Staff Perspectives on Dementia Care in Nursing Homes: A Pre-Implementation, Content Analysis Study Guided by the Practical, Robust Implementation and Sustainability Model.

PURPOSE: To assess implementation context prior to the implementation of Dementia Collaborative Coaching (DCC), a person-centered, communication coaching intervention for speech-language pathologists, certified nursing assistants, and people living with dementia in nursing homes. METHODS: This was a pre-implementation, content analysis of focus groups. Focus group questions and subsequent analysis were guided by the Practical, Robust Implementation and Sustainability Model. RESULTS: Employees (N = 27) from three nursing homes participated in five focus groups. Five themes from directed content analysis included (a) Dementia Care Needs Improvement; (b) Dementia Collaborative Coaching Appears Promising; (c) Awareness of Necessary Implementation and Sustainability Plans; (d) Regulations Need Accurate Interpretation and Local Dissemination; and (e) Appropriate Staffing Concerns. CONCLUSION/IMPLICATIONS: Key factors related to the implementation of DCC included a perceived tension for change from staff to improve dementia care, concerns about appropriate staffing, and the need for explicit implementation and sustainability plans. The importance of continuing education with specific attention to temporary staff was also found to be a necessary element to support better uptake of the person-centered intervention. [Journal of Gerontological Nursing, 50(2), 5-9.].

Forced to Choose: When Medicare Policy Disrupts End-of-Life Care.

In the last six months of life, 30% of Medicare beneficiaries use the skilled nursing facility (SNF) benefit for post-acute care after a hospital stay. Frequently, the circumstances that indicate a need for SNF care are the same as those of a worsening illness trajectory such as functional decline and falls, unstable health conditions, and pain and other symptoms. The following case example and narrative discussion describes the national implications of this issue and the need for Medicare policy changes that allow for concurrent rehabilitative care and hospice services.

Life-Sustaining Treatment Decisions Initiative: Early Implementation Results of a National Veterans Affairs Program to Honor Veterans' Care Preferences.

BACKGROUND: On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans' goals and decisions using a standardized LST template and order set. OBJECTIVE: Evaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion. DESIGN: Retrospective observational study of clinical and administrative data. We identified all completed LST templates, defined as completion of four required template fields. Templates also include four non-required fields. Results were stratified by risk of hospitalization or death as estimated by the Care Assessment Need (CAN) score. SUBJECTS: All veterans with VA utilization between July 1, 2018, and January 31, 2019. MAIN MEASURES: Completed LST templates, goals and LST preferences, and predictors of documentation. RESULTS: LST templates were documented for 108,145 veterans, and 85% had one or more of the non-required fields completed in addition to the required fields. Approximately half documented a preference for cardiopulmonary resuscitation. Among those who documented specific goals, half wanted to improve or maintain function, independence, and quality of life while 28% had a goal of life prolongation irrespective of risk of hospitalization/death and 45% expressed a goal of comfort. Only 7% expressed a goal of being cured. Predictors of documentation included VA nursing home residence, older age, frailty, and comorbidity, while non-Caucasian race, rural residence, and receipt of care in a lower complexity medical center were predictive of no documentation. CONCLUSIONS: LST decisions were documented for veterans at high risk of hospitalization or death. While few expressed a preference for cure, half desire, cardiopulmonary resuscitation. Predictors of documentation were generally consistent with existing literature. Opportunities to reduce observed disparities exist by leveraging available VA resources and programs.

Partnership to Enhance Resident Outcomes for Community Living Center Residents With Dementia: Description of the Protocol and Preliminary Findings.

The goal of this quality improvement project is to improve care planning around preferences for life-sustaining treatments (LST) and daily care to promote quality of life, autonomy, and safety for U.S. Department of Veterans Affairs (VA) Community Living Center (CLC) (i.e., nursing home) residents with dementia. The care planning process occurs through partnerships between staff and family surrogate decision makers. This process is separate from but supports implementation of the LST Decision Initiative-developed by the VA National Center for Ethics in Health Care-which seeks to increase the number, quality, and documentation of goals of care conversations (GOCC) with Veterans who have life-limiting illnesses. The current authors will engage four to six VA CLCs in the Mid-Atlantic states, provide teams with audit and feedback reports, and establish learning collaboratives to address implementation concerns and support action planning. The expected outcomes are an increase in CLC residents with dementia who have documented GOCC and LST plans. [Journal of Gerontological Nursing, 45(3), 21-30.].

