Monroe County MOLST Quality ForumUpdate 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 HospiceProject Co-Director, Finger Lakes Geriatric Education Center of Upstate New York

Thomas_Caprio@urmc.rochester.edu

A nonprofit independent licensee of the BlueCross BlueShield Association

Suzanne Gillespie, M.D. Instructor, Division of Geriatrics & Aging, University of Rochester

Member, Monroe and Onondaga Counties MOLST Implementation TeamSuzanne_Gillespie@urmc.rochester.edu

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

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Response Rate Implementation Rate

Hospital

NH

PACE

Hospice

ALP/AH

ALP/EHP

EHP

AH

Total MOLST Implementation: 2 Years Ago - Present

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

> 2 Years 1-2 Years 6 Months-1 Year < 6 Months

Hospital NH PACEHospice ALP/AH ALP/EHPEHP AH

Total MOLST Outlook: Two Years in the Future

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

July 2006 < 3 Months 3-6 Months 6 Months-1Year

1-2 Years

Hospital NH PACEHospice ALP/AH ALP/EHPEHP AH

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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Monroe County Onondaga County

Hospital

NH

PACE

ALP-EHP

EHP

2006 MOLST QI Tool Results: Accuracy Rate for Life-Sustaining Treatment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Monroe County Onondaga County

Hospital

NH

PACE

ALP-EHP

EHP

AH

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

0102030405060708090

100

2006 2007

Pt/HCAConsent

Accuracy of Completion: DocumentationPatient or Health Care Agent Consent

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

0102030405060708090

100

2006 2007

MD Signature

Accuracy of Completion: MOLST Signed by Physician

Other Advance Directives

• 2006: 62% Health Care Proxy (448/722)

• 2007: 70% Health Care Proxy (238/338)

• No advance directives marked2006: 29% reported2007: 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