Medical Orders for Scope of Treatment (MOST) in KY 1 Christian - - PowerPoint PPT Presentation

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Advance Care Planning/ Medical Orders for Scope of Treatment (MOST) in KY

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Christian Davis Furman, MD, MSPH, AGSF

Margaret Dorward Smock Endowed Chair in Geriatric Medicine Professor, Geriatric & Palliative Medicine Medical Director, Institute for Sustainable Health & Optimal Aging

Justin Magnuson, MA

MOST Coalition and Palliative Care Liaison Institute for Sustainable Health & Optimal Aging

Objectives Understand the importance of Advance Care Planning Complete the Medical Orders for Scope of Treatment (MOST) form

Used with permission from:

Judith S. Black, MD, MHA Senior Medical Director, Senior Markets

Highmark Inc.

judith.black@highmark.com

Marian Kemp, RN POLST Coordinator

Coalition for Quality at the End of Life

papolst@verizon.net

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Why is Advance Care Planning Important

Health and wellbeing of patients Improved system outcomes Cost-effective Triple Aim

Hospice Palliative Care (PC):

Advance care planning & goals for care, pain and symptom control, caregiver support

Diagnosis Death

Continuum of Care Model for Patients with Serious Illness

Bereavement Progression of Serious Illness  

Medical Management of Chronic Disease Integrated with Palliative Care

6mo

Goals for Care shift

12 mo

The Conversation Should be Held Over the Lifespan

At 18 y/o Prior to Diagnosis Children born with debilitating or life-limiting illness Anyone going to have surgery Anyone with a chronic disease Other examples, too

Role of ADVANCE CARE PLANNING in the Goals of Care Conversation

Two Types of Advance Planning Tools

Traditional - little or no impact on immediate care

▪ Health Care Proxy/Health Care Power of Attorney/Health Care Surrogate ▪ Living Will

Actionable Medical Orders - direct and relatively immediate impact on course of care

▪ POLST Paradigm form (POST, MOLST, MOST, etc.) ▪ Do not resuscitate order ▪ Do not hospitalize, no feeding tube, etc.

McAuley & Travis, Am J Hospice & Palliative Care 2003;20(5):353-359

Discussing Treatment Goals

Describe 4 broad potential treatment goals:

• 1. CURE – eliminate disease
• 2. REHABILITATION – restore, maintain or

minimize loss of function

• 3. LIFE-PROLONGING PALLIATIVE CARE –

if looking forward to an event or don’t have their affairs in order

• 4. COMFORT-FOCUSED PALLIATIVE

CARE – nothing to prolong life, nothing to shorten life; let nature take its course

Differences Between a MOST and Advance Directive

Advance Directive MOST Population All Adults Serious illness or frailty Timeframe Future care/future conditions Current care/current condition Who completes form Individuals/Patients Health Care Professional Where completed Any setting, not necessarily medical Medical setting Resulting product Surrogate appointment and statement of preferences Medical orders based on shared decision-making Surrogate role Cannot do Can consent if patient lacks capacity* Portability Patient/family responsibility Health Care Professional responsibility Periodic Review Patient/family responsibility Provider responsibility to initiate

Purpose of MOST

To provide a mechanism to communicate patient preferences for end-of-life treatment across treatment settings See MOST Form

MOST Form – see handout for up-to-date version

Benefits of MOST

 Clearly establishes patient decision for level of care/goals

• f care

 Ensures patients’ wishes are honored  Increases staff comfort with difficult conversations  Improves HCAHPS ratings – patient perspective  Improves Quality  Decreased Hospital Readmissions  Decreased Length of Stay  Generated revenue by billing new Advance Care Planning Codes

MOST in KY

 KY Association of Hospice and Palliative Care –

spearheaded effort to pass legislation  2010– Pilot Project with hospice patient in nursing homes  2012-2015 – Legislative Effort  Brought before legislature 3 times; Signed by Governor March 2015;

• Ky. Board of Medical Licensure website in Nov. 2015

 Statewide MOST Coalition formed in Jan. 2017  Used in Nursing Homes and Health Systems– Christian Care Communities throughout the state; Nazareth Homes; Episcopal Church Home; Norton Healthcare and Baptist Health; Owensboro Health; St. Elizabeth Healthcare

Keys for Successful Implementation

 A system champion;  Staff who understands advance care planning and have comfort level in discussing advance care planning;  Procedures and policies;  Involvement and support from EMS and emergency medicine;  Broadly representative coalition;  Robust Quality Improvement Monitoring Process across facilities;  Physician Involvement.

