POST Facilitation for Community Dwelling Older Adults (POST-RCT)

The POLST paradigm, which stands for Physician Orders for Life Sustaining Treatment, was developed to address inconsistencies between care received and patient and family wishes for treatment, with an aim to increase concordant care. The POLST paradigm is nationally recognized and implemented in a number of states under different names. In Indiana, for example, it is called "Physician Orders for Scope of Treatment" (POST). Because of this, all patient facing materials will refer to POST, however, we use the terms POST and POLST interchangeably in this proposal. POLST affects delivery of medical interventions and improved concordance between patient preferences and care received. Our specific aims are: 1. To test the effect of high quality POLST Facilitation delivered in the home compared to attention control on: a.discordance between preferences for treatment and treatments received in the subsequent 12 months (primary outcome). 2. To test the effect of POLST Facilitation on intermediate outcomes including: 1. The proportion of patients with a completed POLST form in the electronic medical record within 3 months of POLST Facilitation 2. Decision quality regarding ACP as measured by the Decisional Conflict Scale, the advance care planning (ACP) Engagement Survey,and the POLST knowledge survey 3. To test the effect of a POLST Facilitation on secondary outcomes of cost and end-of-life care including: 1. Receipt of life-sustaining interventions or hospice within the 30 days prior to death, for patients who die during the year after POLST Facilitation 2. The psychological well-being (anxiety, depression,and post traumatic stress) of surrogate decision makers after the patient's death 3. The cost effectiveness of POLST Facilitation for the prevention of ICU admissions and hospitalizations