Panel - LeadingAge New York...Patricia Bomba MD, FACP VP & Medical Director Geriatrics, Excellus BlueCross BlueShield Committee Member, IOM Report Dying in America 4 Deaths Among Seniors

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Improving Quality and Honoring Individual Preferences Near the End of Life:

Leading the Way in Long Term Care

LeadingAge New York Annual ConferencePanel Discussion May 19, 2015

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Panel

• Moderator: Karen Lipson, EVP for Innovation Strategies, LeadingAgeNY, Latham

• Patricia Bomba MD, FACP, VP & Medical Director Geriatrics, Excellus BlueCross BlueShield, Rochester

• Judith Peres, Director, Improving End of Life Care, Pew Charitable Trusts, Washington DC

• Michael McRae, President & CEO, St. Ann’s Communities, Rochester

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Objectives

• List the five key recommendations of the IOM Report Dying in America

• Identify critical areas needing improvement and implementation steps required to impact sustainable change, building on promising models and best practices

• Develop an action plan to begin to address the recommendations for all settings in their long term care system

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IOM Report: Current StateWhy IOM Report is Important

Patricia Bomba MD, FACPVP & Medical Director Geriatrics, Excellus BlueCross BlueShield

Committee Member, IOM Report Dying in America

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Deaths Among Seniors

• New York is ranked #1 in hospital deaths among seniors* (worst in the country)

• Estimates suggest that 35% of all New Yorkers 65+ die in the hospital**

• Regional Variation, Medicare Data***

*In Sickness and in Health, Where States are No.1 Wall Street Journal, June 9, 2014

**America's Health Rankings***Dartmouth Atlas5

What Do Common Ways of Dying Look Like?

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How Americans Wish to Die Medicare payments in last year of life account for 25% of all Medicare spending

Data from: Riley G, Lubitz J. “Long‐Term Trends in Medicare Payments in the Last Year of Life.” Health Services Research, 2010; 565‐576.8

“30% of health care is unnecessary or harmful”

How do we shift the cultural mindset from “more treatment is better” to

“the right treatment and care, and no more?”Triple Aim, IHI

Choose Wisely Campaign9

Thoughtful EOLC Discussions: Benefits

• Improve quality; reduce cost * • Only 31% of patients with advanced cancer at EOL had had

discussions with physicians about EOLC * • Patients who had EOL conversations had significantly lower

costs in their final week of life, over $1,000 less *• “Higher costs were associated with worse quality of death” *

**Arch Intern Med. 2009;169(5):480‐488

• "End‐of‐life discussions are associated with less aggressive medical care near death and earlier hospice referrals.” **

• “Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.” **

**Associations Between End‐of‐Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment

JAMA. 2008;300(14):1665‐1673

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Palliative Care

Interdisciplinary care – aims to relieve suffering and improve quality of life for patients with

advanced illness and their families

– offered simultaneously with all other appropriate medical treatment from the time of diagnosis

– focuses on quality of life and provides an extra layer of support for patients and families

Three Key Pillars with Psychosocial & Spiritual Support– Advance Care Planning and Goals for Care

Step 1: Community Conversations on Compassionate Care*

Step 2: Medical Orders for Life‐Sustaining Treatment (MOLST)*

– Pain and Symptom Management

– Caregiver Support

*A Project of the Community‐Wide End‐of‐life/Palliative Care Initiative 12

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Impact on Survival and Quality of Life: Early Integration of Palliative Care

• Randomized study of 151 patients with newly diagnosed non‐small cell lung cancer– Early palliative care plus standard oncologic care or standard

oncologic care

– Quality of life and mood assessed at baseline and at 12 weeks

– Primary outcome: change in quality of life at 12 weeks

• Outcomes– Fewer patients in early palliative care group received

aggressive end‐of‐life care (33% vs. 54%, P=0.05)

– Median survival longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02)

Early Palliative Care for Patients With Metastatic Non-Small Cell Lung CancerNEJM. 2010;363:733-74214

Palliative Care and New Value‐Based, Accountable Care Models

• Palliative care aligns with new care and innovative payment models

– Helps to reduce avoidable hospitalizations and ED use

– Strengthens person‐centeredness and consumer engagement and satisfaction

– Improves coordination along the continuum

– Avoids unnecessary and unwanted service utilization and expense

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DYING IN AMERICA

IOM Report

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Approaching Death in America: Improving Care at the End of Life IOM, 1997

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Implementation: Approaching Death 1997

• Sponsors: RWJF, OSI, other foundations

• Charge: evaluate quality of care and how to improve it near end of life

• Impact: Approaching Death: Improving Care at the End of Life

» Many recommendations identical to those in the current report, calling for clinician training, payment redesign, investment in an evidence base, and public awareness campaigns.

