also develops a roadmap of services. So, for example, for people with multiple sclerosis who currently have, you know, very good functioning, there may come a time, or Parkinson's disease, there may come a time when they are not ambulatory, so they will need a wheelchair. And the advanced care planner helps the family and the patient prepare for that ahead of time, so they know that when it comes to that time, they know how to access the wheelchair and how to pay for it. Advanced care plans can motivate treatment compliance to slow the progression of the disease. If somebody knows, you know, this is what it's going to look like, these are the things that you can do to slow the progression, to improve your quality of life and to, you know, reduce the need for additional services. A lot of times that's real motivating to people. It can also relieve some of the guilt the patient is experiencing, fearing that they may become a burden to loved ones. By creating this anticipatory guidance and planning out ahead of time who's going to do what and what responsibilities people are going to have. Then the patient isn't worried that if they become incapacitated that they will be a burden on their loved ones. They're going to work out a plan so that doesn't happen as much as possible. And advanced care plans can motivate treatment compliance in order to ensure the patient will be able to find financially be able to meet their needs throughout the course of the illness. Wheelchairs, and we're going to talk about wheelchairs a lot because they're a prime example. Wheelchairs occasionally need to be replaced, or somebody may start out with a manual wheelchair and then their disease progresses to a point, or they become frail as they age and may need to transition to a motorized wheelchair. Well, that is an expense that the person needs to be able to plan for in the future. Just like your house, you know, wherever. If you live in a house, you know that, you know, every 10, 15, 20 years, you're going to have to replace the roof and hopefully you kind of budget in for that and you plan for that expense. So when it does occur, you're. It's not something that you're financially unprepared for. Advanced care planning is the term most often used in the research literature. It is strongly recommended that you search for the current best practices for the patient's condition prior to beginning advanced care planning. Advanced care planning is something that you probably ought to consider doing with anyone who has a condition that may be long term. Advanced care planning is also something that you can do with someone who is just aging normally and they want to plan out what life is going to look like, you know, as they become older. As my grandmother became older, you know, we knew exactly what she wanted in terms of care. When my grandfather was still alive, he planned out ahead of time. He worked with a care planner and planned out ahead of time to make sure my grandmother would have enough money to live on, you know, after he had passed. So advanced care planning can be an effective tool for people who are healthy and just going through the normal process of aging as well as for people who, who have long term chronic illnesses that may need, you know, continuous or sporadic intervention. Once you figure out what condition your patient has or conditions there may be multiple conditions, then you want to go to PubMed, which is the National Library of Medicine database. It's a great place, love it. And it's, you can just search online for PubMed and it comes up, but the address is pubmed ncbi.nlm.nih.gov that's a really long one. Just search for PubMed, click on it, it'll come up with a search bar so you can search the database. Use the term advanced care planning and the name of the disease or the disorder. So advanced care planning, diabetes, advanced care planning, multiple sclerosis, and it pull up the current research and best practices for advanced care planning for that particular condition. If your patient happens to have multiple conditions like diabetes and schizophrenia, you're going to want to pull up both of them because you're going to need to attend to all of their presenting issues. Advanced care planning is generally used with people who have chronic conditions like schizophrenia, diabetes, multiple sclerosis, Parkinson's disease, Alzheimer's disease, dementia, HIV or organ failure. But as I said, it can be a tool that people use in order to simply plan for their golden years. Advanced directives for end of life and ongoing treatment are sometimes part of an advanced care plan and should generally be included. You can find free advanced directive forms by state from the American association of Retired Persons. I believe that's what AARP stands for. You can go on there. Each state has their own slightly different requirements for advanced directives to be legit. Most of the time they have to be notorized. Etc. Many of these forms have a section for additional instructions where the person can identify preferred interventions for behavioral health issues. Most advanced directives address end of life decisions. However, some people who have Alzheimer's, who have dementia, who have schizophrenia, you know, there are a variety of conditions that the person may become non communicative and or in crisis, someone with schizophrenia, their hallucinations and delusions may become uncontrollable at some point and they're not able to effectively communicate because they're not lucid. They're not able to effectively communicate their wants, needs and desires. So in this additional instruction section, it's really important for people to identify, you know, if I get into this state where I cannot make my own health decisions for whatever reason, then this is the type of care I want. This is the type of care I don't want. Some people, for example, are very adamant that they don't want electroconvulsive therapy. Some people are very adamant that these are the types of treatments that are helpful. And, and it's important to give people the opportunity to articulate that. So let's talk about the steps in advanced care planning. This sounds like a great