Educate, Educate, Educate

 Providers (physician, NP, PA), SNF and hospital  Nursing staff, skilled nursing units and hospital (especially ER and ICU)  Social work, administration, others  Patients, families, community  Importance of having respected physician champion(s), as well as nursing champion(s) and administrative support in facilities

Key Take Away Points

 The form is not the main thing. Careful facilitated discussions that elicit care preferences are the main thing!  MOST does not replace an advance directive  Advance Care Planning (ACP) CPT (Billing) Codes: 99497 and 99498 – 30 min each  A successful program requires a broadly based implementation plan.

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POLST Website Resources

www.aging.pitt.edu/professionals/resources.htm Aging Institute of UPMC Senior Services and the University of Pittsburgh www.portal.state.pa.us/portal/server.pt/communit y/emergency_medical_services/14138/polst_out

• of-hospital_dnr_orders/556979

PaDOH Bureau of EMS Out-of-Hospital DNR information OOH-DNR protocol within Statewide BLS Protocols www.polst.org Center for Ethics in Health Care Oregon Health & Science University www.coalitionccc.org Coalition for Compassionate Care of California www.compassionandsupport.org/ Excellus Blue Cross Blue Shield MOLST www.wvendoflife.org West Virginia Center for End-of-Life Care POST

Resources

MOST Coalition – provide assistance with in-services/role- play/policies and procedures http://kbml.ky.gov/board/Documents/MOST form.pdf KRS 311.6225 authorized the MOST form https://kbems.kctcs.edu/medical_direction/untitled.aspx (Medical Orders for Scope of Treatment The Conversation Project NetLaw MD

References

Sabatino, Charles; Karp, Naomi, AARP Public Policy Institute, (2011) “Improving Advance Illness Care: The Evolution of State POLST Programs” , http://assets.aarp.org/rgcenter/ppi/cons-prot/POLST-Report-04-11.pdf. Tuohey, John Fr.; Hodges, Marian, MD, Health Progress, (2011) End of Life: POLST Reflects Patient Wishes, Clinical Reality, http://www.chausa.org/Contenttwocolumn.aspx?pageid=4294969209&terms=end+of+life+POLST Arnold, Robert, et.al. Hope for the Best, and Prepare for the Worst. Annals of Internal Medicine.2003;138: 439-443 Hickman, E. Susan PhD et al. The Consistency Between Treatment Provided to Nursing Facility Residents and Orders on the Physician Orders for Life- Sustaining Treatment. JAGS 59:2091-2099, 2011. Kirchhoff, Karin T, PhD, RN, Hammes, B J, PhD, Kehl, Karen A, Phd, RN Briggs, Linda A, MA, MS, RN & Brown, Roger L, PhD. Effect of a Disease- Specific Planning Intervention on Surrogate Understanding of Patient Goals for Future Medical Treatment, J AM Geriatric Society 2010; 2760;1233-1240. Hickman, SE., Sabatino, CP., Moss, AH., Nester Wehrle, J. The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of- Life Care: Potential State Legal Barriers to Implementation. J Law Med Ethics (2008) 36:119-140. Dunn, Patrick M, MD; Tolle, Susan W. MD; Moss, Alvin H. MD; Black, Judith S. MD, MHA. The Polst Paradigm: Respecting the Wishes of Patients and

• Families. Annals of Long-Term Care/Volume 15, Number 9/September 2007: 33-40.

Hickman ,SE, Hammes, BJ, Moss AH, & Tolle, SW. (2005). Hope for the Future: Achieving the Original Intent of Advance Directives. The Hastings Center Report Special Report, 35, (6), S26-S30, www.thehastingscenter.org. Emmanuel, EJ, et. al. Managed Care, Hospice Use, Site of Death, and Medical Expenditures in the Last Year of Life. Arch Intern Med. 2002;162: 1722- 1728.

