1. 1 A nonprofit independent licensee of the BlueCross BlueShield Association Patricia Bomba, M.D., F.A.C.P. Vice President and Medical Director, Geriatrics Chair, MOLST Statewide Implementation Team Leader, Community-wide End-of-life/Palliative Care Initiative Chair, National Healthcare Decisions Day New York State Coalition Patricia.Bomba@lifethc.com CompassionAndSupport.org © Patricia A. Bomba, M.D., F.A.C.P. eMOLST, New York State’s Web-based Version of DOH-5003 MOLST NYS’s POLST Paradigm Program Wren Keber Project Manager, Healthcare Information Technology Fusion Productions

2. 2 Chronic disease or functional decline Advancing chronic illness Multiple co- morbidities, with increasing frailty Death with dignity Maintain & maximize health and independence Healthy and independent Compassion, Support and Education along the Continuum Advance Care Planning © Patricia A. Bomba, M.D., F.A.C.P.

3. 3 Advance Directives Traditional ADs For All Adults Community Conversations on Compassionate Care (CCCC)  New York  Health Care Proxy  Living Will  Organ Donation  State-specific forms Actionable Medical Orders For Those Who Are Seriously Ill or Near the End of Their Lives Medical Orders for Life-Sustaining Treatment (MOLST) Program  Do Not Resuscitate (DNR) Order  Medical Orders for Life Sustaining Treatment (MOLST)  Physician Orders for Life Sustaining Treatment (POLST) Paradigm CompassionAndSupport.org CaringInfo.org CompassionAndSupport.org POLST.org © Patricia A. Bomba, M.D., F.A.C.P.

4. Community Conversations on Compassionate Care Five Easy Steps Five Easy Steps 1.Learn about advance directives  NYS Health Care Proxy  NYS Living Will  Advance Directives from Other States 2.Remove barriers 3.Motivate yourself  View CCCC videos 4.Complete your Health Care Proxy and Living Will  Have a conversation with your family  Choose the right Health Care Agent  Discuss what is important to you  Understand life-sustaining treatment  Share copies of your directives 5.Review and Update A Project of the Community-Wide End-of-life/Palliative Care Initiative

5. 5 Medical Orders for Life-Sustaining Treatment (MOLST Program), A POLST Paradigm Program  Improve the quality of care people receive at the end of life  effective communication of patient wishes  documentation of medical orders on a brightly colored pink form  promise by health care professionals to honor these wishes  Complements the use of traditional advance directives A Project of the Community-Wide End-of-life/Palliative Care Initiative

6. 6 POLST Paradigm Program May 2011 POLST.org Paradigm of communication, documentation, and system responsiveness

7. 7 LTC Office Hospital MOLST: EOL Care Transitions Program A Project of the Community-Wide End-of-life/Palliative Care Initiative

8. 8  Assure Accessibility  Improve Quality Assurance  Build Quality Metrics eMOLST: Goals, Vision and Next Steps http://www.compassionandsupport.org/index.php/for_professionals/molst_training_center/emolst

9. 9 eMOLST: Goals and Vision  Assure Accessibility  Create an electronic registry in the Rochester Community.  Long term vision - build a New York State eMOLST registry that will serve as a model for the nation.  Improve Quality Assurance  Built-in quality controls ensure accuracy of form completion.  Designed to upgrade the workflow around completing the information for a legal medical order with automated user feedback for quality review, notification of missing information and training tools for users.  Build Quality Metrics  Integrate outcome measurement and trend reporting.

10. 10 eMOLST Deployment  Phase One – Deploy eMOLST without Rochester RHIO integration.  Phase Two – Deploy eMOLST with Rochester RHIO integration.  Phase Three – Exchange and view eMOLST forms through the Rochester RHIO and integrated systems, including EMS.

11. 11 Why MOLST?  MOLST is a program and process, not just a form.  Transitions with the patient across settings.  Only vehicle for non-hospital DNI in NYS.  Provides specific actionable orders.  “Encouraging additional POLST (Physician Orders for Life-Sustaining Treatment) efforts that translate chronic care patient’s care goals into easily identifiable, portable and renewable medical orders that follow the patient across settings would go a long way toward enhancing advance care planning in this country.” * * Advance Directives and Advance Care Planning: Report to Congress, U.S. Dept. of Health and Human Services, Aug. 2008

12. 12 Recent MOLST Developments  Streamlined Form (can be used in All settings)  Eliminated Supplemental Forms  Aligns with Family Health Care Decisions Act  General instructions and checklists assist providers in complying with legal requirements for Adult Patients and Minor Patients  http://www.nyhealth.gov/professionals/patients/patient_rights/molst/ http://www.nyhealth.gov/professionals/patients/patient_rights/molst/  MOLST Chart Documentation Forms  http://www.compassionandsupport.org/index.php/for_professionals/ molst/checklists_for_adult_patients http://www.compassionandsupport.org/index.php/for_professionals/ molst/checklists_for_adult_patients  http://www.compassionandsupport.org/index.php/for_professionals/ molst/checklist_for_minor_patients http://www.compassionandsupport.org/index.php/for_professionals/ molst/checklist_for_minor_patients  OPWDD checklist– (any setting) must travel with the patient’s MOLST  http://www.omr.state.ny.us/health/hp_MOLST.jsp http://www.omr.state.ny.us/health/hp_MOLST.jsp

