Process of Setting up a POST Form Program

Presenter: Emily
Guest: Dr. Christopher Pile
Guest Bio: He is the Chair and Medical Director of the Virginia POST (Physicians Orders for Scope of Treatment) Collaborative Executive Committee, and works for the Good Samaritan Hospice in Roanoke, Virginia.

Segment Overview
We discuss the process of setting up a POST form program in the state of Virginia, the findings of the needs assessment, which was the first step, and the training of healthcare professionals to support the movement.


Health Professional Radio

Emily: You’re listening to Health Professional Radio. This is Emily, and I’m speaking with Dr. Christopher Pile. He is the chair and medical director of the Virginia POST Collaborative Executive Committee, and with the Good Samaritan Hospice in Roanoke. Dr. Pile, thanks for your time today.

Dr. Christopher Pile:  Thank you, Emily.

Emily:  I’ve got a question about the POST program in general.  We’re talking of course, about the Physician Orders for Scope of Treatment and that’s a new initiative in Virginia, but it is nationwide, as we’ve been having our discussions about what that means for patients at the end of their lives and how it drives the discussions between patients, families, healthcare providers, and the medical system in general in helping patients to have the best experience and the kind of treatments that they want for their end-of-life care.

I’m wondering about your development of the POST program here in the State of Virginia.  It began with a needs assessment, is that correct?

Dr. Pile:  Yes.  In the Roanoke Valley, there was an organization called the Palliative Care Partnership of the Roanoke Valley that had been created some years previously to bring in healthcare providers in the Roanoke Valley community and to focus on improving care at the end of life.  That was an organization that allowed us then to have a discussion whether the POST form would be something we would …. since it was only present in other parts of the country, whether we felt that the Roanoke Valley would be a good community to try this in.

We had a lot of universal acceptance at that end.  So the different healthcare providers, EMS, long-term care hospitals got together and developed policies and procedures and developed a pilot project back in … the process started way back in 2007.  We finally were able to go live in December 2009 with our pilot project.

Emily:  I see and what were the findings?  What was insufficient in the previous system that is now going to be possible with the POST initiative?

Dr. Pile:  I think there was a misalignment of patient’s expectations of care and the care they received.  It was all about improving that and understanding that when patients experience health [inaudible 0:02:34] at the end of life, they require interventions, no matter what their choices are.  It’s just a matter of what their goals are.  They’re still going to require specialized care to ensure that they don’t suffer needlessly.  The only system that really could respond to a patient in a crisis was the 911 system.

So with the training and developing the policies and the procedures, we’re able to … if patients didn’t want to be transported from their setting of care, we wanted to ensure that they were … [inaudible 0:02:34] comfort and dignity, that the care will be brought to them.  We’re able to create that, and then we’re able to designate their wishes on a form.  They were actually actionable medical orders, not just wishes on a living will.

Emily:  I see.  And what kind of training are the healthcare professionals undergoing in order to provide this kind of care?

Dr. Pile:  It all depends on at what point do you encounter the patients?  The most important training and the longest training we have is what we call Advance Care Planning Facilitator Training.  That’s a full day training with some online learning, and we’re seeing the support so you get credit for that for your profession.  That is training to have the discussion with patients at one setting over a period of time to help facilitate patients’ wishes.  So helping them to make the decisions and then ultimately, documenting those on a POST form.

So that’s the most in-depth training.  We did the most training in that realm and that was training physicians, physician extenders, nurses, social worker, clergy, people that were interested in having these discussions.  And then we also had to have training forhealthcare providers that aren’t necessarily going to have the discussion with the patient but need to know what to do when they see a form.  We call that end-user training.  The EMS has specialized training, nurses in the hospital, in the emergency room, so people know how to respond to a form that’s been completed.

We’ve also done specialized training for physicians and physician extenders that maybe have more or had extensive training in communication skills but just needed … again how they would take that skill set and utilize a POST form and that is a more focused training that can fit with this practitioner’s schedule.  So those are the kinds of three levels of training that we have been … and we trained hundreds of people in Advance Care Training—Facilitator Training throughout the state.

Emily:  What kind of outreach have you needed to do or do you do in order to educate the public about what is going on and how the healthcare system might be changing or how it might impact them?

Dr. Pile:  That’s, Emily, something we just started.  We’ve completed enough pilot projects that we felt we were able to … we really haven’t done any public outreach.  We really just wanted to focus first to help this system and developing the system so we could be ready for when patients start to request it.  It was just through summer that we were able to start to have articles in different publications and newspapers and newsletters that are geared to the public.  But we have not really done a significant amount of outreach to the public because we were still developing the healthcare system and we want to be prepared before we inform the public that this was available.

Emily:  I see and so you don’t really have any feedback that you’ve received as of yet in terms of the response to the public, but you do have feedback in terms of patients who have actually been through the process with you and their experience?