References

Hanson, Laura, MD.,MHP, Tube Feeding Versus Assisted Oral Feeding for Persons With Dementia: Using Evidence to Support Decision-Making, Annals of Long Term Care, January 2013. Glick, Shimon, MD., FACP, Jotkowitz, Alan, MD., Feeding Dementia Patients via Percutaneous Endoscopic Gastrostomy, Annals of Long Term Care, January 2013. Hickman, SE., PhD, Nelson, CA., PhD, RN, Perrin, NA., PhD, Moss, AH., MD, Hammes, BJ., PhD, Tolle, SA., MD,. A comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physician Orders for Sustaining Treatment Program. J Am Geriat Soc 2010; 2955:1241-1248 Bomba, Patricia, MD., Kemp, Marian, Black Judith S., MD., POLST: An improvement over traditional advance directives, Cleveland Clinic Journal Of Medicine Vol 7 9, No. 457-454. July 2 01 2. Bomba PA, Discussing Patient Preferences and End of life Care, Journal of the Monroe County Medical Society, 7th District Branch, MSSNY. 2011; April 2011: 12-15,. http://www.compassionandsupport.org/index.php/research_references/references. Hammes, BJ., PhD, Rooney, BL., PhD, MPH, & Gundrum, JD., MS. La Crosse Advance Directive Study, 2009. Lynn ,J, et.al. Reforming Care for Persons Near the End of Life: The Promise of Quality Improvement. Annals of Internal Medicine. 2002;137: 117-122. Fisher, Elliott, et. al. Implications of Regional Variations in Medicare Spending. Annals of Internal Medicine. 2003:138: 27-298. Callahan, CM, et al. Outcomes of PEG among older adults in a community setting, J Am Geriatr Soc 2000; 48:1048 Lynn J,et.al. Improving Care for the End of Life. Oxford University Press 2000. Holtzman, J, et al. Changes in orders limiting care and the use of less aggressive care in a NH population J Am Geriatr Soc 1994;42:275. Terry, M, et al. Prevalence of advanced directives and DNR orders in community nursing facilities. Arch Fam Med 1994;3:141. Finucane, TE, et al. The incidence of attempted CPR in nursing homes. J Am Geriatr Soc 1991;39:624.

References

Sugiyama, Takehiro, MD., Zingmond, David, MD., PhD., Lorenz, Karl A., MD., MSHS, Diamant, Allison, MD., MSHS, O’Malley Kate, RN., Citko, Judy, JD., Gonzalez, Victor, BA., Wenger, Neil S., MD., MPH, Implementing Physician Orders for Life-Sustaining Treatment in California Hospitals: Factors Associated with Adoption, 2013, JAGS 61:1337-1344 Coleman, Fr. Gerald D. SS, McLean, Margaret R., PhD., POLST Supports Care In Context of ERDs, Journal of the Catholic Health Association Of The United States, Health Progress, November – December 2012, http://www.chausa.org/subjectindex.aspx?year=2012#letter-index-Advocacy Pope, Thaddeus M., Hexum, Melinda, Legal Briefing: POLST: Physician Orders for Life-Sustaining Treatment, Journal of Clinical Ethics, Vol. 23,

• No. 4, p. 353-376, September 1, 2012.

Teno JM, Gozalo PL, Bynum JP, et al. Change in End-of-Life Care for Medicare Beneficiaries. Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470-477 Wenger, Neil S., MD,MPH, et.al., Implementation of Physician Order for Life Sustaining Treatment in Nursing Homes in California: Evaluation of a Novel Statewide Dissemination Mechanism, Journal of General Internal Medicine, August 2012, 10 (3):167. Hammes, Bernard J, PhD, Rooney ,Brenda L. PhD, Gundrum, Jacob D. M.S., Hickman, Susan E., PhD, and Hager, Nickijo, MSN. The POLST Program: A Retrospective Review of the Demographics of Use and Outcomes in One Community Where Advance Directives Are Prevalent, Journal of Palliative Medicine January 2012, Vol. 15, No. 1: 77-85 Kellermann, Arthur MD; Lynn, Joanne MD. Withholding Resuscitation in Prehospital Care, Annals of Internal Medicine 2006; 144:9; 692-694. National Quality Forum, Framework and Preferred Practices for Quality Palliative Care & Hospice Care, 2006. Levy, Cari R, MD et al. Do-Not Resuscitate and Do-Not-Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit. JAGS 53:2060-2068, 2005. Casarett, David MD, et al. Appropriate Use of Artificial Nutrition and Hydration – Fundamental Principles and Recommendations. N Engl J Med 2005; 353:24; 2607-2612.