thing to help people, you know, plan for the future. How do we do it? Well, the first thing is to determine the diagnosis or diagnoses by consulting with the treatment team. You may get a referral from a physician, from a behavioral health care provider, from whomever. And it's important to consult with the entire everybody on the treatment team to make sure you know all of the different diagnoses. Or if you're licensed to do so, you may complete the assessments yourself. A lot of case managers and advanced care planners, life care planners, are nurses or social workers or counselors. So they may be licensed in their state to actually complete at least some of the assessments. Advanced care plans should begin at admission and be modified throughout the process. So when somebody comes in, you know, for counseling, for medical treatment, whatever, they're going to get a diagnosis from the attending provider. That's where we start, and that's when we can start educating the patient about the condition and what they may need in the future. We can start letting them know. So advance care plans should begin at admission and be modified when there are changes in health or mental health status. If they become clinically depressed, start showing signs of dementia, develop health conditions, there should be changes to the advanced care plan or it should at least be reviewed. If there are changes in independent functioning, their place of residence, if they go from living independently to living in an assisted living facility, there may be necessary changes to the advanced care plan. And if there are changes to the financial situation, if they lose their insurance because they can't pay the premiums, if you know, there are a lot of reasons why they're. A change in financial situation might affect their ability to afford services now and in the future. So if there is a change in finances, it's important to revisit that. Additionally, be alert to behavioral health changes due to deaths of friends, existential grief, etc. If you're not a counselor. Existential grief is that grief that people start experiencing as they get older and they start coming to the realization that they're going to die. And they may go into A deep depression, they may look back over their life and have a lot of regrets. If they start showing signs of behavioral health decline, then a referral to a counselor, a social worker, a faithful leader may be in order. The next step is to compassionately explore the person's understanding and misconceptions about the condition, Then educate the patient and family about the illness or illnesses and the anticipated course as needed. But there are a few caveats to that. So generally we want to explore and educate. However, you want to make sure that you're talking to the patient with the family present. You don't want to talk to the family in front of the patient because that's very disempowering to the patient unless the patient is completely not lucid. They're, you know, really doped up on pain medication, and they're not expected to not be heavily medicated for a while. You know, there are occasional times when this may happen, but generally you want to wait for a time when the patient is lucid and able to comprehend and participate, and then you're going to talk to the patient with the family present. This empowers the patient to feel like they've got control over some aspects of their condition and their situation. If someone in the family or the patient lacks disease awareness or is reluctant to talk about the advanced care plan, don't insist. Some people don't want to know. And if they don't want to know, then okay, that, that's fine. Advanced care planning is not mandatory. If the patient says, you know what, Nope, we're just going to go through this blindly. Most of the time, after they've gotten their diagnosis and gone through that grieving process and accepted their diagnosis, then they may be ready for advanced care planning. But immediately after getting a diagnosis, a lot of people may be in denial and not ready to even comprehend those sorts of things. If we're talking about something like cancer, some family members, you know, children, extended family, what have you may not be emotionally able to. To handle the discussion of the disease progression up through and including death. So it's important to be sensitive to what people are able to comprehend and hear without creating imbalance for them. We don't want to push them into crisis. Discuss the information in person and in small amounts, just. Just a small amount at a time. So one day you may cover the topic, like the broader values of the person, what are their goals and values that they want to apply to their situation. And then the next situation, you may talk about their experience of their present, of the present and their fears about the future and potentially end of life. And then the next session, talk about future care. So this advanced care plan, assessment or process often takes five, six, seven sessions. Much of the time that is good because it gives the patient time to digest what you've talked about and to not feel overwhelmed. If you tried to do this all in one sitting for even the per a person who is not in pain, who is not struggling with any sort of conditions, it would be completely freaking overwhelming. So you do want to break it up into segments and just kind of plan that out. Try if you're working with somebody who is having early stages of dementia, or if they're experiencing some sort of physical distress, chronic pain, something like that, you may need to make the sessions very short, 15, 20 minutes, tailoring it to the individual. Some people may be able to go an hour, other people may only be able to go 15 minutes. So you're going to have to tailor the, tailor the process. As I said, ensure the patient and anybody there is as lucid as possible and not in moderate to severe pain to maximize their ability to focus. Some patients, maybe especially those with chronic pain, may always be in some level of pain, but we don't want them to be in so much pain that they can't focus on what you're talking about. You want to use a culturally