Advance Care Planning
&
MOLST
Beverly Hospital & Addison Gilbert Hospital
Shirley Conway, RN, Director of Geriatric Initiatives
Michael Tarmey, RN, Director for Behavioral Health Services
Fay Curtis, RN, Director for Acute Care Services
Greg Bird, RN, (former SVP for Patient Care Services & CNO)
VP for Care Management for Lahey Clinical Performance
Accountable Care Organization
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
1
Advance Care Planning
What's it about?
Choices.
Wishes.
Honoring Choices.
Honoring Wishes.
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
2
What Do the Patients Want?
Massachusetts Residents Dying at
Home: Wishes vs. Reality
100%
80%
60%
67%
40%
20%
24%
0%
Wish To Die at Home
Die at Home
% of Massachusetts Residents
Source:. Patient-Centered Care and Human Mortality : The Urgency of Health System Reforms to Ensure Respect for Patients’ Wishes and Accountability for
Excellence In Care. Report and Recommendations of the Massachusetts Expert Panel on End-of-Life Care. October 2010. P.1.
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
3
What Do the Patients Want?
“Clinicians often fail to properly elicit and
heed the wishes of patients, and
the dominant hospital culture of cure and
save at all costs
leads to care that may be
technically excellent but
adds to suffering
rather than relieving it.”
Source: Steven Pantilat, M.D., Palliative Care Program, University of California, San Francisco in PERSPECTIVES ON DEVELOPING
ISSUES IN HEALTHCARE: FIXING MEDICARE. The Kaufman-Hall. February 2012.
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
4
Addison Gilbert Hospital & Beverly Hospital
Advance Care Planning Framework
Interrelated Initiatives
ACO
STAAR
Advance Care Planning
Life Prolonging Care*
Palliative Care*
5 Wishes
Patient’s Right to
Self-Determination
00
Hospice
Care*
MOLST
NICHE (Nurses Improving Care for Healthsystem Elders)
Community Health
Needs Assessment
Geriatric Initiatives:
Elder Friendly Hospital
Preventing Geriatric Syndromes
Older Patient Bill of Rights
Massachusetts End-of-Life Expert Panel
* Copyright 2008 Center to Advance
Palliative Care.
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
5
Key Advance Care Planning Strategies
• Engaged Executive sponsor
• Created alignment by setting broad goals (e.g. NHC Patient
Care Service Division Goals for FY12):
 Participate in Phase 2 of the Massachusetts MOLST Program
 Spread access to the Five Wishes document within the hospitals
and primary care practices.
 Perform a gap analysis of our practice compared to the
Massachusetts Expert Panel on End of Life Care
 Develop a Bill of Rights for Hospitalized Older Adults
 Establish a pilot Inpatient Palliative Care Consultation service.
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
6
Key Advance Care Planning Strategies
• Created a project leadership team
• Obtained education for leadership team
• Utilized resources provided by the Center to Advance
Palliative Care (CAPC) including leadership training at
Virginia Commonwealth Cancer Center – 2 MDs, 2 RNs
and LICSW (http://www.capc.org/)
• Identified physician champions and engaged them
• Provided interdisciplinary education…at every
opportunity!
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
7
Advance Care Planning with Five Wishes
• Engaged members of the Medical
Advisory Panel to better understand their
role.
• PCP champions volunteered to pilot Five
Wishes in their practices.
• Provided Five Wishes education
sessions in PCP practices, Assisted
Living & Community.
• Provided education to physicians and
hospital leadership
http://www.agingwithdignity.org/
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
8
Improving Palliative Care Access
• Leaders from NHC engaged leaders from Hospice of the North Shore
and Greater Boston to create a more strategic relationship.
• Our goal is to provide inpatients with advance-stage disease earlier
access to palliative or hospice care.
• Resulted in a 1,000% increase in palliative care consults in FY12
Palliative Care Referrals from Beverly Hospital to
Hospice of the Northshore
35
30
20
15
10
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Feb-11
0
Mar-11
5
Jan-11
Number
25
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
9
MOLST Program Implementation
• MOLST Program was set as the next strategic step in ACP
process (set a divisional goal)
• Developed relationship with state experts: Christine McCloskey
• Utilized resources available, tailoring process to our own
system
• Provided leadership team learning through webinars and other
resources (http://molst-ma.org/)
• Identified key internal and external stakeholders
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
10
MOLST Program Implementation
• Held multiple meetings with key stakeholders: STAAR Cross
Continuum Team, Frontline Team, and operational leaders from
IT, Admitting, Medical Staff (Hospitalists), Nursing, PHO, SNFs,
Home Care, Elder Services, etc.
• Project Leadership Team members were change agents and
took the “action steps” necessary to implement MOLST
• An Intranet “Resource Center” with links to state MOLST site
was created
• MOLST Education provided for physicians, nurses, social
workers, case managers, registration staff, medical records
staff, in a variety of forums (department meetings, medical staff meetings,
Medical Executive committee, nursing operations, primary care POD meetings, etc.)
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
11
MOLST Program Implementation
• MOLST Form process was developed:
 Form made available on all inpatient units and emergency
department.
 Completed Forms are scanned into the electronic Medical Record.
 Forms completed in the PCP office can be faxed to Medical Records
department or sent via secure message.
 On admission, Access Services staff ask all ED, SDC, direct
admission patients for presence of a MOLST Form.
 If patient has a MOLST form on admission an alert is put on face
sheet in the patient’s medical record.
• Inpatient CPOE MOLST Order Set was implemented.
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
12
MOLST Program Implementation
Keys to Success:
•
•
•
•
•
•
Executive sponsorship and project team leadership
Providing formal and informal education at every opportunity
Linking ACP to evidenced-based Care NICHE Program
Knowing your patient population
Full day ACP seminar held for MDs RNs, SWs
Obtained ELNEC (End of Life Nursing Education Consortium) Trainthe trainers-certification
• Offered CMEs for Advance Care Planning & MOLST Medical Staff
education.
• Presentations on ACP topics at monthly Leaders Meetings (75+
present)
• Presentations at Staff Meetings: Medicine, Unit, Hospitalist, etc.
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
13
MOLST Program Implementation
Lessons Learned:
•
•
•
•
•
•
•
•
Time Frame Needed: 6+ months
Utilize Policy & Procedure provided – Don’t re-invent
Process will not be perfect until there is a uniform electronic record
Framed as a mandated DPH state-wide program – acceptance is
not an option – link to EMS
Adopt on your own terms and timeline now rather than wait
Tie into existing & synergistic committees or work groups
Move ahead…not every scenario can be anticipated, learn from
your mistakes
Can’t over-communicate
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
14
MOLST Program Implementation
NEXT Steps
• Monitor MOLST form use
• Expand Palliative Care
– Use of “Triggers” to Identify patients appropriate for PC Consults &
Focused unit-based education
• Assist with MOLST implementation across the continuum
• Expand importance of MOLST as we move to an ACO model
in the context of Advance Care Planning
Addison Gilbert Hospital
Beverly Hospital
Bayridge Hospital
15