» Sponsors (largely charitable foundations) invested heavily in the recommendations

» Report called for a new medical specialty in palliative medicine ABMS approves 10 years later, in 2007.

IOM Report Dying in America

• Major gaps in care near end of life

• Urgent attention needed from numerous stakeholder groups

• Patient‐centered, family‐oriented approach to care near the end of life should be a high national priority

• Compassionate, affordable, and effective care is an achievable goal

Released September 17, 2014

Report available: www.nap.edu20

Five Key Areas

• Delivery of person‐centered, family‐oriented care

• Clinician‐patient communication and advance care planning

• Professional education and development

• Policies and payment systems

• Public education and engagement

Released September 17, 2014

Report available: www.nap.edu21

Key Recommendations

• All insurers should cover comprehensive care for individuals with advanced serious illness who are near the end of life

• All insurers should integrate the financing of medical and social services to support quality care consistent with patients’ values and preferences

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Key Recommendations

• Quality standards should be developed for clinician‐patient communication and advance care planning

• Appropriate provider training, certification and licensure should be developed to strengthen palliative care knowledge and skills of all clinicians

• Fact‐based public education that encourages advance care planning and shared, informed medical decision‐making

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Key RecommendationsPolicies and Payment Systems Actions

Provide financial incentives for:

– medical and social support services that decrease the need for emergency room and acute care services

– coordination of care across settings and providers (from hospital to ambulatory settings as well as home and community)

– improved shared decision making and advance care planning that reduces the utilization of unnecessary medical services and those not consistent with a patient’s goals for care

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Key RecommendationsPolicies and Payment Systems Actions

• Require the use of interoperable electronic health records that incorporate advance care planning to improve communication of individuals’ wishes across time, settings, and providers, documenting:

– the designation of a surrogate/decision maker

– patient values and beliefs and goals for care

– the presence of an advance directive

– the presence of medical orders for life‐sustaining treatment for appropriate populations

• Encourage states to develop and implement a Physician Orders for Life‐Sustaining Treatment (POLST) paradigm program in accordance with nationally standardized core requirements

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Why does the IOM matter?

• IOM secures services of eminent professionals to examine policy matters pertaining to the health of the public.

• IOM under the National Academy of Sciences through its congressional charter as advisor to the federal government.

• “IOM” recommendations can have a lot of influence in health care policy decision‐making.

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IOM has now made clear (in 6 reports):Palliative care IS essential to quality

Institute of Medicine Quality Cancer Care Report:Charting a New Course for a Health System in Crisis (2013)

QOL care

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The IOM’s Assessment for Leveraging ReportsCommonalities among reports with major impact, from Harvey Fineberg MD, immediate past president of the IOM:

• Excellence of the product: objective, evidence‐based, grounded in science, well‐reasoned, understandable, thorough, and persuasive

• Importance, Timeliness, and Relevance• Contending Values and Interests• Communication and Promotion• Repetition and Consistency

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CHANGE ‐Strategies to Create Change

• Direct action/stories

– Replace acquiescence with outrage

• Work with Association/Coalitions

– Aging, providers, elders, caregivers

• National leaders /Legislative Champions

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What to do? Impact vs. Feasibility

Low Feasibility

High feasibility

Low impactWhy bother? Whine and complain

Roll your eyes about politics in the U.S.Talk only within the field

High impactNew legislationChange in CMS regulations, Conditions of ParticipationSustained public awareness campaign

*Organizations: Workwithin effective coalitions* Individuals: Writearticles, blogs, use social media*Give talks, webinars*Explicitly link to IOM recommendations

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Opportunity for Long‐term care (LTSS)

• Identify licensure model legislation for all disciplines that states can use to ensure access to qualified palliative care professionals.

• Work toward LTSS inclusion of electronic health records … including: incorporating advance care planning to improve communication of individuals’ wishes across time, settings, and providers.