13. 13 MOLST Instructions and Checklists  Checklist #1 - Adult patients with medical decision-making capacity (any setting)  Checklist #2 - Adult patients without medical decision-making capacity who have a health care proxy (any setting)  Checklist #3 - Adult hospital or nursing home patients without medical decision-making capacity who do not have a health care proxy, and decision-maker is a Public Health Law Surrogate (surrogate selected from the surrogate list)  Checklist #4 - Adult hospital or nursing home patients without medical decision-making capacity who do not have a health care proxy or a Public Health Law Surrogate  Checklist #5 - Adult patients without medical decision-making capacity who do not have a health care proxy, and the MOLST form is being completed in the community.  Checklist for Minor Patients - (any setting)  Checklist for Developmentally Disabled who lack capacity – (any setting) must travel with the patient’s MOLST http://www.nyhealth.gov/professionals/patients/patient_rights/molst/

14. 14 Framework for the Conversation 8-Step MOLST Protocol* 1. Prepare for discussion Understand patient’s health status, prognosis & ability to consent Retrieve completed Advance Directives Determine decision-maker and NYSPHL legal requirements, based on who makes decision and setting 2. Determine what the patient and family know re: condition, prognosis 3. Explore goals, hopes and expectations 4. Suggest realistic goals 5. Respond empathetically 6. Use MOLST to guide choices and finalize patient wishes Shared, informed medical decision-making Conflict resolution 7. Complete and sign MOLST  Follow NYSPHL and document conversation 8. Review and revise periodically * Developed for NYS MOLST, Bomba, 2005; revised 2011

15. 15 MOLST Discussion: Role of Qualified, Trained Health Care Professionals  The MOLST form must be completed based on the patient’s current medical condition, values, and wishes.  Completion of the MOLST begins with a conversation or a series of conversations between the patient, the health care agent or the surrogate, and a qualified, trained health care professional that defines the patient’s goals for care, reviews possible treatment options on the entire MOLST form, and ensures shared, informed medical decision- making.  The conversation should be documented in the medical record. http://www.compassionandsupport.org/index.php/for_professionals/molst/molst_discussion

16. 16 MOLST Discussion: Identify core patient values and beliefs  Ask the patient:  "What makes life worth living?"  "What really matters to the person?"  Examples of responses:  Participation in meaningful relationships  Not to be a burden to loved ones  Avoidance of severe discomfort  Relief of suffering  Improvement or maintenance of quality of life  Maintenance of personhood  Achieve a good death  Support for families and loved ones  Other personal values and beliefs http://www.compassionandsupport.org/index.php/for_professionals/molst/molst_discussion

17. 17 MOLST Discussion: Goals for Care  The degree to which the patient is meeting their core values generally determines their goal for care that in turn guides the patient's choice of treatments.  Broad categories of goals for care include:  Longevity: “Do what is necessary to keep me alive.”  Functional preservation: “I am currently meeting my core values. However if a condition occurs in which I am not likely to recover to meet my core values, I would not want treatments to extend my life and request a change to focus on comfort care.”  Comfort care: “I am currently not meeting my core values and have a poor quality of life. Focus solely on my comfort. Longevity at this point may increase my suffering.” http://www.compassionandsupport.org/index.php/for_professionals/molst/molst_discussion

18. 18 DOH-5003 MOLST Form Community-wide Medical Order Form  Resuscitation instructions when the patient has no pulse and/or is not breathing (CPR or DNR)  Instructions for intubation and mechanical ventilation when the patient has a pulse and the patient is breathing (DNI/trial/long-term)  Treatment guidelines  Future hospitalization/transfer  Artificially administered fluids and nutrition  Antibiotics  Other instructions re: time-limited trial and other treatments (e.g. dialysis, transfusions, etc.)

19. 19 MOLST Chart Documentation Forms Align with NYSDOH Checklists

20. 20 Technical Talking Points  Entire application is Web based, securely served over a HTTPS:// connection  Application is hosted in a physically secure datacenter maintained by Excellus Health Plan  Database holds data at rest in an encrypted format  Links between patient identifiers and patient data are also encrypted  Database and application are two distinctly separate entities  no data may be decrypted directly from the database without the application  meaning the decryption keys are stored in the application, so data cannot be decrypted from the database without it  Application renders beautifully in iOS Safari as well as all Android-based browser options on the market, making eMOLST tablet-friendly  Native iPhone/iPod and Android apps are available to support many eMOLST functions

21. 21 Mobile Apps for iPhone and Android

22. 22 HIPAA and Data Security

23. 23 eMOLST Demo  http://emolstdev.grrhio.org/Account/Log in?ReturnUrl=%2f http://emolstdev.grrhio.org/Account/Log in?ReturnUrl=%2f

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