sensitive approach, respecting cultural values related to pain, disease, death and us utilizing interpreter services when needed. If you're working with somebody for whom English is not their primary language, or someone who is deaf, you may need to use interpreter services. It's also important to recognize that different cultures have different feelings about long term care, whether the family should be involved, how much they should be involved, the use of medications. There's a lot of stuff in long term care that has a lot of cultural significance. So it is important to be open with the patient and be receptive to what their goals and values and preferences are. If the person becomes unable to communicate, respond to their emotions, attend to non verbal communication and observe their behavior to know more about their current quality of life, fears and desires. So we have two main situations where this may happen. You're talking with them, you're going through the advanced care planning and they start to decompensate, they become very overwhelmed. All right, well obviously you're going to stop the planning process at that point. You may connect with them, empathize with them. It's not necessarily important for them to articulate in words what's going on, if they are crying, if they appear to be Overwhelmed or terrified about what's to come. You know, you can probably pick up on that and paraphrase that for them. What we want to do is empathize and validate and support them at that point later in the course of the illness, if they become non communicative, they lose their verbal ability for some reason, then that is the other time where you're going to want to respond to non verbal communications. All behavior is communication. And I'll say it again, all behavior is communication. If you're working with somebody with dementia, for example, and they keep going into their closet and pulling out all their clothes and setting them on the, on the bed, what is that trying? What are they trying to communicate? Are they telling you they're bored? Are there? Are they telling you that they're cold and they want something else to wear? What is it that they're trying to communicate? And any one behavior with dementia, I don't want to get too far into that, but any one behavior may not mean the same thing across different days. So they may have multiple reasons for taking their clothes out of the closet. So you need to be curious each day about what is this person trying to communicate to me at this point in time? Explore the current person's current experiences. Ask the caregiver, family and the patient what their perception is of the person living with the condition. Could be dementia. It could be something else. What is their perception of this person's current status? Their current abilities, their current needs? What are their fears and concerns? So we want to get this both from the patient as well as from their family and caregivers. Why? Because the family and caregivers also need assistance. They also need respite. They also need support. Because caring for someone with a chronic condition can be exhausting emotionally, physically, financially. We do need to make sure to remember that this generally chronic conditions. When you're looking at advanced care planning, a lot of times it is a family process. The patient and family may be in crisis or grieving over the diagnosis or progression of the illness. So it's also vital when you're doing this compassionate exploration when you're educating them about the condition or conditions, the anticipated trajectory. The services available provide handouts summarizing the information, containing links to informative websites and peer support, and ideally links to short videos on the conditions. For example, if you're working with a client that is has dementia handouts and videos that are available on each of the seven stages of dementia that describe what to expect, general tips for how to handle certain behaviors, including always Consulting with the care team and reasons to immediately call the doctor. Don't want to keep you, don't want to make the videos too long, you know, 10 minutes is good. But giving people something that they can go back and reference as many times as needed, because in crisis, our memory is not the same. We have a harder time learning and remembering things. So we want to give people visual tools, we want to give them things they can refer back to and we want to communicate with them, you know, in person as much as possible. When you come back, review the information from the prior appointment, at the next appointment just to make sure that whatever you talked about at that prior appointment, you know, we're all still on the same page. They could, they may have, you know, sort of checked out during that last session or things may have changed and they may need something totally different now. Things can change very rapidly for some conditions. So you do want to review the information from the last appointment to when you're beginning the current appointment. Provides continuity. Make sure that everything's progressing as expected. Identify patient goals, preferences and values. This is often, as I said, probably one of the first sessions that you do with the person. If you, after you talk about and educate them, dispel any misconceptions about the disorder or disorders. The next step is figuring out, okay, this is what you're, what we're dealing with. What are your goals for treatment, what are your goals for your life, you know, the, the next years, what are your preferences for treatment, for care, for who does it, where it happens at, et cetera, and what values that goes to the cultural stuff are important, you know, in this process. If it's a progressive illness, identify the goals, preference and preferences and values for each stage. So they may have different goals, preferences and values when they are still living at home. And their goals, preferences and values may change remarkably when they go into, in home care. When they're at, at home, when they're getting care at home, they may prefer for family to care for them. When they go into a facility, then