POLST is increasingly recognized as an important tool for involving patients in determining preferred level of aggressiveness of medical care, and an essential element in ensuring that appropriate care is provided to patients as they transition among community medical venues. This report of the early dissemination of POLST in California demonstrates widespread use of this public health intervention: after only 18 months, POLST was used in eight of ten nursing homes in this statewide sample, and two-thirds of nursing homes reported receiving a patient with a completed POLST from another care venue, suggesting use of POLST throughout the medical community. The higher rates of POLST use in coalition areas compared to facilities in non-coalition regions and the “dose response” seen in aspects of nursing home structure, education, and use with increasing coalition-nursing home interaction, suggests that the novel community-based dissemination mechanism employed in California is responsible for the rapid uptake of POLST within the state.
The community coalition model focused on creating materials for education about POLST, and implementation of policies and procedures to facilitate use of the documents. Uptake of these efforts was broad, with 82 % of nursing facilities reporting that their staff had received education about POLST, and most nursing homes having a POLST champion and policy. While the majority of nursing homes had used the POLST and many had a completed document for most residents, the heterogeneity of POLST use across nursing homes—as seen in Figure —was large, with 13 % of nursing homes having fewer than 10 % of residents with a completed POLST. Thus, although uptake was broad and rapid, there remains considerable room for improvement, particularly in non-coalition area nursing facilities, early in the course of implementation of this health intervention.
Community-based interventions to improve end-of-life care are not new, although none has used the model studied here. A statewide campaign in Hawaii to improve end-of-life care, “Kokua Mau,” aimed to bring together health care provider organizations, insurance companies, faith communities, policy makers and the public to increase advance directive use. The effort reached many people, but had only a modest effect on increasing advance directive completion.15
Efforts aimed at changing an individual community, such as the Respecting Choices program in La Crosse, Wisconsin, have been successful at changing practices within a relatively circumscribed, homogeneous community.16
The statewide community coalition effort undertaken in California across a large, heterogeneous population appears to be a novel effort that demonstrates the ability to disseminate a health intervention by facilitating local education and advocacy efforts. This model may have implications for states that are initiating POLST efforts.
This study demonstrated broad uptake of POLST after only a brief time, but also pointed out areas in which nursing homes identified improvement needs. While there was little difficulty in translating POLST information into care, more than one third of facilities noted difficulty in engaging physicians, which should be a focus of intervention. Furthermore, nursing homes noted that they had difficulty retrieving POLST documents that were transmitted elsewhere, suggesting that early in dissemination hospitals and other healthcare facilities may be less engaged in the use of POLST; study of POLST dissemination in other areas is needed.
This study has several limitations. The design aimed to obtain a statewide view of POLST use in California, while at the same time evaluating the effect of the community coalition intervention model. This meant that rural counties with few nursing homes were not included in the sampling frame, and that the findings cannot be generalized to such facilities. In addition, the response rate was low; the uptake of POLST reported by respondents may overstate actual penetration. During the study period, other influences, such as interventions from payers, may have affected POLST dissemination and we are unable to account for these. Furthermore, the findings reflect nursing home reported structural changes, education and POLST use; social desirability bias may compromise these data. The study design aimed to minimize these biases by involving a statewide trade organization and an independent evaluation team in order to enhance response rate and survey veracity.
This statewide evaluation of the early dissemination of POLST in California nursing homes shows broad use, suggesting promise for the novel community-based dissemination model. The survey also shows considerable heterogeneity in preparation for and use of POLST across nursing facilities, as might be expected for a new health intervention. Evaluation of POLST uptake in other aspects of healthcare, such as hospitals, is needed as is serial evaluation to study the pattern of further dissemination in nursing facilities. Most importantly, evaluation of the implications of POLST use on the medical care of Californians is needed.