Development and Evaluation of Serious Illness Conversation Training for Interprofessional Primary Care Teams

Impact of a team-based versus individual clinician-focused training approach on primary healthcare professionals' intention to have serious illness conversations with patients: A theory-informed process evaluation embedded within a cluster randomized trial

BACKGROUND

Cluster randomized trials (cRTs) on the effectiveness of training programs face complex challenges when conducted in real-world settings. Process evaluations embedded within cRTs can help explain their results by exploring possible causal mechanisms impacting training effectiveness.

OBJECTIVE

To conduct a process evaluation embedded within a cRT by comparing the impact of team-based vs. individual clinician-focused SICP training on primary healthcare professionals' (PHCPs) intention to have serious illness conversations with patients.

METHODS

The cRT involved 45 primary care practices randomized into a team-based (intervention) or individual clinician-focused (comparator) training program and measured primary outcomes at the patient level: days at home and goals of care. To perform this theory-informed mixed-methods process evaluation embedded within the cRT, a different outcome was measured at the level of the PHCPs, namely, PHCPs' intention to have serious illness conversations with patients as measured with CPD-Reaction. Barriers and facilitators to implementing the conversations were identified through open-ended questions and analyzed using the Theoretical Domains Framework. The COM-B framework was used to triangulate data. Results were reported using the CONSORT and GRAMMS reporting guidelines.

RESULTS

Of 535 PHCPs from 45 practices, 373 (69.7%) fully completed CPD-Reaction (30.8% between 25-34 years old; 78.0% women; 54.2% had a doctoral degree; 50.1% were primary care physicians). Mean intention scores for the team-based (n = 223) and individual clinician-focused arms (n = 150) were 5.97 (standard error (SE): 0.11) and 6.42 (SE: 0.13), respectively. Mean difference between arms was 0.0 (95% CI -0.29; 0.30; p = 0.99) after adjusting for age, education and profession. The team-based arm reported barriers with communication, workflow, and more discomfort in having serious illness conversations with patients.

CONCLUSIONS

Team-based training did not outperform individual clinician-focused in influencing PHCPs' intention to have serious illness conversations. This process evaluation suggests that team-based training could improve intervention effectiveness by focusing on interprofessional communication, better organized workflows, and better support and training for non-clinician team members. Registration: ClinicalTrials.gov (ID: NCT03577002).

Long-Term Effects of Individual-Focused and Team-Based Training on Health Professionals' Intention to Have Serious Illness Conversations: A Cluster Randomised Trial

We aimed to measure the sustainability of health professionals' intention to have serious illness conversations with patients using the Serious Illness Conversation Guide (SICG) after individual-focused training versus team-based training. In a cluster randomised trial, we trained healthcare professionals in 40 primary care clinics and measured their intention to hold serious illness conversations immediately (T1), after 1 year (T2) and after 2 years (T3). Primary care clinics (n = 40) were randomly assigned to individual-focused training (comparator) or team-based training (intervention). Average age of the 373 participants was 35-44 years, 79% were women. On a scale of 1 to 7, at T1, the mean intention was 5.33 (SD 0.20) in the individual-focused group and 5.36 (SD 0.18) in the team-based group; at T2, these scores were 4.94 (SD 0.23) and 4.87 (SD 0.21) and at T3, 5.14 (SD 0.24) and 4.59 (SD 0.21), respectively. At T3, the difference in mean intention between study groups had a significant p-value of 0.01. Intention to have serious illness conversations was lower at T2 and T3 after team-based training than after individual-focused training, with a significant difference at 2 years in favour of individual-focused training. Health professionals reported not enough time during consultations for serious illness conversations as a major barrier.

Registration number

ClinicalTrials.gov (ID NCT03577002) for the parent clinical trial.

Palliative Care and Advance Care Planning Intervention Fidelity Monitoring: Methods and Lessons Learned From PCORI-Funded Large-Scale, Pragmatic Clinical Trials

Over the past decade, the Patient-Centered Outcomes Research Institute (PCORI) funded multiple large-scale, comparative effectiveness clinical trials evaluating palliative care and advance care planning interventions. These are complex multicomponent interventions that need robust but flexible fidelity monitoring. Fidelity is necessary to maintain both internal and external validity within palliative care intervention research and to ultimately evaluate the real-world impact of high-quality interventions. Different trials not only took varying approaches to fidelity monitoring but also uncovered both unique and common challenges and facilitators. This article summarizes 8 of these trials and highlights approaches, adaptations, barriers, and facilitators for intervention fidelity monitoring. Identifying and delivering core elements while simultaneously allowing adaptations of noncore elements is a vital part of fidelity monitoring. Dissemination of such experiences can inform both future palliative care research as well as ongoing implementation of palliative care and advance care planning interventions across diverse clinical practices. Adoption of rigorous intervention fidelity methods is critical to advancing the science and reproducibility of palliative care interventions.

Implementing the Serious Illness Care Program in Safety Net Health Systems: A Qualitative Study

CONTEXT

Interventions to improve the quality of care for people affected by serious illness commonly fail to reach patients from marginalized and underserved communities, which include those characterized by racialized or indigenous identity, sexual and gender minority status, and rural living. Interventions to improve care through serious illness conversations have demonstrated benefit, but little is known about their implementation in health systems that predominantly serve these patient groups.

OBJECTIVES

The study aimed to understand factors influencing implementation of a serious illness communication-focused intervention-the Serious Illness Care Program in health systems who primarily provide care to marginalized and underserved communities.

METHODS

Qualitative interviews (16) and focus groups (3) were conducted with 19 interdisciplinary team members from six geographically diverse U.S. healthcare systems. Using a template analysis approach, investigators coded data inductively and deductively to identify themes.

RESULTS

Three themes emerged: patient factors, intervention elements, and health system contextual factors. Participants highlighted mission-driven efforts, creativity, interprofessional practice, and trainees as enablers of success. They identified weaknesses in the intervention's communication tool-the Serious Illness Conversation Guide as barriers to implementation of conversations. Resource constraints, socio-economic vulnerability, and mistrust in the health system were seen as additional barriers.

CONCLUSIONS

Health systems that provide care to underserved and marginalized communities face unique challenges implementing the Serious Illness Care Program. They also possess assets, some unique to these settings, that support program adoption. Findings suggest that implementation of similar programs in low-resource healthcare settings may help address unmet needs among marginalized populations.

Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments

OBJECTIVE

Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions.

METHODS

The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR).

RESULTS

Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic.

CONCLUSION

Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

Improving serious illness communication: a qualitative study of clinical culture

OBJECTIVE

Communication about patients' values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations.

METHODS

Qualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions.

RESULTS

We completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians' beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from 'end-of-life planning' to 'knowing and honoring what matters most to patients;' improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physician's job; discomfort managing emotions; lack of reliable processes.

CONCLUSIONS

Aspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change.