Facilitation of Advance Directives
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What Facilitation Is
Training of Facilitators
Facilitation Training: Power Point Presentations
Facilitation Training: Observation Checklist
Advance Directive Forms Used in Facilitation
Facilitation Training: The Duke University Facilitation Session Guide
Commentary on the Expanded Advance Directive Form
Other Training Resources
The Facilitator’s Relationship with the CSB
The Facilitator’s Relationship with the Person Completing an Advance Directive
In addition go HERE to see a video special about Advance Directive peer facilitators in Norfolk VA
What Facilitation Is
Training of Facilitators
Facilitation Training: Power Point Presentations
Facilitation Training: Observation Checklist
Advance Directive Forms Used in Facilitation
Facilitation Training: The Duke University Facilitation Session Guide
Commentary on the Expanded Advance Directive Form
Other Training Resources
The Facilitator’s Relationship with the CSB
The Facilitator’s Relationship with the Person Completing an Advance Directive
In addition go HERE to see a video special about Advance Directive peer facilitators in Norfolk VA
What Facilitation Is
To “facilitate” an action is to make it easier. Because most people have not completed an advance directive for their health care, some organizations offer to “facilitate” the completion of advance directives. This is done by having a trained facilitator help a person go through, and understand, the advance directive form. The facilitator helps the person to think about his or her values and preferences regarding health care, and how those values and preferences might affect the person’s choices and instructions for health care.
Training of Facilitators
An effort is underway at some community services boards (CSB’s) in Virginia to train both staff and peer support specialists to assist individuals who have a mental illness in completing advance directives. Research at Duke University has found that as few as 3% of persons with mental illness have completed an advance directive that addresses their mental health care, but that when these individuals are offered assistance (facilitation) in completing such directives, the completion rate jumps to over 65%. The Norfolk CSB has led the way in providing training for peer specialists to become facilitators, and it recently recognized 9 peers and staff who completed training and are “certified” by the NCSB to provide this important service to consumers receiving services from the NCSB. (You can see a video about this program by clicking here.) The NCSB effort has been organized by Sandra (“Sandi”) Lee, the NCSB’s Consumer Relations Coordinator, with strong support from Sandi’s supervisor, Bob Horne, and has been made possible by Dana Traynham, Esq., a staff attorney for the Virginia Office of Protection and Advocacy (VOPA), who has conducted the training program.
While there is not yet a statewide certification process for advance directive facilitators, the Virginia Department of Behavioral Health and Developmental Services (DBHDS) has expressed support for the concept. The materials on this page are intended to provide some initial ideas and guidance for the development of a curriculum and supporting materials that might support a statewide certification program.
Facilitation Training: Power Point Presentations
Advance Directives - An Overview
Advance Directives: Background and History
Advance Directives: A Tour Through an Advance Directive
Facilitating Advance Directives: Guidelines for Helping Others With Their Advance Directive Form
Facilitation Training: Observation Checklist
Persons who are trained to be facilitators must be able to show that they have the knowledge, skills and abilities needed to effectively help people complete their advance directives. People being trained to be facilitators should be observed in monitored facilitation sessions, to see how helpful they are. A checklist, which sets out the key factors for good facilitation, is used as part of this observation. You can get a copy of the checklist used in the Norfolk CSB program by viewing online below or downloading here.
Advance Directive Forms Used in Facilitation
The “standard” Advance Directive form, based upon the form set out in Virginia Code Section 54.1-2984 (part of the Health Care Decisions Act [HCDA]), can be found by viewing online below or downloading here.
A short version of the standard form (2 pages vs. the standard form’s 4 pages), developed by the Virginia Hospital and Healthcare Association, can be found by viewing online below or downloading here.
An “expanded” Advance Directive form has also been developed. It has extra provisions that enable persons with ongoing medical conditions, including mental illness, to give more specific instructions about their future care in the event they are unable to give informed consent to care. That form can be found by viewing online below or downloading here.
Most of the CSB’s currently providing facilitation for consumers use the expanded form, and the training materials below are based on the expanded form. However, as the training materials themselves point out, Virginia law does not require that the Advance Directive form have specific provisions, other than the signature of the person and the signatures of two adult witnesses. Beyond that, any adult can fashion his or her own advance directive.
It is generally wise to include all health care instructions in a single document. However, some persons who have a mental illness have expressed concern about the possibility that they will be treated differently if their doctors become aware that they have a diagnosis of mental illness. People who have this concern may choose to set out their instructions about their mental health care in a document that is separate from the rest of their advance directive. The training materials emphasize that the consumers’ preferences, including preferences about what form to use, should be honored by facilitators.
Facilitation Training: The Duke University Facilitation Session Guide
Dr. Christine Wilder and support staff at Duke University have developed a facilitation guide. It provides a structure that a facilitator can use when the facilitator is helping a person to complete an expanded advance directive form. You can get that guide by viewing online below or downloading here.
Commentary on the Expanded Advance Directive Form
Facilitators likely will want to refresh their memories about the meaning and application of different sections of the Advance Directive form. In addition, people filling out a form may ask questions about a section for which the facilitator does not have an answer. In this section, you can get access to comments and explanations on each of the key sections of the Expanded Advance Directive form.
