Outpatient Palliative Care Implementation to Improve Outcomes for AgingVeterans

近三分之一的老年退伍军人患有多发性疾病，其中许多人患有限制生命的疾病 (有限责任公司)，并可能受益于姑息治疗(PC)。1，2姑息治疗会诊是审查护理目标和 为患有有限责任公司的退伍军人管理复杂的医疗和心理社会需求。PC提高了生活质量， 临终关怀(EOL)的质量；然而，大多数研究都是在住院环境中进行的。 2009年，退伍军人管理局全面临终关怀倡议成立了姑息关怀咨询小组(PCCT) 基础设施投资主要集中在住院环境中。2013年，退伍军人事务部老年医疗和延期护理计划开始 扩大门诊PC(OPC)服务。尽管OPC在退伍军人管理局中的使用越来越多，但人们对OPC的了解很少 OPC在退伍军人管理局中的实施和效果。初步证据表明，OPC咨询可能是 对某些LLC患者有效；然而，在潜在符合条件的患者中，效果是不同的。 要改进PC的适当使用，关键差距包括缺乏关于OPC模式的知识(OPC咨询 特征和时间相对于住院PC、住院、死亡)和PCCT结构特征 和护理实践。该项目将生成支持IIR提案所需的基础知识 比较OPC模型的有效性，并评估在什么条件下OPC可以改善退伍军人的结果。 我的CDA采用解释性顺序设计，首先对OPC REACH和 使用模式(目标1)，然后使用定性数据加强解释(目标2)，以及 调查结果将为开展现场一级调查提供信息，以衡量PCCT结构特征和OPC 实践(目标3)。退伍军人接洽将包括与当地退伍军人接洽的其他讨论 委员会，和一个顾问委员会(由退伍军人参与委员会的代表组成)，确保这项研究 与作战和退伍军人优先事项相结合。AIM 1.1使用CDW数据来识别和描述常见 有限责任公司老年退伍军人的OPC模式。AIM 1.2将评估经验丰富的和现场级别的OPC预测者 通过对PCCT成员的采访，确定具有高OPC和低OPC的站点，以告知AIM 2 和领导力(n=18-24)，目标2将描述OPC模式和感知的组织决定因素 OPC REACH，从组织角度域应用PRISM构造。主题将进行比较 3个高河段和3个低河段之间。AIM 3将改编和试行最近一项针对家庭小学的GEC调查 关注(HBPC)收集5个领域的数据：结构/资源、领导力/团队特征、推荐 工作流程、接受服务的患者组和护理组件。最后，目标4将评估卫生服务的使用情况 与OPC咨询相关，以及常见OPC模式之间的结果有何不同。 我的CDA将最终制定和传播一份姑息治疗路径报告， 描述退伍军人管理局4-5年中OPC的常见模式、顺序和结果。IIR将实施 调查是在CDA中进行的，并使用这些数据来支持OPC的比较有效性研究 使用混合的方法。由拟议的研究计划产生的证据需要用来确定 根据当地需求和资源调整PCCT的战略，同时保持对将 利用有限责任公司为退伍军人改进适当的PC使用。利用这些知识，我们将与运营部门合作 寻找重新设计系统的机会，以改善退伍军人的生活质量和家庭 对EOL护理的满意度。

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.