Massachusetts: Current Developments Care at the End of Life Institute of Medicine May 29, 2013 Peg Metzger, JD pegmetzger@verizon.net
Unique MA Medical-Legal Culture-1 State with the highest: 1 Rate of health insurance coverage Per capita spending on health care Cost being addressed as the current challenge Abundance of academic medical centers; more physicians and more specialists per capita than any other state 2 1 Blue Cross Blue Shield of Massachusetts Foundation. Health Reform in Massachusetts Expanding Access to Health Insurance Coverage: Assessing the Results. March 2013. Accessed on May 18, 2013. 2 Blue Cross Blue Shield of Massachusetts Foundation. Health Care Costs and Spending in Massachusetts: A Review of the Evidence. March 2013. Accessed on May 18, 2013. 2
Unique MA Medical-Legal Culture-2 9 th in percentage of population that is foreign-born, coming from all over the world 3 Health care systems being redesigned using the patient-centered medical home model 4 State law authorizes completion of a health care proxy to appoint a health care agent (MGL c. 201D) No state law authorizing living wills 3 Department of Public Health. Health of Massachusetts (chapter 1). Accessed on May 18, 2013 4 MA Executive Office of Health and Human Services. Massachusetts Patient-Centered Medical Home Initiative. Accessed on May 20, 2013. 3
Unique MA Medical-Legal Culture-3 No state law establishing a hierarchy of default surrogates Emergency responders familiar with out-of hospital DNR protocols Comfort Care/DNR Verification Protocol created by DPH Office of Emergency Medical Services (OEMS) in 1999 MOLST protocol for OEMS adopted for 2012 statewide MOST expansion 4
MA End-of Life-Care Transformations Builds on important work done over a decade ago and benefits from current momentum of health care reform 2006: An Act Providing Access to Affordable, Quality, Accountable Health Care (Chapter 58 of the Acts of 2006) created a Pediatric Palliative Care Network and a Health Care Quality and Cost Council which created an End-of-Life and Chronic Care Committee 2008: An Act to Promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care (Chapter 305 of the Acts of 2008) with 3 end-of-life sections 5
End-of-life Care provisions Chapter 305 of the Acts of 2008 Section 41: Creation of Expert Panel on EoL Care to recommend public policy/best practices for delivery of EOL care to patients with serious chronic illness Section 42: Initiation of a public awareness campaign to highlight importance of EoL care planning Section 43: Initiation of a pilot program for communicating medical orders for life-sustaining treatment across health care settings in at least one region of MA 6
2010-2011 Resulting Activity MOLST demonstration project completed and report with expansion recommendation delivered Recommendations of Expert Panel on End-of-Life Care released: Release delayed but report was well-received Recommendations included: A public awareness campaign MOLST expansion across MA 7
MA Expert Panel Recommendations Inform and empower residents of MA Support a healthcare system that ensures highquality, patient-centered care Ensure a knowledgeable, competent, and compassionate workforce Create financing structures that promote patientcentered care Create a responsible entity to ensure excellence and accountability Employ quality indicators and performance measurement 8
Progress on Expert Panel Recommendations 1 Inform and empower residents The Conversation Project and MOLST expansion High-quality, patient-centered care End-of-life and palliative care provisions included in Chapter 224 of the Acts of 2012: An Act Improving the Quality of Health Care and Reducing Costs Through Increased Transparency, Efficiency and Innovation Knowledgeable, competent, and compassionate workforce Effective 1/1/12: Board of Registration in Medicine licensing requirement of 2 CME credits in EoL care 5 5 Massachusetts Medical Society. Continuing Medical Education Requirements for Physician License Renewal In Massachusetts. Accessed May 20, 2013. 9
