Where: Ritu Suri MD & Associates, a four-clinician primary care practice in Englewood, N.J.
The issue: Documenting end-of-life care preferences for patients at high COVID-19 risk.
When the SARS-CoV-2 pandemic first hit the United States in March 2020, the overall risk for death was quickly shown to be higher across the board for older patients with chronic diseases. Ritu Suri, MD, and her colleagues found this to be true in their own practice and also noticed that many patients who were at increased risk for poor COVID-19 outcomes had not documented their end-of-life care preferences.
“We were doing a lot of stuff remotely at that time, and even if we did have the discussions and then the family did not send the document in, we didn't end up having anything in our chart,” said Dr. Suri. Clinicians in her practice, as well as covering physicians, were being forced to start these vital and time-consuming conversations at square one in situations of high stress and uncertainty, she said. “We needed a way to do this better.”
How it works
With support from the ACP Advance: COVID-19 Recovery Program, Dr. Suri's practice began to work toward improving POLST (Physician Orders for Life-Sustaining Treatment) documentation in this patient population. The goal of the ACP Advance: COVID-19 Recovery Program, which is funded by a grant from Pfizer, is to use team-based quality improvement to improve systems of care for patients with or at risk for COVID-19.
The first step, Dr. Suri said, was to take stock of all of the practice's POLST-eligible patients. After compiling a list of this group, staff members checked to see how many had a completed POLST form on file. Only 34.5% of 261 eligible patients did, Dr. Suri said.
“In any other average primary care practice, everybody's coming to your office, but in our case, we had patients that we made visits at home, we had patients that we were seeing in assisted living, and we were seeing them in facilities,” she said. “So even though we were documenting in our own chart … the limiting factor was that even if it was done in the facility, or was done at the patient's home, we did not have a copy.”
The practice developed a coordinated workflow to help improve completion and documentation of POLSTs. First, they launched a training program for clinicians to review POLST principles and complete online modules on documentation of end-of-life care. The project coordinators (a registered nurse and a premed student) also implemented a new systematic approach to detail how clinicians would obtain documentation and make sure it was updated and reported in the electronic medical record.
In addition, every Tuesday, the project coordinators checked in with the clinicians (two physicians and two nurse practitioners [NPs]) to answer questions and adjust the workflow, if needed. They tracked POLST numbers on the office whiteboard. The main goal of the project was to achieve 90% POLST completion rates in three months, but another goal, Dr. Suri noted, was to improve the quality of the conversations clinicians were having with patients, specifically regarding COVID-19. “This was completely new,” she said. “We needed to make the families and the patients aware of what might happen, what kinds of decisions you might be faced with.”
From November 2020 to February 2021, the practice achieved a 58.1% increase in POLST documentation, with rates improving from 34.5% to 92.6% of eligible patients. Practice staff kept the new workflow in place after the intervention period ended and found that POLST rates continued to rise. Other benefits of the project, Dr. Suri said, included comfort for patients and families once end-of-life preferences were documented, as well as better trust among patients, families, and clinicians.
“Most of the home visits are done by one of our NPs, and then the families were calling me because I would still go over the POLST [with them] before I signed it and made it a formal record, and they would tell me, ‘We're so thankful that she brought this up. It really helps us think through things,’” she said. “It was really an eye opener for everyone, and a moment of reflection during the pandemic.”
Getting the completion rate up during the first wave of the pandemic also helped improve care during the second wave, Dr. Suri added. “Since we had already done this, we were able to have a very smooth transition. We knew whether we were going to recommend monoclonal antibodies, whether we wanted to treat them at home, whether they were going to go on hospice, so we had already a plan in place.”
Dr. Suri and her colleagues are soliciting feedback about what worked and what didn't over the course of the project, she said. Clinicians will also be encouraged to check in with patients and families about document “bottlenecks” and check in with facilities to ensure documentation has been signed. “If we don't have a POLST form on a patient or somebody is a new patient, we send them the form … and then we check to see if they received it and go over it with them,” she said. The practice has added other checks along the way to ensure that the form is completed, signed by all parties, and filed as part of the patient's medical record.
“In [the patient's] mind, they've already had the discussion, so everything should be OK,” Dr. Suri said. “But until we have a document, we cannot follow anything, so we need that documentation in the chart.”
Words of wisdom
Everyone in a practice, from the physicians to the staff member who scans the documents, should be involved in this effort, Dr. Suri said. She noted that some of the best ideas in the practice's new workflow came from brainstorming sessions with the staff. For example, one staff member recommended sending patients and families preaddressed, prestamped envelopes so that it would be easier for them to return a POLST form filled out during a home visit.
In addition, Dr. Suri recommended embracing the concept of team-based learning, which she said may not come easily to all physicians. “It is important to really focus, because going into the value-based world, team-based care is where we are going to be,” she said.