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

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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.