Increasing access and quality in Department of Veterans Affairs care at the end of life: a lesson in change.
ABSTRACT The pursuit of a "good death" remains out of reach for many despite numerous piecemeal solutions to address the growing need for access to quality care at the end of life. In 2002, U.S. veteran deaths were at an all-time high, few Department of Veterans Affairs (VA) hospitals had inpatient palliative care services, and there was no reliable approach to meet home hospice needs. The VA embarked on a course of major change to improve veterans' care at the end of life. A coordinated plan to increase access to hospice and palliative care services was established, addressing policy development, program and staff development, collaboration with community hospices, outcomes measurement, and proving value to the organization. To determine progress and monitor resource allocation, workload and outcome measures were established in all settings. Within 3 years, the number of veterans receiving VA-paid home hospice had tripled, all VA hospitals had a palliative care team, 42% of all veterans who died as VA inpatients received a palliative care consultation, and a nationwide network of VA partnerships with community hospice agencies was established. Through a multifaceted strategic plan and a mission of honoring veterans' preferences for care at the end of life, the VA has made rapid progress in improved access to palliative care services for inpatients and outpatients. The VA's experience serves as a powerful example of the magnitude of change possible in a complex health system and a model for improving access and quality of palliative care services in other health systems.
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ABSTRACT: Objectives To analyze bereaved next of kin's suggestions for improving end-of-life (EOL) care in Veterans Affairs (VA) Medical Centers (VAMCs).DesignQualitative.SettingThis study was part of a larger study testing the effectiveness of a multimodal intervention strategy to improve processes of EOL care in six southeast U.S. VAMCs (Best Practices for End-of-Life Care for Our Nation's Veterans—BEACON Trial).ParticipantsBereaved next of kin (n = 78) of veterans who died between 2005 and 2010.MeasurementsData addressing praise, criticism, and recommendations for enhancing EOL care were abstracted from semistructured interviews of next of kin and aggregated into a code labeled “Suggestions.” Content analysis proceeded iteratively through data review, comparison, and negotiation of emergent themes and integration of all coauthors' insights and interpretations into the evolving interpretive scheme.ResultsNext of kin provided examples that resonated with their conceptions of quality EOL care. They also described distressing situations and perceptions of deficits in care. Major themes derived were compassionate care, good communication, support for family visits and privacy, and the need for death preparation and postdeath guidance. The fifth theme, unique to this study, was the salience of the relationship between the veterans and their families and the VA and the expectations this engendered in terms of dignity and honor.Conclusion Interventions that support staff's ability to convey compassion, communicate information to families and other staff, listen to patients and families, prepare families for the individual's death, and provide consistent, coordinated information regarding after-death activities may optimize EOL hospital care for veterans.Journal of the American Geriatrics Society 03/2014; · 4.22 Impact Factor
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ABSTRACT: IMPORTANCE Characterizing the quality of supportive cancer care can guide quality improvement. OBJECTIVE To evaluate nonhospice supportive cancer care comprehensively in a national sample of veterans. DESIGN, SETTING, AND PARTICIPANTS Using a retrospective cohort study design, we measured evidence-based cancer care processes using previously validated indicators of care quality in patients with advanced cancer, addressing pain, nonpain symptoms, and information and care planning among 719 veterans with a 2008 Veterans Affairs Central Cancer Registry diagnosis of stage IV colorectal (37.0%), pancreatic (29.8%), or lung (33.2%) cancer. MAIN OUTCOMES AND MEASURES We abstracted medical records from diagnosis for 3 years or until death among eligible veterans (lived ≥30 days following diagnosis with ≥1 Veterans Affairs hospitalization or ≥2 Veterans Affairs outpatient visits). Each indicator identified a clinical scenario and an appropriate action. For each indicator for which a veteran was eligible, we determined whether appropriate care was provided. We also determined patient-level quality overall and by pain, nonpain symptoms, and information and care planning domains. RESULTS Most veterans were older (mean age, 66.2 years), male (97.2%), and white (74.3%). Eighty-five percent received both inpatient and outpatient care, and 92.5% died. Overall, the 719 veterans triggered a mean of 11.7 quality indicators (range, 1-22) and received a mean 49.5% of appropriate care. Notable gaps in care were that inpatient pain screening was common (96.5%) but lacking for outpatients (58.1%). With opioids, bowel prophylaxis occurred for only 52.2% of outpatients and 70.5% of inpatients. Few patients had a timely dyspnea evaluation (15.8%) or treatment (10.8%). Outpatient assessment of fatigue occurred for 31.3%. Of patients at high risk for diarrhea from chemotherapy, 24.2% were offered appropriate antidiarrheals. Only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death. Single- vs multiple-fraction radiotherapy should have been considered in 28 veterans with bone metastasis, but none were offered this option. CONCLUSIONS AND RELEVANCE These care gaps reflect important targets for improving the patient and family experience of cancer care.JAMA Internal Medicine 10/2013; · 13.25 Impact Factor
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ABSTRACT: Historically, hospice use by veterans has lagged behind that of non-veterans. Little is known about hospice use by veterans at a population level. To determine whether veteran and non-veteran hospice users differ by demographics, primary diagnosis, location of care, and service utilization. Using the 2007 National Home and Hospice Care Survey, we identified 483 veteran and 932 non-veteran male hospice users representing 287,620 hospice enrollees nationally. We used chi-square and t-tests to compare veterans and non-veterans by demographic characteristics, primary diagnosis, and location of hospice care. We used multivariate regression to assess for differences in hospice diagnosis and location of care, adjusting for demographic and clinical factors. We also compared length of stay and number of visits by hospice personnel between veterans and non-veterans using multivariate regression. Veteran hospice users were older than non-veterans (77.0 vs. 74.3 years, P = 0.02) but did not differ by other demographics. In adjusted analyses, cancer was a more common primary diagnosis among veterans than non-veterans (56.4% vs. 48.4%; P = 0.02), and veteran hospice users were more likely than non-veterans to receive hospice at home (68.4% vs. 57.6%; P = 0.007). The median adjusted length of stay and number of nurse or social worker visits did not differ by veteran status (all P > 0.10), but veterans received fewer home health aide visits than non-veterans (one every 5.3 days vs. one every 3.7 days; P = 0.002). Although veteran and non-veteran hospice users were similar on most demographic measures, important differences in hospice referral patterns and utilization exist.Journal of pain and symptom management 11/2013; · 2.42 Impact Factor