Serious Illness Care Program Research Articles

Advance care planning conversations in primary care: a quality improvement project using the Serious Illness Care Program

BackgroundAdvance care planning (ACP) conversations are associated with improved end-of-life healthcare outcomes and patients want to engage in ACP with their healthcare providers. Despite this, ACP conversations rarely occur in primary care settings. The objective of this study was to implement ACP through adapted Serious Illness Care Program (SICP) training sessions, and to understand primary care provider (PCP) perceptions of implementing ACP into practice.MethodsWe conducted a quality improvement project guided by the Normalization Process Theory (NPT), in an interprofessional academic family medicine group in Hamilton, Ontario, Canada. NPT is an explanatory model that delineates the processes by which organizations implement and integrate new work. PCPs (physicians, family medicine residents, and allied health care providers), completed pre- and post-SICP self-assessments evaluating training effectiveness, a survey evaluating program implementability and sustainability, and semi-structured qualitative interviews to elaborate on barriers, facilitators, and suggestions for successful implementation. Descriptive statistics and pre-post differences (Wilcoxon Sign-Rank test) were used to analyze surveys and thematic analysis was used to analyze qualitative interviews.Results30 PCPs participated in SICP training and completed self-assessments, 14 completed NoMAD surveys, and 7 were interviewed. There were reported improvements in ACP confidence and skills. NoMAD surveys reported mixed opinions towards ACP implementation, specifically concerning colleagues’ abilities to conduct ACP and patients’ abilities to participate in ACP. Physicians discussed busy clinical schedules, lack of patient preparedness, and continued discomfort or lack of confidence in having ACP conversations. Allied health professionals discussed difficulty sharing patient prognosis and identification of appropriate patients as barriers.ConclusionsTraining in ACP conversations improved PCPs’ individual perceived abilities, but discomfort and other barriers were identified. Future iterations will require a more systematic process to support the implementation of ACP into regular practice, in addition to addressing knowledge and skill gaps.

Real World Implementation of the Serious Illness Care Program in Cancer Care: Results of a Quality Improvement Initiative.

Purpose: Guidelines suggest that advance care planning (ACP) and goals-of-care discussions should be conducted for patients with advanced cancer early in the course of their disease. A recent audit of our health system found that these discussions were rarely being documented in the electronic medical record (EMR). We conducted a quality improvement initiative to improve rates of documentation of goals and wishes among patients with advanced cancer. Methods: On the basis of previous analyses of this problem, we determined that provider capability and opportunity were the main barriers to conducting and documenting serious illness conversations. We implemented the serious illness care program (SICP), a systematic multicomponent intervention that has shown potential for conducting and documenting ACP discussions in two oncology clinics. Our goal was to conduct at least 24 serious illness conversations over the implementation period, with documentation of at least 95% of all conversations. Results: The SICP was implemented in two outpatient medical oncology clinics. A total of 15 serious illness care conversations occurred and 14 (93%) of these conversations were documented in the EMR. Total rates of documentation increased between the preimplementation and implementation period (4.2%-5.4% for clinician A and 0%-7.3% for clinician B). Conclusion: Implementation of the SICP resulted in increased rates of documentation, but the target number of conversations was not met. Further improvement cycles are required to address barriers to conducting and documenting routine serious illness conversations.

1516P Real world implementation of Serious Illness Care Program (SICP) in cancer care

1516P Real world implementation of Serious Illness Care Program (SICP) in cancer care

Implementing Serious Illness Communication Processes in Primary Care: A Qualitative Study.

Primary care clinicians face barriers to engaging patients in conversations about prognosis, values, and goals ("serious illness conversations"). We introduced a structured, multi-component intervention, the Serious Illness Care Program (SICP), to facilitate conversations in the primary care setting. We present findings of a qualitative study to explore practical aspects of program implementation. We conducted semi-structured interviews of participating primary care physicians, nurse care coordinators, and social workers and coded transcripts to assess the activities used to integrate SICP into the workflow. We conducted interviews with 14 of 46 clinicians from 6 primary care clinics, stopping with thematic saturation. Qualitative analysis revealed major themes around activities in the timing of the conversation (before, during, and after) and overarching insights about the program. Clinicians used a variety of strategies to adapt program components while preserving key program goals, including processes to generate accountability to ensure that conversations happen in busy clinical workflows. The interviews revealed changes to clinicians' mindset and norms, such as the recognition of the need to start conversations earlier in the illness course and the use of more expansive models of prognostic communication that address function and quality of life. Data also revealed indicators of sustainable behavior change and the spread of communication practices to patients outside the intended program scope. SICP served as a framework for primary care clinicians to integrate serious illness communication into routine care. The shifts in processes employed by inter-professional clinicians revealed comprehensive models for prognostic communication and creative workflows to ensure that patients with complex illnesses had proactive, longitudinal, and patient-centered serious illness conversations and care planning.