Nursing home care trajectories for older adults following in-hospital palliative care consultation.

Palliative care consultation (PCC) during hospitalization is increasingly common for older adults with life-limiting illness discharged to nursing homes. The objective of this qualitative descriptive study was to describe the care trajectories and experiences of older adults admitted to a nursing home following a PCC during hospitalization. Twelve English-speaking adults, mean age 80 years, who received a hospital PCC and discharge to a nursing home without hospice. Data were collected from medical records at five time points from hospital discharge to 100 days after nursing home admission and care trajectories were mapped. Interviews (n = 15) with participants and surrogates were combined with each participant's medical record data. Content analysis was employed on the combined dataset. All PCC referrals were for goals of care conversations during which the PCC team discussed poor prognosis. All participants were admitted to a nursing home under the Medicare skilled nursing facility benefit. Seven were rehospitalized; six of the 12 died within 6 weeks of initial nursing home admission. The two care trajectories were Focus on Rehabilitative Care and Comfort Care Continuity. There was a heavy emphasis on recovering functional status through rehabilitation and skilled nursing care, despite considerable symptom burden and poor prognosis. Regardless of PCC with recommendations for palliative interventions, frail older adults with limited life expectancy and their family caregivers often perceive that rehabilitation will improve physical function. This perception may contribute to inappropriate, ineffective care. More emphasis is needed to coordinate care between PCC recommendations and post-acute care.

Social support needs: discordance between home hospice nurses and former family caregivers.

OBJECTIVE: The two goals of our study were to (1) identify which of five types of social support (Informational, Esteem, Emotional, Tangible, Belonging) are most cited by hospice nurses and family caregivers and (2) determine the match in perception of support needs. METHOD: As part of a larger multiphase project, focus groups were conducted with former family caregivers and hospice nurses to discuss their experiences of home hospice care and to gather their opinions on the important issues involved in that care. Transcripts of focus group discussions were coded for support type (Informational, Esteem, Emotional, Tangible, Belonging) based on definitions from the literature. Nurse and caregiver data were compared to assess for potential match. RESULTS: Analysis of coded data suggested that nurses see different types of support to be needed in equal measure across their caseloads, while caregivers expressed priorities for some types of support. Illustrative examples of each type of support are provided and discussed. SIGNIFICANCE OF RESULTS: Because matching support provided with the type of support desired has been linked to improved physical and psychological outcomes, it is important to focus on this match in healthcare populations particularly vulnerable to psychological stress, including family caregivers of home hospice patients. This research has implications for interventions to match support provision to caregiver needs, or for education for home hospice providers to ensure that they are not only sensitive to the possibility of a broad range of needs but also to the necessity to tailor care to those needs.

A Nurse Practitioner-Driven Palliative and Supportive Care Service in Nursing Homes: Evaluation of a Quality Improvement Project.

This article describes a quality improvement project implemented by a national postacute long-term care organization aimed at enhancing the provision of palliative care to nursing home residents. The project focused on improving advance care planning, end-of-life care, symptom management, and care of people living with serious illness. Both generalist and specialist palliative care training were provided to nurse practitioners in addition to implementing a system to identify residents most likely to benefit from a palliative approach to care. To evaluate the nurse practitioner experiences of the program, survey data were collected from nurse practitioners (N = 7) involved in the project at 5 months after implementation. Nurse practitioners reported the program was well received by nursing home staff, families, and residents. Most nurse practitioners felt more confident managing residents' symptoms and complex care needs; however, some reported needing additional resources for palliative care delivery. Most common symptoms that were managed included pain, delirium, and dyspnea; most common diagnoses cared for were dementia and chronic organ failure (eg, cardiac, lung, renal, and neurological diseases). In the next steps, the project will be expanded throughout the organization, and person- and family-centered outcomes will be evaluated.

A comparison of end-of-life care quality for Veterans receiving hospice in VA nursing homes and community nursing homes.

