MOLST Quality Forums Update on MOLST Implementation Across New York State January 2008
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1 MOLST Quality Forums Update on MOLST Implementation Across New York State January 2008 Patricia Bomba, M.D., F.A.C.P. Vice President and Medical Director, Geriatrics Director, Education for Physicians on End-of-life Care Co-Director, Community-wide End-of-life/Palliative Care Initiative Chair, Monroe and Onondaga Counties MOLST Implementation Team [email protected] A nonprofit independent licensee of the BlueCross BlueShield Association
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MOLST Quality Forums Update on MOLST Implementation Across New York State January 2008. Patricia Bomba, M.D., F.A.C.P. Vice President and Medical Director, Geriatrics Director, Education for Physicians on End-of-life Care Co-Director, Community-wide End-of-life/Palliative Care Initiative - PowerPoint PPT Presentation
Transcript of MOLST Quality Forums Update on MOLST Implementation Across New York State January 2008
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MOLST Quality ForumsUpdate on MOLST Implementation
Across New York State
January 2008
Patricia Bomba, M.D., F.A.C.P.Vice President and Medical Director, Geriatrics
Director, Education for Physicians on End-of-life CareCo-Director, Community-wide End-of-life/Palliative Care Initiative
Chair, Monroe and Onondaga Counties MOLST Implementation Team [email protected]
A nonprofit independent licensee of the BlueCross BlueShield Association
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Objectives
Describe steps needed for community-wide implementation
Review local, regional and statewide implementation efforts
Discuss education and training, efforts, tools and resources, including web tour
Outline next steps for statewide expansion
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Implementation Steps
Needs Assessment Core Working Group Task Force – Collaborative Model Program Coordination Key Components Legal Issues Pilot Project Education and Training Distribution and Fulfillment Program Requirements Relationship to Media Available Resources
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Needs Assessment
Approaching Death: Improving Care at the End of Life Institute of Medicine Report, 1997
Community End-of-Life Survey Report RIPA/EBCBSRR EOL/Palliative Care Professional Advisory
Committee, January 2001
Community-wide End-of-life/Palliative Care Initiative Rochester Health Care Forum, March 2001 Launched May 2001
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Community-wide End-of-life/Palliative Care Initiative
Advance Care Planning Community Conversations on Compassionate Care
Honoring Preferences Medical Orders for Life-Sustaining Treatment (MOLST) PEGS
Pain Management and Palliative Care Community Principles of Pain Management CompassionNet
Education and Communication Education for Physicians on End-of-life Care (EPEC)
Community web site: www.compassionandsupport.org
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Core Working Group
Assemble a workgroup Broad representation – interdisciplinary Leadership Passion, commitment Willing to outreach and educate Sustainability Expand collaboration
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Task Force – Collaborative Model
Broad representation Department of Health
• Hospital, LTC, EMS oversight, surveyors
EMS Hospital Association Long-term Care Associations (NFP and FP) Hospice and Home Health Office for Aging, Society on Aging, Ombudsmen Medical Society Bar Association
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Program Coordination
Leadership Operations
Distribution and Fulfillment Training Quality Improvement Share best practices & lessons learned
Funding Sustainability Variation in models
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Key Components
Standardized practices, policies and form Education and Training
Advance care planning facilitators System implementation
Timely discussions along continuum prompted by: Identification of appropriate cohort Prognosis
Clear, specific language on actionable form Bright colored, easily recognized form Medical orders honored throughout the system Quality improvement process for form and system
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Legal Issues & Pilot Project
Work initiated Fall 2001 Created November 2003 Adapted from Oregon’s POLST Combines DNR, DNI, and other
Life-Sustaining Treatment Collaboration with NYSDOH
began March 2004 Incorporates NYS law Revised October 2005 Approved Inpatient DNR form Legislation passed 2005 Community Pilot Chapter Amendment 2006
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Education and Training
Advance Care Planning Facilitators Traditional advance directives MOLST form and program Goal-based, patient-centered discussions Patient-centered program and process
• not merely the form
Program Implementation Facility-based Physician practice – opportunity for
process improvement
Community education
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Distribution and Fulfillment
Distribution Center Process to order forms, educational and
training resources
Download from web site Considerations
Funding Tracking utilization and implementation
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Relationship to Media
Communication Plan Messaging
Consistent message Approach to avoid
Prepare for interviews Consider 3 key messages
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Community Implementation of the MOLST
in New York State
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Rockland
NiagaraOrleans
Erie
Onondaga
Jefferson
ChautauquaSteuben
Cayuga
Orange
MonroeWayne
Genesee
St. Lawrence
Allegany
Wyoming
Cattaraugus
Ontario Seneca
Livingston
Schuyler
Chemung
Cortland
Oswego
Lewis
Madison
Chenango
Delaware
Franklin
Otsego
Sullivan
Essex
Clinton
AlbanySchoharie
Greene
Washington
Rensselaer
Saratoga
Warren
Schenectady
Columbia
Ulster
Dutchess
Putnam
Westchester
SuffolkNassau
Fulton
Montgomery
Herkimer
Hamilton
Oneida
Tioga
Broome
Oneonta
Watertown
Poughkeepsie
Amsterdam
Binghamton
Elmira
Albany
Rome
Utica
Plattsburgh
Syracuse
AuburnBuffalo
Rochester
Jamestown
Hornell
Ithaca
Batavia
Malone
Potsdam
!
!
