“Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities,” by Hillary Lum, MD, PhD, Oluyomi Obafemi MD, Joanna Dukes MS, Molly Nowels MA, Kristina Samon BSN, and Rebecca S. Boxer MD, MS, was published to JAMDA (Journal of the American Medical Directors Association – The Society for Post-Acute and Long-Term Care Medicine).
Background: Heart failure (HF) patients have a high risk of both rehospitalization and mortality; most HF patients are readmitted within 1 year after admission for acute decompensated HF and one-third die within that year. In addition, about 20% are discharged to skilled nursing facilities (SNFs). Of those discharged to SNFs, most die within 1 year. This study aimed to elicit, describe and document the care preferences of HF patients admitted to SNFs, using POLST (in this study called MOST, or Medical Orders for Scope of Treatment, since the research was conducted in Colorado), and evaluate goal-concordant care based on MOST documentation, emergency department (ED) visits, and hospitalization. Many studies have evaluated the use of POLST for residents in long-term-care nursing home settings, but none have examined the use of POLST for HF patients receiving postacute care in the SNF setting.
Methods: The study is based on retrospective analysis of MOST Forms for patients who participated in an HF-disease management clinical trial called SNF-Connect, for patients enrolled in the trial between July 2014 and May 2016. MOST Forms were first evaluated as valid or invalid based on the specific requirements for a legally valid Colorado MOST Form. Forms are considered valid if treatment preferences are selected in Section A, B or C; congruent treatment preferences are chosen (specifically that “CPR” selected in Section A requires that “Full Treatment” is selected in Section B), and the form is signed by the patient or surrogate decision maker.
Three types of discordant care in this study were defined:
- Patient received CPR after indicating a preference for “No CPR.”
- Patient was hospitalized despite indicating a preference for “Comfort-focused treatment.”
NOTE: Comfort-focused treatment, similar to “Comfort-only” treatment on other POLST Forms, generally indicates the patient’s preference to not be transported to an emergency department, intensive care, or hospital except if required to keep the patient comfortable.
- Patient was admitted to an intensive care unit despite a documented preference for “Selective interventions.”
NOTE: Generally, selective interventions, sometimes called “Limited treatment” on other POLST Forms, is a section intermediate to “Full treatment” and “Comfort only”; the goal of this option is to provide basic medical treatments. Patients want to go to the hospital but do not want to be put in the intensive care unit (ICU) or on a breathing machine. They are okay with antibiotics and IV fluids (unless they have otherwise indicated on the form).
Results: A total of 278 (75%) of the patients in the study had a MOST Form available in their SNF medical record. Of these 279, 182 (65%) were valid; the most common reasons for an invalid MOST Form were missing dates and/or signatures from either patient (52%) and/or provider (34%). Twenty forms were invalid due to incongruent care preference selections (3 selected CPR with Comfort-focused treatment and 17 selected CPR with “Selective treatment”). There were no differences in validity of forms based on the version of the MOST Form used. Older age was associated with a higher frequency of selecting “No CPR” and women overall chose “No CPR” 2.33 times more often than men (P < 0.05).
Goal concordant care was high. Patients with both a MOST Form and an ED visit or hospitalization within 60 days of SNF admission were evaluated for goal concordance; of 182 with a valid MOST Form, 66 (36%) had an ED visit or hospitalization. Of these 66, 63 (95%) received goal-concordant care. The other 3 (5%) received goal-discordant care, and in each of these 3 cases, they were admitted for more than symptom management despite having selected “Comfort-focused treatment” on the MOST Form. Patients without a ED visit or hospitalization within 60-days of SNF admission were not evaluated for goal concordance in this study.
Discussion. The fact that most (75%) MOST Forms were valid (had compatible treatment preference selections and were properly signed and dated) suggested to the study authors that providers held conversations with the patients about their treatment preferences for a majority of these patients. The high rate of ED visits and hospitalizations underscores the importance of the MOST discussions and use of the MOST Form for documenting patient preferences for care treatment, for this high-risk population, that is, HF patients. 95% of patients with valid MOST Forms who were admitted to an ED or hospital within 60 days after SNF discharge received goal concordant care.
Conclusion: 75% percent of patients with heart failure admitted to skilled nursing facilities had care preferences documented using the MOST form, and 95% received goal-concordant care based on care preferences documented during the SNF admission.
Broader context: Similar to recent POLST research in California, West Virginia and Oregon, this study in Colorado found that POLST (there called MOST, or Medical Orders for Scope of Treatment) is used appropriately and effectively, in this case within a study population of heart failure patients admitted to Colorado skilled nursing facilities.
Lum H, O Obafemi, J Dukes, M Nowels, K Samon, and RS Boxer (2017). “Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities,” JAMDA (Journal of the American Medical Directors Association – The Society for Post-Acute and Long-Term Care Medicine) 18:885-890. View article (limited access).
Parts of a POLST Form. Description of the elements of a POLST Form, written for the average consumer. http://polst.org/elements-polst-form/
Elements of a POLST. Description of the elements of a POLST Form, written for the health care professional. http://polst.org/about/polst-form-elements/?pro=1