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Thomas Caprio, M.D. Senior Instructor, Division of Geriatrics & Aging, University of Rochester

Monroe County MOLST Quality Forum Update on MOLST Facility Implementation and Quality Improvement Audits January 2008. Thomas Caprio, M.D. Senior Instructor, Division of Geriatrics & Aging, University of Rochester Co-chair, EMS, Quality and Research Subcommittee

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Thomas Caprio, M.D. Senior Instructor, Division of Geriatrics & Aging, University of Rochester

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  1. Monroe County MOLST Quality ForumUpdate on MOLST Facility Implementation and Quality Improvement Audits January 2008 Thomas Caprio, M.D. Senior Instructor, Division of Geriatrics & Aging, University of Rochester Co-chair, EMS, Quality and Research Subcommittee Member, Monroe and Onondaga Counties MOLST Implementation Team Associate Medical Director, Visiting Nurse Service Hospice Project Co-Director, Finger Lakes Geriatric Education Center of Upstate New York Thomas_Caprio@urmc.rochester.edu Suzanne Gillespie, M.D. Instructor, Division of Geriatrics & Aging, University of Rochester Member, Monroe and Onondaga Counties MOLST Implementation Team Suzanne_Gillespie@urmc.rochester.edu FLGEC-UNY A nonprofit independent licensee of the BlueCross BlueShield Association

  2. Community Implementation: MOLST Facility Survey

  3. MOLST Facility Survey • Early phase: Facility education & training of EMS providers • March 2006: MOLST Facility Survey distributed to 115 facilities in Monroe and Onondaga Counties • Response rate of 98% (n=112) • Time required for implementation varied significantly across facilities, with less adult homes and assisted/enriched living programs planning on adoption of MOLST

  4. MOLST Facility Survey • 52 facilities (46%) implemented MOLST • Hospitals and nursing homes first to implement MOLST, followed by hospice programs, and program of all inclusive care of the elderly (PACE) • 76% of respondents had implemented or planning to implement MOLST

  5. Quality Improvement:MOLST QI Chart Review

  6. MOLST QI Chart Review • November 2006 – Facilities in Monroe & Onondaga Counties • Total of 905 medical records reviewed • Majority of chart reviews were completed for patients that died • Facility Participants: 4 Hospitals, 57 Nursing Homes, 2 PACE, 1 Hospice, 24 Enriched and Assisted Housing, 25 Adult Homes

  7. MOLST QI Chart Review • Repeat Facility QI Review 2007 • Preliminary results since December 2007 • Total of 381 medical records reviewed to date in this repeat survey • Participants: Hospital, NH, Pace, EHP • Comparisons to 2006 survey

  8. QI Target: DNR/CPR Consent • Patient/HCA Consent for DNR – 100% • Supplemental Documentation present 57% (113/198) for 2007 and 58% (227/389) for 2006

  9. Accuracy of Completion: DocumentationPatient or Health Care Agent Consent

  10. Full Code Documentation • Is MOLST being utilized to document full code status? • 7% MOLST document full code in 2006 • 16% MOLST document full code in 2007

  11. Accuracy of Completion: MOLST Signed by Physician

  12. Other Advance Directives • 2006: 62% Health Care Proxy (448/722) • 2007: 70% Health Care Proxy (238/338) • No advance directives marked 2006: 29% reported 2007: 21% reported

  13. Life-Sustaining Treatment • Other Treatment Directives • 2006 None Specified 48% • 2007 None Specified 33% • Comfort-oriented care only: when other instructions identified • 2006 8% • 2007 23%(majority in PACE and nursing home)

  14. Life-Sustaining Treatment Other Documented Treatment Guidelines: • Intubation and Ventilation Instructions • 2006 44% • 2007 55% (higher documentation hospital) • Artificial Hydration/Nutrition Directives • 2006 38% • 2007 52% (higher documentation in PACE)

  15. Future Hospitalizations Documented Treatment Guidelines: • Hospitalization and Transfer • 2006 13% • 2007 49% (higher documentation in PACE)

  16. 2008 QI Targets Identified • Review/Renew section of MOLST • Issues of capacity and consent(Supplemental form completion) • Additional treatment directives

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