• Partner w/ emerging models of care to deliver palliative care and institutional and HCBS level.

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Opportunity for Long‐term care (LTSS)

• Identify & share quality and cost measures for aspects of

LTSS related to palliative and end‐of‐life care.

• Support model quality improvement projects focused on the delivery of palliative care in all care settings (private payers, CMS, Medicare).

• Educate policy leaders on how to revise existing state and federal legislation encouraging the delivery of palliative care in all settings.

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Delivery of Care Opportunities for Social Work in LTSS

• Every consult is an opportunity to identify support needs and answers.

• Bring the expertise of the IDT approach, whole person perspective, and experience with prognosis to the acute care and long‐term care setting.

• Inform administrators and Increase advocacy for the role of palliative care delivery

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1. Access to Palliative Care / Hospice Care to all that need it, across settings

2. Communication – Advance Care Planning (developing metrics)

3. Professional Education and Development (ensure training/certification/expanded to other providers)

4. Policies and Payment Systems (major reform efforts to link medical/social services)

5. Public Engagement and Communication (changing the climate, culture)

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Opportunities for Immediate Action‐Key Messages for the Field• Access to palliative care: Palliative care is high quality care for people

living with serious illness and their families. Payers and health delivery systems must be accountable and, through payment and accreditation mechanisms, ensure access to skilled palliative care, and hospice care, throughout the course of illness and across settings.

• Communication and advance care planning: To ensure shared decision‐making that accounts for evolving patient needs and respects their goals of care, the quality of clinician‐patient communication must be measured and incentivized in reimbursement, licensing, and credentialing.

• Clinician training: All clinicians who care for people with serious illness must be competent in providing basic palliative care, including communication skills, interprofessional collaboration, and symptom management; and certifying bodies should require demonstration of these core competencies.

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Pew Project: Improving End‐of‐life CareEfforts to Implement IOM Recommendations

Judith R. Peres, MSWDirector, Improving End of Life Care, Pew Charitable Trusts


Pew Improving End‐of‐Life Care Project

• Project seeks:

‐ to advance policies that help people articulate their preferences for future treatment when they can’t speak for themselves,

‐ hold hospitals and healthcare providers accountable for quality care,

Pew Improving End‐of‐Life Care

‐ highlight innovative ways of providing care to seriously ill people and their families, and

‐ improve documentation of patients’ preferences for their care as they reach the end of their lives.


Goal # 1

Establish Medicare reimbursement for advance care planning

• Welcome to Medicare – 2003• Affordable Care Act - 2010• Wellness Visit – 2011• CPT Editorial Panel -2016

complex ACP servicesCodes - 99497 & 99498

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Public Policy Attempts to “have the conversation”

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Goal #2

Implement quality metrics for palliative and end‐of‐life care.

Place of death

In the absence of conversations about prognosis, goals, and outcomes of treatment, patients do not have the opportunity to express their values and preferences.

Leading clinicians to assume that patients want additional interventions, even late in the illness.Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.


Goal # 3

Ensure accessibility of advance directives across health care settings.


Goal # 4

Support evaluation and dissemination of promising end‐of‐life care delivery models.


Goal #5

Encourage states to improve Physician Orders for Life Sustaining Treatment (POLST) programs

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Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life

• Report available: http://www.iom.edu/Reports/2014/Dying‐In‐America‐Improving‐Quality‐and‐Honoring‐Individual‐Preferences‐Near‐the‐End‐of‐Life.aspx

• Free slide deck for download

• IOM will engage in 12 month dissemination phase:

o Developing materials

o Engaging relevant stakeholders and key audiences

Palliative Care in Long Term Care: Opportunities and Challenges

Michael McRaePresident & CEO

St. Ann’s Communities

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St. Ann’s Communities

• Brief History of St. Ann’s Community

• Two Models of end of life care:

– Fully integrated Palliative Care

– General Inpatient Hospice – Leo Center for Caring

• Challenges faced and how they were handled

• eMOLST

• The Money Follows

Palliative Care Program Implementation • High level “how‐to” steps, e.g.,:

– Interdisciplinary approach

– Develop clinical/community/family partners

– Training

– Analyze unit costs and reimbursement

– Technology

– Measure performance

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Palliative Care Unit

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Integrated Palliative Care Model

• Focus on All service Lines:

– Skilled, Transitional Care, Housing, Assisted Living, Adult Day Services

• Starts with each new hire

• Interdisciplinary Care Team drives culture

• Ethic Consults – Lower then expected

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G.I.P.• Partnership with Visiting Nurse

• 10 Bed Unit

• Average Length of Stay = 5 days

• Raised skill set of Interdisciplinary Team

• Available for consults

• 415 Deaths in 2014

eMOLST: Improving Quality and Safety, Reducing Resident Harm

Patricia Bomba, MD, FACP, eMOLST Program DirectorVP & Medical Director Geriatrics, Excellus BlueCross BlueShield


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Definitions

• National POLST Paradigm: process of communication & shared decision making results in POLST; has established endorsement requirements

• POLST: Physician Orders for Life Sustaining Treatment ‐different states use different names to describe the state POLST program: such as MOLST, POST, LaPOST, MOST

• MOLST: New York State’s Endorsed POLST paradigm program

Advance Care Planning Preferred PracticesNational Quality Forum

• Document the designated agent (surrogate decision maker) in a Health Care Proxy for every patient in primary, acute and long‐term care and in palliative and hospice care.

• Document the patient/surrogate preferences for goals of care, treatment options, and setting of care at first assessment and at frequent intervals as condition changes.

• Convert the patient treatment goals into medical orders and ensure that the information is transferable and applicable across care settings, including long‐term care, emergency medical services, and hospital, i.e., the Medical Orders for Life‐Sustaining Treatment—MOLST, an endorsed POLST Paradigm Program.

• Make advance directives and surrogacy designations available across care settings: eMOLST, a statewide data source for SHIN‐NY.

• Develop and promote healthcare and community collaborations to promote advance care planning and completion of advance directives for all individuals. e.g. Respecting Choices and Community Conversations on Compassionate Care.

60National Quality Forum, Framework and Preferred Practices

for Palliative & Hospice Care Quality, 2006, Adapted for New York State

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Advance Care Planning Preferred PracticesNational Quality Forum

• Establish or have access to ethics committees or ethics consultation across care settings to address ethical conflicts at the end of life. (special requirements exist with Family Health Care Decisions Act)

• For minors with decision making capacity, document the child's views and preferences for medical care, including assent for treatment, and give them appropriate weight in decision making. Make appropriate professional staff members available to both the child and the adult decision maker for consultation and intervention when the child's wishes differ from those of the adult decision maker. (aligns with Family Health Care Decisions Act)

National Quality Forum, Framework and Preferred Practices for Palliative & Hospice Care Quality, 2006, Adapted for New York State

Medical Orders for Life‐Sustaining Treatment (MOLST) Program – More Than a Form

• Standardized clinical process – discussion of patient’s goals for care

– shared medical decision‐making between health care professionals and seriously ill patients

• Result: a set of medical orders – reflect the patient’s preference for life‐sustaining treatment they wish to receive or avoid

– common community‐wide form

MOLST and New York State Department of Health (NYSDOH)

• NYSDOH approved MOLST for use in all health care facilities in 2005

• NYSDOH approved MOLST for statewide use in all settings, including the community, in 2008.

• MOLST became a NYSDOH form in 2010.

• MOLST is the ONLY form approved by NYSDOH for both Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders.

• All healthcare professionals, including EMS, must follow the MOLST in all clinical settings.

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New York eMOLST: Definitions

• Form: Refers to MOLST form and the Chart Documentation Form (CDF) that documents the key elements of the discussion and process

• Users: persons with different clinical and administrative roles with regards to creating, updating, or accessing MOLST forms or other registry content

• EMR: Electronic Medical Record

• EHR: Electronic Health Record

• Registry: Electronic database centrally housing MOLST forms and CDFs to allow 24/7 access in an emergency

• eMOLST: electronic form completion system for MOLST that serves as the NYeMOLST Registry

New York eMOLST

• An electronic system that guides clinicians and patients through a thoughtful discussion and MOLST process.

• eMOLST makes sure MOLST is completed correctly and ensures it is accessible.

• Allows the clinician to print a copy of the eMOLST form on bright pink paper for the patient.

• Serves as the registry of NY eMOLST forms to make sure a copy of the medical orders and the discussion are available in an emergency.

• eMOLST is available statewide and accessed at NYSeMOLSTregistry.com.

