1. 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.

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

3. 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 P.1.

4. 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.

5. 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.

6. 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.

7. 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 (
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.

8. 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

9. 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

10. 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 (
Identified key internal and external stakeholders

11. 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.)

12. 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.

13. 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.

14. 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

15. 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