Beverly Hospital & Addison Gilbert Hospital 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 Intro –thanks, etc.

Advance Care Planning What's it about? Choices. Wishes. Honoring Choices. Honoring Wishes. Intro –thanks, etc.

What Do the Patients Want? Intro –thanks, etc. 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.

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.” Intro –thanks, etc. 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.

Advance Care Planning Framework Addison Gilbert Hospital & Beverly Hospital Advance Care Planning Framework Interrelated Initiatives ACO STAAR Advance Care Planning Palliative Care* Life Prolonging Care* Hospice Care* Bereavement* 5 Wishes MOLST Patient’s Right to Self-Determination NICHE started work in 2007 with our Senior Adult Unit Geriatric syndromes Evidenced-based care, education to our staff 350 RNs and 50 Cas attended 2 day Geriatric Resource Training Sessions STAAR – many readmissions related to end of life issues ACP Center to advance palliative care framework 5 Wishes MOLST NICHE (Nurses Improving Care for Healthsystem Elders) Geriatric Initiatives: Elder Friendly Hospital Preventing Geriatric Syndromes Older Patient Bill of Rights Massachusetts End-of-Life Expert Panel Community Health Needs Assessment * Copyright 2008 Center to Advance Palliative Care.

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. Don’t read this list but give advice on these steps. More detail on how you made these things happen.

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! Don’t read this list but give advice on these steps. More detail on how you made these things happen.

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/

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

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

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.)

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.

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) Train-the 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.

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

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