It is no surprise that one of the ways CMS is looking to reduce costs is by decreasing the 30 day readmission rate. ACO's are critically looking at the 30 day readmission rate and requiring LTC/SAR to submit data reporting what strategies are in place to save costs in this area. One of the ways we can decrease hospital readmission's is through advanced care planning (ACP), Completion of a POLST form is an essential component of ACP. The purpose of this article is to address the who, when, and why of the POLST form and to understand that a quality POLST is better than 100 POLSTS that have not been thoroughly explained to the patient and family.
The NJ POLST legislation was signed by Governor Christie in December of 2011. According to the law, this form must be completed by an MD or an APN. The reason this form needs to be completed by an MD or an APN is because the completion of this form revolves around a clinical discussion. This discussion needs to address the disease trajectory, how the labs are influencing the disease trajectory, how the previous hospitalizations have impacted the disease process, as well as what the patients and families wishes are. Many facilities are having the Social Worker (SW) complete these forms which not only goes against the law but many SW's have expressed to me they are not comfortable answering some of the clinical questions that come up during the POLST discussion.
This article is not meant to be a how to complete the POLST but address concerns around POLST completion. In reviewing the POLST forms that are on the charts one major concern I have is regarding the goals of care, the first section of the POLST form. Goals of care is very individualized based on who the person is and what is important to them. Global statements like longevity, and quality of life are not appropriate here. Everyone wants quality of life and many 80 and 90 year old are not seeking longevity, they are hoping for a death with dignity. Goals of care should include statements like "wanting to be as mobile as possible for as long as possible, want to attend church services or receive communion whenever it is offered, and visits from pets or grandchildren may be very important to some residents."
Another common mistake is giving the family the POLST Form to take home and fill out. This may be appropriate after a conversation has taken place and the family wants to confer with other family members before making a final decision, but should not occur without a discussion.
Questions that need to be discussed when completing a POLST form are, Did the patient have an advanced directive and if so what is the families understanding of what it says, did they state their wishes in the past, what are the risks and benefits of resuscitation, feeding tubes, and hospitalization based on their disease trajectory. I think it is clear that this should be a clinical discussion initiated by the APN or MD. This discussion usually takes about an hour and many primary providers don't have the time or training to have this discussion. The palliative care APNS at Always Think Comfort are trained and comfortable having these discussions with families and can see patients and families for a goals of care discussion after a consult order is obtained from any of the providers.
As the ACO's push for completion of more POLST forms, facilities need to be aware that the POLST is not recommended for ALL patients. POLST should be completed for patients that are in the last 2 years of life . It is really about having QUALITY POLST forms completed and not just the QUANTITY of the POLST forms completed.
