Today 70% of seniors want to pass away at home, but only 30% actually do. Why patients are not getting the care they want at the end of life comes from communication barriers between patients, their families, and their medical providers. Many of these barriers result from a general lack of understanding of available options, limited transparency or involvement with the care process, and discomfort from all parties about talking about death and dying. So is it that patients find it difficult to navigate the options they have, and do not feel comfortable enough or know how to ask their medical provider. Most medical providers, on the other hand, do not have the time or the confidence to initiate and sustain these conversations due to a lack of proper training and language, cultural, and religious barriers and disparities in health literacy that significantly impede efficient and effective conversation. Families are not often kept on the same page throughout the process, with personal biases that can lead to paternalistic decision-making that is not aligned with the patient’s goals. And even when these conversations do occur, they are often removed from the process of official documentation, creating further vulnerability to miscommunication during a time of crisis.

Addressing these barriers requires not only redesigning how advance care planning should be approached, but also consideration of who should be initiating these conversations. Copilots In Care addresses this communication inefficiency by removing the activation barrier to starting advance care planning conversations off both medical providers and patients. We enable sustained and receptive communication by combining an accessible digital platform with an empathetic social worker (or Copilot) matched with the patient through a predictive algorithm. Copilots guide patients and their families through a set of reflection questions and educational materials designed to help them determine how they can achieve what matters most to them. After completion of this reflection and education process, Copilots meet with patients and their family in-person to facilitate discussion about their responses and complete proper documentation (i.e., the POLST and advance directive) that is sent to the medical provider. Finally, prepared and informed patients and their family then meet with their medical provider for an efficient conversation guided by a checklist of discussion points. With continuous follow-up to ensure that documentation is kept up-to-date and aligned with the patient’s wishes as their condition changes, the result is a patient with more confidence, a family with less stress, a provider with fewer burdensome conversations, and an insurer with less unwanted interventions.

For more information, please visit our website at http://www.copilotsincare.com/.