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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. [ABSTRACT FROM AUTHOR]

Objective: To develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM. Methods: Sequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age≥65 years. Results: Items for each scale/subscale demonstrated high factor loading (>.5) and good to excellent internal consistency (Cronbach α .76–.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks’λ =.555–.809, η 2 =.068–.178, p ≤.001 for all models. Conclusion: Core constructs of the TTM as applied to ACP can be measured with high reliability and validity. Practice implications: Cross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the Pros and Cons of participation in ACP and promote the use of certain Processes of Change in order to promote older persons’ engagement in ACP. [Copyright &y& Elsevier]

Objective: To develop and test a simple tool to elicit the preferences of older persons based on prioritization of universal health outcomes. Methods: Persons age ≥65 participating in a larger study were asked to rank 4 outcomes on a visual analogue scale: (1) maintaining independence, (2) staying alive, (3) reducing/eliminating pain, (4) reducing/eliminating other symptoms. Results: Interviewers rated 73% of the 81 participants as having good to excellent understanding, and cognitive interviews demonstrated the tool captured how participants thought about trade-offs. Test-retest reliability was fair to poor for ranking most of the outcomes as either most or least important (kappa .28–1.0). Patient characteristics associated with ranking “keeping you alive” as most important have been shown to be associated with a preference for life-sustaining treatment, a related construct. There was substantial variability in the outcome ranked as most important. Conclusions: The task of ranking 4 universal health outcomes was well understood, captured what was important when considering trade-offs, and demonstrated content validity. However, test-retest reliability was fair to poor. [Copyright &y& Elsevier]