Volume 24, Number 2 Summer 2017 Serving Physicians, Medical Directors, Advanced Practice Nurses, Pharmacists, Physician Assistants, and Nursing and Nursing Home Administrators Practicing in Florida’s Post-Acute and Long-Term Care Continuum FMDA — Moving POLST Forward in Florida By Kenneth Brummel-Smith, MD, Professor Emeritus, Department of Geriatrics, Florida State University College of Medicine dvance care planning (ACP) is getting then on. The patient (or surrogate if appropriate) can increased attention throughout our nation. ask the provider to change the orders at any time. But A New concepts have evolved – that ACP is the key difference between them and an advance a process, not just the signing of forms, and directive is that other health care providers, such as that people at different stages of life need different EMTs and hospital personnel, can use them to guide aspects of ACP. For our patients, moving from a general their medical interventions. expression of wishes (such as a living will and appoint- Providers in Florida are familiar with the DNRO (the ment of a surrogate decision-maker) to a specific set yellow) form. This order directs EMTs, hospital or of medical orders (such as a DNRO or the POLST) is desired by nursing home personnel, and others not to attempt resuscitating patients and necessary for providing effective medical care. a patient if he or she experiences a cardiopulmonary arrest. It Advance directives are documents created by patients. is appropriately ordered when a patient expresses a desire to Individual documents, such as the Florida Living Will, can serve forgo CPR, or when it is clear that CPR would not provide as a general guideline as to how the patient wants to approach benefits to the patient. The Physician Orders for Life-Sustaining difficult medical decisions in the future. Similarly, the appointment Treatment (POLST) form goes beyond that to include orders of a health care surrogate can for a level of medical interven- stipulate who the patient wants tions and whether and how to speak for them medically, if FMDA is in the perfect position artificial nutrition will be used. the patient cannot speak for POLST was created to foster him or herself. Comprehensive to engage stakeholders and high-quality, patient-directed documents, like the 5-Wishes care across health care sites. form or the Empath Choices move the process forward. Patients in the long-term-care form, combine these two (LTC) system are among the decisions into one form. Ideally, highest risk for experiencing all adults should consider completing these documents. transitions in care, and care being provided by multiple Orders to direct care near the end of life are not advance different providers. LTC providers nationally are among the best directives. They should be used in patients near the end of life at providing advance care planning, since it is a fundamental or who have advanced frailty. It is in this stage of life when the part of our care. However, all too often we have seen how a patient may have clear wishes to avoid certain kinds of care, deep and repeated conversation about the care plan is lost or when the burdens of certain types of care may outweigh when our patients go to the hospital or another setting. Hence, the benefits. They, unlike advance directives, are not completed the need for an effective method to communicate the patient’s by patients. They must be completed and signed by a physician wishes for medical interventions across sites of care is (and some states an NP or PA). Once the order is signed by the particularly important to us. provider and the patient, they are used to direct care from Continued on page 19 w w w . f m d a . o r g ❖ w w w . b e s t c a r e p r a c t i c e s . o r g Page 2 FMDA - The Florida Society for Post-Acute and Long-Term Care Medicine From the President FMDA: On the Move Serving physicians, medical directors, advanced practice nurses, pharmacists, physician assistants, and nursing and nursing MDA has developed patients and home administrators in Florida’s post-acute, and will continue to families. While sub-acute, skilled care, home care, F develop powerful many readmissions hospice, and assisted living facilities. leaders and mentors are necessary, a lot www.fmda.org to improve quality of care and are avoidable. PRESIDENT drive better patient outcomes. FMDA leadership and staff have Leonard Hock Jr., DO, MACOI, CMD This energy is the force behind been on the move. Ian Cordes, our Boca Raton our society and we will use this executive director, and I attended (561) 714-1531 [email protected] momentum to engage industry thought- HSAG’s meeting in May in Tampa, titled The leaders as we move forward. Real World: Healthcare Coordination. I was VICE PRESIDENT Rhonda L. Randall, DO Our CME-Education Committee has the opening speaker and welcomed everyone Orlando