Introduction
Section I(A) - Appointment of Agent
Section I(B) - Powers of the Agent, Introduction
Section I(B)(1) - General Health Care Power
Sections I(B)(2), (3) and (10) - Executive Powers of the Agent
Section I(B)(4) - Admission to Health Care Facilities by Agent
Section I(B)(5) - Admission to Mental Health Care Facilities by Agent
Section I(B)(6) - Authority to Continue Acting as Agent Over Objection
Sections I(B)(7), (8) - Consent to Participate in Research
Section I(B)(9) - Authority to Determine Visitation
Section I(B)(11) - Anatomical Gifts
Section I(C) - Authority to Consent to Care Over Objection
Section II - Introduction
Section II(A) - Health Condition and Treatments
Section II(B) - Emergency Contacts
Section II(C) - Medications
Section II(D) - Mental Health Crisis Intervention
Section II(E) - Other Health Instructions and Information Sharing
Section II(F) - Life Management Preferences
Section II(G) - Life Prolonging Treatment
Signature and Right to Revoke
Other Training Resources
The National Resource Center on Psychiatric Advance Directives maintains a website that includes a variety of education and training materials aimed at helping individuals to complete an advance directive to address future mental health care. You can visit that site by clicking here.
The Facilitator’s Relationship with the CSB
An advance directive is a legal document. Health care providers are required by the HCDA to recognize it. Given this status of the advance directive, some have asked whether a layperson who helps someone fill out an advance directive could be engaged in the unlawful practice of law. There is no clear guidance at this time on when such help would amount to the unlawful practice of law if it is provided by a person who is not affiliated with the health care system. However, the HCDA, in Section 54.1-2988 states: “The distribution to patients of written advance directives in a form meeting the requirements of § 54.1-2984 and assistance to patients in the completion and execution of such forms by health care providers shall not constitute the unauthorized practice of law pursuant to Chapter 39 (§ 54.1-3900 et seq.).” (emphasis added)
Local community services boards are “health care providers” under Virginia law, and Virginia’s definition of a “health care provider” includes employees and “agents” who carry out the work of the health care provider, so that these employees and agents are considered to be a part of the health care provider. (See Virginia Code § 8.01-581.1.) Therefore, peer support specialists and others who provide facilitation services on behalf of a community services board are NOT engaged in the unlawful practice of law because they are part of the “health care providers” protected by Section 54.1-2988.
In order to confirm the role of the peer facilitator, and the facilitator’s relationship with the local community services board, it may be helpful to have a formal agreement between the CSB and the facilitator that describes that relationship. You can review a model of such an agreement, entitled “Peer Facilitation Memorandum of Understanding”, by viewing online below or downloading here.
The Facilitator’s Relationship with the Person Completing an Advance Directive
It can also be helpful to have a written document that clearly sets out for the person who is completing an advance directive what the facilitator is doing, and is not doing, through the facilitation process, and what steps need to be taken to ensure that the completed advance directive will be recognized and used. To review a proposed “facilitation explanation document” that can be used with consumers, by viewing online below or downloading here.
To “facilitate” an action is to make it easier. Because most people have not completed an advance directive for their health care, some organizations offer to “facilitate” the completion of advance directives. This is done by having a trained facilitator help a person go through, and understand, the advance directive form. The facilitator helps the person to think about his or her values and preferences regarding health care, and how those values and preferences might affect the person’s choices and instructions for health care.
Training of Facilitators
An effort is underway at some community services boards (CSB’s) in Virginia to train both staff and peer support specialists to assist individuals who have a mental illness in completing advance directives. Research at Duke University has found that as few as 3% of persons with mental illness have completed an advance directive that addresses their mental health care, but that when these individuals are offered assistance (facilitation) in completing such directives, the completion rate jumps to over 65%. The Norfolk CSB has led the way in providing training for peer specialists to become facilitators, and it recently recognized 9 peers and staff who completed training and are “certified” by the NCSB to provide this important service to consumers receiving services from the NCSB. (You can see a video about this program by clicking here.) The NCSB effort has been organized by Sandra (“Sandi”) Lee, the NCSB’s Consumer Relations Coordinator, with strong support from Sandi’s supervisor, Bob Horne, and has been made possible by Dana Traynham, Esq., a staff attorney for the Virginia Office of Protection and Advocacy (VOPA), who has conducted the training program.
While there is not yet a statewide certification process for advance directive facilitators, the Virginia Department of Behavioral Health and Developmental Services (DBHDS) has expressed support for the concept. The materials on this page are intended to provide some initial ideas and guidance for the development of a curriculum and supporting materials that might support a statewide certification program.
Facilitation Training: Power Point Presentations
Advance Directives - An Overview
Advance Directives: Background and History
Advance Directives: A Tour Through an Advance Directive
Facilitating Advance Directives: Guidelines for Helping Others With Their Advance Directive Form
Facilitation Training: Observation Checklist
Persons who are trained to be facilitators must be able to show that they have the knowledge, skills and abilities needed to effectively help people complete their advance directives. People being trained to be facilitators should be observed in monitored facilitation sessions, to see how helpful they are. A checklist, which sets out the key factors for good facilitation, is used as part of this observation. You can get a copy of the checklist used in the Norfolk CSB program by viewing online below or downloading here.
