IPRO
Moderator:Chris Stegel
9/17/2013- 1:00PMET
Confirmation #1621059
Page1
IPRO
Moderator:Chris Stegel
September17, 2013
1:00PMET
Operator: Good day, ladies and gentlemen, and welcome to the IPRO Care Transition Learning in Action presentation conference call. At this time, all participants are in a listen-only mode. Later, we will conduct a question-and-answer session and instructions will follow at that time. If anyone should require assistance during today's conference, please press star then zero on your touchtone telephone. As a reminder, this conference is being recorded. I would like to introduce your host for today's conference, Ms. Chris Stegel. Ms. Stegel, you may begin.
Chris Stegel: Thank you, Michele, and good afternoon and welcome, everyone, to this afternoon's IPRO Care Transitions Learning in Action Network series presentation. We appreciate you joining us for this conference call presentation, which is a part of a series of educational offerings addressing cross-setting community efforts to improve transitions of care, to address readmissions for Medicare seniors. The topic for this afternoon's presentation will focus on MOLST, Medical Orders for Life-Sustaining Treatment, implementation in the hospital setting. Although MaryRose Kott, our presenter, will be focusing on the hospital setting, much of what she says can also be adapted and will be applicable to other settings as well.
Those of you who registered for today's conference call were forwarded via e-mail a copy of the slides that will be referenced during today's presentation, along with a program evaluation form. As a reminder, this conference call session is being recorded and will be posted to the Events section of the IPRO Care Transition Web page at usually within about five to seven days after the program, for future reference.
As mentioned, all your lines are currently muted, but following the presentation we'll be opening up the lines for questions, comments and further discussion.
So, today I would like to introduce MaryRose Kott. She is a palliative care nurse practitioner at St. Joseph's Hospital in Syracuse, New York. In her role as palliative care nurse practitioner, she collaborates with the palliative care team in assessing, planning and implementing plan of care for patients with advanced illness. She also acts as a consultant for all disciplines and issues of end-of-life care.
Since 2010, she has been the clinical educator responsible for advance healthcare directive education within her organization, and she collaborates with an interdisciplinary team on ethics issues. At this time, I'd like to turn the program over to you, MaryRose, for this presentation.
MaryRose Kott:Thank you, Chris. Thank you, everyone, for participating in today's presentation, and hopefully I will give you some hints and some ideas as how to implement MOLST in you respective settings. Hopefully, today what I'll be able to accomplish is to share some of the things we learned to help implement the MOLST program, not only in our hospital setting but across the continuum of care.
Also, talk a little bit about the MOLST resources and utilization of compassionandsupport.org, and also to utilize the MOLST Training Center to help you prepare for implementation and helping with policies and procedures.
A little bit about my facility. St. Joseph's Hospital Health Center is a 433-bed acute care facility. We also have a home care agency, surgery centers, maternal and child health and physician groups. We also have dialysis facilities throughout our network, as well as we are a huge cardiac and ortho surgery center.
We here at St. Joe's were part of the initial MOLST pilot with Monroe and Onondaga Counties, which started in 2003. So, I have been working with the MOLST implementation team and Pat Bomba since 2003, and we've had a lot of hills and valleys, and they still continue to this day. So, hopefully some of our experience can help you in implementing within your facility. And, as stated, I'm also on the MOLST statewide implementation team since its inception, from 2003.
So, some of the things we learned is, when we went forward and became part of the pilot, we needed to get buy-in by the institution. And what we did is we then went to our board of directors and our medical executive committee and presented the plan for going forward. And also at that time I had two physician champions who presented to these respective bodies. And it was the decision by the board of directors of our institution that we would implement the MOLST, the Medical Orders for Life-Sustaining Treatment.
We then began to develop policies and procedures as to how we would want these filled out and how we would want to implement this. At that time we had seven different kinds of forms for DNR policies, and if you don't think that was confusing. I know people today say the MOLST is confusing, but when you have seven different pieces of forms trying to figure out which one to use became very confusing. So, what the board said was when we are ready to implement, we will remove all the old forms, and the only form that will be available is the MOLST.
