Lead/Presenter: Ciaran Phibbs,
Resource Center - HERC
All Authors: Phibbs CS (HERC, VA Palo Alto Health Care System, Stanford University), Scott WJ (HERC, VA Palo Alto Health Care System, Stanford University), Wong JA (HERC, VA Palo Alto Health Care System, Stanford University) Sales A (VA Ann Arbor Healthcare System, University of Michigan School of Medicine) Ersek MT (Corporal Michael J. Crescenz VAMC, University of Pennsylvania School of Nursing) Levy CR (Eastern Colorado Health Care System, University of Colorado School of Medicine) Henry J (VA Ann Arbor Healthcare System) Lowery JS (National Center for Ethics in Health Care, Veterans Health Administration, US Department of Veterans Affairs) Foglia MB (National Center for Ethics in Health Care, Veterans Health Administration, US Department of Veterans Affairs)
The VA Life-Sustaining Treatment Decisions Initiative (LSTDI) is designed to elicit, document, and honor goals of care and preferences for life-sustaining treatments (LST) for Veterans at high-risk of a life-threatening event. A key component of the LSTDI is the implementation of standardized, durable LST progress note templates and order sets for documenting goals of care conversations (GoCC). Implementation coordinators at each VA Medical Center received an Implementation Guide, support teleconferences, template installation support, educational resources, and GoCC training. The objective of this analysis was to examine the percentages of patients with completed LST templates in Community Living Centers (CLC) or enrolled in Home-Based Primary Care (HBPC) and describe how these varied across medical centers and VISNs to inform ongoing implementation efforts.
Data were extracted from the VA Corporate Data Warehouse (CDW) for all Veterans with completed LST templates overlapping July 1st, 2018 to December 31st, 2018; CLC and HBPC patients were identified using CDW and MDS assessment data and the HBPC Masterfile, respectively. We calculated incidence (completed LST templates between July 1 and December 31) and prevalence (LST templates completed by December 31). We reported data separately for the four LSTDI demonstration sites and compared to all other sites.
For CLC residents, the overall LST templates incidence was 24.2% and the prevalence was 57.5%, indicating that many CLC residents had documented LST preferences prior to the implementation of the LSTDI. For HBPC the incidence was 18.8% and the prevalence was 28.0%. For VISNs, the incidence and prevalence ranges were 12.8-33.5% and 25.9-82.8% for CLCs, and 6.5-29.8% and 8.6-53.0% for HBPCs. By facility, these ranges were 0.0-74.2% and 0.0-100% for CLCs and 0.0-76.2% and 1.0-93.3% for HBPCs. For the four demonstration sites, the average prevalence was 72.9% for CLCs and 89.7% for HBPCs.
There is considerable variance across VISNs and facilities in the rate at which LST decisions are being recorded for these high-risk patients. The higher rates at the demonstration sites indicate high rates can be achieved.
Increasing rates of documented preferences for LST across a large integrated medical system has the potential to help seriously-ill Veterans receive goal-concordant care.