Real-world implementation of serious illness care program (SICP) in cancer care.

e24112 Background: The Serious Illness Care Program (SICP) is a system-based intervention, including a conversation guide, which facilitates improved advance care planning (ACP) conversations between clinicians and seriously ill patients. A recent randomized control trial found the program reduced symptoms of depression and anxiety amongst oncology out-patients and improved process outcomes. We implemented the SICP in our center to determine if the effects of this program could be translated into the real world. Methods: Two outpatient oncology clinics implemented the SICP, each over a 16-week period. Patients were identified based on an answer of “no” to the question “would I be surprised if this patient died within the next year?”, or any patient with a diagnosis of metastatic pancreatic cancer, or symptom scores of > 7 on more than three categories of the patient reported outcome dashboard. Physicians were trained on how to conduct the SICP conversation. One patient per week was identified and prepared to have the SICP conversation with the goal of at least 12 conversations in each 16-week period. Rates of SICP conversation documentation on our system’s “ACP and goals of care designation (GCD) Tracking Record” and GCD orders were recorded. Patient satisfaction after each conversation and physician comfort level over time were assessed. Results: 16 patients were identified (8 patients in each 16-week period). One patient was lost to follow-up. Of the remaining 15 patients who had the SICP conversation, 14 (93%) had documentation on the Tracking Record and 8 (53%) had a GCD order. This was a major improvement over baseline rates of documentation (e.g. < 1 % Tracking Record use and 16% GCD for patients with GI cancers). 14 patients completed satisfaction surveys, of which 12 (86%) felt “completely” or “quite a bit” more heard or understood. Physician comfort level increased from 3.6 to 4.8 and from 4.8 to 5 out of 5, respectively over each 16-week period. Conclusions: SICP implementation resulted in high rates of documentation of goals and preferences. Patients felt heard and understood by their healthcare team, and comfort in these conversations improved over time for physicians. The goal number of conversations was not met, but otherwise the SICP was feasible to implement in the real world. Further study is required to identify the appropriate triggers and barriers to routine SICP conversations.

Quality of clinicians' conversations with patients and families before and after implementation of the Serious Illness Care Program in a hospital setting: a retrospective chart review study.

Seriously ill patients in hospital have indicated that better communication with practitioners is vital for improving care. The aim of this study was to assess whether the quality of conversations about serious illness improved after implementation of the Serious Illness Care Program (SICP). In this retrospective chart review study, we evaluated patients who were admitted to a medical ward at Hamilton General Hospital, had a stay of at least 48 hours, and were at risk for a lengthy stay or increased need for community-based services (inter-RAI Emergency Department Screener score of 5 or 6). The SICP study period was from Mar. 1, 2017, to Jan. 19, 2018. We used a validated codebook to assess the quality of documented conversations regarding serious illness for eligible patients before (usual care [control group]) and after SICP implementation (intervention group), specifically examining the following domains: patients' values and goals, understanding of prognosis and illness, end-of-life care planning, and code status or desire for other life-sustaining treatments. The study sample included 56 patients in the control group and 56 patients in the intervention group. The overall quality of documented conversations about serious illness was significantly higher in the intervention group than in the control group (p < 0.001) and was significantly higher in the subdomains of values and goals (p < 0.001), understanding of prognosis and illness (p < 0.001) and life-sustaining treatments (p = 0.03) but not end-of-life care planning (p = 0.48). Implementation of the SICP in a hospital setting was associated with higher quality of documented conversations regarding serious illness with patients at high risk for clinical or functional deterioration. The SICP is transferable and adaptable to a hospital setting, and was associated with an increase in adherence to best practices compared to usual care.

Evaluating Diverse Methodologies and Interventions for Facilitating Advance Care Planning (ACP) Among Seriously Ill Patients: Lessons from Ongoing PCORI-funded ACP Trials (FR415)

•Describe diverse methodologies for implementing interventions to increase advance care planning for seriously ill patients in three PCORI-funded large, multi-site comparative effectiveness trials.•Describe real-world challenges of implementing and evaluating advance care planning interventions for seriously ill patients.•Engage in an interactive activity to identify barriers and solutions to implementing advance care planning in a variety of real-world clinical settings. PCORI recently funded three large, multi-site trials focused on advance care planning (ACP) among seriously ill patients. Each trial takes a unique methodologic approach including different ACP interventions, implementation strategies, and methods for measuring program success. Collectively these trials answer critical questions related to delivery of ACP in real-world settings including identifying the optimal mix of clinicians needed to engage in ACP, evaluating approaches for reducing disparities in ACP and associated outcomes, and understanding the intensity of ACP interventions needed to facilitate optimal patient and caregiver outcomes.•One study is evaluating two different implementation strategies for the Serious Illness Care Program (SICP): primary care clinician-focused versus multidisciplinary team focused, and will enroll over 1,000 patients from 42 primary care clinics in the U.S. and Canada.•A second study is comparing the effectiveness of two ACP interventions (Respecting Choices vs. Five Wishes) in reducing racial disparities in ACP and patient outcomes among 800 seriously ill older adults from 10 clinics in Southern U.S.•A third population-based study is comparing the effectiveness on multi-level outcomes of three ACP interventions that vary in intensity (advance directive alone; advance directive plus the Prepare For Your Care decision support website; advance directive plus PREPARE plus ACP health care navigator facilitation. This study will enroll 6,000 patients with serious illness from 50 primary care clinics in California. In this session, we will review and contrast the variety of ACP models and tools, including supporting evidence, being tested in these studies. We will also explore the different approaches to population selection, ACP implementation and evaluation, and stakeholder engagement taken in these studies. Participants will then be engaged in an interactive exercise to consider how the experience to date in these three trials could inform the implementation of ACP for their own clinics and health systems.

