Update on Palliative Care and POLST (Practitioner Orders for Life Sustaining Treatment)

1. Update on Palliative Care and POLST (Practitioner Orders for Life Sustaining Treatment) Amy Frieman, MD Medical Director, Palliative Care Services Meridian Health

2. 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

3. 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

4. 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

5. 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 5

6. 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)

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

8. Satisfaction Data

9. 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

10. 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

11. 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

12. How Advance Directives and POLST Work Together

13. 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/