Preferences Elicited and Respected for Seriously-Ill Veterans through Enhanced Decision-Making (PERSIVED)

这个2级QUERI计划的影响目标是，吸引和尊重 通过增强决策(PERSIVED)重病退伍军人，是为了防止不受欢迎的、繁重的 通过激发重病退伍军人对护理的偏好来进行生命维持治疗(LST)。这个目标 解决退伍军人管理局致力于零伤害和减少不必要的变异的现代化优先事项。 在生命末期进行积极的干预往往是繁重的，而不是有益的。一个坚强的人 研究基础表明，重病患者在患病时会选择不那么激进的干预措施 了解各种治疗方案，包括以舒适为中心的护理。这些知情人士 促进偏好敏感型护理的选择，是通过对患者的 护理的价值和目标、疾病轨迹以及所有护理选项的风险和收益。向病人致敬 治疗偏好，这些选择应记录在持久的、明确的指令中，这些指令 可在多个护理环境中使用。开展护理对话目标(GoCC)和记录治疗 偏好与较低的治疗相关发病率、提高患者的生活质量、较低的急性 护理/急诊科使用，降低医疗成本，以及更好的患者和家庭体验 关心。新冠肺炎疫情加剧了积极开展全球气候变化和应对气候变化的重要性 记录患有潜在严重疾病的患者对维持生命治疗的偏好。 这项提案关注两组重病退伍军人：那些在家庭小学注册的退伍军人 护理(HBPC)方案和退伍军人在社区养老院(CNH)接受护理。我们把重点放在这些 两个群体，因为两个群体都代表着基于社区的大型GEC计划，服务于 在未来1-2年内有很高的住院和死亡风险。尽管他们冒着承受负担的风险 在医疗保健方面，许多HBPC和CNH计划的护理偏好文档率较低。 该提案的目标和循证实践(EBP)是：目标1(EBP1)：装备临床医生 使用数据和工具来记录HBPC中退伍军人的LST首选项，并将他们的首选项转换为 可采取行动的订单，以促进与目标一致的护理；和目标2(EBP2)：为临床医生配备数据和工具，以 一致记录接受退伍军人付费护理的退伍军人的LST偏好，并将其 将偏好转化为可操作的顺序，跨越退伍军人管理局和非退伍军人管理局的设置，以促进目标一致的护理。EBP 1 将涉及12个LST模板完成率较低的HBPC项目，这些项目将随机进行审计 以及使用阶梯式楔形设计的反馈加促进。EBP 2将涉及翻译退伍军人的目标 和偏好转换为州授权便携订单(SAPO)。对于EBP 2，6个VA CNH计划将是 使用阶梯式楔形设计随机进行审计和反馈，并提供便利。这两个EBP的一个关键目标是 集成到现有工作流中，自动化可由团队在以下位置实施的可操作反馈 不同的场地和当地冠军的教练。 我们将使用中断时间序列/分段回归分析来评估EBP的实施 使用三个质量指标：提前护理计划、医院免费天数和目标一致性护理。关键质量 指标包括：1)HBPC退伍军人LST模板完成率和Sapos完成率 退伍军人在退伍军人健康保险计划下接受护理；2)每位患者无住院天数；3)和谐 在选择舒适护理目标的退伍军人中，记录的LST偏好和接受的护理之间存在差异。 除了我们对EBP的具体目标外，该QUERI计划的具体计划目标是： 目标3：保持富有成效的伙伴关系，以促进对业务伙伴请求的快速反应；和目标4： 通过正规教育和以实践为基础，培养新一代退伍军人实施科学家 与PERSIVED QUERI调查人员和运营合作伙伴一起学习。

The impact goal of this Level 2 QUERI Program, entitled Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED), is to prevent unwanted, burdensome life-sustaining treatments (LST) by eliciting preferences for care from seriously ill Veterans. This goal addresses the VA’s modernization priorities of committing to zero harm and reducing unwanted variation. Aggressive interventions at the end of life are often burdensome rather than beneficial. A strong research base shows that seriously ill individuals choose less aggressive interventions when they are knowledgeable about the full range of treatment options, including comfort-focused care. These informed choices, which promote preference-sensitive care, are facilitated by robust discussions about the patient’s values and goals for care, illness trajectory, and risks and benefits of all care options. To honor patients’ treatment preferences, these choices should be documented in durable, unambiguous directives that are accessible across care settings. Conducting goals of care conversations (GoCC) and documenting treatment preferences is associated with lower treatment-related morbidity, enhanced patient quality of life, lower acute care/emergency department use, decreased healthcare costs, and better patient and family experiences of care. The COVID-19 pandemic has heightened the importance of proactively conducting GoCC and documenting preferences for life-sustaining treatments for patients with underlying serious illness. This proposal focuses on two groups of seriously ill Veterans: those enrolled in Home Based Primary Care (HBPC) programs and Veterans receiving care in community nursing homes (CNHs). We focus on these two groups because both represent large, expanding community-based GEC programs serving Veterans who are at high risk of hospitalization and death in the next 1–2 years. Despite their risk of receiving burdensome care, many HBPC and CNH programs have low rates of documentation of care preferences. The aims and evidence-based practices (EBPs) for this proposal are: Aim 1 (EBP 1): Equip clinicians with data and tools to document LST preferences for Veterans in HBPC and convert their preferences into actionable orders to promote goal-concordant care; and Aim 2 (EBP 2): Equip clinicians with data and tools to consistently document LST preferences among Veterans receiving VA-paid care in CNHs and convert their preferences into actionable orders that cross VA and non-VA settings to promote goal-concordant care. EBP 1 will involve 12 HBPC programs with low rates of LST template completion, which will be randomized to audit and feedback plus facilitation using a stepped-wedge design. EBP 2 will involve translating Veterans’ goals and preferences into a state authorized portable order (SAPO). For EBP 2, six VA CNH programs will be randomized to audit and feedback plus facilitation using a stepped-wedge design. A key goal for both EBPs will be integration into existing workflow, automation of actionable feedback that can be implemented by teams at diverse sites and coaching of local champions. We will use interrupted time series/segmented regression analysis to evaluate EBP implementation using three quality metrics: Advance Care Plan, Hospital Free days, and Goal-Concordant Care. Key quality metrics include: 1) rates of completed LST templates among HBPC Veterans and rates of SAPOs among Veterans receiving care under the VA CNH program; 2) hospital free days per patient; and 3) concordance between documented LST preferences and care received among Veterans who choose a comfort goal of care. In addition to our specific aims for the EBPs, this QUERI program’s specific programmatic aims are to: Aim 3: Maintain productive partnerships to promote rapid response to operational partner requests; and Aim 4: Prepare the next generation of VA implementation scientists through formal education and practice-based learning with PERSIVED QUERI investigators and operational partners.