obviously family's not going to be able to care for them as much. So what type of facility do they want to go into? Ideally, they start the, the patient is still lucid and functional enough to explore some of the long term care facilities ahead of time in order to pick one out that they may, they think they may want to be admitted to when and if that time comes. If it's a static illness like schizophrenia, then an overall plan that takes into consideration standard physical and cognitive decline like reduced liver Functioning, depression, slowed thinking, all of that would also be important. Remember that all patients who have chronic conditions like diabetes or Alzheimer's or Parkinson's also will have to deal with normal aging issues. And this should be part of an advanced care plan. Transitioning to a geriatric specialist at a certain point is recommended, for example, because the way people who are older handle medications is very different. You know, processed medications in their body is very different than younger people. So a geriatric specialist is often advised. For example, as people get older, they start to have more difficulty with balance. So even, you know, somebody with schizophrenia who needs a, an advanced care plan, somebody who has been in supported living all their life, they may need additional assistance and interventions. If they live in a environment in which there are stairs, you know, they may not be. They may get to the point where they can't navigate stairs anymore. So that is part a condition that the advanced care plan can address. That is not necessarily part of schizophrenia. It's part of the normal aging process. But we want to make sure that this person is getting all of their holistic needs met as much as possible. You want to factor in future major expenses, such as the need to install a power lift to get the person upstairs or a step in bathtub. Again, this is something that can happen to any person, regardless of their prior physical status or cognitive status, if their back or their knee goes out, or if they start to have difficulty with balance and inability to get to your bedroom. Inability to bathe yourself, you know, obviously creates a major barrier to independent living. So we do want to be able to make sure that we plan ahead for some of these things, Knowing that once people reach a certain age, it's usually recommended that they move to a step in bathtub so they don't have to try to step over wheelchairs. I told you we were going to keep using wheelchairs. Manual wheelchairs are fine for people who are strong enough. They generally last 10 years or more. However, they will probably need to be replaced with a power wheelchair at some point. The person, you know, may lose the strength or the ability to navigate a manual wheelchair. Power wheelchairs have annual maintenance costs associated with the battery and the motor and those sorts of things. And all wheelchairs, whether it's the manual foldable kind or the power wheelchairs, often have costs associated with vehicle modifications. This is especially true with power wheelchairs that you can't just throw in the back seat. But a lot of cars now are compact enough that it's almost impossible to get a, even a manual wheelchair. In the back seat or in the trunk. So a kit is needed to be installed on the back of the vehicle. And in order to transport that mobility device, communicate with family members and caregivers to also identify their needs and attempt to integrate those with the patient's goals, preferences, and values. This comes up a lot with families. As people age and they start to have more health problems, they become less able to live independently. And family members may try to pitch in, may try to help the person remain an independent living as long as possible. Sometimes they move the parent or grandparent in with them. That's not always possible. Some people don't have the room or for some other reason, can't or won't move the parent or grandparent into the house with them. They may not be able to have a family member with the parent or grandparent 24 hours a day, seven days a week. So it's really important to identify what is it that the patient wants to happen? How much do they want their family involved in their care? And from the family standpoint, we know what the patient wants. How much of that can and are you willing to do, and how much of it, you know, may be overwhelming. I have a patient right now whose mother is struggling with a lot of physical health issues and mobility issues, and he spends a lot of time going back and forth to her house and helping her out. But it's cutting into his ability to function at work, to help out his family, to do things that he needs to do. So it's important to understand and, you know, be as compassionate as possible with people. They will do their very best. However, they may not be able to meet the expectations or the desires of the patient. My grandmother and I talked about this in the last video when she was getting older. She did not want to leave her home home. She wanted to stay in that house that she'd lived in for the past 35 years until she died. Unfortunately, she started developing a lot of cognitive issues and she didn't want to move in with my mother, which would have moved her to an entirely different state. She would have had to move from Florida to North Carolina. She said no, not doing that. So that wasn't an option. She My uncle was unable to move her in because he didn't have space in his residence to move her in. He was stopping by every day to check in on her, but he couldn't be there 24 7, and it was not in the cards to afford a 24 7, 365 caregiver to provide custodial in home care. So at a certain point, even though it wasn't what she wanted, you know, we had to look at placement in a assisted living facility and the family did as much as they could up until the point that they just could not meet her needs anymore in a way that allowed them to have a meaningful life. So it is important to recognize that the patient's goals, preferences and values may not completely align with the families and the other caregivers. However, we want to try to find