End of Life Planning: Best Practices in POLST
During a recent NASHP webinar, experts and state administrators spoke about the benefits of POLST as well as promising practices and lessons learned from West Virginia and Louisiana.
A POLST is a portable medical order that communicates treatment goals and preferences for people with serious illness or advanced frailty. The use of POLST can help to ensure that patients’ treatment preferences are respected in critical clinical situations and to avoid unwanted treatments if patients cannot speak for themselves during a medical crisis. A 2020 JAMA study found that, while many patients still received care that did not reflect their POLST order, treatment-limiting POLSTs were associated with significantly lower rates of intensive care unit (ICU) admission compared with full-treatment POLSTs.
States adopt POLST as part of a range of efforts to strengthen person-centered care and advance care planning for people with serious illness. While advance directives are advisable for all adults to help direct their care should they become unable to do so, POLST is specifically for people with serious illness or frailty. POLST provides specific medical orders regarding health care and end of life decisions compared to the general wishes described in advance directives and more options than Do Not Resuscitate orders.
State Use of POLST
In its 2015 seminal report, Dying in America, the National Academy recommended that states develop and implement POLST in accordance with nationally standardized core requirements. National POLST is working toward the adoption within states of a National POLST form to support portability and consistency across states.
While most states use POLST forms, the forms may not be available to all people who could benefit, or may not be standard practice throughout hospitals, nursing homes, and hospices across the state.
What States Can Do to Promote POLST?
Support state POLST Programs. All states have adopted a statewide POLST form and most have a coalition or task force supporting education efforts to ensure appropriate use of POLST.
Consider Adopting or Adapting the National POLST Form. States have already adopted a single statewide form to create a standardized document, but they can also adopt the National POLST form for portability and consistency across states. Seven states–Arizona, Maine, New Hampshire, Iowa, Alabama, West Virginia, and Alaska–either use or have adapted the National POLST form. In West Virginia, for example, the state legislature enacted the “Health Care Decisions Act” in 2000 to ensure that a patient’s right to self-determination in health care decisions be communicated and protected. In 2002, the Act was amended to include the West Virginia Physician Orders for Scope of Treatment form, now referred to simply as “POST”, which is used statewide.
Develop a comprehensive POLST registry. Electronic registries enable emergency medical service personnel and medical providers statewide to access the treatment preferences of anyone who has completed a POLST form. The West Virginia Center for End-of-Life Care was established with support from the legislature and houses the state’s e-Directive registry. The registry provides access to POLST and other advance care planning information in a medical crisis – for example, while emergency medical personnel are in route. Health care providers have 24/7 online access through West Virginia Health Information Network—the state’s Health Information Exchange—which enables the secure electronic exchange of patient health information among providers. This information is password protected and HIPAA compliant. National POLST tracks the states with registries and provides information for those considering one.
Conduct outreach and education. States have emphasized the importance of education and outreach to garner legislative support for statewide adoption of POLST and implementation of a registry. The Louisiana Health Care Quality Forum, a private, nonprofit organization, administers the statewide Louisiana Physician Order for Scope of Treatment (LaPOST) Registry. The Forum educates physicians, health care professionals in nursing homes and assisted living, emergency medical service personnel, and the general public. Currently, the Forum is working to allow providers across settings in the state to electronically complete, store, and access patients’ end-of life wishes.
Learn from other states and get involved with National POLST. There is a wealth of state experience with medical order forms, which provides important lessons learned. For example, the Louisiana legislature enacted Act 954 in 2010 to provide for the Louisiana Physician Order for Scope of Treatment (POST) program and form. Unfortunately, the legislature embedded the POST document into the statute. It is advisable to omit embedding the actual form into the legislation to allow flexibility in updating the document as new research or improved practices emerge. Legislatures can include language requiring a form and describing baseline requirements for POLST to allow for updates.
To learn more from other states about advance care planning and palliative care, NASHP hosts a Palliative Care Resource Hub—funded by a grant from The John A. Hartford Foundation—that contains a series of state policy tools and resources.