Advance Directive Forms Used in Facilitation
The “standard” Advance Directive form, based upon the form set out in Virginia Code Section 54.1-2984 (part of the Health Care Decisions Act [HCDA]), can be found by viewing online below or downloading here.
A short version of the standard form (2 pages vs. the standard form’s 4 pages), developed by the Virginia Hospital and Healthcare Association, can be found by viewing online below or downloading here.
An “expanded” Advance Directive form has also been developed. It has extra provisions that enable persons with ongoing medical conditions, including mental illness, to give more specific instructions about their future care in the event they are unable to give informed consent to care. That form can be found by viewing online below or downloading here.
Most of the CSB’s currently providing facilitation for consumers use the expanded form, and the training materials below are based on the expanded form. However, as the training materials themselves point out, Virginia law does not require that the Advance Directive form have specific provisions, other than the signature of the person and the signatures of two adult witnesses. Beyond that, any adult can fashion his or her own advance directive.
It is generally wise to include all health care instructions in a single document. However, some persons who have a mental illness have expressed concern about the possibility that they will be treated differently if their doctors become aware that they have a diagnosis of mental illness. People who have this concern may choose to set out their instructions about their mental health care in a document that is separate from the rest of their advance directive. The training materials emphasize that the consumers’ preferences, including preferences about what form to use, should be honored by facilitators.
Facilitation Training: The Duke University Facilitation Session Guide
Dr. Christine Wilder and support staff at Duke University have developed a facilitation guide. It provides a structure that a facilitator can use when the facilitator is helping a person to complete an expanded advance directive form. You can get that guide by viewing online below or downloading here.
Facilitators likely will want to refresh their memories about the meaning and application of different sections of the Advance Directive form. In addition, people filling out a form may ask questions about a section for which the facilitator does not have an answer. In this section, you can get access to comments and explanations on each of the key sections of the Expanded Advance Directive form.
Introduction
Section I(A) - Appointment of Agent
Section I(B) - Powers of the Agent, Introduction
Section I(B)(1) - General Health Care Power
Sections I(B)(2), (3) and (10) - Executive Powers of the Agent
Section I(B)(4) - Admission to Health Care Facilities by Agent
Section I(B)(5) - Admission to Mental Health Care Facilities by Agent
Section I(B)(6) - Authority to Continue Acting as Agent Over Objection
Sections I(B)(7), (8) - Consent to Participate in Research
Section I(B)(9) - Authority to Determine Visitation
Section I(B)(11) - Anatomical Gifts
Section I(C) - Authority to Consent to Care Over Objection
Section II - Introduction
Section II(A) - Health Condition and Treatments
Section II(B) - Emergency Contacts
Section II(C) - Medications
Section II(D) - Mental Health Crisis Intervention
Section II(E) - Other Health Instructions and Information Sharing
Section II(F) - Life Management Preferences
Section II(G) - Life Prolonging Treatment
Signature and Right to Revoke
Other Training Resources
The National Resource Center on Psychiatric Advance Directives maintains a website that includes a variety of education and training materials aimed at helping individuals to complete an advance directive to address future mental health care. You can visit that site by clicking here.
The Facilitator’s Relationship with the CSB
An advance directive is a legal document. Health care providers are required by the HCDA to recognize it. Given this status of the advance directive, some have asked whether a layperson who helps someone fill out an advance directive could be engaged in the unlawful practice of law. There is no clear guidance at this time on when such help would amount to the unlawful practice of law if it is provided by a person who is not affiliated with the health care system. However, the HCDA, in Section 54.1-2988 states: “The distribution to patients of written advance directives in a form meeting the requirements of § 54.1-2984 and assistance to patients in the completion and execution of such forms by health care providers shall not constitute the unauthorized practice of law pursuant to Chapter 39 (§ 54.1-3900 et seq.).” (emphasis added)
Local community services boards are “health care providers” under Virginia law, and Virginia’s definition of a “health care provider” includes employees and “agents” who carry out the work of the health care provider, so that these employees and agents are considered to be a part of the health care provider. (See Virginia Code § 8.01-581.1.) Therefore, peer support specialists and others who provide facilitation services on behalf of a community services board are NOT engaged in the unlawful practice of law because they are part of the “health care providers” protected by Section 54.1-2988.
In order to confirm the role of the peer facilitator, and the facilitator’s relationship with the local community services board, it may be helpful to have a formal agreement between the CSB and the facilitator that describes that relationship. You can review a model of such an agreement, entitled “Peer Facilitation Memorandum of Understanding”, by viewing online below or downloading here.
The Facilitator’s Relationship with the Person Completing an Advance Directive
It can also be helpful to have a written document that clearly sets out for the person who is completing an advance directive what the facilitator is doing, and is not doing, through the facilitation process, and what steps need to be taken to ensure that the completed advance directive will be recognized and used. To review a proposed “facilitation explanation document” that can be used with consumers, by viewing online below or downloading here.