Now, prior to doing that, we integrated the MOLST into our advance health directives and DNR policy and procedure. We then carefully clarified the role of physician and clinical affiliates and the social worker, and focused in on the physician accountability. We also demonstrated what the supportive role of other healthcare professionals that were key. And this includes the whole interdisciplinary team -- nurses, respiratory therapists, physical therapists, occupational therapist, our technicians, and again throughout our continuum of our network.
We then set up a target date as to when we would be going live with the MOLST. We then set up staff education, including physician education. Now, we had fortunately some passionate people who were committed to this educational process. And we also facilitated collaboratively with our homecare agency and our surgery centers and our other outpatient scenarios.
We then, when we were able to get that managed, at that time because we were in a pilot state, we needed to get approvals from our legal review, from our administrators, from our ethics committee, from our [forms] committee and our policy committee, and that did take a fair amount of time to do. And we then went forward with our educational process.
Initially, our educational process, it was 24/7. We had set dates in central locations and I was able to utilize our clinical development department, which are our educators who were trained, and we then held, as I mentioned, face-to-face presentations for several days. Now, for the physician group, my physician champion and myself went to all the committee meetings and presented MOLST. And then we had an ongoing presentation in the doctors' lounge so that there was somebody available to help physicians with trying to understand how this would need to be implemented.
And as we went forward, there was a lot of concern about switching over. We developed what we called a MOLST factsheet, so that was available online as well on every specific area in the unit. We also implemented a mandatory PowerPoint that was on our website for staff as well as physicians, and we emphasized the issues of portability.
And in the beginning, the way we started was we understood -- one of the things we learned very quickly was when we were doing the educational process that there was a wide range of variability in patient knowledge and communication skills, and acceptance by the provider. I can tell you to this day, physicians still say to me, "MaryRose, can't we change the form, it's too complex?" And we've been doing this now for 10 years.
We also needed to be sure that we contact not only the full-time but also the part-time medical staff. And between my physician champion and the vice president of medical affairs, they really were instrumental in facilitating this process.
When we made the transition, when we started our target, we started it on all new admissions. And then we rolled it out as patients began to ask that they wanted, or decided that they wanted to be a Do Not Resuscitate or Do Not Intubate.
Our physician groups that are offsite in their own facilities, their own offices, we were able to put all that information on our, what we call the physician portals, so that they had access to it in their office. Our physicians do have access in their office into what we call the physician portal, so they could pull up the information. We also made available to them stacks of MOLST that they could take to their offices. And so that was initially and that continues to be ongoing even to this day.
We, because of our community and we have patients that are in nursing homes, assisted living, etc., we did have some of those facilities come to our institution and we did a presentation for them. In the years back, Pat Bomba did come to Syracuse and also do community presentations. We clarified that the original would go with the patient and a copy would be made and placed in our medical records. And I will come back to that a little bit later.
The other thing, initially we found many families were not ready to have discussions, physicians were not prepared to have these discussions. Because we have a huge dialysis population, our physicians expected the social worker to have the conversation. We also found that patients did not understand what do not resuscitate means. Also, at that time and even today we find that there is no identified agent or surrogate, and also there is multitude issues of guardianship in trying to get that implemented when you have individuals in your institution who have mental disabilities and are affiliated with OPWDD.
We found the language was difficult for families, so there ended up being some unintended consequences. Another huge issue is cultural barriers in health literacy, and also reading ability. Those things all come into play. Besides reading ability, the individual who is hard of hearing or is classified as deaf, and the issues with patients who are blind.
When we implemented the education, it made eventually using the form less intimidating and it began to become very helpful to nursing and families. I can tell you in my institution the nurses have it down cold. They know the MOLST very, very well.
One of the things I had failed to mention is because this is a process 24/7 and we created what we call MOLST Super Users. This was staff interdisciplinary that, again, goes across the continuum, and also was available 24/7. The staff are aware of who their MOLST Super Users are, and they continue to contact them with questions or issues. And if they find that they can't answer them very well, they will contact me and we'll go forward.
With the implementation of the present MOLST, it helps in framing the discussion on advance care directives. As you know, there are the checklists that are available for each of the different forms. I can tell you what we did is we amended those checklists to be a little more simple. And what we did was we created what needs to know in a separate entity and what needs to be on a checklist and made everything checkboxes.