How Federal Funds Can Support States In Modernizing The Behavioral Health Crisis Continuum Of Care
Background
The COVID-19 pandemic has both exacerbated behavioral health needs in states and uncovered systemic gaps to service delivery, including for crisis intervention services. In response, new federal funds through the American Rescue Plan Act (ARPA) are available to states to help expand and modernize the full continuum of crisis services so that individuals can be assessed, triaged, and diverted away from higher levels of care – including hospitalization, incarceration, and involuntary commitment. These resources include:
- Section 9813 of the ARPA, which provides an enhanced federal medical assistance percentage (FMAP) rate of 85% for a new state Medicaid plan option to deliver team-based, mobile crisis intervention services.
- ARPA planning grants through the Centers for Medicare and Medicaid Services (CMS) for state Medicaid agencies to consider how to develop mobile crisis intervention service-specific state plan amendments, section 1115 demonstration applications, or 1915(b) or (c) waiver requests. The recipient states of these planning grants now have additional capacity to do this work.
- Section 9817 of the ARPA provides states with a temporary 10 percent increase to the federal medical assistance percentage (FMAP) for qualifying home and community-based services (HCBS). States may choose to use this FMAP increase to enhance their crisis service systems, including implementing 988 hotlines, increasing mobile crisis response capacity, and standing up crisis stabilization units. Most states have also been awarded 988 state planning grants by the Substance Abuse and Mental Health Services Administration (SAMHSA) to assist with the planning and rollout of the national hotline in July 2022.
- Section 2713 of the ARPA, which allocates an additional $420 million in expansion grants for the certified community behavioral health clinic (CCBHC) model of care, which seeks to increase access to integrated, community-based substance use and mental health services and sustainably reimburse for these services.
In considering how to leverage these funds, the majority of which are time-limited, the challenge for states is in aligning these opportunities to build crisis capacity into existing systems and policy landscapes. Key considerations for state policy makers include:
- Maximizing and aligning Medicaid and other funding sources: Georgia is maximizing its Medicaid dollars by using Medicaid Administrative Funding, along with state funds, to cover the cost of its behavioral health crisis line, mobile crisis response, and peer-run respite services.
- Sustaining new crisis capacity: Given the time-limited nature of these funds, states will need to find sustainable funding sources to maintain newly developed infrastructure. States can look to the Model Bill for Core State Behavioral Health Crisis Services Systems when considering how to efficiently implement the federally mandated 988 crisis hotline system.
- Providing crisis services in rural areas: Delivering crisis services in rural areas can prove particularly challenging, as it is challenging to attract and retain providers, and transportation over long distances presents a significant access barrier. Co-responder models that utilize telehealth to connect the person in crisis with a mental health professional, like Missouri’s Virtual-Mobile Crisis Intervention program, can help states extend their behavioral health workforce to hard-to-reach clients.
- Addressing endemic workforce challenges: Leveraging non-licensed workforce, such as peers and community health workers, is one strategy to help to alleviate acute workforce shortages. Staffers working New Mexico’s statewide Peer-to-Peer Warmline offer callers both peer and clinician services and triage accordingly. Further, states can continue investing in telehealth infrastructure and payment policy to help alleviate pressures on existing clinical staff. Enhanced federal HCBS funds also offer an opportunity for states to provide reimbursement increases and other supports to recruit and retain workforce.
- Sharing data: Arizona’s Crisis Response Network (CRN), one of several organizations in the state that works with community-based providers to offer 24/7 mobile teams-based crisis services, supports a public-facing data dashboard. The dashboard shares call volume and mobile team dispatch, top geographic regions served, and how the call was resolved.
- Investing strategically: Alabama established three Crisis Centers at community mental health centers in 2021 and has funded a fourth and fifth center in FY 2022 and 2023, respectively. The state will transition all Crisis Centers to the CCBHC model to ensure the sustainability of these services over time.
Conclusion
As part of its State Policy Academy on Rural Mental Health Crisis Services, NASHP is currently working with five state teams to support their work to improve rural crisis response systems. Stay tuned for more NASHP resources as we continue to work with these states over the course of the next nine months.
State-based Marketplace (SBM) Directors Support Continued Tax Credit Enhancements
In this letter to Congressional leaders, directors of 17 state-based marketplaces express support for extending enhancements to health insurance premium tax credits (PTC) currently included in the proposed Build Back Better Act (BBBA). The enhancements, temporarily enacted through 2022, increased affordability for the millions of Americans who access coverage through the health insurance marketplaces and helped drive enrollment of an additional 2.8 million individuals in coverage this year. As currently proposed, the BBBA would extend PTC enhancements through 2025.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
