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
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
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