Increasing Access and Quality in Department of Veterans Affairs Care at the End of Life: A Lesson in Change
Department of Veterans Affairs, Veterans Health Administration, Office of Geriatrics and Extended Care, Washington, DC, USA.Journal of the American Geriatrics Society (Impact Factor: 4.57). 11/2007; 55(10):1645-9. DOI: 10.1111/j.1532-5415.2007.01321.x
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.
- [Show abstract] [Hide abstract]
ABSTRACT: There is a lack of studies concerning improvement of medication use in palliative care patients in nursing homes. This study was conducted to evaluate whether a geriatric palliative care team reduced unnecessary medication prescribing for elderly veterans residing in a nursing home. This was a retrospective, descriptive study of patients who died while residing in a geriatric palliative care unit between August 1, 2005, and July 31, 2007. Prescribed medications were evaluated using the Unnecessary Drug Use Measure, which contains 3 items from the Medication Appropriateness Index concerning lack of indication, lack of effectiveness, and therapeutic duplication. This measure was applied at 2 time points: on transfer/admission to the palliative care unit and at the last 30-day pharmacist medication review before death. Paired t tests and McNemar tests were used to compare medication use at these 2 points. Eighty-nine patients were included in the study. The majority were male (97.8%) and white (78.7%), with a mean (SD) age of 79.7 (7.8) years. The median length of stay on the unit was 39.0 days, and the mean number of chronic medical conditions was 8.4 (4.3). At baseline, the mean number of scheduled medications was 9.7 (4.3). The number of unnecessary medications per patient decreased from a mean of 1.7 (1.5) at admission to 0.6 (0.8) at closeout (P = 0.003). The decrease was seen in all 3 categories of the Unnecessary Drug Use Measure. The geriatric palliative care team was associated with a reduction in the number of unnecessary medications prescribed for older veterans in this nursing home. Future studies should evaluate the impact of decreasing unnecessary prescribing on clinical outcomes such as adverse drug reactions.The American Journal of Geriatric Pharmacotherapy 03/2009; 7(1):20-5. DOI:10.1016/j.amjopharm.2009.02.001 · 3.13 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: The Veterans Affairs (VA) has made significant investments in care for veterans. However, it is not known whether these investments have produced improvements in end-of-life care in the VA compared to other settings. Therefore, the goal of this study was to compare families' perceptions of end-of-life care among patients who died in VA and non-VA facilities. Retrospective 32-item telephone surveys were conducted with family members of patients who died in VA and non-VA facilities. Five Veterans Affairs medical centers and their affiliated nursing homes and outpatient clinics. Patients were eligible if they received any care from a participating VA facility in the last month of life and if they died in an inpatient setting. One family member per patient completed the survey. In bivariate analysis, patients who died in VA facilities (n = 520) had higher mean satisfaction scores compared to those who died in non-VA facilities (n = 89; 59 versus 51; rank sum test p = 0.002). After adjusting for medical center, the overall score was still significantly higher for those dying in the VA (beta = 0.07; confidence interval [CI] = 0.02-0.11; p = 0.004), as was the domain measuring care around the time of death (beta = 0.11; CI = 0.04-0.17; p = 0.001). Families of patients who died in VA facilities rated care as being better than did families of those who died in non-VA facilities. These results provide preliminary evidence that the VA's investment in end-of-life care has contributed to improvements in care in VA facilities compared to non-VA facilities.Journal of palliative medicine 08/2010; 13(8):991-6. DOI:10.1089/jpm.2010.0044 · 1.91 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Hospice is a major expansion area within the Veterans Health Administration (VHA). The objective of this retrospective study was to explore trends in hospice utilization among older veterans receiving services at the end of life over a 4-year (2006-2009) time period. Reviewing trends, the number of veterans receiving hospice services increased annually, with 5779 veterans receiving services during 2009, up from 1742 veterans in 2006. The total cost of providing hospice rose dramatically, increasing from $1.98 million in 2006 to $5.91 million in 2009. More funds were spent on younger veterans, with an average of $1.5 million spent on veterans aged 55 to 64 and less than $400,000 spent on veterans aged 85 and older. Findings highlight the growing need and demand for hospice within the VHA to provide end-of-life services.The American journal of hospice & palliative care 02/2011; 28(6):424-8. DOI:10.1177/1049909110397655 · 1.38 Impact Factor
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.