Clinician Insights into Effective Components, Delivery Characteristics, and Implementation Strategies of Ambulatory Palliative Care for People with Heart Failure: A Qualitative Analysis

Abstract

AbstractObjectivesTo elicit perspectives from specialist palliative care (SPC) and cardiology clinicians on the necessary components, delivery characteristics, and implementation strategies of successful ambulatory SPC for people with heart failure (HF).BackgroundPalliative care is a recommended component of guideline-directed care for people with HF. However, optimal strategies to implement SPC within ambulatory settings are unknown.MethodsFollowing a positive deviance frame, we conducted a qualitative study comprising interviews with SPC and cardiology clinicians at Veterans Affairs Medical Centers (VAMCs) with the highest number of ambulatory SPC consultations within the VA system among people with HF from 2021-2022. Clinicians were asked how they provided ambulatory SPC and what they felt were the necessary components, delivery characteristics, and implementation strategies of care delivery. Interviews were analyzed using content analysis.ResultsWe interviewed 14 SPC clinicians and 9 cardiology clinicians at seven national VAMCs; 43% were physicians 48% were advanced practice registered nurses/physician associates, and 10% were psychologists or social workers. Discussion of goals of care (e.g., prognosis, advance directives) and connecting patients/caregivers to resources (e.g., homecare) were essential components of ambulatory SPC provided at participating facilities. Clinicians preferred and used integrated (i.e., embedded) approaches to SPC delivery, employed standardized patient selection and referral procedures, and formalized procedures for handoffs to and from SPC. Necessary strategies to address barriers to ambulatory SPC implementation included deploying palliative champions, educating non-SPC clinicians on the value of ambulatory SPC for people with HF, and developing ambulatory models through leadership support.Conclusions/ImplicationsFacilitating the broader adoption of ambulatory SPC may be achieved by prioritizing these mutually valued and necessary features of delivery.