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POLST in California: Use in Nursing Homes & Hospitals, Quality of Completion and Impact of Community Coalitions Neil Wenger, MD Catherine McGregor, MSN,

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Presentation on theme: "POLST in California: Use in Nursing Homes & Hospitals, Quality of Completion and Impact of Community Coalitions Neil Wenger, MD Catherine McGregor, MSN,"— Presentation transcript:

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

2 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 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 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 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

6 Community Coalition areas Non- Community Coalition areas

7 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 Coalition CountiesNon-Coalition Counties Alameda/Contra Costa20 (10)Fresno20 Humboldt/Del Norte6 (6)LA - East20 Kern15 (3)LA - North20 LA – SFV20 (3)LA - Long Beach20 LA – West20 (2)LA – Pasadena20 Mendocino4 (4)Lake3 Monterey16 (15)Marin16 Napa6 (6)Placer11 Orange20 (10)Orange - East15 Riverside 20 (10)San Francisco14 Sacramento20 (6)San Joaquin20 San Bernardino 20 (10)San Mateo19 San Diego20 (10)San Luis Obispo9 Santa Clara20 (10)Santa Barbara14 Santa Cruz10 (5)Shasta8 Sonoma20 (11)Solano10 Ventura18 (8)Stanislaus18 Yolo6 (5)Tulare14 TOTAL281 (134)TOTAL273

9 9 CA Nursing Homes, 2010: POLST Preparation SNF staff received POLST education? 82% SNF has formal policy on POLST?59% POLST Champion in the SNF?70% % SNF staff received POLST education 43% (range 0-100%) (N=283/546)

10 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 11 CA Nursing Homes, 2010: POLST Use SNF has admitted a resident with a POLST69% SNF has completed a POLST with a resident after admission 81%

12 12 Percentage of Residents Admitted in Past 30 Days with a Completed POLST # of SNFs

13 13 CA Hospitals, 2011: POLST Preparation and Use Formal policy on POLST66% Blank POLSTs available89% Staff educated on POLST84% Admitted pt with a POLST89% Chance a new DNR order would be reflected in a POLST on d/c to SNF 45% (N=286/345)

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

15 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?

16 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 17 POLST Key Findings in SNF, 2010 and 2011 Common Missing Information: Missing info for preparer39.2%**30.3%** Not dated25.7%**11.4%** MD signature not dated21.4%**14.0%** Missing with whom POLST was discussed18.8%21.0% No patient/decision maker signature*9.9%7.1% No physician signature*8.7%7.1% Section A & Section B did not correlate7.1%5.1% Name or DOB missing6.3%6.9% *Error makes the POLST form invalid **p<0.01 for comparison of 2010 to 2011

18 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

19 19

20 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


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