QUERI – Quality Enhancement Research Initiative

Evaluation of the National Implementation of the VA Diffusion of Excellence Initiative on Advance Care Planning via Group Visits

Little Rock, AR

Overview

To ensure that Veterans receive the healthcare they prefer in the event of a medical crisis or surrounding end-of-life-care – and to avoid the personal and financial costs of unnecessary interventions that increase suffering for Veterans and their families, it is essential that Advance Directives (AD) be in place. Advanced directives are written, legal instructions regarding preferences for medical care, particularly at the end of life. However, whenever a person is unable to make decisions for him- or herself (i.e. serious injury, unconscious, etc.), an advanced directive can guide healthcare providers, caretakers, and loved ones in decision-making. More than one-third of US adults have advanced medical directives (Reuters Health, 2017). This means that an estimated 6 million of the 9.05 million Veterans enrolled in VA healthcare, may NOT have an advanced directive.

The objective of QUERI’s Evaluation of the National Implementation of the VA Diffusion of Excellence Initiative on Advance Care Planning via Group Visits (ACP-GV) Partnered Evaluation Initiative is to evaluate and to determine best practices to facilitate a nationwide spread of one of VA’s Diffusion of Excellence Initiatives, ACP-GV, which includes the cost saving- and process-oriented approach of hosting discussions regarding the topic of advanced care planning and advanced directives among groups of Veterans. Regarding the ACP-GV National Program, investigators in this QUERI initiative will:

• Evaluate the impact of the Program on the proportion of advanced care planning discussions with Veterans in VA care by comparing ACP-GV sites to control sites not implementing ACP-GV.
• Document and compare sites funded by VA’s Office of Rural Health (ORH) and Diffusion of Excellence Initiative sites that are unfunded on the effectiveness of implementation strategies used on ACP discussion and advanced directive completion rates across the VA healthcare system.
• Determine the budget impact of the ACP-GV National Program.
• Identify the characteristics of high-performing (e.g., high rates or sustainers) and innovative sites (e.g., unique local program design or implementation of ACP) to inform sustainability and further spread.

Methodology

The ACP-GV National Program is responsible for the implementation, evaluation, and spread of ACP-GV across the VA healthcare system using five implementation strategies:

• Provide seed-funding for new or dedicated staff (e.g., social worker and medical support assistant) who deliver ACP-GV in rural VA facilities and community-based outpatient clinics;
• Create a learning collaborative;
• Conduct ongoing training;
• Identify and prepare champions; and,
• Conduct audits and feedback against productivity benchmarks using national data from the VHA Support Services Center (VSSC).

The ACP-GV National Program has spread to 35 VA sites in VISN 1, 9, 15, 16, 20, and 21 who have implemented ACP-GV, delivering it to more than 10,000 enrolled Veterans (FY17 = 2,381 and FY18 = 7,761 Veterans), with 20% of these attendees creating a new AD. Moreover, 304 VA providers were trained in ACP-GV in FY17 and FY18.

Anticipated Impacts

QUERI investigators plan to expand this evaluation beyond only ORH-funded rural sites to examine the impact and effectiveness of the ACP-GV National Program in all VA facilities. They also will examine the variation in implementation where a funded staff person who conducts ACP-GV (i.e., ORH-funded vs. Diffusion of Excellence Initiative-unfunded) is the main difference among ACP-GV sites in the implementation strategies used to facilitate the ACP-GV National Program.

Corresponding Principal Investigators: Monica M. Matthieu, PhD, LCSW; contact at Monica.Matthieu@va.gov .

Operations Partners: VA’s Office of Rural Health (ORH) and Care Management, Patient Care Services’ National Chaplain Center, and Social Work Services.