Goals of Care Management
Advance Care Planning (ACP) is a way to help patients, families and decision-makers to think and talk about their wishes for health care. A Goals of Care Designation (GCD) is a medical order used to communicate the patient's general aim for health care, including any preferred location for and limits to that care.
The Connect Care clinical information system has tools that facilitate recording patient's wishes, attaching advanced care planning documents to the chart, documenting evolving wishes, capturing a specific GCD status and sharing this information across the continuum of care. Quick info:
Goals of Care Designation (GCD)
Summary goals of care information is prominent in the Patient Storyboard, which appears as the leftmost column of all opened patient charts. At the top of Storyboard, just underneath the patient identifiers, is a "ACP/GCD" line. Hovering over this brings up a summary of the current patient's goals of care information, including:
Current GCD Status
GCD Status History (past designations and changes)
Details of most current status
List of attached ACP documents
Goals of Care History and Documentation
Selecting (clicking on) the ACP/GCD line in Storyboard opens an "Advanced Care Planning and Goals of Care Designations" navigator within the patient's chart. The navigator has links for activities that relate to capacity assessment, designating alternate decision-makers and jumping to the Orders activity to enter a GCD order.
There is also a link to a "Tracking Record" (see below) where documentation about additional details or changes in patient wishes should be recorded. Ideally, a GCD Tracking Record note is added each time there is a change in GCD designation.
Goals of Care Designation Orders
A Goals of Care Designation (GCD) is required for all patients in all contexts (emergency, outpatient, inpatient, long-term care, continuing care, etc.). A first registration of a patient's GCD level is entered into Connect Care as a prescriber order, as are any subsequent changes to the GCD level.
A GCD order becomes active upon signing and remains active until changed or replaced. It pertains wherever Connect Care is the record of care, spanning all encounters. It is printed and placed in the patient's "Green Sleeve" or faxed when transitions of care involve facilities that do not use Connect Care as the record of care.
It is important to ensure that all patients have an active GCD, to enter changed GCD orders with care, and to periodically review and reconcile GCD orders in compliance with advanced care planning policies. All GCD orders include details about the location and those included in the GCD order discussion, as well as a space for any clarifying comments. More details, as well as evolving considerations, are documented in the GCD "Tracking Record".
Common GCD order tasks for prescribers include:
Add GCD Order (patient currently without GCD Status)
Use "GCD" or "goal" as an order search term in the Orders activity.
Select an appropriate GCD order, reflecting the intended GCD Status (R1, R2, R3, M1, M2, C1, C2).
The order composer provides a quick reminder about the definition of the requested GCD level (e.g., R1), followed by three questions and a field for optional clarifying comments.
Indicate the GCD order location (home or facility), decision-maker (patient and/or alternate) and validation (awaiting a dispute resolution status or not). Supplemental clarifying comments can be attached to the order and resulting GCD status.
Note that a "tracking documentation" link is provided within the order. This can be used to generate a GCD tracking note to accompany the order and GCD.
Sign the order. The resulting e-signature is valid without need for any other "wet" signature on the resulting GCD printed report. Printed GCD orders are added to the patient’s Green Sleeve so their Green Sleeve remains the source of truth.
Modify GCD Order (change in existing GCD order details)
If new information about an existing GCD status (e.g., change in decision-maker or no longer under dispute resolution) emerges, the current GCD order can be modified by using the "Modify" button (attached to existing order) in the Orders activity.
Any significant change in GCD instructions should be recorded using the "Tracking Record" documentation link.
Sign the modified order.
Replace GCD Order (change in GCD status)
If the patient's GCD level changes (e.g., M2 to C1), a new GCD order should be entered. This will automatically replace and update the old GCD order. It is not necessary to delete the old order first.
If a patient presents with a Green Sleeve, Green Sleeve documentation must be reviewed with the patient and any discrepancies between the Green Sleeve and Connect Care chart reconciled. Both the Green Sleeve and Connect Care should reflect the most current and relevant GCD order.