the best compromise possible and empower the patient as much as possible without guilting or shaming people who say, you know what, I just can't do that. I, I can't move grandma in with me. That's, that's not going to happen. The case manager can review insurance policies to see if any of the insurance policies will provide for part time or full time home care when the person needs it. Another option is if the person has long term care insurance, they might be getting enough money that they can pay for a CNA to be there or a caregiver to be there with them 24 hours a day. So it's important to examine what are our options here. Let's kind of get out of the box and see how creative we can be. Sometimes there are programs through people's churches, especially at the, really the smaller, close knit churches where the pastor of Congregational Care may have a list of people that are willing to pitch in and take shifts doing some of the custodial care for, you know, one of their, one of their congregate congregation members in order to give the family respite. Now this isn't something that usually is an ongoing. It's not like you can expect people to volunteer 20 hours a week every week, but they may be willing to volunteer one day for eight hours to give the family a break and let them go out and, you know, go out to dinner, whatever they need to do in order to get rejuvenated a little bit. Congregational Care is a great resource to reach out to if your patient is involved in a church or a synagogue or some other faith based organization, because there are a lot of people that want to help. And like I said, that is one of the best places to potentially find people who are willing to volunteer to provide respite services. There are also adult daycare programs where, and I don't like the term daycare, but that's what they're called, where the adult is brought to a facility like a senior center and they stay there all day long. So the family can go to work just like you would do if you had a child that couldn't stay independently. So there are a lot of options. And it's important to connect with your local community services to find out what's available. Not everybody who has dementia is, is elderly. Not everybody who needs ongoing care is elderly either. So you want to make sure that, you know, you know, for people with schizophrenia are there that generally in mental health, they're called clubhouse programs. But reach out to your local community mental health facilities and find out what services are available again for people that have severe and persistent mental illness. Ultimately, there may come a time when safety mandates that people are transitioned to inpatient care. The case manager can work with the family and treatment team to try to stave off that as long as possible. So obviously the case manager is going to work with the treatment team. If the patient wants to stay at home for as long as possible, which most do, the case manager will work with the treatment team to try to figure out how many different ways that we can kind of, you know, duct tape things together, paperclip things together in order to provide the services necessary to help the person live safely and a high quality of life independently. Once there comes a time for transition to inpatient care or assisted living, the individual and family may experience a significant amount of grief. That's a big step. That's an acknowledgment that this condition has progressed significantly. So individual and family counseling may be necessary to help the family adjust to the new realities and grieve. The patient who is being admitted to the assisted living facility may be angry, they may be grieving. So there's a lot of stuff that needs to be worked out. The case manager should also focus on helping the patient and family feel empowered and motivated to take of care, take all necessary steps to stay healthy to prevent the progression of the disease or development of other health or behavioral health issues like burnout, alcoholism, opioid dependence, gambling addiction. There are a lot of things that can develop stress related illnesses. Physical and behavioral health illnesses can develop both in the patient as well as in their caregivers when there is an ongoing illness or condition. So we do need to be acutely aware of these things and intervene as much as possible, making sure that support, counseling, respite services are available for everybody, not just the patient. A caregiver who is burned out is going to be at a much greater risk of being neglectful or abusive. So we do want to, you know, make sure that we're preventing those sorts of things, things the next step is to explore who the significant people in the person's life are and who can be involved in the advanced care plan. You know, you may have already done this or you may be doing this now. To add on people you know, we've identified those core people that were in the initial meeting, but are there others who may be able to be involved? My mother, for example, lived in North Carolina, but she would fly down to Florida every three months and stay for two weeks in order to give my uncle a break. So she wasn't one that was involved in the day to day care so much, even though she talked to grandma every day. But she was integrated into that plan in order to make sure that my uncle had a breather and didn't get burned out. You also want to explore who can become the person's legal representative. Even in normal aging, there may come a time when the person's cognitive capacities decline so much that they need a legal representative. It doesn't mean it has to happen, but if there comes a time that it does happen, ideally you want to have somebody picked out ahead of time. You want to discuss with the family and caregivers as well as the individual. And I keep saying and caregivers because sometimes you will have non family caregivers that have been volunteering or being paid to help before you even come in. So you want to get everybody on the on the same page and talk about factors that make the symptoms for the patient worse and things that improve symptoms. So for example, maybe bright lights or strong