Mom’s Money is Missing: Bank Records Analysis in a Fraud Examination Case

Bank records analysis is a vital component of many forensic accounting and fraud examination engagements. This case provides students with a hands-on opportunity to conduct a fraud examination based upon a detailed review of bank records. The context of this case is an elderly client who has appointed her son as her durable power of attorney. Unfortunately, he violates his fiduciary duty and misappropriates money from his mother. The students’ assignment is to trace the missing money through numerous bank accounts and prepare a report for the local county attorney who will prosecute the case. Students will learn how to trace money through multiple bank accounts, prepare a succinct report for the prosecutor, cope with a large quantity of source documents, and manage a relatively unstructured task.

Capturing patient advance directives status in a community oncology practice using an electronic patient-reported outcomes (ePRO) system.

5 Background: The American Society of Clinical Oncology recommends that providers encourage early advance care planning with their patients; yet, many cancer patients do not have advance directives (ADs). A potential reason for low AD rates is inadequate communication between the provider and patient. To address this gap, we developed an outpatient clinic AD initiative for any stage cancer patients via an ePRO system. The AD module was designed to ensure patients are aware of ADs and to assess whether or not the patient had ADs, specifically a Living Will and/or a durable power of attorney and their interest in receiving information about ADs. The study purpose was to assess patient AD status at the patient’s initial visit to an oncology clinic. Methods: This study used a retrospective, observational design that involved use of PRO data collected via the Patient Care Monitor (PCM), a web-based ePRO system linked to electronic medical record data. All study data were collected as part of routine clinical care. All patients at an initial visit to an oncology clinic completed the PCM survey, including the AD module, via a handheld e-tablet. Results: Overall, 18,239 patients completed the AD module (mean age 62; 32% male/68% female; 55% married; 60% White, 36% Black). One third of all patients (30%) reported having an AD at the time of the initial visit to the oncology clinic, specifically 11% indicated having a Living Will and 19% a durable power of attorney. The remaining two-thirds (70%) indicated either NOT having an AD (58%) or not knowing if they had an AD (12%). Patients with ADs were more likely to be older (M= 69 v. 59 yrs) and White (77% v 20% Black) ps < .0001. Of the patients without ADs, 10% requested more information on ADs. These patients were more likely to be older (M= 61 v. 58 yrs), female (68% v 32%), Black (54% v 40% White) and non-married/non-partnered (53% v 47%); ps < .005. Conclusions: This study demonstrates that the majority of patients do not have ADs at the time of an initial visit to a community-based oncology practice. Using an ePRO system can be an innovative and non-threatening way to identify unmet needs of patients and link them to resources for developing advance directives.

Understanding patient advance directives status in a community oncology practice using an electronic patient-reported outcomes (ePRO) system.

e23181 Background: The National Comprehensive Cancer Network and the American Society of Clinical Oncology recommend that providers encourage early advance care planning with their patients1; yet, many cancer patients do not have advance directives (ADs). A potential reason for low AD rates is inadequate communication between the provider and patient. To address this gap, we developed an outpatient clinic AD initiative for any stage cancer patients via an ePRO system. The AD module was designed to ensure that patients are aware of ADs and to assess whether or not the patient had ADs, specifically a Living Will and/or a durable power of attorney. The study purpose was to assess patient AD status at the patient’s initial visit to an oncology clinic. Methods: This study used a retrospective, observational design that involved use of PRO and clinical data collected via the Patient Care Monitor™ (PCM), a web-based ePRO system linked to electronic medical record data. All data used in this study were collected as part of routine clinical care. All patients at an initial visit to an oncology clinic completed the PCM survey, including the AD module, via a handheld e-tablet. Results: Overall, 9,682 patients completed the AD module (mean age 63; 31% male/69% female; 58% married; 62% White, 35% Black). Cancer type was known for 75% of all patients (29% breast, 11% hematologic, 7% lung, 7% colorectal, 3% prostate, 17% other types). One third of all patients (33%) reported having an AD at the time of the initial visit to the oncology clinic, specifically 24% indicated having a Living Will and 9% a durable power of attorney. The remaining two-thirds (67%) indicated either NOT having an AD (56%) or not knowing if they had an AD (11%). Patients with ADs were more likely to be older ( M=68 v. 60 yrs), male (38% v 31%), White (41% v 20% Black) and married/partnered (35% v 29%); ps <.0001. Conclusions: This study demonstrates that the majority of patients do not have ADs at the time of an initial visit to a community-based oncology practice. Using an ePRO system can be an innovative and efficient way to identify unmet needs of patients and link them to resources for developing advance directives. 1Brown AJ, Shen MJ, Urbauer D, et al. Room for improvement: An examination of advance care planning documentation among gynecologic oncology patients. Gynecol Oncol. Sep 2016;142(3):525-530.

An invitation to complete: Making advance directives part of the new patient process.

7 Background: In Colorado, there is no legal designation as to who is authorized to make healthcare decisions for an adult unable to make decisions for themselves. Completing an advance directive is increasingly associated with better end-of-life outcomes. Failure to complete an advance directive leads to fewer days on hospice and expensive, end-of-life care. It was hypothesized that patients who completed a Medical Durable Power of Attorney (MDPOA) document early may have higher adoption of advance care planning and earlier hospice at end-of-life. Methods: The Rocky Mountain Cancer Centers (RMCC) is the largest private oncology group in Colorado with multiple offices across the state. The RMCC-Pueblo clinic developed and piloted a new patient process where, at registration, all new patients were invited to complete a MDPOA while also completing other new patient forms. The Medical Durable Power of Attorney (MDPOA) is a document that appoints a healthcare decision maker (“healthcare agent”). Data on 4,441 patients from Nov. 1, 2017, to June 30, 2018, were extracted from the electronic health record (EHR), including code status, advance care planning counseling appointment, advance directive completion, and outcomes. Results: During this pilot, advance directive capture within the EHR rose from 15.4% to 21.4%. While the number of patients who elected hospice enrollment at the end of life was about the same, the length of hospice stay increased from an average of 14 to over 20 days, a 50% improvement. Conclusions: A MDPOA as a routine part of the new patient intake process is feasible and scalable. It opens the door to future ACP discussions and improved hospice utilization. Because of these findings, we are currently expanding this process to all RMCC practice sites. The results suggest that early completion of an Advance Directive lead to ongoing and healthy discussions about the patient’s end-of-life preferences for care, including appropriate hospice enrollment.