2018 in Review

We started 2018 with an earnest effort to review and revise, our community website focused on advance care planning, pain management and palliative care that has been providing public education since 2002. As our MOLST content has continued to grow we also took this opportunity to create We also launched several new features to the websites including a shopping cart and a “subscribe to newsletter” function to improve customer service, automate some elements, and streamline key processes within our small team. To tackle this effort, we partnered with Bross Group and our internal engineering team for the revision and we successfully launched the websites in the first quarter.

We also spent time in the first several months of the year advocating for the passage of the combined health care proxy and MOLST registry bill. The bill did not pass; we’ll be focusing again on this in 2019 as the legislative session permits. A new sponsor for the bill will also be needed.

Simultaneously we prepared for a revision to the NYSDOH MOLST Form, as we expected NYSDOH would launch a new form in alignment with the May 28, 2018 update to public health law which expanded the scope of practice for nurse practitioners in withholding/withdrawing life-sustaining treatment, participating in the legal-ethical process, and signing MOLST orders in our state. (Learn more about that update and additional changes for NPs that will be coming in 2019 in our “featured resource” section of this newsletter.) As part of this update we took the opportunity to get extensive clinical feedback on the MOLST Form from physicians, nurse practitioners and other clinicians who participate in the MOLST process. As many of you know, an updated version of the MOLST Form has still not been released by NYSDOH, but we are hopeful that the department will incorporate both the legal revisions and necessary clinical feedback in the updated MOLST Form which we anticipate in 2019.

eMOLST required extensive changes, including a brand new clinical role specific to NPs, to comply with the updates to public health law. You can read about our additional updates and progressive growth with eMOLST, as well as the National POLST Technology Consensus Conference in the other article in this newsletter.

This summer we focused on the Fall 2018 launch of ECHO MOLST. ECHO MOLST follows the University of New Mexico’s Project ECHO model and is the first ECHO focused on advance care planning and completion of end-of-life medical orders on New York’s MOLST Form, in alignment with the National POLST paradigm. ECHO MOLST was comprised of eight “telementoring” sessions. Each session incorporated 15 minutes of didactic MOLST education and the remaining time was spent on case presentation, clarifying questions, and case-based learning using Project ECHO’s “all teach, all learn” approach. Health systems, primary care settings and nursing homes from across New York State participated in ECHO MOLST and presented their cases for peer learning. We were thrilled to have more than 150 different clinicians attend our first ECHO MOLST series. We expect to repeat this series in 2019. Please be on the lookout for additional details!

Many thanks to all of our partners in this work. Please enjoy the holiday season with your loved ones. We look forward to a productive 2019!

Featured Resource: NP Authority Under Current NYS Law Web Page & Tables

The web page and reference table have been revised to reflect changes regarding NP’s authority to perform capacity determination and sign MOLST forms, as of 5/28/18 and 2/3/19.

The first table at the bottom of the web page clarifies current NYSPHL and the NP’s authority to do capacity and concurrent capacity determination and is accurate as of 2/3/19. The second table clarifies current NYSPHL and the NP’s authority to participate in the MOLST process and sign MOLST orders. This table is accurate as of 5/30/18. The 2018 amendments to the health care proxy law do not impact this table.

Special thanks to Robert Swidler, Esq., St. Peters Health Partners for creating the reference tables.

FAQ: Why Are Some Materials in the Cart Out of Stock?

The MOLST form and Advance Care Planning (ACP) booklets remain out of stock while we wait for the NYSDOH to make revisions to the MOLST form. At this point we don’t have a timeline for when the revisions will be completed. The MOLST form is included in the ACP Booklet. The ACP booklet will be revised once we have a revised MOLST form.

In the meantime, you can print more MOLST forms off of our website directly onto pink paper, or use eMOLST. You can also directly print ACP booklets from the websites as well. Thank you for your patience!

eMOLST Champion: VNSNY

The Visiting Nurse Service of New York (VNSNY) Hospice & Palliative Care team is the only organization to deliver home-based hospice and palliative care services to patients in all 5 boroughs of NYC. VNSNY Hospice serves more than 1100 patients and their families every day.

Under the leadership of Rosemary Baughn, MSN, RN, Senior VP, Dr. Ritchell Dignam, CMO and Hospice Medical Director, and direction of Rivkah Brenenson, LCSW, QI Manager, they began planning for eMOLST implementation in early 2017. Rivkah and Dr. Frederick Lambert, Hospice Team Physician, led the creation of policies and procedures specific to MOLST and eMOLST, along with appropriate staff education materials. Simultaneously, the clinical team improved their understanding and expertise of goals of care conversations. IT supported the work by implementing SSO, reducing adoption barriers.

