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1/20/2016

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POLST in Primary Care and QIP Measure Specification Changes

Date: January 20, 2016

Audio InstructionsAudio Instructions

To avoid echoes and feedback, we request that you use the telephone instead of your computer microphone for listening/talking during the webinar.

1/20/2016

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Contact InformationContact Information

Email: Caron Lee‐ [email protected]

Joy Dionisio‐ [email protected]

Mark Apfel, MDMark Apfel, MD

Mark Apfel is a board‐certified family physician. He has worked at Anderson Valley Health Center since 1976. He believes healthcare should be a collaborative process based on the patient’s wishes and needs. He is also board certified in Hospice and Palliative Medicine. In 2007, he founded the Mendocino POLST Coalition, which was one of the original 7 Coalitions to implement POLST in California.

1/20/2016

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Advance Care Planning MeasureAdvance Care Planning Measure

Existing Specifications: Providers will receive payments for each eligible advance care planning attestation submitted for $100 per form (max.100 per practice per measurement year). All PHC members including Medi‐Medis.

Updated Specifications:Starting January 1, 2016, the measure will pay for ACP discussion with Medi‐Cal members only.

Questions?Questions?

If you have a question or would like to share your comments, please

• Type your question in the “question” box, or

• Click the “raise your hand” icon

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California POLST Education Program©August 2014 Coalition for Compassionate Care of CaliforniaMaterials made possible by a grant from the California HealthCare Foundation

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POLST in Primary Care

PhysicianOrders for LifeSustainingTreatment


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AB 637

California Medical Association (CMA) House of Delegates voted to support this in 2014 after previous opposition.

Assembly Bill 637 was co-sponsored by the California Medical Association and the Coalition for Compassionate Care of California.

Signed by Governor Brown in August 2015.

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AB 637

Authorizes nurse practitioners and physician assistants under the supervision of a physician and within their scope of practice to sign POLST forms.

Law went into effect on January 1, 2016.

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New Medicare Billing Codes

99497

Advance care planning including theexplanation and discussion of advancedirectives such as standard forms (withcompletion of such forms, when performed), by the physician or other qualified health careprofessional; first 30 minutes, face-to-facewith the patient, family member(s), and/orsurrogate.

99498

Advance care planning including theexplanation and discussion of advancedirectives such as standard forms (withcompletion of such forms, when performed), by the physicians or other qualified health careprofessional; each additional 30 minutes (Listseparately in addition to code for primaryprocedure).

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Advance Care Planning : Something We All Need

• We are living longer with higher disease burdens.

• Medical decisions are more complex.

• We may need someone to make decisions for us.


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Why POLST?

1. Patient wishes often are not known.– The Advance Healthcare Directive

(AHCD) may not be accessible.

– Wishes may not be clearly defined in AHCD.

– The AHCD is not a physician order.

2. Allows healthcare providers to know and honor wishes during serious illness.

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What is POLST?

A Clinician order recognized throughout the medical system.

Portable document that transfers with the patient.

Brightly colored, standardized form for entire state of CA.


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What is POLST?

Allows individuals to choose medical treatments they want to receive, and identify those they do not want.

Provides direction for healthcare providers during serious illness.

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Who Would Benefit from Having a POLST Form?

Chronic, progressive illness

Serious health condition

Medically frail

Tool for determination– “You wouldn’t be surprised if this patient

died within the next year.”


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Where Does POLST Fit In?

Advance Care Planning Continuum

Complete an Advance Directive

Complete a POLST Form

Age 18

Treatment Wishes Honored

Diagnosed with Serious or Chronic, Progressive Illness (at any age)

Update Advance Directive Periodically

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POLST History

POLST development began in Oregon in 1991.

It was developed initially for SNF patients who are often transferred from one care setting to another -mainly SNF to acute care and back to SNF or home.

Expanded to 46 states, which use some version of POLST, MOLST, COLST or POST

Developing Programs

National POLST Paradigm Programs

Endorsed Programs

No Program (Contacts)

*As of January 2014

Mature Programs

Regionally Endorsed Program

www.polst.org

Programs That Do Not Conform to POLST Requirements

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POLST is EffectiveOregon Study: Location of Death and POLST Orders

• 58,000 deaths reviewed, 31% had POLST in Oregon Registry

• Patient treatment choices honored, including avoiding dying in hospital

caPOLST.org


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POLST in California

The Coalition for Compassionate Care of California (CCCC) is lead agency.

Support from California HealthCare Foundation.

Grassroots efforts of local POLST coalitions and communities.

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POLST in California

Effective January 1, 2009


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POLST in California

One form for entire state.

Use not mandated.

Honoring form is mandated.

Provides immunity from civil or criminal liability.AB 3000, Wolk. Part 4, Sec 7, Probate Code Section 4782

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POLST vs. Advance Healthcare Directive

POLST complements the Advance Healthcare Directive (AHCD).

POLST is not intended to replace the AHCD.

Both are legal documents.AB 3000, Part 4, Sec 3, Probate Code 4780 (3) (c)

California POLST Education Program© May 2009 California Coalition for Compassionate CareMaterials made possible by a grant from the California HealthCare Foundation

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POLST vs. Advance Healthcare Directive

POLST AHCD For seriously ill/frail,

at any age For anyone 18 and

older

Specific orders for current treatment

General instructions for future treatment

Can be signed by decisionmaker

Appoints decisionmaker

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Why is ACP Difficult?

