Evaluating implementation strategies to support documentation of veterans' care preferences

Abstract

Objective: To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented. Data Sources: Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020.Study Design: In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites.Data Collection Methods: Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation.Principal Findings: LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate À2.38, standard error 0.72).Conclusions: Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

“…For this reason, we chose to continue our work with HBPC and to capitalize on our experiences and existing partnership with the national HBPC program office. In contrast to the wide range of LST template completion in HBPC programs at the end of the LTC QUERI, mean LST template completion rates across all VA CLCs exceeded 80% [31]. This high baseline completion rate limited the potential impact of additional implementation efforts, and thus, we turned our attention to the VA CNH program, where LST template completion ranges from 2 to 87% (Internal VA data, 2022).…”

“…The team used lessons learned from the LTC QUERI to inform PERSIVED. For example, LTC QUERI outcomes demonstrated that more intensive engagement with champions and implementation facilitation yielded better outcomes [31]. We also recognized that LST template completion rates for Veterans in VA HBPC varied greatly across programs [32] following the initial implementation of the LSTDI, which indicated significant opportunities for improvement.…”

“…The analytic plan to evaluate success in increasing LST plans and orders at sites is similar to the one we used in the LTC QUERI [31]. Because many sites are not chosen or assigned to a cohort at random, we will need to control for selection bias in our outcomes analysis.…”

“…The initiation of audit with feedback and facilitation represents the interruption in each analysis. ITS/SRA has been used frequently for quasi-experimental study designs, including previous analyses by the LTC QUERI [31].…”

Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration

“…In late 2020, the Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) VA Quality Enhancement Research Initiative or QUERI, quality improvement program was developed to address high variation in completion of life-sustaining treatment templates for seriously ill Veterans. The PERSIVED QUERI was established following the completion of the VA Long-Term Care QUERI program (3,6,7). The Long-Term Care QUERI supported implementation of the LSTDI in VA's longterm care settings, which included VA nursing homes, known as Community Living Centers, and VA Home Based Primary Care (HBPC) programs (2).…”