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

Abstract

Background Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings. Methods PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations. Discussion The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

Evaluating feedback reports to support documentation of veterans’ care preferences in home based primary care

“…These findings informed design by the LTC QUERI team of a program entitled Preferences Elicited and Respected for Seriously Ill Veterans (PERSIVED) to extend their work in HBPC and community nursing homes [ 25 ]. In this ongoing project, implementation facilitation is utilized to address problems and offer customized support adapted to the context and individual characteristics of the recipients of the intervention [ 26 , 27 ].…”

Barriers and facilitators to goals of care conversations with Veteran residents of community nursing homes

“…We conducted semi-structured pre-implementation interviews with 40 key stakeholders (CNH program coordinators, field staff, and leadership) from the six VA Medical Centers participating in the PERSIVED program between July 2021 and July 2022. 18 With support from the VA National Program for Purchased and Long-Term Care, sites were selected based on program size and geographic diversity, avoiding sites with high rates of LST completion (>60%). All interdisciplinary staff from the participating CNH program sites were invited to participate via email.…”

“…To address these challenges, a VA‐funded program called Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision‐Making (PERSIVED) was initiated in 2021 18 . The goals of this multi‐phase implementation project are to improve the consistent documentation of LST preferences among Veterans in CNHs, support the conversion of Veterans' preferences into durable orders, and ensure that preferences are clearly communicated across VA and non‐VA settings 18 .…”

“…To address these challenges, a VA‐funded program called Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision‐Making (PERSIVED) was initiated in 2021 18 . The goals of this multi‐phase implementation project are to improve the consistent documentation of LST preferences among Veterans in CNHs, support the conversion of Veterans' preferences into durable orders, and ensure that preferences are clearly communicated across VA and non‐VA settings 18 . As part of pre‐implementation efforts, we conducted qualitative baseline interviews with VA CNH program teams at the six participating VA sites with less than 60% LST completion to understand the barriers and facilitators to conducting GoCCs and documenting LST orders with Veteran residents of VA‐contracted CNHs.…”