If anyone is interested in seeing any of those, feel free to contact me. I forgot to say at the beginning of this presentation, my e-mail is on the first slide. Unfortunately, I just noticed that it should be .org, o-r-g, not o-r-d. So, I will be available to help you in the future.
The other thing that we did is because our advance health directives in our medical record, which still is hard copy but slowly evolving into eMAR, we moved the advance healthcare directive to the front of the chart, because our advance health directives were buried. So, this way, when you first open the chart, the section AHD is right there, and whatever forms are available, they would be placed there.
The other thing, talking about the advance healthcare directive, as we know, we have patients who come and go in our institutions or in our facilities. And as you all know, a Xeroxed copy or a faxed copy are legal documents for the MOLST. So, we have created within our institution that if a patient comes in, our health information management team reviews previous records. If there is advance healthcare directives, they are then faxed to the unit and then the patient, the nurse and the physician can review them in a timely fashion.
The one thing that occurs is if you have the pink MOLST, that it's going to stand out very well, but if you give a copy, pink does not scan -- at least at our institution -- as pink, so we need to always remind people to look for the advance healthcare directive. And, again, emphasize that pink does not mean DNR. We have had ongoing issues on there, as you all know, that first page of the MOLST, where it has CPR and DNR, and that's to facilitate the [portability] of this particular document so that we really need to emphasize this.
And as everyone knows, the physicians must be engaged in this discussion. I find in my facility, we have several clinical affiliates that do a great job and really have, most of the times have the conversations. So, they are a huge help in getting advance health directives in place.
So, some of the barriers that we have seen and still continue to see is filling out the form inappropriately. There isn't a physician signature -- and right now I'm just talking about the front of the MOLST. And we have seen lack of physician documentation filling how many witnesses do you need. So, it's an ongoing education.
Also, we have experienced all the changes in the law that have occurred from 2003, 2005, 2008 and 2010. So, as the changes have been made in the law, we continue to educate to PowerPoint, educate our most Super User, and continue to get that information out to all our staff. I do still have a physician champion that does help to facilitate getting the message out.
As you all know, the medical order must be signed by a licensed physician. We do have residents here at St. Joe's, so not all our residents are licensed, so that is again an educational process for our institution that needs to be a licensed physician, preferably the patient's attending.
We also have here at our institution a waiver, and what the waiver consists of is there are times that patients and/or families are going to a procedure and they have decided at that point in time that during that procedure, if something should happen, they would like to be resuscitated. Our waiver is really specific in time frame as to how long it stands. And, again, the waiver has gotten by the physicians and, as I stated, it's a real specific time frame, depending on if you're doing a procedure in IR, or if you're doing surgery in our OR. Still here the form is too difficult and can't we change it?
And, as already mentioned, we need for ongoing education of all disciplines. We have incurred issues with non-hospital DNR forms. Many of you may be aware of that there has been a New York State DOH non-hospital DNR, and now the law reads that the MOLST is a non-hospital DNR. And EMS can respect the insides of the MOLST form, which I'll talk about in a few minutes.
The non-hospital DNR, if our patient comes in to our facility and has this old form of non-hospital DNR, there is a conversation if they would like that to continue. And then we transfer that information on to the MOLST. We usually during that conversation also discuss do not intubate, especially with our severe COPDers.
With that said, that brings me to the inside of the MOLST, which are other life-sustaining treatments. I can tell you this section has some difficulty in getting it filled out. And many times the conversations on these different sections are held at different times. They're not always held at the same time. Now, it may be true in the physician's office, if someone has terminal illness or the thought is that the patient has less than a year to live, that they will have this conversation. So, possibly the whole MOLST will be filled out.
What we have done here at our institution since the inception of the present MOLST form, because it doesn't give you a lot of leeway making adjustments. And we also know that there are times that we don't -- patients are unable to sign again or whatever. We will in each section document date and sign, and then, of course, document in the progress notes as to what the conversation has been. So, it has been ongoing.
And as the little cartoon shows, "Just so you know, I never wanted to live in a vegetative state, dependent on some machine. If that ever happens, just unplug me, okay?" "Okay." And what you see is this gentleman is in front of his TV and she unplugs the TV. And this goes back to patients and families having significant functional illiteracy with regards to life-sustaining treatment, adding to the burdens of medical decision-making.