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Monroe County MOLST Quality ForumUpdate 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 HospiceProject Co-Director, Finger Lakes Geriatric Education Center of Upstate New York
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 [email protected]
FLGEC-UNY
Community Implementation: MOLST Facility Survey
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
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
Total MOLST Survey Response & Implementation Rates
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Response Rate Implementation Rate
Hospital
NH
PACE
Hospice
ALP/AH
ALP/EHP
EHP
AH
Total MOLST Implementation: 2 Years Ago - Present
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
> 2 Years 1-2 Years 6 Months-1 Year < 6 Months
Hospital NH PACEHospice ALP/AH ALP/EHPEHP AH
Total MOLST Outlook: Two Years in the Future
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
July 2006 < 3 Months 3-6 Months 6 Months-1Year
1-2 Years
Hospital NH PACEHospice ALP/AH ALP/EHPEHP AH
Quality Improvement:MOLST QI Chart Review
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
2006 Overall MOLST QI Tool Results: Accuracy Rate for DNR Orders
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Monroe County Onondaga County
Hospital
NH
PACE
ALP-EHP
EHP
2006 MOLST QI Tool Results: Accuracy Rate for Life-Sustaining Treatment
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Monroe County Onondaga County
Hospital
NH
PACE
ALP-EHP
EHP
AH
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
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
0102030405060708090
100
2006 2007
Pt/HCAConsent
Accuracy of Completion: DocumentationPatient or Health Care Agent Consent
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
0102030405060708090
100
2006 2007
MD Signature
Accuracy of Completion: MOLST Signed by Physician
Other Advance Directives
• 2006: 62% Health Care Proxy (448/722)
• 2007: 70% Health Care Proxy (238/338)
• No advance directives marked2006: 29% reported2007: 21% reported
Life-Sustaining Treatment
• Other Treatment Directives– 2006 None Specified 48%– 2007 None Specified 33%
• Comfort-oriented care only: when other instructions identified– 2006 8%– 2007 23%
(majority in PACE and nursing home)
Life-Sustaining Treatment
Other Documented Treatment Guidelines:
• Intubation and Ventilation Instructions– 2006 44%– 2007 55% (higher documentation hospital)
• Artificial Hydration/Nutrition Directives– 2006 38%– 2007 52% (higher documentation in PACE)
Future Hospitalizations
Documented Treatment Guidelines:
• Hospitalization and Transfer– 2006 13%– 2007 49% (higher documentation in PACE)
2008 QI Targets Identified
• Review/Renew section of MOLST
• Issues of capacity and consent(Supplemental form completion)
• Additional treatment directives