POLST in California: Use in Nursing Homes Hospitals, Quality of Completion and Impact of Community Coalitions

1. POLST in California:Use in Nursing Homes & Hospitals,Quality of Completion andImpact of Community Coalitions Neil Wenger, MD Catherine McGregor, MSN, FNS,C February 16, 2012

2. POLST Implementation in California POLST mandated by California law Jan 2009 California HealthCare Foundation and Coalition for Compassionate Care of California statewide implementation Began in 2007 Statewide taskforce of stakeholders Educational materials and standardized approach Local grassroots coalitions

3. Survey to Evaluate Nursing Home and Hospital POLST Use Survey instrument development Statewide POLST Taskforce Community Coalitions California Association of Health Facilities (CAHF) Mailed and electronic survey Telephone follow up

4. Survey to Evaluate Nursing Home and Hospital POLST Use Topics Experience of with POLST POLST policy POLST education and needs POLST handling and attitudes Problems with POLST

5. Evaluation of POLST Dissemination in California Nursing home use, statewide 2010 Coalition and non-coalition areas Hospital use, statewide 2011 Nursing home POLST quality 2010 and 2011 Coalition areas

7. Nursing Home POLST Evaluation:Sample selection Selected SNFs from each study county Up to 20 SNFs in each county If >20 SNFs, randomly selected If Community Coalition county, select 50% as partner SNFs Partner SNFs randomly selected Backfilled to maximize county sample

8. SNF Sample for Survey

9. CA Nursing Homes, 2010: POLST Preparation

10. Nursing Home POLST Evaluation:Sample selection Selected SNFs from each study county Up to 20 SNFs in each county If >20 SNFs, randomly selected If Community Coalition county, select 50% as partner SNFs Partner SNFs randomly selected Backfilled to maximize county sample

11. CA Nursing Homes, 2010: POLST Use

13. CA Hospitals, 2011: POLST Preparation and Use

14. Effect of Coalitions:Admitted a Resident with a POLST

15. Quality of POLST Completion in Coalition Area Facilities What is the quality of completion of POLST forms from Nursing Homes with which Coalitions worked? Is there improvement in completion with feedback of findings? Goal for this next year is to engage coalition members in extending the POLST Q/I processGoal for this next year is to engage coalition members in extending the POLST Q/I process

16. Quality of POLST Completion in Coalition area Nursing Homes Convenience sample of 6 SNFs in each of 5 coalition areas Orange County, Sacramento, San Diego, San Fernando Valley, Santa Clara July/August 2010: Review of 538 randomly selected charts with POLST forms Feedback of findings to SNF July/August 2011: Review of 594 randomly selected charts with POLST forms

17. POLST Key Findingsin SNF, 2010 and 2011 Common errors included: Forms that were missing either the name or contact information (or both) for the provider who prepared the form. Missing the date that that the form was prepared. As mentioned before, it is very important to document the date the POLST is executed, so that the appropriate level of intervention is provided. Missing the date of the physician�s signature. Best practice suggests that MD signatures are dated. No box marked for who POLST was discussed with. Documentation of who was involved in the POLST conversation is important so that should there be discrepancies in a resident�s medical management, reference to others who were involved in the discussion can be made for further clarification. Missing a patient or decision maker signature. Missing a physician�s signature. If a patient or decision maker, or a physician signature is not present on the POLST, it is not an ACTIONABLE order. There were occasions that Section A did not correlate with Section B. For example: Attempt CPR and Comfort Measures Only. In some cases, the patient name or DOB were incorrect. Other errors included: No decision maker contact information Common errors included: Forms that were missing either the name or contact information (or both) for the provider who prepared the form. Missing the date that that the form was prepared. As mentioned before, it is very important to document the date the POLST is executed, so that the appropriate level of intervention is provided. Missing the date of the physician�s signature. Best practice suggests that MD signatures are dated. No box marked for who POLST was discussed with. Documentation of who was involved in the POLST conversation is important so that should there be discrepancies in a resident�s medical management, reference to others who were involved in the discussion can be made for further clarification. Missing a patient or decision maker signature. Missing a physician�s signature. If a patient or decision maker, or a physician signature is not present on the POLST, it is not an ACTIONABLE order. There were occasions that Section A did not correlate with Section B. For example: Attempt CPR and Comfort Measures Only. In some cases, the patient name or DOB were incorrect. Other errors included: No decision maker contact information

18. Challenges and Opportunities POLST�another thing to do Staff turnover Lack of education/scarce resources Diverse cultures Explaining CPR, prognosis, statistical outcomes Difficulty in having goals of care conversations Physician engagement Processes in getting the POLST back from Hospitals

20. Summary of Findings 18 months after implementation, substantial uptake of POLST in SNFs Most facilities had structures and staff education 2/3 of SNFs had admitted a resident with a POLST 80% had used POLST in their SNF By 2011, hospitals using POLST regularly Community Coalition mechanism increased dissemination of POLST POLST quality generally good Documentation difficulties common after 18 months improved with feedback