BACKGROUND: While the Veterans Health Administration (VA) has long provided hospice care within VA community living centers (CLCs, i.e., VA nursing homes), an increasing number of Veterans are receiving hospice in VA-contracted community nursing homes (CNHs). However, little data exist about the quality of end-of-life (EOL) care provided in CNHs. The aim of this study was to compare family ratings of the quality of EOL care provided to Veterans receiving hospice in VA CLCs and VA-contracted CNHs. METHODS: We conducted a retrospective analysis of national data from VA's electronic medical record and Bereaved Family Survey (BFS) for Veterans who received hospice in VA CLCs or VA-contracted CNHs between October 2021 and March 2022. The final sample included 1238 Veterans who died in either a CLC (n = 1012) or a CNH (n = 226) and whose next-of-kin completed the BFS. Our primary outcome was the BFS global rating of care received in the last 30 days of life. Secondary outcomes included BFS items related to symptom management, communication, emotional and spiritual support, and information about burial and survivor benefits. We compared unadjusted and adjusted proportions for all BFS outcomes between those who received hospice in CLCs and CNHs. RESULTS: The adjusted proportion of family members who gave the best possible rating (a score of 9 or 10 out of a possible 10) for the overall care received near EOL was more than 13 percentage points higher for Veterans who received hospice in VA CLCs compared to VA-contracted CNHs. Our findings also revealed quality gaps of even greater magnitude in specific EOL care-focused domains. CONCLUSIONS: Our findings document inadequacies in the quality of multiple aspects of EOL care provided to Veterans in CNH-based hospice and illuminate the urgent need for policy and practice interventions to improve this care.

Nursing Home Star Ratings and End-Of-Life Care Quality: Lessons Learned From the Veterans Health Administration.

OBJECTIVES: More than 25% of deaths among older adults occur in nursing homes. Thus, assessments of nursing home quality, including the widely used 5-star rating systems, should reflect quality of end-of-life (EOL) care. Our objective was to examine the associations between Veterans Affairs (VA) nursing home star ratings and quality of EOL care as measured by the VA's Bereaved Family Survey (BFS). DESIGN: National, retrospective observational study. SETTING AND PARTICIPANTS: VA nursing homes, known as Community Living Centers (CLCs). All veterans who died in a CLC from October 2018 to September 2019 whose next of kin completed a BFS. METHODS: Using linked VA data sources, we examined the BFS-Performance Measure (BFS-PM) (ie, the % of BFS respondents who provided an "excellent" overall rating) by the Overall Star Rating and domain star ratings (unannounced survey, staffing, and quality) for the 133 CLCs in our sample. Logistic and linear regression was used to examine the associations between CLC Overall Star Rating and individual-level BFS outcomes. Outcomes included the BFS-PM (primary), the 3 BFS factor scores of Respectful Care and Communication, Emotional and Spiritual Support, and Death Benefits, and 2 symptom management items. RESULTS: Differences in the BFS-PM by CLC star rating were small to none and not statistically significant across all star rating domains. The relationship between a higher CLC Overall Star Rating and odds of an "excellent" BFS global rating was not statistically significant. Similarly, no significant associations were observed between a higher CLC Overall Star Rating and scores on the BFS factor scores and symptom management items. CONCLUSIONS AND IMPLICATIONS: Our findings suggest that the current CLC star rating system is not sufficient to assess the quality of EOL care. BFS scores, or a comparative EOL quality of care measure, should be integrated into CLC quality rating systems.

Life-sustaining treatment decisions and family evaluations of end-of-life care for Veteran decedents in Department of Veterans Affairs nursing homes.

BACKGROUND: Modeled after the Physician Orders for Life Sustaining Treatment program, the Veterans Health Administration (VA) implemented the Life-Sustaining Treatment (LST) Decisions Initiative to improve end-of-life outcomes by standardizing LST preference documentation for seriously ill Veterans. This study examined the associations between LST documentation and family evaluation of care in the final month of life for Veterans in VA nursing homes. METHODS: Retrospective, cross-sectional analysis of data for decedents in VA nursing homes between July 1, 2018 and January 31, 2020 (N = 14,575). Regression modeling generated odds for key end-of-life outcomes and family ratings of care quality. RESULTS: LST preferences were documented for 12,928 (89%) of VA nursing home decedents. Contrary to our hypothesis, neither receipt of wanted medications and medical treatment (adjusted odds ratio [OR]: 0.85, 95% confidence interval [CI] 0.63, 1.16) nor ratings of overall care in the last month of life (adjusted OR: 0.96, 95% CI 0.76, 1.22) differed significantly between those with and without completed LST templates in adjusted analyses. CONCLUSIONS: Among Community Living Center (CLC) decedents, 89% had documented LST preferences. No significant differences were observed in family ratings of care between Veterans with and without documentation of LST preferences. Interventions aimed at improving family ratings of end-of-life care quality in CLCs should not target LST documentation in isolation of other factors associated with higher family ratings of end-of-life care quality.

