How To Design And Implement Outpatient Palliative Care Among Persons With Advanced Heart Failure: A Positive Deviance Analysis

Introduction Clinical practice guidelines for persons with advanced heart include recommendations to consult palliative care to help address this population's many palliative needs. Yet, few successful models exist, particularly in the ambulatory setting, and there remains little guidance on how best to deliver this care. Therefore, we sought to identify best practices in the implementation of outpatient palliative care for persons with advanced heart failure by identifying “positive deviants” and describing the factors that contribute to these programs’ success. Methods We conducted individual, semi-structured interviews with palliative care and cardiology clinicians at four Veterans Affairs Medical Centers (VAMCs) in Connecticut, Illinois, Florida, and Utah. We purposefully selected these VAMCs as they had the most completed outpatient consultations from cardiology to palliative care among persons with heart failure in the national VA system. Clinicians were asked about their perceptions of the most helpful components of outpatient palliative care and how it was delivered and implemented at their VAMC for persons with advanced heart failure. Three researchers inductively coded and analyzed data using summative content analysis. Interviews and coding occurred concurrently until data saturation. Results Interviews were conducted with ten palliative care and seven cardiology clinicians (7=Connecticut, 4=Illinois, 3=Florida, 3=Utah). Of the sample, 86% were white, non-Hispanic, and the mean age was 46.9 years (standard deviation = ±7.5). Palliative care and cardiology clinicians viewed goals of care discussions about prognosis, expected illness trajectories, and patient preferences for advanced therapies as the most important component of outpatient palliative care delivery. Both palliative care and cardiology clinicians initially preferred using integrated (e.g., co-located within the cardiologic clinic with co-visits) over independent (separate clinics/visits) models of outpatient palliative care delivery. A key implementation strategy involved changing the delivery and intensity of palliative care involvement over time. Most successful programs shifted the provision of palliative care from integrated to independent delivery as cardiology providers became more familiar with these services and confident palliative care could address patient and family needs. Conclusions Characteristics of successful outpatient palliative care programs for persons with advanced heart failure include a focus on discussions of goals of care, the initial use of integrated care delivery models, and flexibility to shift model delivery and intensity over time. Study findings begin to provide a roadmap for other cardiology programs wishing to implement outpatient palliative care for persons with advanced heart failure. Clinical practice guidelines for persons with advanced heart include recommendations to consult palliative care to help address this population's many palliative needs. Yet, few successful models exist, particularly in the ambulatory setting, and there remains little guidance on how best to deliver this care. Therefore, we sought to identify best practices in the implementation of outpatient palliative care for persons with advanced heart failure by identifying “positive deviants” and describing the factors that contribute to these programs’ success. We conducted individual, semi-structured interviews with palliative care and cardiology clinicians at four Veterans Affairs Medical Centers (VAMCs) in Connecticut, Illinois, Florida, and Utah. We purposefully selected these VAMCs as they had the most completed outpatient consultations from cardiology to palliative care among persons with heart failure in the national VA system. Clinicians were asked about their perceptions of the most helpful components of outpatient palliative care and how it was delivered and implemented at their VAMC for persons with advanced heart failure. Three researchers inductively coded and analyzed data using summative content analysis. Interviews and coding occurred concurrently until data saturation. Interviews were conducted with ten palliative care and seven cardiology clinicians (7=Connecticut, 4=Illinois, 3=Florida, 3=Utah). Of the sample, 86% were white, non-Hispanic, and the mean age was 46.9 years (standard deviation = ±7.5). Palliative care and cardiology clinicians viewed goals of care discussions about prognosis, expected illness trajectories, and patient preferences for advanced therapies as the most important component of outpatient palliative care delivery. Both palliative care and cardiology clinicians initially preferred using integrated (e.g., co-located within the cardiologic clinic with co-visits) over independent (separate clinics/visits) models of outpatient palliative care delivery. A key implementation strategy involved changing the delivery and intensity of palliative care involvement over time. Most successful programs shifted the provision of palliative care from integrated to independent delivery as cardiology providers became more familiar with these services and confident palliative care could address patient and family needs. Characteristics of successful outpatient palliative care programs for persons with advanced heart failure include a focus on discussions of goals of care, the initial use of integrated care delivery models, and flexibility to shift model delivery and intensity over time. Study findings begin to provide a roadmap for other cardiology programs wishing to implement outpatient palliative care for persons with advanced heart failure.