Decisions

& RECOMMENDATIONS

Decisions

& RECOMMENDATIONS

PATIENT/FAMILY

Goals and Values

PATIENT/FAMILY

Goals and Values

UncertaintiesUncertainties

Clinican

Prognosis and medical options

Clinican

Prognosis and medical options


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Myth Busting

“Talking about end of life takes away hope.”

POLST and ACP conversations don’t take away hope, they lower stress and anxiety

“We can’t talk about prognosis, it is too imprecise.”

Exact prognostication is always imprecise, we just have to be open about the uncertainty.

Balance hope and honesty.

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Myth Busting

“Patients don’t want to hear this.”

We won’t know if they want the information if we don’t ask: Assess prognostic awareness and readiness to receive information.


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POLST Conversations

Should focus on patient values and goals.

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Having the POLST Conversation

• Senior staff often too busy or may lack training • Support staff may be trained and utilized to

initiate ACP and / or POLST conversations (prime the pump for Clinicians)

• It takes time, more than one conversation is often required

• Social Worker, Chaplain and RN can assist when trained


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Skills for POLST Conversations

• Ask-Tell-Ask• Tell me more…• SPIKES• NURSE• Aligning with patient’s hopes• Preserving Cultural Dignity

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Communication Skills for End of Life Care Conversations

Assess desire for information• Ask/Tell/AskCommunicate information or prognosis kindly• Hope/worry/wishIdentify the affective response• Name and respondHope for things that are possibleConclude with a plan


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ASK-TELL-ASK & Tell Me More

Avoids giving too much informationAllows honest discussion of patient needsRespects their need to be / feel heardHelps gather more information

There are no right answers

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Discussing Distressing News

Compassionate Communication with SPIKES

• Setting• Perception• Invitation• Knowledge• Empathy• Support


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Perils and Pitfalls

AVOID:• Not knowing the patient’s needs and agenda• Jumping in too soon with your agenda• Not setting a focus for the interview• Medicalese and physiology lectures• Offering relief or reassurance prematurely

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Responding to Emotion

Challenges:• Medicine is objective, emotion is subjective• We are busy, emotion can hijack a

conversation• Emotions can be contagious.


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Using NURSE to respond to Emotion

NamingUnderstandingRespectingSupportingExploring

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Patients Needs and Desires for Information Vary

• All patients want HONESTY• Over 90% of patients want their physician to

maintain OPTIMISM• Some patients want hard numbers• Other patients don’t desire details on prognosis• There are no patient characteristics to predict

which patients want high detailWE HAVE TO ASK

Innes S Advanced cancer patients’ prognostic preferences: A review. Palliat Med 2009 Jan;23(1):29-29

Kutner JS Information needs in terminal illness. Soc Sci Med 1999 May;48(10):1341-52


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Preserving Dignity and Cultural Respect in POLST and ACP Discussions

Respecting culture will make conversations flow.

We need:• Skilled translators • Staff who are aware and trained• Practices that preserve cultural dignity

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2016 POLST Form – Front Side

2014 POLST Form – Front Side


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Section A: CPR

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3737

Section B: Medical Interventions


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Diagram of POLST Medical Interventions

CPR

Comfort-Focused Treatment

DNR

Full Treatment*

Selective Treatment

*Consider time/prognosis factors under “Full Treatment”“Trial Period of Full Treatment” may be checked if prolonged life

support is not desired.

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Section C: Artificially Administered Nutrition


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The POLST Conversation

POLST is not just a check-box form.

The POLST conversation provides context for patients/families to:– Make informed choices.

– Identify goals of treatment.

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2014 POLST Form

2016 POLST Form – Information & Signatures

2014 POLST Form

2016 POLST Form - Signatures

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Who Can Speak for the Patient?

Patient who has capacity

Surrogate decisionmaker/agent

Parent, registered domestic partner, guardian, conservator

Closest available relative

2014 POLST Form – Back Side

2016 POLST Form – Back Side

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Who Can Help Complete POLST?

Healthcare providers – “licensed, certified, or otherwise authorized to provide healthcare in the normal course of business.”

Best practice suggests use of those trained in the POLST Conversation:– Physicians– Nurses, Nurse Practitioners, Physician Assistants– Social Workers– Chaplains– Social Service Designees

2016 POLST Form – Directions for Health Care Provider

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2014 POLST Form

2016 POLST Form – Modifying and Voiding POLST


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When Should POLST be Reviewed?

Transfer from one care setting to another.

Change in patient’s health condition.

Patient’s treatment preferences change.

Patient Care Conference.

Recommendation: Update POLST forms to the 2016 version when reviewing 2009, 2011 or 2014 POLST forms.

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Can POLST be Changed?

Patient with capacity can request alternative treatment or revoke a POLST at anytime.

Legally recognized decisionmaker may request a change based on condition change or new information regarding patient wishes in collaboration with the Clinician


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POLST: Depth of the Process

POLST is more than a form.

POLST:– Facilitates rich conversations with

patients/families.

– Complements the AHCD.

– Incorporates the importance of comfort.

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Resources

http://coalitionccc.org/2015/11/webinar-polst-in-2016-what-nps-pas-and-everyone-else-needs-to-know/

http://coalitionccc.org/tools-resources/advance-care-planning-resources/advance-care-planning-reimbursable-under-medicare/

https://csupalliativecare.org/programs/polst/


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Questions?

[email protected]

polst in primary care - revised 1 20 16 [read-only] › providers › quality › documents ›...

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