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Takeaway: PERSIVED QUERI implements interventions to elicit, document, and honor seriously ill Veterans' goals, values, and preferences for end-of-life care. They have developed evidence-based approaches that are being evaluated in six VA Community Nursing Home (CNH) programs and will eventually be incorporated into standard practices across all VA CNH teams to increase goals of care conversations and documentation of Veterans' preferences for life-sustaining treatments.
Currently, 37% of U.S. Veterans are aged 70 and older (Pew Research Center, 2021). VA has taken on the challenge of meeting the healthcare needs of older Veterans, including ensuring quality of care at the end of life. Patients with chronic illness frequently use durable medical orders that are honored across community healthcare settings (i.e., Physician Orders for Life-Sustaining Treatment [POLST]) to document their preferences for end-of-life care, so they do not receive unwanted, potentially burdensome, treatments in the final chapter of their lives.
VA Home Based Primary Care (HBPC) programs care for more than 54,000 Veterans with complex, chronic illness and have an annual mortality of 24%. In addition, the VA Community Nursing Home (CNH) program is responsible for managing care for nearly 41,000 Veterans who are likely to experience a life-threatening event in the next 1-2 years of their life. Veterans in this program have an annual mortality rate of 30% and an average of two hospitalizations per year. Moreover, many HBPC and CNH programs have low rates of Veterans’ documented care preferences.
The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) QUERI program aims to equip clinicians with the information and tools to document life-sustaining treatment preferences for Veterans in HBPC and CNH programs – and convert their preferences into actionable orders that cross VA and non-VA settings to promote goal-concordant care.
PERSIVED QUERI implements interventions to elicit, document, and honor seriously ill Veterans’ goals, values, and preferences for end-of-life care.
PERSIVED QUERI is co-led by Cari Levy, MD, PhD, Division Head of Geriatric Medicine, Director of the Multidisciplinary Center on Aging, and Section Chief of Palliative Medicine at the Rocky Mountain Regional VA Medical Center; and Mary Ersek, PhD, RN, FPCN, who is part of HSR&D’s Center for Health Equity Research and Promotion (CHERP) and a Professor of Palliative Care at the University of Pennsylvania School of Nursing.
Results
PERSIVED QUERI partnered with VA’s National Center for Ethics in Health Care and the Geriatrics and Extended Care Program leadership to identify and implement best practices in six CNH teams across the United States. One of these evidence-based tools—a national visit template that includes evaluation of goals of care conversations and life-sustaining treatments (LST) documentation—is now national VA policy and will be used by all VA CNH teams. Eleven HBPC programs are participating in PERSIVED. All of these programs had lower than 50% LST template completion for their Veterans at baseline before taking part in PERSIVED. All HBPC programs participating in PERSIVED have increased their rates of LST template completion, with rate increases ranging from 8 to 50% from initial rates at baseline.
Implications
The PERSIVED QUERI provided input on national VA recommendations for LST template completion in HBPC. PERSIVED QUERI has supported Home Based Primary Care programs in making LST template completion a standard of care. The ongoing evaluations will eventually lead to standard practices across all VA CNH teams to increase goals of care conversations and documentation of Veterans’ preferences for life-sustaining treatments
Publications
Haverhals L, Magid K, and Kononowech J. 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. Front Health Services. September 2, 2022;2:doi:10.3389/frhs.2022.935341.
Ersek M, Sales A, Keddem S, et al. Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): A protocol for an implementation study in the Veterans Health Administration. Implement Science Communications. July 20, 2022;3(1):78.
