QUERI – Quality Enhancement Research Initiative

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Implementing Goals of Care Conversations with Veterans in VA Long-Term Care (LTC) Settings

Ann Arbor, MI

Principal Investigators: Anne Sales, PhD, RN (Corresponding PI, VA Ann Arbor), Mary Ersek, PhD (VA Philadelphia), Orna Intrator, PhD (VA Canandaigua)

Principal Operational Partners: VA Geriatrics and Extended Care, VACO GEC Operations, National Center for Ethics in Health Care, and the Office of Nursing Services.

Executive Summary:

This QUERI program focuses on improving the provision of Veteran-centered care in VA Community Living Centers (CLCs) and Home-Based Primary Care Programs (HBPCs), and is designed to support a process that incorporates Veterans' preferences for care, particularly services and interventions that are typically used in the event of a life-threatening emergency. This includes life-sustaining measures such as cardiac resuscitation, mechanical ventilation, and other forms of life support. However, Veteran preferences for care go beyond whether or not they receive life-sustaining treatments, and include whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive.

Program Objectives:

The primary Program objective is to support the implementation of Veteran-centered care conversations related to long-term care services within the VA healthcare system. This will be accomplished through the following specific aims.

  • Assess variation in practice measures related to implementation of Goals of Care (GoC) conversations in CLCs and HBPC programs over time nationally.
  • Design, implement, and test tools to improve performance, including:
    • Tools for feedback reports to provide information on progress in those key measures, and
    • Tools for learning collaboratives to support action-planning to address performance gaps.
  • Use measures derived from two widely-used implementation research frameworks (the Consolidated Framework for Implementation Research and the Theoretical Domains Framework) in order to assess barriers and facilitators to implementing GoC conversations.

Program investigators also will use audit with feedback interventions, coupled with action-planning through learning collaboratives, and will conduct rapid tests of different designs within these strategies to overcome barriers to implementing GoC conversations.

MyVA Goals: Improve Veteran engagement by involving family members in goals of care, and establish a culture of continuous performance improvement. The MyVA initiative will reorient VA around Veterans' needs and empower employees to assist them in delivering excellent customer service to improve their experience with VA healthcare.

Program Methods:

In all projects, investigators will use information to design feedback reports for staff to help them understand how well they are meeting expectations in terms of asking Veterans about their preferences, and making sure these are documented. They also will use what are called "learning collaboratives" - meetings in which staff come together and problem-solve issues they encounter regarding how to get Veterans' preferences expressed and documented, as well as how to make sure that those preferences are acted upon.

Project Summaries:

Project 1 (Quality Improvement):Investigate how quickly CLCs currently complete GoC conversations with Veterans, determine how to more efficiently have and document these conversations, and use audit and feedback and action planning through learning collaboratives to better implement GoC conversations and improve individual care for Veterans.

Project 2(Quality Improvement):Emphasize the role that family members and nursing assistants have in making care-related decisions with CLC residents who have dementia, using Partnership to Enhance Resident Outcomes.
Project 3(Quality Improvement):Determine current barriers to the implementation of GoC conversations in HBPCs, and create new processes and procedures to circumvent these obstacles and improve adherence to the Life-Sustaining Treatment Initiative and the quality of conversations regarding treatment plans.