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Long-Term Care QUERI Program Works to Improve Goals of Care Conversations

The Life-Sustaining Treatment Decisions Initiative is a national quality improvement project sponsored by VA's National Center for Ethics in Health Care to improve patient-centered care for Veterans with serious illness. A cornerstone of this Initiative is Handbook 1004.3, "Life Sustaining Treatment Decisions: Eliciting, Documenting, and Honoring Patients' Values, Goals and Preferences." Through this handbook update, practitioners throughout all care delivery settings in the VA healthcare system will be required to hold Goals of Care (GoC) conversations aimed at including high-risk Veterans and their families in decision making related to limitations of medical treatment at the end of life. Moreover, GoC conversations will be documented in a new CPRS (Computerized Patient Record System) template, and care plans will be developed to be consistent with the goals expressed by Veterans and their families.

The overall goal of this Implementing Goals of Care Conversations with Veterans in VA Long-Term Care (LTC) Settings QUERI program is to support the Veteran-centered implementation of GoC conversations in VA Community Living Centers (CLCs) and Home Based Primary Care (HBPC). Veterans residing in these settings are often vulnerable, frail and may face critical decisions about their care.

LTC-QUERI's overall goal will be accomplished through the following specific aims:

• Assess variation in practice measures related to the implementation of GoC conversations in CLCs and HBPC programs nationally over time.
• Design, implement, and test tools to improve performance, including:
  • Tools for feedback reports to provide information on progress in those key measures, and
  • Tools for learning collaboratives to support action-planning to address performance gaps.
• Use measures derived from two widely-used implementation research frameworks [Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework] in order to assess barriers and facilitators to implementing GoC conversations.
• Use audit with feedback interventions - coupled with action planning through learning collaboratives - to conduct rapid tests of different designs within these strategies to overcome barriers to implementing GoC conversations in CLCs and HBPC.

LTC-QUERI investigators anticipate that this program will have an impact on Veterans' health and the VA Healthcare System. GoC conversations with Veterans and their families ensure that the treatment they are receiving is concordant with the Veteran's preferences. For example, a Veteran may express their preference for receiving care in the CLC rather than being hospitalized for acute care problems. As Veterans receive care in accordance with their preferences, patient care experiences and satisfaction will improve.

Operational partners for this QUERI program include: VA Central Office Geriatrics and Extended Care Policy and Planning and VACO GEC Operations, the National Center for Ethics in Health Care, the Office of Nursing Services (ONS), and VISN (Veterans Integrated Service Network) partners.

For more information about LTC-QUERI, please contact Anne Sales, PhD, RN, at Anne.Sales@va.gov.