Update on Palliative Care and POLST (Practitioner

Orders for Life Sustaining Treatment)

Amy Frieman, MDMedical Director, Palliative Care

ServicesMeridian Health

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State of Palliative Care at Meridian Health

• Inpatient consultation teams at all 5 hospitals• Facility-based consultation teams at all 5 MNR facilities• CMS Demonstration Project bringing Palliative Care

into the home• Joint Commission Advanced Certification for Palliative

Care at JSUMC in 12/12 (the first hospital in NJ)– OMC Certification projected in Fall, 2013

• Introduction of POLST across Meridian Health– First collaborative initiative for the Richard Hader

Institute of Clinical Integration

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Acceptance of Palliative Care at Meridian Health

• Total for 2012:– 2,327 unique patients seen by palliative care

• 1602 inpatients• 725 outpatients (MNR facilities + CMS)

– 6,673 palliative care consultations• Quarter 1, 2013:

– 1,329 unique patients seen by palliative care• 509 inpatients• 820 outpatients (MNR facilities + CMS)

– 3,609 palliative care consultations

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CMS Demonstration Project

• Objectives:– Improve the quality of life for patients and families

facing serious or life‐limiting illness– Partner with primary physician to provide:

• Aggressive management of physical symptoms• Psychosocial and spiritual support for patients and their

families• Coordination of care among physicians, affiliated

facilities, services, family and community outside hospital walls

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Original Enrollment Criteria

• Medicare Part A and B (without Managed Care)• Age 65 or older• Not on Hospice• Discharged from one of three Meridian hospitals with

one or more of 35 MS-DRGs representing seven specific disease states– Cancer, heart failure, COPD, dementia, stroke, end-

stage renal disease, end-stage liver disease

Expanded Enrollment Criteria

• Patient must have one of the 35 previously defined MS-DRG’s OR

• Any one of the 191 ICD-9s that comprise the 35 MS-DRGs

AND• ≥3 of top 20 ICD-9’s, concordant in our baseline

group and group identified using the 191 ICD-9’s (i.e. CHF, COPD, CAD, Stroke)

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-130

100

200

300

400

500

600

700

158

6076

47 59 6285

10684

103 107

2 15 17 11 11 23 34 2141 34 29

156

201

260

296

344

383

434

519

562

631

709

Gross Monthly Enrollment

Attrition

Net Enrollment (Cumulative)

*Gross Enrollment to Date: 940

CMS Demonstration – Enrollment (7/1/12 – 5/31/13)

Question Total

 

Agree, Strongly Agree

The Team was respectful and professional 9196%

I was able to talk about my goals and preferences of care. 8793%

The Team helped me feel more comfortable (example: decreased my pain, helped my breathing, improved my nausea).

79

86%

The Team helped me Coordinate my care both in and outside the hospital. 80

90%

The educational material was helpful and easy to read. 8791%

I am satisfied with the program 8993%

Satisfaction Data

Practitioner Orders for Life Sustaining Treatment (POLST)

• Developed in response to patients receiving medical treatments that were inconsistent with their wishes

• Goals of POLST Program:– To honor patients’ end-of-life treatment

preferences even when transferred from one care setting to another

• POLST Form– A medical order form, used to write orders

indicating life-sustaining treatment wishes for seriously ill patients

– Translates the values expressed in an advance directive into immediately active medical orders which do not require interpretation or further activation

– Portable from one care setting to another

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Who Should Have a POLST Form?

• The Surprise Question: Would I be surprised if this patient died in the next year?

• Patients with a terminal illness• Patients with advanced chronic illness• Elderly patients with significant frailty

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How is POLST Different Than an Advance Directive?

• Does not require loss of decision-making capacity• Can be created by a physician or nurse practitioner

with the patient or surrogate• Applies immediately – no interpretation/evaluation• Set of actionable medical orders

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How Advance Directives and POLST Work Together

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POLST in New Jersey

• Signed into law by Governor Christie, December 2011• Launched at NJHA, February 2013

– Mary O’Dowd, Commissioner of Health• NJHA website with POLST form and education

– http://www.njha.com/quality-patient-safety/advanced-care-planning/polst/

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