Barriers Facing Primary Care Leaders in Implementing Goals of Care Conversations with Seriously Ill Veterans

Outcomes 1. To better understand provider barriers faced by organizational leaders when implementing goals of care conversations in primary care settings.2. To better understand teamwork and system barriers faced by organizational leaders when implementing goals of care conversations in primary care settings. Key Message The session will report on research findings that capture the perspectives of organizational leaders on what barriers they face when implementing goals of care conversations in primary care settings. This research is being conducted as part of a large, multi-site pragmatic implementation trial to improve uptake of goals of care conversations within the Veterans Health Administration. Introduction/Context Across the Veterans Health Administration (VHA), few goals of care conversations (GoCCs) occur in primary care (PC) settings. We aimed to identify current barriers PC organizational leaders face when implementing GoCC for seriously ill Veterans. Methods We conducted semi-structured interviews with 20 interdisciplinary organizational leaders (physicians, nurses, and social workers) from three VA facilities. We used the Consolidated Framework for Implementation Research (CFIR) to inform interview guide development. Our analytic approach relied on thematic analysis, in conjunction with team and role theories to inform coding. Results Five themes represented barriers reported by organizational leaders (Table 1). Leaders recognized GoCCs as foundational but would rather focus efforts on engaging patients and iteratively preparing them for future decision making – such as focusing on goals, values, and surrogate decision makers – rather than capturing preferences for life-sustaining treatments alone (Theme 1). Additionally, leaders perceived documentation as burdensome and limited in capturing high-quality GoCC (Theme 2). They viewed documentation by clinicians as often variable, thus variably useful. In addition to describing barriers specific to conversations and documentation, leaders shared factors impeding successful teamwork regarding GoCC. Interdisciplinary team members disagreed about whose role it was to complete tasks. Lack of a shared mental model and insufficient time were commonly reported (Theme 3). Leaders cited difficulties in engaging and training all team members on how to implement GoCC effectively, even when materials were available for dissemination (Theme 4). Lastly, even if there were capacity to train teams, perform GoCC, and document, leaders worried about insufficient prioritization of quality improvement initiatives (Theme 5), largely because quality metrics that facilities are judged on do not pertain to GoCC. Conclusion We identified key barriers for implementing GOCCs, including beliefs regarding the content of GoCC, challenges with documentation, role identities of interdisciplinary team members, team engagement, and prioritization. Keywords Shared Decision Making / Advance Care PlanningPatient Outcomes