Dr. Richard Shank returns for a third year as our conference emcee. Interspersing the announcements of the day with his own anecdotes and stories, Dr. Shank is wonderful at keep the mood right and the timing spot-on!

Led by Monisha Richard, a Community Health Worker (CHW) with the passion to serve the community for several years. She is currently the Outreach Coordinator at Volunteers of America for the Culturally Responsive Caregiver Support and Dementia Services program. In this role she trains the Community Health Workers on connecting with diverse communities in various ways. VOA partnered with Honoring Choices to educate the African American community on the importance of ACP. This presentation will include Monisha’s personal story as a caregiver and why it is of great importance for her to educate the community about Health Care Directives. It will also address some of the challenges the Culturally Responsive team faced and how they overcame the barriers and reached the community.

In 2018, HCM approached the Center of American Indian and Minority Health (CAIMH) to collaborate on a project to increase the number of health care directives in American Indian/Alaska Native (AI/AN) communities. CAIMH is a 47 year old program within the U of M Medical School, Duluth Campus that was created to serve Native American communities by increasing the numbers of Native doctors and by serving as a conduit for health information between the medical school and Native American communities.The ultimate goal of this project is to begin the conversation on advance care decision making in a way that is culturally appropriate and respectful. Our pilot project has been completed in two communities and we are assessing our strategy for the future. Presenters: Dr. Mary Owen, Director of the Center of American Indian and Minority Health, and Assistant Professor in the Department of Family Medicine and Biobehavioral Health at the University of Minnesota School of Medicine, Duluth campus. And, Mangan Golden, MA, the Research Coordinator for the Center of American Indian and Minority Health at the University of Minnesota School of Medicine, Duluth Campus.

Stratis Health partnered with Honoring Choices to address several challenges in their work including how electronic health records (EHRs) are able to store and received data and documents supporting Advanced Care Planning. Reid will describe the methodology and resulting EHR Reference Guide for ACP that Honoring Choices now uses in its work when engaging with new communities. This guide provides insights into how a few of the most prevelant EHRs in our state handle ACP documentation. He will also provide a few insights into the importance of Health Information Exchange and how it will impact vendors and the evolution of their EHR products with regard to ACP functionality. Presented by Reid Haase, Program Manager, Healthcare IT Consultant, Stratis Health.

This presentation will focus on making POLST conversations accurate and more comfortable for social workers, nurses, physicians, and patients and their families. Presented by Dr. Vic Sandler, a Board Certified physician in Internal Medicine, Geriatric Medicine and Hospice and Palliative Medicine. He has served as medical director of geriatrics for Health Partners and Park Nicollet, medical director of two hospices and two nursing homes. Currently Medical Director of Home Care and Associate Medical Director of Hospice for Fairview Health Services, Co-chair of the Bioethics Committee for University of Minnesota Medical Center, President of Minnesota Network of Hospice and Palliative Medicine Physicians, and Co-Chair of the Minnesota POLST Task Force.

Mild cognitive impairment, progressive dementia and Alzheimer’s disease affect an individual’s ability to function and make decisions. Is it appropriate for people with these conditions to make their own care decisions? How do we determine the extent of diminished capacity and whether someone can give informed consent? Can advance care planning and end-of-life conversations make a difference in outcomes for the individual and their loved ones? This session will provide information about symptoms and changes to help you identify those struggling with cognitive impairment, determine decision-making abilities in individuals with a dementia diagnosis, facilitate shared decision-making when appropriate, and encourage advocacy for the individual’s end-of-life preferences. Real-life case examples will be discussed to share positive approaches to conversations with those with dementia and their families to improve the end-of-life experience for everyone. Led by Valerie Richards, MBA, Alzheimer’s Educator & Family Coach.

Three Minnesota certificate-holding Community Health Workers (CHWs) will present their experiences completing health care directives with patients in both clinic and community settings. Learn how CHWs deliver and document services, and how this information is shared with the patients' care teams. Training, protocols, best practices and example standing orders for ACP services will be shared, as well as information about how CHW services can be billed for patients with Minnesota Medicaid. Speakers: Megan Ellingson, CHW, MHA, Co-Founder and Principal, Consulting Services, CHW Solutions; Tara Nelson, CHW, Community Health Worker Program Manager, Intercultural Mutual Assistance Association (IMAA); Connie Norman, CHW, Community Health Worker, Sanford Health Bemidji.

Over the last three years, Benedictine Health System (BHS) challenged the status quo and worked to create (and sustain) a culture of excellence in supportive and palliative care for residents living in the skilled nursing (SNF) and assisted living (ALF) care environments. As part of "doing the ordinary, extraordinarily", advance care planning became a core system and process that ultimately birthed "ACP the BHS Way". By hearing the story of BHS ACP implementation, participants will learn: 1) how to utilize Respecting Choices curriculum and creatively meld it into common everyday work practice in a SNF and ALF; 2) how to develop and harness EMR analytics in meaningful ways to help drive ACP implementation (and know when success isn't being achieved); and 3) how to leverage organizational Core Values and ethical principles to help sustain the ACP journey within your own organization. Presented by Neal C. Buddensiek, MD, CMD, Chief Medical Officer for BHS, and Janna Kovach, LSW, Social Services Specialist for BHS.

The demographic bulge known as the Baby Boom cohort is now more than half way through the life continuum. A growing portion of this group is composed of “solos.” These are individuals who cannot/do not rely on family to help navigate life events and make health decisions. Interviews with solos conducted over the past two years reveal an independent streak as they think and talk about aging. Many are electing to limit the involvement of family and friends when support is needed, or not to involve them at all, even when relationships are solid. This generational preference alongside of the sheer number of older adults is creating new challenges when it comes to planning for long term care and the end of life. Minnesota is the first state to begin tackling this issue--looking at how to be proactive rather than waiting until people have lost capacity. Led by Linda J. Camp, Independent Consultant, Owner - Turning Point Consulting.

Pre-operative appointments are a common source of visits to a medical provider, and are increasingly being done at dedicated centers by a provider other than a patient's primary. However, minimal research has been conducted on the potential for advance care planning (ACP) in this setting. This talk will describe original research done into patient and provider attitudes toward ACP discussions in a pre-operative assessment center at the University of Minnesota, as well as plans for future interventions. Presented by Michael Berres, 4th year Medical Student at the University of Minnesota Medical School.

Presented by Mary S. Carlsen, Professor of Social Work & Family Studies at St. Olaf College, and students from the 'Living and Dying: Explorations with Young Adults' course.

Closing and farewell from Dr. Richard Shank.