Outpatient Palliative Care Implementation to Improve Outcomes for AgingVeterans

近三分之一的老年退伍军人有多种疾病，其中许多人管理生命限制条件 (LLC)并可能受益于姑息治疗（PC）。1，2 PC咨询是审查护理目标的机会， 管理复杂的医疗和心理社会需求的退伍军人与有限责任公司。PC提高生活质量， 临终关怀（EOL）质量;然而，大多数研究都是在住院患者中进行的。 2009年，VA综合临终关怀倡议成立了姑息治疗咨询团队（PCCT） 基础设施投资主要集中在住院病人身上。2013年，VA老年病和延长护理开始 扩大门诊PC服务。尽管在VA中越来越多地使用OPC，但对 OPC在VA中的实施和有效性。初步证据表明，OPC咨询可能是 在某些LLC患者中有效;然而，在潜在合格患者中效果不均匀。 为了提高PC的正确使用，关键的差距包括缺乏对OPC模式的了解（OPC咨询 与住院PC、住院、死亡相关的特征和时间）和PCCT结构特征 护理实践。该项目将产生支持IIR提案所需的基础知识， 比较OPC模型的有效性，并评估OPC在何种条件下改善退伍军人的结果。 我的CDA采用了一种解释性的顺序设计，从OPC范围的定量分析开始， 使用模式（目标1），然后使用定性数据加强解释（目标2）， 调查结果将为测量PCCT结构特征和OPC的现场水平调查的发展提供信息 实践（目标3）。退伍军人参与将包括与当地退伍军人参与的额外讨论 委员会，和一个咨询委员会（与退伍军人参与委员会的代表），确保这项研究 与行动和老兵的优先事项相结合。目标1.1使用CDW数据识别和描述常见的 老年退伍军人与LLC之间的OPC模式。目标1.2将评估OPC的退伍军人和研究中心水平的预测因素 模式，并确定具有高和低OPC范围的站点，以告知目标2。通过与PCCT成员的访谈 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范围，从组织视角域应用PRISM结构。主题将比较 在3个高和3个低到达站点之间。目标3将调整和试点最近的GEC调查，以家庭为基础的小学 护理（HBPC）收集5个领域的数据：结构/资源，领导/团队特征，转诊 工作流程、服务的患者群体和护理组件。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模式的结果如何不同。 我的CDA将最终发展和传播姑息治疗途径报告， 描述了4-5年VA中OPC的常见模式、排序和结局。IIR将执行 在CDA中开发的调查，并使用这些数据来支持OPC的比较有效性研究 使用混合方法。需要通过拟议的研究计划产生的证据来确定 使PCCT适应当地需求和资源的战略，同时保持对组件的忠诚， 改善退伍军人与有限责任公司适当的PC使用。利用这些知识，我们将与运营 合作伙伴，以确定系统重新设计的机会，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.