Identifying Successful Strategies of Specialist Palliative Care Implementation for People with Advanced Heart Failure

Project Summary Over 280,000 people die from advanced heart failure each year in the United States. This population experiences burdensome symptoms, frequent hospitalizations, and delayed transitions to hospice care. Clinical practice guidelines recommend the use of palliative care for people with advanced heart failure to address their many palliative needs. However, fewer than 20% receive specialist palliative care, highlighting its markedly limited reach among this population. Little is known about the palliative care and cardiology program composition (i.e., structures) or operational characteristics (i.e., processes) that increase the reach of specialist palliative care or improve care near the end of life. As a result, medical centers nationally struggle to implement specialist palliative care for people with advanced heart failure and implementation varies widely. Our proposal will address these critical knowledge gaps. Our long-term goal is to increase the reach of specialist palliative care and improve the quality of end-of-life care among people with advanced heart failure. As a step towards this goal, the objective of this proposal is to identify the key modifiable structures and processes of specialist palliative care delivery that result in high-reach and three end-of-life care outcomes highly valued by people with advanced heart failure: days at home in the last three months of life, hospice enrollment ≥ 7 days before death and family-reported end-of-life care quality. To accomplish our objectives, we will conduct a rigorous multisite, mixed methods study within the Department of Veterans Affairs (VA). The VA is the largest healthcare system in the United States comprised of 146 nationwide medical centers. Moreover, it is the only healthcare system with an integrated electronic health record that includes detailed variables on structures and processes of specialist palliative care, cardiology programs and practices, and surveys of bereaved family members. We will combine VA data with data from the Centers for Medicare and Medicaid to comprehensively examine care near the end of life within and outside of the VA. We will evaluate associations between specialist palliative care and cardiology program structures and processes and the reach of specialist palliative care (Aim 1), and the three outcomes of end-of-life care quality (Aim 2). Next, we will conduct interviews with specialist palliative care and cardiology clinicians and analyze policy documents and consultation templates to identify strategies employed by medical centers that have successfully implemented specialist palliative care for people with advanced heart failure and compare them to those medical centers that have not (Aim 3). Finally, we will integrate quantitative and qualitative data to identify comprehensive strategies that facilitate the implementation of specialist palliative care for this population. This proposal directly aligns with NOT-HL-20- 737, by identifying practical strategies that can effectively overcome barriers and support sustained delivery of specialist palliative care. Findings from our project will provide valuable insights that can be utilized by palliative care and cardiology programs across the country, ultimately improving patient care.