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8‐Step MOLST Protocol

1. Prepare for discussion• Understand patient’s health status, prognosis & ability to consent• Retrieve completed Advance Directives• Determine decision‐maker and NYSPHL legal requirements, based on who

makes decision and setting

2. Determine what the patient and family know• re: condition, prognosis

3. Explore goals, hopes and expectations4. Suggest realistic goals 5. Respond empathetically6. Use MOLST to guide choices and finalize patient wishes

• Shared, informed medical decision‐making• Conflict resolution

7. Complete and sign MOLST– Follow NYSPHL and document conversation

8. Review and revise periodically

Developed for NYS MOLST, Bomba, 2005; revised 2011 66

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MOLST Instructions and ChecklistsEthical Framework/Legal Requirements

• Checklist #1 ‐ Adult patients with medical decision‐making capacity (any setting)

• Checklist #2 ‐ Adult patients without medical decision‐making capacity who have a health care proxy (any setting)

• Checklist #3 ‐ Adult hospital or nursing home patients without medical decision‐making capacity who do not have a health care proxy, and decision‐maker is a

Public Health Law Surrogate (surrogate selected from the surrogate list)

• Checklist #4 ‐ Adult hospital or nursing home patients without medical decision‐making capacity who do not have a health care proxy or a Public Health Law Surrogate

• Checklist #5 ‐ Adult patients without medical decision‐making capacity who do not have a health care proxy, and the MOLST form is being completed in the community.

• Checklist for Minor Patients ‐ (any setting)

• Checklist for Developmentally Disabled who lack capacity – (any setting) musttravel with the patient’s MOLST

http://www.nyhealth.gov/professionals/patients/patient_rights/molst/67

MOLST and MOLST Chart Documentation Forms

Align with NYSDOH Checklists 68

Why eMOLST?

• Adds value

• Improves quality outcomes & patient safety

• Reduces patient harm & improves legal outcomes

• Improves provider satisfaction

• Assures accessibility

• Provides a system‐based solution

• Achieves the triple aim

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eMOLST Feedback: NYSDOH

• “I did log on to the eMOLST Training Site, and I did fill out a MOLST form, download it and print it.”

• “I do think eMOLST has all the advantages of using TurboTax vs. trying to do your taxes using paper forms with a pencil.”

• “The electronic form didn't let me make mistakes ‐ it prevented me from filling out the form in a way that was illegal, inconsistent or illogical. I think this is great!”

Jonathan Karmel, JD, NYSDOH Division of Legal Affairs, Legal Counsel

CMS Clinical Standards and Quality: Advance Care Planning

• Failure to comply with MOLST

– NYSDOH: Survey deficiency

– Medical Perspective: Medical error

– Legal perspective: Battery

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Advance Care Planning: Surveillance Issues

• Failure to follow MOLST orders

– Hospitalization – Immediate Jeopardy

– Lab work and hydration – Actual harm

– Failure to make resident/representative aware of right to decline treatment – Potential for more than minimal harm

– Failure to obtain medical orders that were consistent with the resident’s documented wishes ‐ Potential for more than minimal harm

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• Severity Level 4 Considerations: Immediate Jeopardy

• “As a result of the facility’s failure to obtain and implement medical orders related to life‐sustaining treatments, after the resident had documented choices, the resident was transferred to the hospital for an acute change of condition against his wishes, where he was resuscitated against his documented wishes, despite the facility’s knowledge that the intervention was against the resident’s wishes.”

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• Severity Level 3 Considerations: Actual Harm that is Not Immediate Jeopardy

• The facility failed to identify the medical orders that detailed the resident’s wishes to forego lab work, IV antibiotic treatment and IV hydration for the resident’s 7th episode of aspiration pneumonia. Furthermore, the nurses refused to allow the resident to attend his son’s wedding, insisting that the resident remain in the nursing home so that a chest x‐ray and blood work be done, which went against the resident’s expressed wishes. The resident suffered emotional harm.

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• Severity Level 2 Considerations: No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy

• “As a result of the facility’s failure to establish and implement policies and procedures regarding the rights to decline treatment and other related interventions, the resident and/or the resident’s legal representative was unaware of the opportunities to decline medical treatment, although a situation involving the use of life‐sustaining treatment options had not yet arisen in the resident’s care.”