Selecting outcomes for pragmatic clinical trials in dementia care: The IMPACT Collaboratory iLibrary.

BACKGROUND: Many interventions improve care and outcomes for people with Alzheimer's Disease and related dementias (ADRD), yet are never disseminated. Pragmatic trials facilitate the adoption and dissemination of best practices, but gaps in pragmatic outcome measurement are a critical obstacle. Our objectives are (1) to describe the development and structure of the IMbedded Pragmatic ADRD Clinical Trials Collaboratory (IMPACT) iLibrary of potential outcome measures for ADRD pragmatic trials, and (2) to assess their pragmatic characteristics. METHODS: We identified potential outcome measures from several sources: a database of administrative and clinical outcome measures from ADRD clinical trials registered in ClinicalTrials.gov, published reviews, and IMPACT pilot pragmatic trial outcome measures. The iLibrary reports (a) number of items, (b) completion time, (c) readability for diverse populations, (d) cost or copyright barriers to use, (e) method of administration, (f) assessor training burden, and (g) feasibility of data capture and interpretation in routine care; a summary of pragmatic characteristics of each outcome measure (high, moderate, low); items or descriptions of items; and links to primary citations regarding development or psychometric properties. RESULTS: We included 140 outcome measures in the iLibrary: 66 administrative (100% were pragmatic) and 74 clinical (52% were pragmatic). The most commonly addressed outcome domains from administrative assessments included physical function, quality of care or communication concerns, and psychological symptoms or distress behaviors. The most commonly addressed outcome domains from clinical assessments were psychological symptoms or distress behaviors, physical function, cognitive function, and health-related quality of life. CONCLUSIONS: Pragmatic outcome measures are brief, meaningful to diverse populations, easily scored and interpreted by clinicians, and available in electronic format for analysis. The iLibrary can facilitate the selection of measures for a wide range of outcomes relevant to people with ADRD and their care partners.

Telehealth Palliative Care in Nursing Homes: A Scoping Review.

OBJECTIVES: Many adults older than 65 spend time in a nursing home (NH) at the end of life where specialist palliative care is limited. However, telehealth may improve access to palliative care services. A review of the literature was conducted to synthesize the evidence for telehealth palliative care in NHs to provide recommendations for practice, research, and policy. DESIGN: Joanna Briggs Institute guidance for scoping reviews, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews frameworks were used to guide this literature review. SETTINGS AND PARTICIPANTS: Reviewed articles focused on residents in NHs with telehealth palliative care interventionists operating remotely. Participants included NH residents, care partner(s), and NH staff/clinicians. METHODS: We searched Medline (Ovid), Embase (Elsevier), Cochrane Library (WileyOnline), Scopus (Elsevier), CINHAL (EBSCOhost), Trip PRO, and Dissertations & Theses Global (ProQuest) in June 2021, with an update in January 2022. We included observational and qualitative studies, clinical trials, quality improvement projects, and case and clinical reports that self-identified as telehealth palliative care for NH residents. RESULTS: The review yielded 11 eligible articles published in the United States and internationally from 2008 to 2020. Articles described live video as the preferred telehealth delivery modality with goals of care and physical aspects of care being most commonly addressed. Findings in the articles focused on 5 patient and family-centered outcomes: symptom management, quality of life, advance care planning, health care use, and evaluation of care. Consistent benefits of telehealth palliative care included increased documentation of goals of care and decrease in acute care use. Disadvantages included technological difficulties and increased NH financial burden. CONCLUSIONS AND IMPLICATIONS: Although limited in scope and quality, the current evidence for telehealth palliative care interventions shows promise for improving quality and outcomes of serious illness care in NHs. Future empirical studies should focus on intervention effectiveness, implementation outcomes (eg, managing technology), stakeholders' experience, and costs.

Evaluating the pragmatic characteristics of advance care planning outcome measures in dementia clinical trials: A scoping review.