TompkinsYates
MOLST12/03 – 10/05
**
* ***
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Rockland
NiagaraOrleans
Erie
Onondaga
Jefferson
ChautauquaSteuben
Cayuga
Orange
MonroeWayne
Genesee
St. Lawrence
Allegany
Wyoming
Cattaraugus
Ontario Seneca
Livingston
Schuyler
Chemung
Cortland
Oswego
Lewis
Madison
Chenango
Delaware
Franklin
Otsego
Sullivan
Essex
Clinton
AlbanySchoharie
Greene
Washington
Rensselaer
Saratoga
Warren
Schenectady
Columbia
Ulster
Dutchess
Putnam
Westchester
SuffolkNassau
Fulton
Montgomery
Herkimer
Hamilton
Oneida
Tioga
Broome
Oneonta
Watertown
Poughkeepsie
Amsterdam
Binghamton
Elmira
Albany
Rome
Utica
Plattsburgh
Syracuse
AuburnBuffalo
Rochester
Jamestown
Hornell
Ithaca
Batavia
Malone
Potsdam
!
!
TompkinsYates
MOLST11/05 - present
**
* **
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MOLST Order Form Comparison Between Original and Revised Form
23,710
161,008
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
Original Form 12/03 -10/05
Revised Form 11/05 -1/08
# o
f F
orm
s O
rder
edMOLST Order Form Comparison Between
Original and Revised Form
23,710
161,008
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
Original Form 12/03 -10/05
Revised Form 11/05 -1/08
# o
f F
orm
s O
rder
edMOLST Order Form Comparison Between
Original and Revised Form
23,710
161,008
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
Original Form 12/03 -10/05
Revised Form 11/05 -1/08
# o
f F
orm
s O
rder
ed
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MOLST Order Form Comparison Between Original and Revised FormPre- and Post- MOLST DVD
161,008
69,189
23,710
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
OriginalForm 12/03 - 10/05
Revised Form 11/05 - 6/07 Pre-MOLST DVD
Revised Form 11/05 - 1/08 Post-MOLST DVD
# o
f F
orm
s O
rder
ed
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Lessons LearnedFacility Implementation
Buy-in by the institution helps Integrate MOLST into AD/DNR Policy
and Procedure Clarify role of MD, NP/PA, SW Physician accountability Supportive role of other health care
professionals helps MOLST physician and systems
champion in facility
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Advance Care Planning
Community Goals and
Advance Care Planning and
MOLST Resources
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Advance Care Planning Community Goals
Document the designated agent (surrogate decision maker) in a Health Care Proxy for every patient in primary, acute and long-term care and in palliative and hospice care.
Document the patient/surrogate preferences for goals of care, treatment options, and setting of care at first assessment and at frequent intervals as condition changes.
National Quality Forum, Framework and Preferred Practices for Quality Palliative Care & Hospice Care, 2006, Adapted for New York State
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Advance Care Planning Community Goals
Convert the patient treatment goals into medical orders and ensure that the information is transferable and applicable across care settings, including long-term care, emergency medical services, and hospital, i.e., the Medical Orders for Life-Sustaining Treatment—MOLST, a POLST Paradigm Program.
National Quality Forum, Framework and Preferred Practices for Quality Palliative Care & Hospice Care, 2006, Adapted for New York State
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Advance Care Planning Community Goals
Make advance directives and surrogacy designations available across care settings
Develop and promote healthcare and community collaborations to promote advance care planning and completion of advance directives for all individuals
National Quality Forum, Framework and Preferred Practices for Quality Palliative Care & Hospice Care, 2006, Adapted for New York State
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Community ResourcesAdvance Care Planning
Advance Care Planning Booklet (English, Spanish)
Advance Care Planning Poster and Tent card Behavioral Readiness “tools” Community Conversations on
Compassionate Care (CCCC) workshop CCCC video Advance Care Planning Facilitator Training Life Choices Program
www.compassionandsupport.org
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Community ResourcesMedical Orders for Life-Sustaining Treatment
MOLST 8-Step Protocol MOLST Guidebook MOLST Patient & Family Brochure (English, Spanish) Sample Facility Policies & Procedures Sample Facility Implementation Workplans Sample Facility Education Workplans MOLST Training Manual MOLST Train-the-Trainer Sessions MOLST Conferences MOLST DVD and web-based tools
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Advance Care Planning:Life Expectancy of Less than One Year
Start:Physician / Patient
Conversation
Educate aboutImportance of
Advance Directives
Elicit Patient's Valuesand Preferences for
End-of-Life Care
Discuss Palliative Care Options
Including Hospice
Consider Introducing the
Palliative Care Team
Work to Overcome Barriers
Does Patient HaveAdvance Directives?
Provide Informationon Advance Directives
Reassess Periodicallyor as Needs Change
Are There Barriers to Completing
Advance Directives?
YesNo
Reinforce Need for Updated Advance
Directives
Yes
No
No
Yes
Are the Advance Directives
Up-to-Date?
Encourage Patientto Discuss Wishes
with Family
Obtain Copy of Completed
Advance Directives
Assess Appropriatenessof Designated
Health Care Agent
Complete POLST
Form
Motivate Completionof Advance Directives
Assess Barriersto Completing
Advance Directives
Inquire about Organ Donationand/or Autopsy
Complete MOLST Form
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Behavioral Readiness to Change
Precontemplation: See no need
Contemplation: Recognize need, but have barriers
Preparation: Ready to complete
Action: Advance Directive reflects wishes
Maintenance: Advance Directive needs update
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