Presentation on theme: "1 A nonprofit independent licensee of the BlueCross BlueShield Association Patricia Bomba, M.D., F.A.C.P. Vice President and Medical Director, Geriatrics."— Presentation transcript:
Community Conversations on Compassionate Care Five Easy Steps Five Easy Steps 1.Learn about advance directives NYS Health Care Proxy NYS Living Will Advance Directives from Other States 2.Remove barriers 3.Motivate yourself View CCCC videos 4.Complete your Health Care Proxy and Living Will Have a conversation with your family Choose the right Health Care Agent Discuss what is important to you Understand life-sustaining treatment Share copies of your directives 5.Review and Update A Project of the Community-Wide End-of-life/Palliative Care Initiative
5 Medical Orders for Life-Sustaining Treatment (MOLST Program), A POLST Paradigm Program Improve the quality of care people receive at the end of life effective communication of patient wishes documentation of medical orders on a brightly colored pink form promise by health care professionals to honor these wishes Complements the use of traditional advance directives A Project of the Community-Wide End-of-life/Palliative Care Initiative
6 POLST Paradigm Program May 2011 POLST.org Paradigm of communication, documentation, and system responsiveness
7 LTC Office Hospital MOLST: EOL Care Transitions Program A Project of the Community-Wide End-of-life/Palliative Care Initiative
8 Assure Accessibility Improve Quality Assurance Build Quality Metrics eMOLST: Goals, Vision and Next Steps
9 eMOLST: Goals and Vision Assure Accessibility Create an electronic registry in the Rochester Community. Long term vision - build a New York State eMOLST registry that will serve as a model for the nation. Improve Quality Assurance Built-in quality controls ensure accuracy of form completion. Designed to upgrade the workflow around completing the information for a legal medical order with automated user feedback for quality review, notification of missing information and training tools for users. Build Quality Metrics Integrate outcome measurement and trend reporting.
10 eMOLST Deployment Phase One – Deploy eMOLST without Rochester RHIO integration. Phase Two – Deploy eMOLST with Rochester RHIO integration. Phase Three – Exchange and view eMOLST forms through the Rochester RHIO and integrated systems, including EMS.
11 Why MOLST? MOLST is a program and process, not just a form. Transitions with the patient across settings. Only vehicle for non-hospital DNI in NYS. Provides specific actionable orders. “Encouraging additional POLST (Physician Orders for Life-Sustaining Treatment) efforts that translate chronic care patient’s care goals into easily identifiable, portable and renewable medical orders that follow the patient across settings would go a long way toward enhancing advance care planning in this country.” * * Advance Directives and Advance Care Planning: Report to Congress, U.S. Dept. of Health and Human Services, Aug. 2008
12 Recent MOLST Developments Streamlined Form (can be used in All settings) Eliminated Supplemental Forms Aligns with Family Health Care Decisions Act General instructions and checklists assist providers in complying with legal requirements for Adult Patients and Minor Patients MOLST Chart Documentation Forms molst/checklists_for_adult_patients molst/checklists_for_adult_patients molst/checklist_for_minor_patients molst/checklist_for_minor_patients OPWDD checklist– (any setting) must travel with the patient’s MOLST
13 MOLST Instructions and Checklists Checklist #1 - Adult patients with medical decision-making capacity (any setting) Checklist #2 - Adult patients without medical decision-making capacity who have a health care proxy (any setting) Checklist #3 - Adult hospital or nursing home patients without medical decision-making capacity who do not have a health care proxy, and decision-maker is a Public Health Law Surrogate (surrogate selected from the surrogate list) Checklist #4 - Adult hospital or nursing home patients without medical decision-making capacity who do not have a health care proxy or a Public Health Law Surrogate Checklist #5 - Adult patients without medical decision-making capacity who do not have a health care proxy, and the MOLST form is being completed in the community. Checklist for Minor Patients - (any setting) Checklist for Developmentally Disabled who lack capacity – (any setting) must travel with the patient’s MOLST
14 Framework for the Conversation 8-Step MOLST Protocol* 1. Prepare for discussion Understand patient’s health status, prognosis & ability to consent Retrieve completed Advance Directives Determine decision-maker and NYSPHL legal requirements, based on who makes decision and setting 2. Determine what the patient and family know re: condition, prognosis 3. Explore goals, hopes and expectations 4. Suggest realistic goals 5. Respond empathetically 6. Use MOLST to guide choices and finalize patient wishes Shared, informed medical decision-making Conflict resolution 7. Complete and sign MOLST Follow NYSPHL and document conversation 8. Review and revise periodically * Developed for NYS MOLST, Bomba, 2005; revised 2011
15 MOLST Discussion: Role of Qualified, Trained Health Care Professionals The MOLST form must be completed based on the patient’s current medical condition, values, and wishes. Completion of the MOLST begins with a conversation or a series of conversations between the patient, the health care agent or the surrogate, and a qualified, trained health care professional that defines the patient’s goals for care, reviews possible treatment options on the entire MOLST form, and ensures shared, informed medical decision- making. The conversation should be documented in the medical record.
16 MOLST Discussion: Identify core patient values and beliefs Ask the patient: "What makes life worth living?" "What really matters to the person?" Examples of responses: Participation in meaningful relationships Not to be a burden to loved ones Avoidance of severe discomfort Relief of suffering Improvement or maintenance of quality of life Maintenance of personhood Achieve a good death Support for families and loved ones Other personal values and beliefs
17 MOLST Discussion: Goals for Care The degree to which the patient is meeting their core values generally determines their goal for care that in turn guides the patient's choice of treatments. Broad categories of goals for care include: Longevity: “Do what is necessary to keep me alive.” Functional preservation: “I am currently meeting my core values. However if a condition occurs in which I am not likely to recover to meet my core values, I would not want treatments to extend my life and request a change to focus on comfort care.” Comfort care: “I am currently not meeting my core values and have a poor quality of life. Focus solely on my comfort. Longevity at this point may increase my suffering.”
18 DOH-5003 MOLST Form Community-wide Medical Order Form Resuscitation instructions when the patient has no pulse and/or is not breathing (CPR or DNR) Instructions for intubation and mechanical ventilation when the patient has a pulse and the patient is breathing (DNI/trial/long-term) Treatment guidelines Future hospitalization/transfer Artificially administered fluids and nutrition Antibiotics Other instructions re: time-limited trial and other treatments (e.g. dialysis, transfusions, etc.)
19 MOLST Chart Documentation Forms Align with NYSDOH Checklists
20 Technical Talking Points Entire application is Web based, securely served over a HTTPS:// connection Application is hosted in a physically secure datacenter maintained by Excellus Health Plan Database holds data at rest in an encrypted format Links between patient identifiers and patient data are also encrypted Database and application are two distinctly separate entities no data may be decrypted directly from the database without the application meaning the decryption keys are stored in the application, so data cannot be decrypted from the database without it Application renders beautifully in iOS Safari as well as all Android-based browser options on the market, making eMOLST tablet-friendly Native iPhone/iPod and Android apps are available to support many eMOLST functions