Do you have questions about the MOLST process and form? Are you overwhelmed by COVID-19 and want to ensure your patient’s end-of-life preferences are honored? Are you a PA or NP wondering how recent legislative changes affect you? If you answered “Yes” to any of these questions, please consider attending ECHO MOLST + eMOLST. The ECHO MOLST + eMOLST clinic series kicks off on March 4, 2021. Weekly videoconferencing clinics are held via Zoom on Thursdays from 12:00 – 1:00pm ET. Interested in joining? Email Meg.Greco@Excellus.com.

ECHO, which stands for Extension for Community Healthcare Outcomes, is an all-teach-all-learn telementoring model that uses case-based learning. Specialists and experts at a “hub” meet regularly with clinicians at “spokes” via videoconferencing to support in the delivery of specialty care services. The ECHO Model and virtual telementoring approach are particularly well-suited to a time when we need to be physically separated but the need for sharing knowledge and experience is higher than ever, particularly when it comes to end-of-life care. To learn more about the ECHO model and its history, watch this short video by Project ECHO’s founder, Dr. Arora and visit hsc.unm.edu/echo.

The aims of ECHO MOLST + eMOLST are to provide sustainable MOLST education and to improve the quality of thoughtful MOLST discussions and documentation to ensure patient preferences are honored. The goals of the clinic series have been updated to reflect the pandemic, as accurate documentation of these preferences is critical amidst the ever-changing situation with COVID-19.

Weekly hour-long clinics begin with brief introductions and a short 15-minute didactic presentation. This is followed by a 35 to 40-minute real patient case presentation given by a “spoke” using a Q&A and discussion format. Upon completion of the 9-week ECHO MOLST + eMOLST clinic series, attendees will:

• Use MOLST for appropriate patient populations
• Describe the difference between standard medical care, advance directives & MOLST
• Improve their comfort level with end-of-life conversations
• Describe the benefits of eMOLST vs. paper MOLST regarding quality & patient safety
• Possess a working knowledge of the eMOLST system – and much more!

Data collected using a pre-test, post-test method proves that ECHO MOLST + eMOLST works. Scores have consistently shown that through participation in a clinic series, attendees significantly increase their knowledge of the MOLST process, including identification of incompatible medical orders and understanding that MOLST is not an advance directive. Furthermore, attendees recognize the importance of their own advance care planning, with health care proxy completion rates among participants rising an average of 28 percent.

To date, ECHO MOLST has provided end-of-life education to 826 participants from 116 health care organizations across New York State. This rapid spread of knowledge is crucial to ensuring patient preferences for end-of-life are honored amidst a pandemic such as COVID-19.

Don’t miss out on this important educational opportunity. For more information on ECHO MOLST + eMOLST, including objectives and who should attend, visit molst.org/training/echo or contact Meg.Greco@Excellus.com to enroll in the next ECHO MOLST + eMOLST clinic series today.

AMA Designation Statement
Project ECHO® designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ANCC Designation Statement
Project ECHO® designates this live activity for a maximum of 1.0 ANCC contact hour. Nursing contact hours will be awarded for successful completion of program components based upon documented attendance and completion of evaluation.

Dr. Indra Daniels is a Palliative Medicine physician and Nephrologist at Mount Sinai South Nassau (MSSN). She is on the Faculty of the Internal Medicine Residency program at MSSN, and is a Clinical Assistant Professor at Icahn School of Medicine.

As a proponent of eMOLST and MOLST, Dr. Daniels has a significant role in quality improvement at MSSN. She capitalized on the launch of ECHO MOLST in 2018 as a key to education on structured goals of care conversations, and then advocated for and led enrollment in the eMOLST Registry. She welcomed nurse practitioners and physician assistants into the MOLST process, providing training as they prepare to assume authority and accountability for MOLST.

ECHO MOLST piqued Dr. Daniels’s interest in using ECHO MOLST as an innovation in resident education. She now helps craft each series, and supervises MSSN residents as they prepare case presentations that highlight clinical, ethical and legal aspects of end-of-life care. She codesigned a palliative care curriculum for Family and Internal Medicine residents; and Surgery, Obstetrics and Gynecology, and Podiatry residents attend select lectures.

