Correction to: Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol.

CORRECTION: The authors would like to correct errors in the original article [1] that may have lead readers to misinterpret the scope, evidence base and target population of VHA Handbook 1004.03 "Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients' Values, Goals, and Preferences".

Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol.

BACKGROUND: The program "Implementing Goals of Care Conversations with Veterans in VA LTC Settings" is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive. METHODS: Three projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives-meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans' preferences expressed and documented, and acted on-to support action planning to improve performance. DISCUSSION: We will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration.

Improving the long-term care referral process: insights from patients and caregivers.

Large increases in the need for long-term care (LTC) services are expected as baby boomers age. Little has been published about patient and caregiver preferences for information about LTC. However, our qualitative research findings suggest that potential consumers may find it difficult to obtain accurate and timely information about LTC programs and services. In-person, semistructured interviews were conducted with 47 subjects, including patients (n = 25) within 90 days of their referral to a LTC placement (including NH, assisted living, home care, and community) and their caregivers (n = 22). Interview questions addressed the events that seemed to trigger their need for a LTC referral, the resources they used to become more informed about LTC options and the issues they confronted with the LTC referral process. Qualitative analyses identified a number of patient and informal caregiver-reported barriers to making decisions about LTC services, including insufficient information about LTC programs and community resources, unclear funding requirements and inadequate funding, and difficulty knowing how to plan for LTC or make LTC decisions. A potential solution may be an online LTC Guide designed to provide accurate information about the range of LTC services, with an emphasis on home and community-based services. This Guide was developed to address the gap in comprehensive LTC information identified in the findings of this study.

Barriers to home and community-based service referrals: the physician's role.

The purpose of this study was to obtain information about Department of Veteran Affairs (VA) long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. This primarily qualitative study was conducted at five VA Medical Centers. The study used three linked methods: interviews with patients and informal caregivers; focus groups with LTC administrators, providers, and social workers; and written rankings of the barriers to HCBS referrals. We unexpectedly identified a cluster of findings indicating the importance of physicians' role in the LTC referral process and the need for more LTC training, particularly about HCBS.

Emergency mental health care for youth in Washington State: qualitative research addressing hospital emergency departments' identification and referral of youth facing mental health issues.

OBJECTIVES: The purpose of this formative research was to gain a better understanding of how Washington State hospital emergency departments (EDs) identify and refer children and adolescents with mental health concerns. Increased understanding of emergency mental healthcare for youth will lead to the development and implementation of strategies and policies that enhance the system of providing mental health services to children and adolescents. METHODS: We conducted structured group interviews, a form of qualitative research, with ED, social work, and mental health administrators and providers in 9 hospitals in Washington State. RESULTS: Interviews reflected a systemwide lack of emergency mental health services for youth, as well as a lack of coordination between the larger mental health system and hospital ED. In addition, we identified issues specific to the hospital/ED such as insufficient availability of social work and mental health staff, lack of mental and behavioral health screening tools, lack of knowledge of available mental health services, and lack of clarity about the ED's role in identification of mental health concerns. CONCLUSIONS: Specific interventions should be developed, implemented, and evaluated to increase coordination between the ED and the larger mental health system. This should include methods for increasing ED staff knowledge of available and accessible mental health services for youth, perhaps through an online system. In addition, the role of the ED in identifying youth facing mental health issues should be clarified, and a brief, nonintrusive screening tool for identifying emergency mental health concerns should be developed.

Cardiopulmonary resuscitation training in Washington state public high schools.

To determine the best approaches for increasing cardiopulmonary resuscitation (CPR) training opportunities for public high school students, we conducted a statewide survey of all 310 public high schools in Washington State. The findings describe CPR student training currently provided by high schools, barriers to providing, and strategies to increase CPR training of high school students. The response rate was 89% (276 schools) from a combination of mail and telephone surveys; 35% (n=97) reported that they did not provide any CPR student training. Of the 132 schools that provided CPR student training, 23% trained less than 10% of their students, and 39% trained more than 90% of their students. The majority of public high schools, 70%, did not have any teacher trained to teach CPR or had only one teacher with such training. Yet 80% of schools felt that CPR training is best provided in school settings. Schools perceived the greatest benefit of CPR training as providing students with the skill to save a life (43%). The most frequently identified barriers were logistical: limited time to teach the curriculum (24%), lack of funds (16%), and instructor scheduling difficulties (17%). Less than 5% of respondents voiced any opposition to CPR training, and that opposition was for logistical reasons. To increase CPR training, the single best strategies suggested were: increase funding, provide time in the curriculum, have more certified instructors, and make CPR student training a requirement.