Remove GCD Order (patient status has become indeterminate)
The "Remove" order button within the Orders activity should only be used for a GCD order if the responsible clinician(s) determines that an existing order is outdated and there is compelling reason to not indicate a GCD status. Usually, uncertainty (e.g., no designated decision-maker and significant change in clinical status and patient unable to self-advocate) is handled by defaulting to R1 or the last-recorded GCD status.
GCD Tracking Record
The Goals of Care Tracking Record is a note type used to document the content of Advance Care Planning (ACP) and Goals of Care Designation (GCD) conversations or decisions. Tracking Record notes can be added as needed and should be added whenever there is a change in GCD status.
Tracking Record notes can help other healthcare providers (shared across the continuum of care) to be aware of previous conversations, to understand the reasons for a particular GCD order and to heed any specific limits to care. Tracking Record notes are printed and included with a patient's Green Sleeve.
Tracking Record notes can address any of the following questions, usefully included in discussions about advance care planning:
Have you completed a Personal Directive?
Have you selected an alternative decision-maker? Do they know your wishes?
What is your understanding of where you are with your illness?
If your health situation worsens, what are your important goals?
Missing GCD Orders
All patients should have a GCD status, achieved through entry or re-entry of a GCD order. There are a few places in the chart where clinicians are reminded about GCD orders requiring attention.
Inpatient Charts
A "Sidebar Summary" appears by default in the rightmost panel/column of opened patient charts. The summary presented to prescribers is consistent.
Look for a section (usually third down) entitled "Admission Checklist".
If a current inpatient does not have a valid GCD status, a "Has Active and Reviewed Goals of Care Designation Order" item will appear in the "Overdue" section of the checklist.
Clicking on this opens the Orders activity, where a GCD order can be entered.
Patient Lists
The Patient Lists activity is the usual gateway to inpatient encounters for currently admitted patients. Any list can be used to rapidly access a physician checklist that includes information about missing GCD status.
When a patient (list row) is selected, a "report" appears in the bottom half of the list screen (can be configured to be side-by-side).
A search box appears at the top right of the report viewing area, allowing alternative reports to be selected for display.
The "IP Physician Checklist" report includes the "Admission Checklist", where any missing GCD orders are highlighted.
All Provider Team lists (found via "System Lists" >> "Facility" >> "Provider Teams") have a column showing GCD status.
It is also possible to edit a personalized Patient List to include "GCD" as one of the columns. This allows very fast discovery of patients within a list who need attention to GCD orders.
Outpatient Charts
The easiest way to discover a missing GCD status during an outpatient encounter is to see if the ACP/GCD section of the patient Storyboard says "No active order; search scanned docs".
Green Sleeve GCD
A goals of care directive "Green Sleeve" (printed) remains an important tool and source of truth for documenting patients' wishes, particularly because not all providers (i.e., community practitioners) have access to Connect Care. A non-R1 Connect Care GCD order will generate a new printout which should be placed in the Green Sleeve, replacing any prior Green Sleeve content. The printed Green Sleeve stays with the patient (typically placed in a residence refrigerator for ease of EMS access) and is invaluable to providers who do not have access to Connect Care.
When a patient has a Green Sleeve, it should accompany them to their healthcare appointments and any transfers between healthcare facilities. Patients who do not have a Green Sleeve should be provided with one at the time that goals of care are confirmed and ordered in Connect Care.
It is imperative that the Green Sleeve have the most up to date Goals of Care Designation (GCD) Order, whether printed from Connect Care or written on a GCD form. If a patient retains outdated printed goals of care documents, providers should clearly add a "VOID/Expired on date ___" marking and initial the addition.
A patient’s GCD Order must be reviewed with the patient/alternate decision-maker with any change in location of care, health status or at the patient’s request.
GCD Orders contained in the Green Sleeve and Connect Care must be reviewed and reconciled to ensure that both sources reflect the most recent order. Non-Connect Care Green Sleeve documents should be uploaded to the patient’s Connect Care chart.
In a medical emergency, the GCD Order with most recent date and time should be followed.
In the absence of a Green Sleeve or GCD order, healthcare providers should engage in a discussion(s) and review Goals of Care with the patient/alternate decision maker. When appropriate, a printed new or revised GCD Order and ACP/GCD Tracking Record are placed in the Green Sleeve and returned with the patient upon discharge/transfer.