1. Monroe County MOLST Quality Forum Update 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 Hospice Project 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 Team Suzanne_Gillespie@urmc.rochester.edu FLGEC-UNY

2. Community Implementation: MOLST Facility Survey

3. 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

4. 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

8. Quality Improvement: MOLST QI Chart Review

9. 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

13. 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

14. 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

15. Accuracy of Completion: Documentation Patient or Health Care Agent Consent

16. 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

17. Accuracy of Completion: MOLST Signed by Physician

18. 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

19. 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)

20. Life-Sustaining Treatment Other Documented Treatment Guidelines: Intubation and Ventilation Instructions –200644% –2007 55% (higher documentation hospital) Artificial Hydration/Nutrition Directives –2006 38% –200752% (higher documentation in PACE)

21. Future Hospitalizations Documented Treatment Guidelines: Hospitalization and Transfer –200613% –2007 49% (higher documentation in PACE)

22. 2008 QI Targets Identified Review/Renew section of MOLST Issues of capacity and consent (Supplemental form completion) Additional treatment directives