Evaluation of the National Implementation of the VA Diffusion of Excellence Initiative on Advanced Care Planning with Group Visits

概述：目前，为期五年(FY17-FY21)的农村卫生办公室(ORH)企业范围协作 农村接入解决方案赠款正在通过集团整合黄金地位实践、高级护理计划(ACP) 访问(ACP-GV)，访问VHA的一些农村退伍军人医疗中心和社区门诊 (CBOCs)。作为以小组形式向退伍军人提供非加太项目讨论的新兴最佳做法模式， ACP-GV已获得好评，被认为是ORH的“有前途的实践”和“伙伴关系之路”计划 增加机场核心计划讨论的巨大潜力，使其超越农村设施，进入所有VHA设施及其 CBOCs。为了确定最有效和最高效的交付机制，可以持续到 或者资助，严格评估当前的计划是必不可少的。在ACP-GV，退伍军人，他们的家人， 和训练有素的具有ACP专业知识的临床工作人员在小组环境中会面，讨论ACP和 退伍军人和他们信任的其他人的好处是有一个预先指令(AD)到位。这些讨论 可以潜在地降低退伍军人接受不同于他们希望的护理的风险 接受不必要的干预，可能导致更多的痛苦和更高的医疗费用。作为 ORH的主要资金合作伙伴已经认可了这一质量增强研究倡议(QUERI)合作伙伴 评估倡议(PEI)，旨在扩大目前由ORH资助的评估计划，以回答关键问题 可持续发展问题，并衡量非加太-GV对成本和其他成果各方面的影响。 目标：与农村卫生和保健办公室的主要合作伙伴密切合作制定 管理和社会工作服务，来自VISN 16老年研究、教育和 临床中心(GRECC)和ORH项目负责人金伯利·加纳博士表示，该合作伙伴的目标是 对ACP-GV的评估是：1)评估ACP-GV国家计划对ACP比例的影响 通过比较ACP-GV站点与未实施倾向得分匹配的对照站点，在VHA中进行讨论 ACP-GV；2)在ACP-GV站点中，记录和比较由ORH资助和DEI未资助的站点 各地点就机场核心计划讨论所采用的实施策略(个别和组合)的成效 和整个VHA的AD完成率；3)决定ACP-GV国家计划的预算影响；以及 4)确定高绩效(例如，高比率或持续者)和创新网站的特征(例如， 独特的当地方案设计或实施)，以促进可持续性和进一步传播。 方法：本次评估将依靠定量和定性的方法来评估一套 在ACP-GV国家计划部署的五个实施战略中，主要通过使用 实施研究综合框架(CFIR)与RE-AIM框架相结合。 这些战略是：(1)为在农村地区提供ACP-GV的新的或专门的工作人员职位提供新的资金 VHA设施和CBOC，(2)在站点之间创建学习协作，(3)与 (4)确定和准备冠军企业；(5)利用来自 VHA支持服务中心(VSSC)。此QUERI合作评估有三个主要数据来源： (1)VHA支持服务中心(VSSC)数据库，其中包含VHA国家ACP和AD数据，位于 患者、提供者、诊所和设施级别；(2)ACP-GV实施团队站点跟踪报告，包括 关于ORH强制性数据要素的月度报告和收集的关于这些站点参与 ACP-GV国家计划及其实施活动；(3)ACP-GV评估小组定性 访谈，将收集有关预算影响和执行挑战、成功、意外的数据 结果，以及实施非加太项目-GV产生的意外后果。作为观察性实施 评估，QUERI合作评估的下一步将是检查 实施和推广ACP-GV，将其推广到全国所有的VHA设施。

Overview: At present, a five-year (FY17-FY21) Office of Rural Health (ORH) Enterprise Wide Collaborative Rural Access Solution grant is integrating a Gold Status Practice, Advance Care Planning (ACP) via Group Visits (ACP-GV), into some of the VHA’s rural VA Medical Centers and Community-Based Outpatient Clinics (CBOCs). As an emerging best practice model for the delivery of ACP discussions to Veterans in a group format, ACP-GV has garnered acclaim as an ORH “Promising Practice” and a “Pathways to Partnership” program with great potential to increase access of ACP discussions beyond rural facilities to all VHA facilities and their CBOCs. In order to determine the most effective and efficient delivery mechanism that can be sustained beyond ORH-funding, it is essential to rigorously evaluate the current program. In ACP-GV, Veterans, their families, and trained clinical staff with expertise in ACP meet in a group setting to have discussions about ACP and the benefits to Veterans and their trusted others of having an Advance Directive (AD) in place. These discussions can potentially decrease the risk of Veterans receiving care that is different than what they would prefer or receiving unwanted interventions that could lead to increased suffering and higher health care costs. As the primary funding partner, ORH has endorsed this Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative (PEI), which seeks to expand the current ORH-funded evaluation plan to answer key sustainability questions and to measure the impact of ACP-GV on dimensions of cost and other outcomes. Objectives: Developed in close collaboration with key partners from the Office of Rural Health, Care Management and Social Work Services, the developers from the VISN 16 Geriatric Research, Education, and Clinical Center (GRECC) and ORH project lead, Dr. Kimberly Garner, the objectives of this partnered evaluation of ACP-GV are to: 1) evaluate the impact of the ACP-GV National Program on the proportion of ACP discussions in VHA by comparing ACP-GV sites to propensity score matched control sites not implementing ACP-GV; 2) among ACP-GV sites, document and compare ORH-funded and DEI-unfunded sites on the effectiveness of implementation strategies (individual and the combinations) used by sites on ACP discussion and AD completion rates across VHA; 3) determine the budget impact of the ACP-GV National Program; and 4) identify the characteristics of high-performing (e.g., high rates or sustainers) and innovative sites (e.g., unique local program design or implementation of ACP) to inform sustainability and further spread. Methodology: This evaluation will rely on quantitative and qualitative methods to evaluate the impact of a set of five implementation strategies deployed by the ACP-GV National Program, primarily through using the Consolidated Framework for Implementation Research (CFIR) in combination with the RE-AIM framework. The strategies are: (1) provide new funding for new or dedicated staff positions who deliver ACP-GV in rural VHA facilities and CBOCs, (2) create a learning collaborative among sites, (3) conduct ongoing training with sites, (4) identify and prepare champions, and (5) conduct audit and feedback using national data from the VHA Support Services Center (VSSC). There are three main data sources for this QUERI partnered evaluation: (1) the VHA Support Services Center (VSSC) data base, which contains VHA national ACP and AD data at the patient, provider, clinic, and facility level; (2) ACP-GV Implementation Team Site Tracking Reports, which are monthly reports on ORH mandatory data elements and national data collected on the sites’ participation in the ACP-GV National Program and its implementation activities; and (3) ACP-GV Evaluation Team qualitative interviews, which will collect data on budget impact and implementation challenges, successes, unexpected outcomes, and unintended consequences from ACP-GV implementation. As an observational implementation evaluation, the next steps for this QUERI partnered evaluation will be to examine the natural variation in implementation and spread of ACP-GV as it rolls out to all VHA facilities across the country.