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 A nonprofit independent licensee of the BlueCross BlueShield Association Mark Buttiglieri, ACSW Director, Social Work/Continuum of Care, University Hospital Upstate Medical University Member, Monroe and Onondaga Counties MOLST Implementation Team 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

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

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

Full Code Documentation Is MOLST being utilized to document full code status? 7% MOLST document full code in % MOLST document full code in 2007

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 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% –200723% (majority in PACE and nursing home)

Life-Sustaining Treatment Other Documented Treatment Guidelines: Intubation and Ventilation Instructions –200644% – % (higher documentation hospital) Artificial Hydration/Nutrition Directives – % –200752% (higher documentation in PACE)

Future Hospitalizations Documented Treatment Guidelines: Hospitalization and Transfer –200613% – % (higher documentation in PACE)

2008 QI Targets Identified Review/Renew section of MOLST Issues of capacity and consent (Supplemental form completion) Additional treatment directives