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• Severity Level 2 Considerations: No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy

• “As a result of the facility’s failure to obtain medical orders that were consistent with the resident’s documented wishes, the direct care staff was unaware of the resident’s wishes, although a situation involving life‐sustaining treatment options had not yet arisen in the resident’s care.”

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Ensuring Effectiveness of eMOLSTRequires a Multidimensional Approach

• Culture change

• Provider training

• Community education & empowerment

• Thoughtful discussions

• Shared, informed decision‐making

• Care planning that supports MOLST

• System implementation

• Dedicated system and physician champion

• Sustainable payment stream based on improved compliance with person‐centered goals, preferences for care and treatment – improved resident/family satisfaction – reduced unwanted hospitalizations

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Successful eMOLST Implementation in LTC: St. Ann’s Community

Michael McRae, President & CEO, St. Ann’s Communities

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eMOLST Success at St. Ann’s Community

• 2004: First LTC facility to implement NY MOLST

• 2012: First LTC facility to implement NY eMOLST

• We have successfully converted 430 long‐term care paper MOLST into eMOLST in one month!

Getting Started

• Need commitment from

– CEO

– Administrator

– Director of Nursing

– Medical Director

– Director of Social Work

• Identify a Champion

– Ideally Medical Director or designee

Getting Started

Need buy‐in from Medical Staff

• Introduce eMOLST at medical staff meeting

• Invite Dr. Pat Bomba or Katie Orem from Excellus BlueCross BlueShield to do eMOLST demonstration (in person or webinar) & eMOLST training

• Quality Improvement Project: providers convert paper MOLST to eMOLST

eMOLST Feedback: Physician

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Process of Converting Paper MOLST to eMOLST

• Identify team to accomplish this

• St. Ann’s Community team consisted of Medical Director and RN familiar with MOLST

• Convert one floor/unit at a time

• Work with nurse manager on floor/unit and educate them regarding importance of eMOLST

• Accomplish conversion ASAP to avoid working off of two systems simultaneously

• Once a floor/unit is converted to eMOLST, ensure that all subsequent MOLST forms are electronic

Post eMOLST Conversion

• Once a floor/unit is converted to eMOLST, scan paper MOLST if no EHR or send paper MOLST to medical records

• DO NOT continue paper MOLST and eMOLST simultaneously

• Outline explicit instructions for other team members to access eMOLST; copy of instructions should be posted at every nursing station

• Identify a point person to troubleshoot problems

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eMOLST Implementation: Achieving the Triple Aim

Michael McRae, President & CEO, St. Ann’s Communities

Patricia Bomba, MD, FACP, eMOLST Program Director

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Research: Site of Death vs. Treatment Requested

• Death records: 58,000 people who died of natural causes in 2010 and 2011 in OR

• Nearly 31% of people who died: POLST forms entered in OR's POLST Registry

• Compared location of death with treatment requested

– 6.4% of people with POLST forms who selected "comfort measures only" died in hospital

– 34.2% of people without POLST forms in the registry died in the hospital

Fromme, Erik et al (2014). JAGS, on‐line June 9, 201486

eMOLST Aligns with New Value‐Based, Accountable Care Models

• Improves quality: discussion of personal‐centered values, beliefs and goals for care drives choice of life‐sustaining treatment

• Honors individual preferences: provides MOLST orders and copy of discussion across care transitions

• Reduces unnecessary and unwanted hospitalizations, ED use, service utilization and expense

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Where eMOLST Aligns With Health System Priorities

• Palliative Care

• Advance Care Planning

• Quality, Patient Safety & Risk Management

• Compliance with NYSPHL

• Care Transitions

• Reducing Readmissions

• Accountable Care Organizations

• Innovative Payment Models

• Medicaid Redesign: DSRIP, FIDA, Health Homes

• NY State Health Innovation Plan

• IOM Dying in America Recommendations88

New York eMOLST

• If you would like your facility implement and your residents’ MOLST forms included in NY’s eMOLST registry, visit NYSeMOLSTregistry.com.

ContactseMOLST Program Director: [email protected] Administrator: [email protected]

Next Steps and Questions

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Documents

Panel - LeadingAge New York...Patricia Bomba MD, FACP VP & Medical Director Geriatrics, Excellus BlueCross BlueShield Committee Member, IOM Report Dying in America 4 Deaths Among Seniors