Improving End-of-Life Care for Veterans: PROMISE
In this decade, the number of Veterans older than age 85 has tripled. VHA has taken on the challenge of meeting all the healthcare needs of our older Veterans, including ensuring quality of care at the end of life. While hospice and palliative care have demonstrated many benefits, in 2002 few VA healthcare facilities offered these services. VA's Comprehensive End-of-Life Care Initiative was initiated as a large-scale effort to increase access to high-quality hospice and palliative care services among Veterans. The PROMISE Project is in integral part of this initiative. Established in 2008, the Performance Reporting and Outcomes Measurement to Improve the Standard of care at End-of-Life (PROMISE) Center, based at HSR&D's Center for Health Equity Research and Promotion, coordinates qualitative and quantitative measurement of the quality of end-of-life care throughout the VA healthcare system.
How It Began
In 2003, VA leadership adapted payment structures, paving the way for palliative care consult programs and hospice relationships at every facility. At the same time, VA developed a national palliative care fellowship program, and local facilities began collaborating with community hospices. This resulted in greater access to palliative care for hospitalized Veterans—from 29% in 2003 to 42% in 2006, and a three-fold increase in the use of hospice services among outpatients—from 8% in 2003 to 22% in 2006.
During this time, Veterans and their families provided invaluable feedback about their VA experiences that will help VA improve end-of-life care. However, because Veteran and family member perspectives are a central part of this health care improvement process, a method was needed to gather and disseminate that information.
Creating the FATE Survey
Surveying grieving relatives immediately after a Veteran's death can be challenging. Led by Dr. David Casarett, VA investigators determined that a family survey administered approximately two months after a Veteran's death offered the most feasible and sensitive solution for obtaining information about the end-of-life experience of all VA patients and their families. The Family Assessment of Treatment at the End of Life (FATE) survey was developed through a process of in-depth, conversational interviews with Veterans' family members, as well as reviews by a panel of palliative care providers. The FATE 32-item survey takes about 14 minutes to complete and asks family members about:
- Patient's well-being and dignity,
- Communication between the family and care providers,
- Care around time of death,
- Emotional and spiritual support,
- Symptom management,
- Respect for treatment preferences,
- Access to home-care services, and
- Access to services after the patient's death.
Validation of the FATE survey showed that hospice and palliative care benefited Veterans and their families, and led to a 19-item shortened version.
From FATE to PROMISE
The PROMISE staff use the shortened version of the FATE survey, in combination with medical record reviews, to measure the quality of end-of-life care that Veterans receive in the VA healthcare system. The information gathered from medical records and surveys is tabulated on an ongoing basis and reported quarterly to facilities, VISN leadership, and VA Central Office.
The main goals of PROMISE are to:
" Identify and reduce unwanted variation in the quality of end-of-life care throughout VA, and
" Define and disseminate processes of care (best practices) that contribute to improved outcomes for Veterans near the end of life, and optimal experiences for their families.
Implementation and Impact
PROMISE is now a VA-wide evaluation program, implemented in 13 VISNs in FY09 and extended nationally in FY10. PROMISE survey and medical record data are tabulated and reported monthly to 141 facilities, VISN leadership, and VA Central Office so that quality of end-of-life care can be monitored and improved. Through FY10, PROMISE staff have completed 16,600 interviews and 29,300 chart reviews.
The PROMISE program is making a substantial impact on Veterans' end-of-life experience as VA healthcare inpatients. For example, the proportion of Veterans who died as inpatients and that received a palliative care consult in their last year of life increased from 47% in FY08 to 59% in FY09 to 67% in the first quarter of FY10. Moreover, the PROMISE approach to measuring the quality of end-of-life care is highly exportable to other settings. Healthcare systems can:
- Use medical record review (chart abstraction) to define the rates of processes of care, such as pain assessment or documentation of a surrogate decision-maker;
- Employ surveys of family members to elicit opinions about the quality of end-of-life care that their loved ones received; and
- Ensure rapid reporting of meaningful data to front-line providers and leaders who can use those results to guide clinical care and policy.
Below are just a few specific examples of how VA has made good on its PROMISE to help Veterans and their families at the end of life.
Comprehensive Bereavement Program Attends to All
The VAMC in Bedford, MA offers a comprehensive bereavement program based on the philosophy that such support is crucial because it may impact both the grieving process and its outcomes. The staff recognizes that the grieving process is comprised of multiple stages and myriad aspects, which required addressing grief before, during, and after the death of the patient. Additionally, the Bedford program attends to the bereavement and emotional needs of its staff, particularly the nurses who witness medical futility, the prolongation of suffering, and death. The effect of Bedford's efforts to improve its support to Veterans, families, and staff is significant: bereavement contact following a Veteran's death increased from 14% in the first quarter of FY08 to 70% in the first quarter of FY09. The key to this success is in the program's comprehensive scope—attending to the various stages and elements of grieving, and to all the individuals involved.
Integrating PROMISE Results into VISN-Wide Quality Improvement
As VISN 22 began to receive PROMISE results, they embarked on a VISN-wide effort to use those results to improve care. They used the survey to identify best practices as well as system gaps across their region. A VISN-wide coordinating committee is now working to identify priorities for improvement, and they anticipate that two of the performance improvement initiatives for FY10 will focus on palliative care, based on gaps indentified by PROMISE results.
Kind, Caring and Respectful Staff
The doctors and staff of the VA Medical Center in Danville, IL have consistently been described by Veterans' families has being kind, caring and respectful. This facility puts a high priority on hiring staff that care for and respect Veterans, and leadership emphasizes palliative care training and skills. For example, all nurses and nursing assistants on the palliative care team are certified by the Hospice and Palliative Care Nurses Association and have completed training with the End-of-Life Nurses Education Consortium. The staff's knowledge is supplemented by a series of palliative care in-service trainings and a supportive environment that encourages questions and feedback.
Honoring Veterans after Death: The Flag Protocol
The White River Junction VAMC developed and implemented the use of an American Flag to honor deceased Veterans. It began with three ICU nurses who wanted to provide a way for all staff to honor Veterans' lives and memory immediately following death. They also wanted to show the Veterans' families how much the staff honors and respects their loved ones and the service of all Veterans. Therefore, they use the following "flag" protocol for all inpatient deaths:
- Either a chaplain or a nurse approaches the family around the time of death and describes the flag drape protocol as an option.
- When families agree, the American flag is used to drape over the gurney to transport the Veteran through the hospital to the morgue.
- An encased American flag is placed on the empty bed for up to two hours as a mark of respect. (The flag cases are designed and built by a Veteran who is a finish carpenter and volunteers time at the VAMC.)
For more information about PROMISE, please go to www.cherp.research.va.gov