The value of eMOLST was clear to VNSNY as the tool aligns with numerous efforts focused on improving customer satisfaction, reducing unwanted hospitalizations, and improving the ability to honor patient preferences. eMOLST also helped the team front-load critical conversations about patient preferences, along with ensuring DNI/DNH orders could be honored in the patient’s home. eMOLST also guaranteed they’d have goals documentation available to all staff 24/7.

In Spring 2018 they launched their first phase of this initiative with a team in Queens, led by physicians Dr. Lambert and Dr. Maria del Mar Ortega-Rios. Feedback from staff, patients and families was positive, and emphasized the benefits of having early discussions; physicians reinforced the ease of using the eMOLST system. VNSNY quickly spread eMOLST through their hospice services in all boroughs, implementing fully by 9/2018. VNSNY uses a team-based approach with physicians, nursing and social work. Social workers Barbara Frank, Joseph Bleiberg, Melanie Littman, Yungae Yook and Ellen Lourie have been especially critical in ensuring success. Since implementation VNSNY has used the eMOLST system to document EOL conversations with approximately 400 patients.

Almost immediately VNSNY began seeing the benefits of the statewide registry as they had overlap with other health systems, particularly NYU Langone Health. VNSNY’s clinical team could pick up where NYU had left off in eMOLST and vice versa for shared patients. The experience of both organizations in seeing their patients’ preferences honored across care settings has been exciting and motivating.

2018 eMOLST Growth

In 2018 the demand for eMOLST implementation rose sharply and we now have more than 35,000 current forms in the eMOLST system. We receive daily inquiries from hospitals, nursing homes, hospices and PCP or specialty offices that would like to implement eMOLST. We’ve chosen to highlight health systems in this article that have made particularly strong progress in 2018, but we want to deeply thank all of our current eMOLST users for making this work successful and for providing great examples for additional hospitals, nursing homes, hospices, and practices to implement in 2019 and beyond.

Regionally, we have seen particularly remarkable eMOLST growth in the greater Binghamton area, which became the first city in the state where all hospitals in the area are using the eMOLST system. UHS has been fully implemented since 2017 and Lourdes began implementation in 2018 and will be fully implemented in 2019. Numerous nursing homes and PCP or specialty offices have followed suit including the Good Shepherd Communities and the United Methodist Homes. We look forward to working with additional partners in greater Binghamton in 2019 as well. We also expect all hospitals in the Oneida-Utica-Rome region will be implemented in 2019 which will make it the second community in the state where all hospitals in the area will be using the eMOLST system.

In NYC we saw the benefits of eMOLST forms crossing care transitions, especially with the continued growth at NYU Langone Health and Maimonides Medical Center, and the addition of VNSNY Hospice in particular. We are looking forward to additional growth in NYC and Long Island in 2019 with commitments from both Mount Sinai and South Nassau.

In the Hudson Valley ORMC continued its leadership with eMOLST and we’ve seen additional uptake from area nursing homes and practices. In Northern NYS we have had several health systems lay the groundwork in 2018 to move implementation forward in 2019. St. Lawrence Health System (Canton-Potsdam Hospital and Gouverneur Hospital), Claxton-Hepburn Medical Center, and Lewis County General Hospital have all made progress towards 2019 implementation.

Within the eMOLST system itself, we successfully updated the tool to comply with significant changes in public health law that ensure nurse practitioners can function at the top of their license in fully participating in the legal-ethical process for end-of-life decision making and signing MOLST orders; nuances in this process are explained here. NPs’ scope of practice will continue to grow with additional legal changes that were signed into law in November 2018 and are going into effect on February 3, 2019; eMOLST will be updated accordingly.

Finally, in November 2018, Katie Orem, our eMOLST Administrator, and Greg Smalter, our lead eMOLST developer from Bross Group, were thrilled to attend the first National POLST Technology Consensus Conference. This conference was a critical opportunity to participate in the planning process to develop standards around MOLST/POLST technology solutions, such as eMOLST, as well as data exchange, the role of health information exchanges, and the best ways to position POLST on the technology stage. This conference was invite-only and highlighted the key leadership role that we have played with the development and growth of New York’s eMOLST system. In 2019 we expect National POLST will release a whitepaper on the conclusions and opportunities drawn from these sessions.

We are already looking forward to the challenges and successes of 2019. Please reach out to us if your organization would like to implement eMOLST and we’d be happy to send you information on how to get started.