BACKGROUND: Advance care planning (ACP) is a process that involves discussing a person's goals, values, and preferences; it is particularly important for persons living with dementia (PLWD) given that dementia is incurable and progressive. To ensure results that will impact real-world practices, ACP outcome measures must be psychometrically strong, meaningful to key partners, and pragmatic to collect. Therefore, we conducted a scoping review of outcome measures utilized in ACP randomized controlled clinical trials (RCTs) enrolling PLWD or their care partners and evaluated their pragmatic characteristics. METHODS: We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for peer-reviewed ACP RCTs enrolling PLWD or their care partners from 2011 to 2021. We abstracted characteristics of primary and secondary outcome measures, including pragmatic characteristics using an adapted Psychometric and Pragmatic Evidence Rating Scale and ACP outcome domains using the standardized ACP Outcome Framework (i.e., process, action, healthcare, or quality of care). RESULTS: We included 21 ACP RCTs. Trials included 103 outcome measures (39 primary and 64 secondary), of which 11% measured process, 14% measured action, 49% measured healthcare, and 26% measured quality of care. Twenty-four (23%) outcome measures were highly pragmatic, the majority of which (67%) reflected healthcare outcome measures. Sixty-one (59%) outcomes were assessed as highly relevant to PLWD or their care partners. Only 20% (n = 21) of outcome measures were embedded into clinical practice. Most (62%) RCTs were conducted in nursing homes, and 33% were focused PLWD with advanced stage disease. CONCLUSIONS: In RCTs testing ACP interventions to support PLWD, only 23% of outcome measures were highly pragmatic, and most of these measured healthcare utilizations. Outcome assessments were rarely integrated into the EHR during routine clinical care. New outcome measures that address the lived experience of PLWD and their care partners plus have high pragmatic characteristics are needed for embedded pragmatic clinical trials.

Identifying Nursing Home Residents with Unmet Palliative Care Needs: A Systematic Review of Screening Tool Measurement Properties.

OBJECTIVES: Despite common use of palliative care screening tools in other settings, the performance of these tools in the nursing home has not been well established; therefore, the purpose of this review is to (1) identify palliative care screening tools validated for nursing home residents and (2) critically appraise, compare, and summarize the quality of measurement properties. DESIGN: Systematic review of measurement properties consistent with Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. SETTINGS AND PARTICIPANTS: Embase (Ovid), MEDLINE (PubMed), CINAHL (EBSCO), and PsycINFO (Ovid) were searched from inception to May 2022. Studies that (1) reported the development or evaluation of a palliative care screening tool and (2) sampled older adults living in a nursing home were included. METHODS: Two reviewers independently screened, selected, extracted data, and assessed risk of bias. RESULTS: We identified only 1 palliative care screening tool meeting COSMIN criteria, the NECesidades Paliativas (NEC-PAL, equivalent to palliative needs in English), but evidence for use with nursing home residents was of low quality. The NEC-PAL lacked robust testing of measurement properties such as reliability, sensitivity, and specificity in the nursing home setting. Construct validity through hypothesis testing was adequate but only reported in 1 study. Consequently, there is insufficient evidence to guide practice. Broadening the criteria further, this review reports on 3 additional palliative care screening tools identified during the search and screening process but which were excluded during full-text review for various reasons. CONCLUSION AND IMPLICATIONS: Given the unique care environment of nursing homes, we recommend future studies to validate available tools and develop new instruments specifically designed for nursing home use. In the meantime, we recommend that clinicians consider the evidence presented here and choose a screening instrument that best meets their needs.

Building Strong Clinician-Researcher Collaborations for Successful Hospice and Palliative Care Research.

Hospice and palliative care research aim to build a knowledge base to guide high-quality care for people with serious illness and improve their quality of life. Considering its focus on patient and family caregiver's experiences, hospice and palliative care research activities primarily take place in real-world clinical settings where seriously ill patients and their family caregivers receive care (eg, nursing homes, clinics, inpatient units). Conducting research in these settings poses many challenges because researchers, clinicians, and administrators may have different priorities-and scientific control is difficult. Therefore, clinician-researcher-administrator collaboration in planning and conducting studies is critical for successful hospice and palliative care research. For an effective collaboration, clinicians, researchers, and site administrators must be considered equal partners. Each collaborator brings their unique expertise, knowledge, and skills that when combined can strengthen scientific rigor, feasibility, and success of the project, as well as have study outcomes that are more translatable to real-world practice. However, little guidance exists to give actionable steps to build collaborative partnerships for hospice and palliative care researchers. The purpose of this article is to describe the process of forming successful clinician-researcher-administrator collaborations through five phases of the research life cycle: idea generation, partnership, proposal writing, research process, and dissemination. Exemplars are drawn from the authors' experiences conducting collaborative research and highlight strategies and resources for successful hospice and palliative care collaborations.

