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

这个二级QUERI项目的影响目标，题为“获得和尊重的偏好”

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.