smells or certain times of day may make the person more agitated or exacerbate their hallucinations or delusions or whatever the case may be, it's important to know those things. That way you can develop this advanced care plan and their service plan centered around maximizing all of these mitigating factors. You know, if they do really well, when there's classical music on and the lights are on, and you know, you can make a list of conditions that generally help the person feel calmer, more grounded, more present, more lucid, then we want to enhance those as much as possible and identify any of the factors, the exacerbating factors that make their symptoms worse, and try to minimize those. For some people, if they may love their dogs, and they may really want to have their dogs there because it's an emotional support animal. But if the dog gets yappy every time somebody walks by the front window, one intervention may be to put blinds or curtains there so the dog can't see people walking in front of the front window and agitate the patient. So there are things that you're going to consider, you do want to talk about with the family and the caregivers and the patient, the spectrum of the condition, management issues. So as the person with Parkinson's, for example, progresses, their tremors may get worse, they may start having hallucinations, they may develop depression. You know, you want to have difficulty with balance, you want to talk about all of the things that may start happening and options for managing those symptoms, including pain, including managing their pain, cognitive decline, mobility, independent living, and psychiatric symptoms. It's really important, like I said at the beginning, that you know, whatever these conditions are that your patient has, you know them inside and out, you know what their trajectory looks like, you know what types of services you can anticipate the person needing. You know what the spectrum is. You know, some people only go this far and it doesn't progress anymore. Some people get worse really quickly. Excuse me. And that way you can explain that to the family. And again, you can make a better advanced care plan if you know what to all of the symptoms to expect emotionally, cognitively and physically. Particularly document the patient and family preferences and document any changes in patient and family preferences as you update the advanced care plan. As the patient's condition progresses, you may have thought that XYZ intervention was going to work and you discover that, you know what, that's not working. At that point, you may need to adjust the advanced care plan, saying, okay, well this isn't working, so we're not going to continue to do it. You want to initiate these ongoing discussions and have the family and the patient feel open to communicate with you at each visit about what's going well, what's not working, and any modifications that need to be made. You want to communicate the advanced care plan to everybody in the care team from the CNA that comes by three days a week to check meds all the way up through the attending physician and legal representatives. Obviously, the advance care plan may include, may should include advance directives. So you want to make sure the legal representatives know what they're responsible for and make sure to re communicate all of these, the, the advanced care plan to all of these people when there's changes in it and when there is transfer to another care setting. So you may have everything, you know, humming along just great at home. And then the person has to transfer to inpatient care. They suddenly, you know, they're, they're doing well on, within home care and then they develop pneumonia and they have to go to a long term care facility or a rehabilitation facility until their pneumonia clears. You know, they may not be there forever. They may still be planning on coming back to in home care. But while they're at that facility, it's crucial to make sure that their advanced care plan is communicated to all of those caregivers in order to best respect the patients wishes and needs. Advanced care planning can empower patients and families to adhere to treatment recommendations through active participation. It can enhance relationships with the case manager or the care planner, whatever you're calling yourself. Because you are regularly engaging in dialogue with the person, you're soliciting information from them about what their preferences are. You're empowering them to take control of those aspects of the situation that they are able to control. It can allay anxieties by providing anticipatory guidance and a roadmap for services. For example, when you're working with people with diabetes, there are a lot of things that they can do to slow the progression of their condition and, but people who don't follow those guidelines may very quickly get to the point where they're having complications. So allaying these anxieties, telling them what could happen, but also what interventions are possible and if they follow those interventions, what the probability is. Some of these discussions may be discussions they have with their attending physician, but some of these discussions may also be discussions they have with you as a health educator. And finally, advanced care planning can ensure the patient has access to financial resources necessary to meet their changing needs. To the extent possible that you're going to look and see, you know, what resources we have and in what ways can we best help this person meet their, meet their needs so they don't get just like the example I gave with the roof, so they don't get caught unawares 10, 10 years down the road when all of a sudden they need a power wheelchair and they're like, that's $15,000. I don't know where I'm going to come up with that amount of money. If they have been planning for it ahead of time, then hopefully they've worked that in. So that is where the advanced care planning team comes in to really help people forecast, plan, anticipate and take charge of their quality of life and the trajectory of their process. Thank you for being with me today. And we've got more videos that are coming up.