Dr. Pile:  Yeah.

Emily:  I see.

Dr. Pile:  We turn quality assurance reviews and again, looking at first the patient’s and family’s response and satisfaction with the process and then we we’re able to do retrospective review of alignment of care for patients receiving the care that they that they documented it in their POST form.  We had a very high, above 90% alignment of care which is much greater than what you see in most studies for advance care, the documents and the alignment is usually close to 60%.

Emily:  Wow, that’s great.  Is there a relationship between your work with the POST initiative and with the hospice?  Would you say that they are two individual entities that are based on a similar philosophy, or would say that one grows out of the other?

Dr. Pile:  Again, the POSTs are neutral forms.  So patients can request all potential interventions or limit the care they want to receive depending on their goals.  A hospice is certainly, especially in the United States, is focused from a Medicare benefits and the [inaudible 0:08:22] that limits the interventions the patients wish to receive.  So a POST form may lead to hospice intervention or it may not.

What I would say also is that the hospice allows a POST form to be successful from the standpoint of, if a patient does want to receive care at home or outside of the hospital, they still need expert nursing care, expert intervention with skilled providers, medical equipment, medicine.  Hospice is the vehicle for bringing the care to the patient as opposed to the patient having to go to the hospital to receive that care.  So again, if a patient’s goals are aligned with hospice, hospice is the vehicle to expertly provide that care.

Emily:  I see.  You mentioned that hospice, there’s a financial aspect to that.  Is there a financial implication to this program?  Is there a high cost of implementing the program, or are there concerns that there could perhaps be financial incentives for the program?

Dr. Pile:  That’s not one of the outcomes that we study.  What we’re trying to do is ensure the POST form allows alignment of careexpectations with care received.  Again, what we know from multiple studies is that the majority of the American public somewhere north of 80% to 90% envision and the life care at that time to be something that’s focused on comfort, dignity, and some type of control.  Control is received in a home setting, bringing the care to the patient.  Anytime a patient at any stage of the disease goes to the hospital, you lose control.

If I go to the hospital, the first thing they do is they take away your clothes and put you in a gown.  So you really lose the autonomy and control.  Again that’s usually [inaudible 0:10:36] want to make, if they expect an outcome where they’re going to improve and regain their autonomy later.  But if they’re not going to regain their autonomy, then you’re just losing more, so most patients don’t want to be in these settings.  So there’s a misalignment and it’s again a lose-lose-lose situation for everybody.  Patients are receiving care that they do not wish.

They’re receiving care that’s not effective, and they’re receiving high-cost care.  So no one wins out when that happens.  If we can improve that, you get what we call a triple aim goal of getting the care the patients want, we give care that’s effective, that’s going to help them achieve their goals of comfort and dignity.  It reduces cost and that’s okay because it’s not a cost-saving measure.  If we’re doing it, we’re doing it again for those first few aims which is patient satisfaction and comfort and dignity.

Emily:  Are there individuals whose specific role it is to be a liaison, say, between the healthcare providers and the patients?  As a non-physician, I frequently approach my healthcare as something that I would really prefer not to do as far as the hospital is a scary place.  It’s populated with people who are exhausted and too busy and perhaps don’t have the time or the motivation so see to it that I or my loved ones are cared for appropriately.

So I could see how from an outsider’s standpoint, walking into the hospital or even see my primary care physician which now is much less like having a personal doctor and more like having whoever can fit you in and walking into that person and having them say, “Let’s talk about what is and isn’t realistic.”  And having a concern that perhaps they were being lazy, for lack of a better word, or out to promote a certain course of action for some goal other than my best interest.  Is there a need for someone who can mediate those kinds of fears?

Dr. Pile:  Yeah.  The Advance Care Planning Facilitator course really uses that model.  Again it’s modeled after respecting choices [indecipherable 13:08] program and again it focuses on listening skills mostly so we can engage patients and help facilitate.  Not make decisions for them but facilitate, because they need information to make decisions.  It will still be personal choices but again, how do you as a facilitator encourage the information that they want to receive and when they receive it.  It can be a lengthy process as you said.

You really can’t be rushed and that’s why the POST form is so important because this conversation takes time.  Patients have to be engaged.  If you wait until the actual event, they might have lost capacity and they may be suffering too much to really … and then panicking during this time.  So if you wait until the event, you won’t have a good discussion but you can have it advance.  But then how do you take that possibly hours of discussion to make sure now that it impacts patient care.  That’s where the form comes in and takes that conversation at the time that it’s needed.

It gives direction to the providers who may not have been involved in that discussion.

Emily:  I see.  Yes.  You’re listening to Health Professional Radio.  This is Emily and I’m speaking with Dr. Christopher Pile from the Roanoke Good Samaritan Hospice in Roanoke, Virginia.  Dr. Pile, thanks so much for your time today.

Dr. Pile:  Thank you, Emily.

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