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VA Center for Clinical Management Research

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QUERI Program: Implementing Goals of Care Conversations with Veterans in VA LTC Settings (LTC QUERI)

In VA Community Living Centers (CLCs) and Home-Based Primary Care Programs (HBPCs), identifying and respecting Veteran preferences about where and how they want to be cared for is critical to promoting quality end-of-life care. The updated CLC Handbook includes new guidelines for having thorough conversations about these preferences with patients and their families, which will be implemented throughout VA. LTC QUERI, led by a multi-site team of Anne Sales, Mary Ersek (Philadelphia), and Orna Intrator (Canandaigua), is a group of 4 interrelated projects with the overall goal of helping VA staff implement and expand on these Goals of Care (GoC) conversations.

LTC QUERI is designed to ensure that Veterans in CLCs and HBPCs are able to express their preferences for care, make sure it is documented in a place where the entire team can find it, and make sure that their preferences are acted upon in the care and services they receive. Projects 1 and 3 will support CLC staff in VISN 11 and HBPC staff in VISNs 19 & 21 respectively as they complete and document GoC conversations. Projects 2 and 4 will build on these preferences with personalized care plans for Veterans with dementia in VISNs 4 & 11 (Project 2) and emphasis on physical activity programs in VISNs 19 & 21 (Project 4). The implementation strategy will include an audit with feedback coupled with action plans developed through learning collaboratives.