Outpatient Palliative Care Implementation to Improve Outcomes for AgingVeterans

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Nearly one in three older veterans have multi-morbidity, many of whom manage life-limiting conditions (LLC) and may benefit from palliative care (PC).1,2 A PC consultation is an opportunity to review care goals and manage complex medical and psychosocial needs for veterans with LLCs. PC improves quality of life and quality of end-of-life (EOL) care; however, most research has been conducted in the inpatient setting.3-7 In 2009, the VA Comprehensive End of Life Care Initiative established Palliative Care Consult Teams (PCCT) with infrastructure investments largely in inpatient settings. In 2013, VA Geriatrics and Extended Care began expanding outpatient PC (OPC) services. Despite increasing use of OPC in the VA, little is known about the implementation and effectiveness of OPC in the VA. Preliminary evidence suggests OPC consults may be effective in patients with certain LLCs; however, effects are heterogeneous across potentially eligible patients. To improve appropriate PC use, critical gaps include lack of knowledge about OPC patterns (OPC consult characteristics and timing relative to inpatient PC, hospitalization, death) and PCCT structural characteristics and care practices. This project will generate the foundational knowledge needed to support an IIR proposal to compare effectiveness of OPC models and evaluate under what conditions OPC improves Veteran outcomes. My CDA employs an explanatory sequential design starting with quantitative analyses of OPC reach and patterns of use (aim 1) followed by enhanced interpretation using qualitative data (aim 2) and together these findings will inform the development of a site-level survey measuring PCCT structural characteristics and OPC practices (aim 3). Veteran engagement will include additional discussions with the local Veteran engagement board, and an advisory board (with representatives from the Veteran Engagement Board), ensuring this research is integrated with operational and veteran priorities. Aim 1.1 uses CDW data to Identify and describe common OPC patterns among aging veterans with LLC. Aim 1.2 will evaluate veteran- and site-level predictors of OPC patterns and identify sites with high and low OPC reach to inform Aim 2. Through interviews with PCCT members and leadership (n=18-24), Aim 2 will characterize OPC patterns and perceived organizational determinants of OPC reach, applying PRISM constructs from the Organizational Perspective domain. Themes will be compared between 3 high and 3 low reach sites. Aim 3 will adapt and pilot a recent GEC survey for Home Based Primary Care (HBPC) to collect data in 5 domains: structure/resources, leadership/team characteristics, referral workflows, patient groups served, and care components. Finally, Aim 4 will evaluate health services use associated with OPC consult and how outcomes differ across common OPC patterns. My CDA will culminate in the development and dissemination of a Palliative Care Pathways report that describes common patterns, sequencing, and outcomes of OPC in the VA in years 4-5. The IIR will implement the survey developed in the CDA and use these data to support a comparative effectiveness study of OPC using mixed methods. This evidence generated by the proposed research program is needed to identify strategies for tailoring PCCT to local needs and resources while retaining fidelity to the components that will improve appropriate PC use for veterans with LLC. Using this knowledge, we will work with operational partners to identifying opportunities for system redesign to improve veterans’ quality of life and families’ satisfaction with EOL care.