polst in california: use in nursing homes & hospitals, quality of completion and impact of...
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POLST in California:Use in Nursing Homes & Hospitals,Quality of Completion andImpact of Community Coalitions
Neil Wenger, MD
Catherine 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
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0 5 11 17 23 29 35 41 47 53 59 65 71 77 83 89 95
%
1
2
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
en
t o
f N
urs
ing
Ho
mes
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 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 **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