Earlier identification of seriously ill patients: an implementation case series

ObjectiveTo describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around...

Driving Organizational Change in Serious Illness Communication: Successes and Challenges of Implementing the Serious Illness Care Program (QI729)

1.Describe different approaches to the use of clinical tools, clinician training, and systems-changes to improve serious illness communication throughout a system.2.Examine aggregate implementation data across three health systems on structures and processes of implementing a primary palliative care program focused on communication.3.Explore strategies to maximize clinician behavior change and factors that may influence uptake of serious illness communication on the frontlines. Clinicians commonly miss opportunities to engage seriously ill patients in conversations about values and goals, or do so late in the illness course. Achieving more, earlier, and better serious illness communication requires system-level change. Examine early learnings about successes and challenges of implementing a communication quality-improvement initiative in three health systems. Three U.S. systems have adapted and implemented the Serious Illness Care Program (SICP), which includes tools, training, and systems-changes, in partnership with Ariadne Labs (AL) using a system-level implementation model. We combined and analyzed structure and process data from the three systems and routinely collected coaching notes to understand early successes and challenges. From 2016-present, AL trained and coached 24 champions (including 20 palliative care specialists) at the 3 systems. Champions launched SICP in cardiology, oncology, geriatrics, surgery, and primary care; Champions have trained 330 clinicians. EMRs have been modified to include an accessible template; 1,852 patients have a documented conversation thus far. Preliminary analysis of coaching notes revealed: 1) Structures and capabilities (e.g. clinician training, EHR template) can be replicated, yet clinician uptake of serious illness conversations varies and may depend on factors not captured in the model, e.g. attitudes toward palliative or end-of-life care; 2) Uncertainties about the role of inter-professionals (e.g. nurses) and specialists vs. generalists in serious illness communication may contribute to workflow challenges; 3) Supportive coaching, leadership/peer engagement, and/or data-reporting are likely to enhance practice change but require time and resources. Successful adaptation and adoption of SICP structures and processes in three health systems suggests the promise of a systems-level implementation model to improve serious illness communication. More effective workflows that activate the care team and a better understanding of the mechanisms and contextual factors that support practice change are likely to enhance efforts.

For Change You Need a Roadmap: An Implementation Model to Improve Serious Illness Communication Across Health Systems (S860)

1.Describe the three phases of a novel implementation model designed to achieve system-level improvement in serious illness communication.2.Apply incremental milestones derived from implementation science and organizational change to primary palliative care programs. Programs that aim to improve clinician-patient communication about values and goals (‘serious illness communication’) often focus on skills-training while neglecting the system in which communication takes place. Driving measurable improvements in communication requires organization-level change. Develop a novel implementation model for improving serious illness communication across a health system with practical steps for palliative care leaders. Researchers and implementers with the Serious Illness Care Program (SICP) at Ariadne Labs (AL) conducted a four-stage process: 1) Assembled an expert panel (n=10) to draft a theory of change. 2) Reviewed the implementation science and organizational change literature. 3) Synthesized learnings into key implementation features and engaged a designer to create a “roadmap.” 4) Refined the roadmap with feedback from its application in three systems. The ‘Implementation Roadmap’ has three phases: Prepare; Train/Coach; Sustain. Phase one creates a supportive environment for implementation. Actions include engaging leaders and colleagues to gain buy-in, assembling and training a team of champions (trainers + implementation team) with dedicated resources, selecting levers to support practice change, choosing pilot sites, and customizing the program (clinician training/coaching; workflow; EHR template; metrics for monitoring/evaluation). Phase two launches the program in pilot sites with rapid-cycle-improvement. The team trains early-adopter clinicians in serious illness communication who initiate the workflow, resulting in documented conversations with patients. The team uses metrics to track conversations, get feedback, and provide support to frontline clinicians. Phase three expands the program to new sites and plans for evaluation and sustainability, e.g. dashboards, automated triggers. An Implementation Roadmap provides incremental milestones and practical steps to support palliative care leaders interested in organization-level, measurable improvements in serious illness communication across populations and settings.

The Effects of the Serious Illness Care Program (SICP) on Health Care Resource Utilization (HRU): A Retrospective Cohort Study.

The Effects of the Serious Illness Care Program (SICP) on Health Care Resource Utilization (HRU): A Retrospective Cohort Study.