Progress on Expert Panel Recommendations 2 Financing structures that promote patientcentered care ACOs emerging from payment reform Responsible entity to assure excellence and accountability Remains a challenge Quality indicators and performance measurement DPH developing regulations requiring hospitals, SNFs, and clinics to provide information about palliative care and end-of-life options to appropriate patients as directed by Chapter 224 of the Acts of 2012 10
2012 2014 MOLST Expansion Across MA 11
MOLST Program Phases Demo 2010 MOLST Demonstration Project in Worcester area MOLST Implementation Tool Kit available at www.molstma.org Pre- Expansion 2011 Plan for statewide expansion and train emergency responders across the state 2008 2009 Acts of 2008 mandate for POLST pilot project; planning begins Pilot implementation training with acute care institutions Expansion 2012-2014 Goal: 2014 Statewide MOLST use Self-paced MOLST implementation at institutions throughout MA 12
MOLST Leadership Oversight from the MA Executive Office of Health and Human Services, Department of Public Health (DPH) and Executive of Office of Elder Affairs Program management provided by the Center for Health Policy and Research at Commonwealth Medicine, a division of UMass Medical School Endorsers of MOLST and MOLST expansion include: The Board of Registration in Medicine The Boards of Registration for nurses, NPs and PAs The Massachusetts Medical Society The Massachusetts Expert Panel on End of Life Care 13
MOLST Background Community Engagement: extensive input from lay community and health care community was solicited and incorporated; form and program are tailored to MA environment MOLST adopted and expanding as a standard of practice with respect to documenting and communicating patient preferences regarding life-sustaining treatment options at EoL DPH communication through circular bulletins and email to: Announce and endorse the MOLST demonstration project and the April 1, 2012 start of statewide expansion Encourage all DPH regulated entities to consider MOLST as part of the process for counseling individuals about end of life choices (November 2012) 14
MOLST Report Card 15
Legal Issues that Impede Uptake Whether/to what extent does MA law permits a guardian to sign a MOLST form? Is DNR an extraordinary medical decision requiring a substituted judgment determination? Default surrogates cannot sign MOLST forms 16
MA End-of Life-Care Transformation Summary Has required innovation by ALL players in health care delivery system: Patients Providers Institutions Payers Legislators/Regulators 17
Questions? 18
Web Links for References Blue Cross Blue Shield of Massachusetts Foundation. Health Reform in Massachusetts Expanding Access to Health Insurance Coverage: Assessing the Results. March 2013. http://bluecrossmafoundation.org/sites/default/files/download/publication/m onitoring%20ma%20reform%20march%202013_0.pdf. Blue Cross Blue Shield of Massachusetts Foundation. Health Care Costs and Spending in Massachusetts: A Review of the Evidence. March 2013. http://bluecrossmafoundation.org/sites/default/files/download/publication/co st%20deck%20march%202013.pdf. Department of Public Health. Health of Massachusetts (chapter 1). http://www.mass.gov/eohhs/docs/dph/communications/hom-chapter-1.pdf. MA Executive Office of Health and Human Services. Massachusetts Patient- Centered Home Initiative. http://www.mass.gov/eohhs/gov/commissions-andinitiatives/healthcare-reform/pcmhi/. Massachusetts Medical Society. Continuing Medical Education Requirements for Physician License Renewal in Massachusetts. http://www.massmed.org/continuing-education-and-events/continuing- Medical-Education-Requirements-for-Physician-License-Renewal-in- Massachusetts/#.UZpuNLnD-70 19
MOLST Expands on Existing OOH Comfort Care/DNR Verification Protocol CC / DNR Documents that a medical order exists Always instructs DNR - not to use CPR Orders about CPR only Honored in outpatient settings by EMTs M O L S T Is a medical order form May instruct to use OR not use treatments Orders about several types of life-sustaining treatments Honored across settings by all health professionals The CC/DNR form remains valid in Massachusetts! 20
MOLST Sequential roll-out to health care organizations and then to individual clinicians and the public Emergency Acute Care Services Post Acute Care Services Home Care Services Outpatient Services Services 21