Quality care at the end-of-life should involve honoring a person’s preferences, values, and beliefs; be based on evidence-based medicine; and allow for sound, informed medical decisions made collaboratively and deliberately among the individual, family/caregiver, and healthcare professionals.

This fundamental belief is the basis for the Special Innovation Project newly awarded to IPRO, the Medicare Quality Improvement Organization for New York State. In partnership with Patricia Bomba, MD, F.A.C.P., Vice President & Medical Director, Geriatrics – Excellus BlueCross BlueShield; Chair, MOLST Statewide Implementation Team & eMOLST Program Director, IPRO will provide outreach and education to Medicare beneficiaries and their families/caregivers in the Long Island region of NYS, on the importance of Advance Care Planning, including strategies to communicate end-of-life wishes to family and health care professionals.

IPRO will also collaborate with the hospitals, skilled nursing facilities, home health agencies, hospices, emergency medical services and physician practices within the target region to provide training and technical assistance for a community based adoption and implementation of eMOLST.

IPRO’s project aligns with the National Quality Strategy and CMS Quality Strategy triple aim to improve health, improve care and lower costs using innovative techniques to achieve the following goals:

• Make care safer by reducing harm
• Strengthen person and family engagement
• Promote effective communication and coordination of care
• Work with communities to promote best practices of health living

Launch events for the project are in the planning stages for the first quarter of 2016. For more information on the project please contact Carolyn Kazdan, MHSA, NHA, Quality Improvement Specialist at IPRO, Carolyn.Kazdan@area-I.hcqis.org or 518-320-3590.

IPRO has developed a new web page, “Transforming End-of-Life”. The page features the key areas of focus for the IPRO Special Innovations Project on eMOLST. Shared medical decision making that is well informed depends on clinician training and public education, as recommended in the 2014 IOM Report, Dying in America.

No. A facility does not need to be using paper MOLST forms in order to implement eMOLST. In fact, eMOLST implementation is easier if a facility is not yet using MOLST, as the paper conversion process can be skipped. However, for those facilities already using MOLST, there are conversion tools embedded within the eMOLST application to help with the process.

Sara Butterfield, RN, BSN, CPHQ, CCM serves as the Senior Director for the Healthcare Quality Improvement Program for IPRO. Ms. Butterfield is responsible for facilitating and managing quality improvement initiatives addressing the National Quality Improvement Priorities for Medicare beneficiaries identified by the Centers for Medicare and Medicaid Services (CMS). She leads the CMS Coordination of Care Task for IPRO in addition to two newly awarded CMS Special Innovation Projects designed to advance the quality of healthcare for Medicare seniors.

Ms. Butterfield is an active member of the MOLST Executive Committee and the Statewide Implementation Team and strongly believes in the importance of early advance care planning and the value of NY’s MOLST program. She proposed and serves as the lead for the CMS Special Innovation Project, “Transforming End-of-Life Care” which focuses on increasing the utilization of MOLST/eMOLST in the Long Island target region. She has been instrumental in mentoring Health Care Coalitions across NYS as they work to improve care transitions and implement early advance care planning, MOLST and eMOLST in their communities.

As a result of her mentorship role, Ms. Butterfield has become a staunch advocate of eMOLST. She has seen the results of quality gaps in the paper world, including incompatible orders, failure to have a palliative care plan support MOLST and lack of accessibility to the medical orders in a medical emergency. Additionally, she knows the value of having access to the thoughtful MOLST discussions in helping patients and/or their health care agent make additional end-of-life medical decisions as health status and prognosis worsen over time, prompting a change in personal goals for care and desired medical interventions.

Ms. Butterfield appreciates the need for a multidimensional approach to ensuring effectiveness of New York’s MOLST program. She is a dedicated system community champion who has collaborated on physician and clinician MOLST training along with community education and empowerment of individuals, their families, caregivers and medical decision-makers. Both are needed to support shared medical decision-making that is well informed.

By SARAH BUTTERFIELD, RN, BSN, CPHQ, CCM

IPRO, the Medicare Quality Improvement Organization (QIO) for New York State, has been collaborating with cross-setting healthcare providers and key community stakeholders to improve transitional care since the Centers for Medicare & Medicaid Services (CMS) Pilot Project initiated in August of 2008. IPRO was one of fourteen QIOs nationally chosen by CMS to build the framework and test best practices to improve communication, patient activation and engagement and seamless care coordination across the healthcare continuum for Medicare seniors.

Early on the IPRO Care Transitions team noted that an essential component of this effort was to ensure that important health care information was shared among, and understood by patients, caregivers and other health care professionals who were involved in the future care management of the patient in the community. Of special concern were the significant gaps identified in transfer of the most current, accurate advance directive information between healthcare settings at the time the patient transitioned across the care continuum as this timely information is vital to prevent actions that the patient would not desire.

Based upon these findings, IPRO focused efforts to improve communication and coordination of healthcare decisions for Medicare) beneficiaries and their caregivers about end-of life care management. This approach incorporated a thorough community based model to engage stakeholders and providers in promoting shared responsibility for improved advance care planning and to facilitate productive and collaborative changes in systems within the community.

It was at that time back in 2008, in search of experts to support this effort that IPRO formed a collaborative partnership with Patricia Bomba, MD, F.A.C.P, whose mission focused on making New York State a preeminent leader in advocating for facilitated discussions on planning for end-of-life care and for ensuring excellence in the provision of end-of-life/palliative care, for all segments of the community.

Since this collaboration began, Dr. Bomba has provided numerous educational conferences, training sessions, webinars and teleconferences to all levels of health care providers on MOLST, eMOLST and system-based approaches to implementing traditional directives for healthy adults and the MOLST Program for seriously ill adults. These educational programs focus on the importance of effective communication, documentation of medical orders on a common community MOLST form, and ensuring health care providers are trained to honor patient preferences.

Dr. Bomba’s expertise and passion for this work has been instrumental in supporting IPRO’s goal to implement community based partnerships across the healthcare continuum in New York State to educate and engage patients, caregivers, and healthcare clinicians about advance care planning options to lead to a better understanding of illness staging and progression so care planning can occur for symptom management, medical treatment and procedures, and problems leading to safer care management which honors patient preferences and wishes.