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（FY 17-FY 21）的农村卫生（ORH）企业范围合作办公室 农村接入解决方案补助金通过集团整合了黄金状态实践，高级护理规划（ACP） 访问（ACP-GV），进入VHA的一些农村VA医疗中心和社区门诊诊所 （CBOCs）。作为一个新兴的最佳实践模式，以小组形式向退伍军人提供ACP讨论， ACP-GV已获得赞誉为ORH“有前途的做法”和“途径合作伙伴关系”计划， 很大的潜力，以增加获得ACP讨论超越农村设施，所有VHA设施和他们的 CBOC。为了确定能够持续到2010年以后的最有效和最高效的交付机制， ORH的资金，它是必不可少的严格评估目前的计划。在ACP-GV，退伍军人，他们的家人， 和经过培训的具有ACP专业知识的临床工作人员以小组形式会面，讨论ACP和 对退伍军人和他们信任的其他人有一个预先指令（AD）的好处。这些讨论 可以潜在地降低退伍军人接受不同于他们所希望的护理的风险， 接受不必要的干预，可能导致痛苦增加和医疗保健费用增加。为 主要的资助伙伴，ORH已经批准了这个质量提高研究计划（QUERI） 评估倡议（PEI），旨在扩大目前的ORH资助的评估计划，以回答关键问题， 这是一个可持续性问题，并衡量非加太-全球价值观对成本和其他成果的影响。 目标：与农村卫生、保健和医疗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，开发人员从VISN 16老年研究，教育， 临床中心（GRECC）和ORH项目负责人Kimberly Garner博士表示， 评估ACP-GV的目的是：1）评估ACP-GV国家方案对ACP比例的影响 通过比较ACP-GV研究中心与未实施ACP-GV的倾向评分匹配对照研究中心，在VHA中进行讨论 ACP-GV; 2）在ACP-GV研究中心中，记录并比较 各地点在ACP讨论中使用的实施策略（单独和组合）的有效性 和整个VHA的AD完成率; 3）确定ACP-GV国家方案的预算影响;以及 4)识别高性能的特征（例如，高费率或维持者）和创新站点（例如， 独特的地方方案设计或ACP的实施），以告知可持续性和进一步传播。 方法：本评价将依靠定量和定性方法来评价一套方案的影响。 * 非加太-全球志愿人员国家方案部署的五项执行战略，主要通过利用 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）在各研究中心之间建立学习协作，（3）与 （4）确定和准备冠军，（5）使用来自国家的数据进行审计和反馈， VHA支持服务中心（VSSC）。本次QUERI合作评价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， 患者、提供者、诊所和设施级别;（2）ACP-GV实施团队现场跟踪报告， 每月报告ORH强制性数据元素和收集的关于研究中心参与 非加太国家方案及其执行活动;和（3）非加太国家方案评价小组的质量 访谈，将收集有关预算影响和执行挑战、成功、意外 执行非加太-全球价值观方案产生的预期成果和意外后果。作为一个观察性的实现， 评估，该QUERI合作评估的下一步将是检查 ACP-GV的实施和推广，因为它推广到全国各地的所有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.