Palliative Nephrology is a natural fusion of Dr. Daniels’s interests. She collaborated on developing content on dialysis for MOLST.org. Last year her chapter titled "End-Stage Renal Disease and Shared Decision-Making Dilemmas" was published in Palliative Care for Frontline Physicians: Case Vignettes in Everyday Hospital Medicine. Her recent grand rounds, "Shared Decision-Making Dilemmas in End-Stage Renal Disease", was timely, and she will discuss "The Role of Palliative Care in Organ Donation Decisions in the Critical Care Unit" at grand rounds in the spring. She supervises several residents in clinical research on outcomes of cardiorenal syndrome.

A global perspective and interest in culture have led her to volunteer and teach seminars in Haiti, Guyana, and Kyrgyzstan. She co-authored "Ethical Dilemmas in Palliative Care: Application of Jewish Medical Ethics to Inform Decision-Making" for Studies in Judaism, Humanities and the Social Sciences: Annual Review 2020. She served on the organizing committee and coordinated medicine research efforts for a health care disparities initiative that all MSSN residents undertook last fall.

Dr. Daniels is delighted to collaborate with the NYS MOLST Implementation Team in pursuing best practices for patient care and education of the next generation.

Indra Daniels, MD, Nephrology and Hospice & Palliative Care
Clinical Assistant Professor, Icahn School of Medicine at Mount Sinai

Since the inception of the ECHO MOLST series in fall 2018, we have found ECHO MOLST indispensable at Mount Sinai South Nassau (MSSN):
• MOLST and eMOLST promote practices to ensure patient safety and quality of care.
• ECHO MOLST meets end-of-life training requirements of the Accreditation Council on Graduate Medical Education, which oversees residency education.
• ECHO MOLST fosters intra and extramural community in palliative care.

MOLST usage at MSSN had been increasing before 2018, but ECHO MOLST ramped up staff education, providing a structured approach to difficult conversations. We simultaneously proposed that MSSN enroll in the NYS eMOLST registry, and launched access in 2019. Nurse practitioners Dina Kret, Maria Meek and Tiffany Thalappillil have worked tirelessly as members of our eMOLST team to ensure a successful implementation. Internal medicine resident Dr. James McGee and intensivist Dr. Michael Megally round out our team providing clinical insight including suggestions for electronic medical record upgrades to enhance patient safety. We now use MOLST and eMOLST throughout the hospital, having dispensed with a less comprehensive form that could not be utilized after discharge.

The ECHO MOLST series is also integrated into education for all our residency programs, and we are proud of our residents who presented several difficult cases in 2020:
• Isolation and Trust in the Covid-19 Pandemic
• Capacity/Guardianship in Covid-19 Patients with Mental Illness
• Perioperative Implementation of MOLST
• Utility of eMOLST in the Critical Care Unit
• Ethical Dilemmas in Surgical Intensive Care
• Jewish Medical Ethics in End-of-Life Care
• Prognostication and Hospice in Colorectal Cancer

Benefits to Residents include the opportunity to field questions from senior colleagues at a state level, and to become resources among their peers and beyond.

Finally, intra and extramural collaboration and sense of community are offshoots of ECHO MOLST sessions. Attending physicians from surgical and medical specialties, residency program directors, and our Chief of Medicine have enthusiastically served as panelists to support our MSSN residents during presentations, providing valuable perspectives for the audience. In the clinical arena, from our unit clerks who search the eMOLST registry, to our care coordination team who delve into the psychosocial concerns of each patient, to nursing staff who often initiate the goals of care conversations, to providers who complete the process, ECHO MOLST and the lessons we learn in each session serve to honor patients’ wishes and ensure safety in transitions of care.

The next ECHO MOLST + eMOLST clinic series kicks off on March 4, 2021. Weekly videoconferencing clinics are held via Zoom on Thursdays from 12:00 – 1:00pm ET. Interested in joining? Email Meg.Greco@Excellus.com.