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

概述：目前，农村卫生办公室 (ORH) 企业范围内的协作计划为期五年（2017 财年至 2021 财年） 农村接入解决方案拨款正在通过集团整合黄金状态实践、预先护理计划 (ACP) 访问 (ACP-GV)，参观 VHA 的一些农村 VA 医疗中心和社区门诊诊所 （央行）。作为以小组形式向退伍军人提供 ACP 讨论的新兴最佳实践模式， ACP-GV 被誉为 ORH“有前途的实践”和“合作之路”计划， 增加 ACP 讨论范围（从农村设施到所有 VHA 设施及其设施）的巨大潜力 央行。为了确定最有效和最高效的交付机制，并且可以持续超过 在 ORH 资助下，严格评估当前计划至关重要。在 ACP-GV 中，退伍军人及其家人， 受过 ACP 专业知识的临床工作人员以小组形式开会，讨论 ACP 和 制定预先指示 (AD) 对退伍军人及其信任的其他人来说是有好处的。这些讨论 可能会降低退伍军人接受与他们希望的不同的护理的风险，或 接受不必要的干预，这可能会导致痛苦增加和医疗费用增加。作为 主要资助伙伴 ORH 已认可这项质量增强研究计划 (QUERI) 评估计划 (PEI)，旨在扩大当前 ORH 资助的评估计划，以回答关键问题 可持续性问题并衡量 ACP-GV 对成本和其他结果维度的影响。 目标：与农村卫生、护理办公室的主要合作伙伴密切合作开发 管理和社会工作服务，VISN 16 老年研究、教育和 临床中心 (GRECC) 和 ORH 项目负责人 Kimberly Garner 博士介绍了此次合作的目标 ACP-GV 评估的目的是： 1) 评估 ACP-GV 国家计划对 ACP 比例的影响 通过将 ACP-GV 站点与未实施的倾向评分匹配的对照站点进行比较，在 VHA 中进行讨论 ACP-GV； 2) 在 ACP-GV 站点中，记录并比较 ORH 资助和 DEI 未资助的站点 ACP 讨论站点使用的实施策略（单独的和组合的）的有效性 以及整个 VHA 的 AD 完成率； 3) 确定 ACP-GV 国家计划的预算影响；和 4) 确定高绩效网站（例如，高利率或可持续网站）和创新网站（例如， 独特的本地计划设计或 ACP 实施），以促进可持续性和进一步传播。 方法论：此评估将依靠定量和定性方法来评估一组的影响 ACP-GV 国家计划部署的五项实施战略，主要通过使用 实施研究综合框架 (CFIR) 与 RE-AIM 框架相结合。 这些策略是：(1) 为在农村提供 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) 在站点之间建立学习协作，(3) 与 (4) 确定并准备冠军，(5) 使用来自国家的数据进行审核和反馈 VHA 支持服务中心 (VSSC)。此次 QUERI 合作评估有三个主要数据源： (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，包括 关于 ORH 强制性数据元素和在各场所参与 ORH 过程中收集的国家数据的月度报告 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实施挑战、成功、意外的数据 ACP-GV 实施的结果和意外后果。作为观察性实施 评估，该 QUERI 合作评估的下一步将是检查 随着 ACP-GV 推广到全国所有 VHA 设施，ACP-GV 的实施和推广。

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.