POLST in California Use in Nursing Homes Hospitals

POLST in California: Use in Nursing Homes & Hospitals, Quality of Completion and Impact of Community Coalitions Neil Wenger, MD Catherine Mc. Gregor, MSN, FNS, C February 16, 2012

POLST Implementation in California l l POLST mandated by California law Jan 2009 California Health. Care 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 2

Survey to Evaluate Nursing Home and Hospital POLST Use l Survey instrument development • Statewide POLST Taskforce • Community Coalitions • California Association of Health Facilities (CAHF) l Mailed and electronic survey • Telephone follow up 3

Survey to Evaluate Nursing Home and Hospital POLST Use l Topics • • • Experience of with POLST policy POLST education and needs POLST handling and attitudes Problems with POLST 4

Evaluation of POLST Dissemination in California l Nursing home use, statewide • 2010 • Coalition and non-coalition areas l Hospital use, statewide • 2011 l Nursing home POLST quality • 2010 and 2011 • Coalition areas 5

Community Coalition areas Non. Community Coalition areas

Nursing Home POLST Evaluation: Sample selection l Selected SNFs from each study county l Up to 20 SNFs in each county • If >20 SNFs, randomly selected l If Community Coalition county, select 50% as partner SNFs • Partner SNFs randomly selected l Backfilled to maximize county sample 7

SNF Sample for Survey Coalition Counties Alameda/Contra Costa Non-Coalition Counties 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 16 (15) Marin 16 6 (6) Placer 11 Monterey Napa 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

CA Nursing Homes, 2010: POLST Preparation (N=283/546) SNF staff received POLST education? SNF has formal policy on POLST? 82% POLST Champion in the SNF? 70% % SNF staff received POLST education 9 59% 43% (range 0 -100%)

Nursing Home POLST Evaluation: Sample selection l l Selected SNFs from each study county Up to 20 SNFs in each county • If >20 SNFs, randomly selected l If Community Coalition county, select 50% as partner SNFs • Partner SNFs randomly selected l Backfilled to maximize county sample 10

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% 11

# of SNFs Percentage of Residents Admitted in Past 30 Days with a Completed POLST 12

CA Hospitals, 2011: POLST Preparation and Use (N=286/345) 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% 13

Effect of Coalitions: Admitted a Resident with a POLST 14

Quality of POLST Completion in Coalition Area Facilities l l 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? 15

Quality of POLST Completion in Coalition area Nursing Homes l Convenience sample of 6 SNFs in each of 5 coalition areas • Orange County, Sacramento, San Diego, San Fernando Valley, Santa Clara l July/August 2010: Review of 538 randomly selected charts with POLST forms l l Feedback of findings to SNF July/August 2011: Review of 594 randomly selected charts with POLST forms 16

POLST Key Findings in SNF, 2010 and 2011 Common Missing Information: 2010 2011 Missing 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 17 **p<0. 01 for comparison of 2010 to 2011

Challenges and Opportunities l l l l 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 18

19

Summary of Findings l 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 l l l By 2011, hospitals using POLST regularly Community Coalition mechanism increased dissemination of POLST quality generally good • Documentation difficulties common after 18 months improved with feedback 20