Palliative Care and Documented Suicide: Association Among Veterans With High Mortality Risk.

CONTEXT: Palliative care consultations (PCCs) are associated with reduced physical and psychological symptoms that are related to suicide risk. Little is known, however, about the association between PCCs and death from suicide among patients at high risk of short-term mortality. OBJECTIVE: To examine the association between the number of PCCs and documentation of suicide in a cohort of Veterans at high risk of short-term mortality, before and after accounting for Veterans' sociodemographic characteristics and clinical conditions. METHODS: An observational cohort study was conducted using linked Veterans Affairs clinical and administrative databases for 580,620 decedents with high risk of one-year mortality. Logistic regression models were used to examine the association between number of PCCs and documentation of suicide. RESULTS: Higher percentages of Veterans who died by suicide were diagnosed with chronic pulmonary disease as well as mental health/substance use conditions compared with Veterans who died from other causes. In adjusted models, one PCC in the 90 days prior to death was significantly associated with a 71% decrease in the odds of suicide (OR = 0.29, 95% CI = 0.23-0.37, P < 0.001) and two or more PCCs were associated with a 78% decrease (OR = 0.22, 95% CI = 0.15-0.33, P < 0.001). Associated "number needed to be exposed" estimates suggest that 421 Veterans in this population would need to receive at least one PCC to prevent one suicide. CONCLUSION: While acknowledging the importance of specialized mental health care in reducing suicide among high-risk patients, interventions delivered in the context of PCCs may also play a role.

High-Quality Nursing Home and Palliative Care-One and the Same.

Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches' effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration.

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.

Evaluating implementation strategies to support documentation of veterans' care preferences.

OBJECTIVE: To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented. DATA SOURCES: Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020. STUDY DESIGN: In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites. DATA COLLECTION METHODS: Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation. PRINCIPAL FINDINGS: LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate -2.38, standard error 0.72). CONCLUSIONS: Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites. The large increases in completion rates are likely due to the well-planned national roll-out of the LSTDI. This finding suggests that when dissemination and support for widespread implementation are present and system-mandated, significant enhancements in the adoption of evidence-based practices may require more intensive support.

An extensive invasive intracranial human glioblastoma xenograft model: role of high level matrix metalloproteinase 9.

The lack of an intracranial human glioma model that recapitulates the extensive invasive and hypervascular features of glioblastoma (GBM) is a major hurdle for testing novel therapeutic approaches against GBM and studying the mechanism of GBM invasive growth. We characterized a high matrix metalloproteinase-9 (MMP-9) expressing U1242 MG intracranial xenograft mouse model that exhibited extensive individual cells and cell clusters in a perivascular and subpial cellular infiltrative pattern, geographic necrosis and infiltrating tumor-induced vascular proliferation closely resembling the human GBM phenotype. MMP-9 silencing cells with short hairpin RNA dramatically blocked the cellular infiltrative pattern, hypervascularity, and cell proliferation in vivo, and decreased cell invasion, colony formation, and cell motility in vitro, indicating that a high level of MMP-9 plays an essential role in extensive infiltration and hypervascularity in the xenograft model. Moreover, epidermal growth factor (EGF) failed to stimulate MMP-9 expression, cell invasion, and colony formation in MMP-9-silenced clones. An EGF receptor (EGFR) kinase inhibitor, a RasN17 dominant-negative construct, MEK and PI3K inhibitors significantly blocked EGF/EGFR-stimulated MMP-9, cell invasion, and colony formation in U1242 MG cells, suggesting that MMP-9 is involved in EGFR/Ras/MEK and PI3K/AKT signaling pathway-mediated cell invasion and anchorage-independent growth in U1242 MG cells. Our data indicate that the U1242 MG xenograft model is valuable for studying GBM extensive invasion and angiogenesis as well as testing anti-invasive and anti-angiogenic therapeutic approaches.