Background Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings. Methods PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations. Discussion The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.

Reference 1. Ersek M, 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 Sci Commun. 2022;3:78.