neil wenger, md catherine mcgregor, msn, fns,c february 16, 2012

POLST in California:Use in Nursing Homes & Hospitals,Quality of Completion andImpact of Community Coalitions

Neil Wenger, MDCatherine McGregor, MSN, FNS,CFebruary 16, 2012

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POLST Implementation in California

POLST mandated by California law Jan 2009 California HealthCare Foundation and Coalition

for Compassionate Care of California statewide implementation• Began in 2007• Statewide taskforce of stakeholders• Educational materials and standardized approach• Local grassroots coalitions

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Survey to Evaluate Nursing Home and Hospital POLST Use

Survey instrument development• Statewide POLST Taskforce• Community Coalitions• California Association of Health Facilities

(CAHF) Mailed and electronic survey

• Telephone follow up

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Survey to Evaluate Nursing Home and Hospital POLST Use

Topics• Experience of with POLST• POLST policy• POLST education and needs• POLST handling and attitudes• Problems with POLST

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Evaluation of POLST Dissemination in California

Nursing home use, statewide• 2010• Coalition and non-coalition areas

Hospital use, statewide• 2011

Nursing home POLST quality• 2010 and 2011• Coalition areas

Community Coalition areas

Non-Community Coalition areas

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Nursing Home POLST Evaluation:Sample selection

Selected SNFs from each study county Up to 20 SNFs in each county

• If >20 SNFs, randomly selected If Community Coalition county, select 50% as

partner SNFs• Partner SNFs randomly selected

Backfilled to maximize county sample

SNF Sample for SurveyCoalition Counties Non-Coalition Counties

Alameda/Contra Costa 20 (10) Fresno 20

Humboldt/Del Norte 6 (6) LA - East 20

Kern 15 (3) LA - North 20

LA – SFV 20 (3) LA - Long Beach 20

LA – West 20 (2) LA – Pasadena 20

Mendocino 4 (4) Lake 3

Monterey 16 (15) Marin 16

Napa 6 (6) Placer 11

Orange 20 (10) Orange - East 15

Riverside 20 (10) San Francisco 14

Sacramento 20 (6) San Joaquin 20

San Bernardino 20 (10) San Mateo 19

San Diego 20 (10) San Luis Obispo 9

Santa Clara 20 (10) Santa Barbara 14

Santa Cruz 10 (5) Shasta 8

Sonoma 20 (11) Solano 10

Ventura 18 (8) Stanislaus 18

Yolo 6 (5) Tulare 14

TOTAL 281 (134) TOTAL 273

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CA Nursing Homes, 2010: POLST Preparation

SNF staff received POLST education?

82%

SNF has formal policy on POLST? 59%

POLST Champion in the SNF? 70%

% SNF staff received POLST education

43%(range 0-100%)

(N=283/546)

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Nursing Home POLST Evaluation:Sample selection

Selected SNFs from each study county Up to 20 SNFs in each county

• If >20 SNFs, randomly selected If Community Coalition county, select 50% as

partner SNFs• Partner SNFs randomly selected

Backfilled to maximize county sample

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CA Nursing Homes, 2010: POLST Use

SNF has admitted a resident with a POLST 69%

SNF has completed a POLST with a resident after admission 81%

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0

2

4

6

8

10

12

14

16

18

0 5 11 17 23 29 35 41 47 53 59 65 71 77 83 89 95

%

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Percentage of Residents Admitted in Past 30 Days with a Completed POLST

# of

SN

Fs

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CA Hospitals, 2011: POLST Preparation and Use

Formal policy on POLST 66%

Blank POLSTs available 89%

Staff educated on POLST 84%

Admitted pt with a POLST 89%

Chance a new DNR order would be reflected in a POLST on d/c to SNF 45%

(N=286/345)

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Effect of Coalitions:Admitted a Resident with a POLST

NH Admitted a Resident with a POLST

58.00%

60.00%

62.00%

64.00%

66.00%

68.00%

70.00%

72.00%

74.00%

76.00%

78.00%

Perc

ent o

f Nur

sing

Hom

es

Non-coalition area NH

Coatition area NH - Nointeraction

Coalition area NH - Withinteraction

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Quality of POLST Completion in Coalition Area Facilities

What is the quality of completion of POLST forms from Nursing Homes with which Coalitions worked?

Is there improvement in completion with feedback of findings?

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Quality of POLST Completion in Coalition area Nursing Homes

Convenience sample of 6 SNFs in each of 5 coalition areas• Orange County, Sacramento, San Diego, San

Fernando Valley, Santa Clara July/August 2010: Review of 538 randomly

selected charts with POLST forms Feedback of findings to SNF July/August 2011: Review of 594 randomly

selected charts with POLST forms

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POLST Key Findingsin SNF, 2010 and 2011

Common Missing Information: 2010 2011Missing info for preparer 39.2%** 30.3%**

Not dated 25.7%** 11.4%**

MD signature not dated 21.4%** 14.0%**

Missing with whom POLST was discussed 18.8% 21.0%

No patient/decision maker signature* 9.9% 7.1%

No physician signature* 8.7% 7.1%

Section A & Section B did not correlate 7.1% 5.1%

Name or DOB missing 6.3% 6.9%

*Error makes the POLST form invalid **p<0.01 for comparison of 2010 to 2011

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Challenges and Opportunities

POLST…another thing to do Staff turnover Lack of education/scarce resources Diverse cultures Explaining CPR, prognosis, statistical outcomes Difficulty in having goals of care conversations Physician engagement Processes in getting the POLST back from Hospitals

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Summary of Findings

18 months after implementation, substantial uptake of POLST in SNFs• Most facilities had structures and staff education• 2/3 of SNFs had admitted a resident with a POLST• 80% had used POLST in their SNF

By 2011, hospitals using POLST regularly Community Coalition mechanism increased

dissemination of POLST POLST quality generally good

• Documentation difficulties common after 18 months improved with feedback