Transcript Slide 1

Onondaga County MOLST Quality Forum
Update on MOLST Facility Implementation
and Quality Improvement Audits
January 2008
Cheryl Morrow, M.D.
Chief Medical Officer of CNY, Director of CNY Operations, Elder Medical Services P.C.
Faculty Member, Education for Physicians on End-of-life Care
Member, Monroe and Onondaga Counties MOLST Implementation Team
[email protected]
Mark Buttiglieri, ACSW
Director, Social Work/Continuum of Care, University Hospital
Upstate Medical University
Member, Monroe and Onondaga Counties MOLST Implementation Team
[email protected]
A nonprofit independent licensee of the BlueCross BlueShield Association
FLGEC-UNY
Community Implementation:
MOLST Facility Survey
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
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
Total MOLST Survey Response & Implementation Rates
Hospital
100.0%
90.0%
NH
80.0%
PACE
70.0%
60.0%
Hospice
50.0%
ALP/AH
40.0%
30.0%
ALP/EHP
20.0%
EHP
10.0%
AH
0.0%
Response Rate
Implementation Rate
Total MOLST Implementation:
2 Years Ago - Present
Hospital
Hospice
EHP
NH
ALP/AH
AH
PACE
ALP/EHP
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
> 2 Years
1-2 Years
6 Months-1 Year
< 6 Months
Total MOLST Outlook:
Two Years in the Future
Hospital
Hospice
EHP
NH
ALP/AH
AH
PACE
ALP/EHP
120.0%
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
July 2006
< 3 Months
3-6 Months
6 Months-1
Year
1-2 Years
Quality Improvement:
MOLST QI Chart Review
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
2006 Overall MOLST QI Tool Results:
Accuracy Rate for DNR Orders
100%
90%
80%
70%
Hospital
NH
PACE
ALP-EHP
EHP
60%
50%
40%
30%
20%
10%
0%
Monroe County
Onondaga County
2006 MOLST QI Tool Results: Accuracy
Rate for Life-Sustaining Treatment
100%
90%
80%
70%
Hospital
NH
PACE
ALP-EHP
EHP
AH
60%
50%
40%
30%
20%
10%
0%
Monroe County
Onondaga County
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
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
Accuracy of Completion: Documentation
Patient or Health Care Agent Consent
100
90
80
70
60
50
40
30
20
10
0
Pt/HCA
Consent
2006
2007
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
Accuracy of Completion:
MOLST Signed by Physician
100
90
80
70
60
50
40
30
20
10
0
MD Signature
2006
2007
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
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)
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)
Future Hospitalizations
Documented Treatment Guidelines:
• Hospitalization and Transfer
– 2006 13%
– 2007 49% (higher documentation in PACE)
2008 QI Targets Identified
• Review/Renew section of MOLST
• Issues of capacity and consent
(Supplemental form completion)
• Additional treatment directives