been hard at work since December 2016 to the daylong event. HSAG is the Quality (407) 758-4573 • Fax: (407) 823-8989 diligently developing another exceptional Innovation Network-Quality Improvement [email protected] Best Care Practices in the Post-Acute and Organization (QIN-QIO) for Florida. CHAIRMAN OF THE BOARD Long-Term Care (PA/LTC) 2017 Continuum On May 30, Ian and I spent the day in John Symeonides, MD, FAAFP, CMD conference. They recently finalized the Tallahassee. Our first meeting was with Paul Palm Coast conference agenda and I urge you to review Ledford, Executive Director of Florida (386) 283-5654 the excellent offering of clinical and Hospice. We also met with Pam King, Agency [email protected] administrative topics (page 17) and for Health Care Administration (AHCA) Health SECRETARY/TREASURER schedule at a glance (pages 14-15). In Information Exchange Information Coor- Michael G. Foley, MD, CMD addition, you may start registering online dinator; followed by a meeting with AHCA Crestview at www.bestcarepractices.org or use the Sec. Justin Senior; AHCA Asst. Sec. Molly (850) 682-6143 • Fax: (850) 682-0227 [email protected] registration form on page 13 to attend our McKinstry; Kimberly Smoak, Chief of Field 26th Annual Conference, Oct. 12-15, 2017, Operations, Division of Health Quality IMMEDIATE PAST-PRESIDENT Robert G. Kaplan, MD, FACP, CMD at Disney’s Grand Floridian Resort. Assurance, AHCA; and Sec. Senior’s chief of Longwood There is a growing need to solve staff. Next, we met with Prof. Marshall Kapp (407) 862-7054 • Fax: (407) 862-0563 common challenges or break barriers with at FSU’s College of Medicine to discuss POLST. [email protected] strategic industry partners. Through We may have an opportunity to collaborate collaboration with other like-minded with a non-profit institute to see if we can DIRECTORS Marva Edwards-Marshall, DNP, organizations, FMDA’s Quality Advocacy secure Civil Money Penalty grant funds from ARBP-BC Coalition, ably co-chaired by Dr. Steven CMS. This is very exciting and offers some Palm Bay Selznick and Dr. Rick Foley, is planning its important implications for FMDA. If this Rick Foley, PharmD, CGP next major meeting — a Strategic Forum comes to fruition, we would be involved in Sorrento on End of Life Issues and Their Impact on setting up research protocols, gathering data, Elizabeth Hames, DO, CMD Preventing Hospital Readmissions. The and managing PA/LTC-specific research. We Fort Lauderdale purpose of this initiative is to achieve a are currently considering a particular project Gregory James, DO, MPH, CMD statewide reduction in unnecessary acute Tampa episodes and their associated burdens on Continued on page 17 Michelle Lewis, MSN, ARNP, FNP, GNP Cocoa Claudia Marcelo, DO, CMD FMDA Progress Report has a circulation of more than 1,100 Oakland Park physicians, advanced practice nurses, physician assistants, John Potomski Jr., DO, CMD consultant pharmacists, directors of nursing, administrators, and Melbourne other PA/LTC professionals. Progress Report is a trademark of Angel Tafur, MD, CMD FMDA. Progress Report Editor Elizabeth Hames, DO, CMD, The Villages welcomes letters, original articles, and photos. If you would like to contribute to this newsletter, please email your article to FMDA QUALITY ADVOCACY COALITION [email protected]. Steven Selznick, DO, CMD; Chair Rick Foley, PharmD, CGP; Co-Chair Any statements of fact or opinion expressed here are the sole Executive Director responsibility of the authors. Copyright © 2000-2017 FMDA. All Ian Cordes, MBA, NHA rights reserved. No portion of this newsletter may be reproduced 400 Executive Center Drive, Suite 208 without written permission from FMDA. West Palm Beach, FL 33401 (561) 689-6321 • Fax: (561) 689-6324 [email protected] FMDA Progress Report ✧ Summer 2017 FMDA - The Florida Society for Post-Acute and Long-Term Care Medicine Page 3 Editor’s Corner Update on Alternate Decision Making By Elizabeth Hames, DO, CMD; Assistant Professor, Department of Geriatrics, NSU-COM; Associate Program Director, Geriatric Medicine Fellowship, Broward Health; Editor, Progress Report MDA recently brought you information of decision making.2 on National Healthcare Decisions Day According to DeMartino et al., there is wide F (NHDD) and its 10-year anniversary. The variance among U.S. states in the procedures for goal of NHDD is to encourage advance appointing surrogates, the ranking of decision care planning through education and grassroots makers, and strategies for dispute resolution. This community efforts. The Conversation Project aims lack of uniformity impacts patients and practitioners. to empower individuals to make their preferences Some health care systems reach beyond state lines, for end-of-life care known, and to have those wishes health care providers may practice in more than respected. The Conversation Project manages NHDD.