The VA is the largest integrated health care system in America. In recent years, the VA has focused on the needs of aging and seriously ill veterans and has implemented a networkwide performance standard that targets two high-priority areas for improving end-of-life care: advance care planning and pain management. Patients who have severe diseases, such as congestive heart failure and chronic obstructive pulmonary disease (COPD), are included. Hospitals can meet the standards in two ways: by referring patients to hospice care and by documenting specific services for patients, ranging from advance care planning to pain management. Performance evaluation looks at a center's progress toward the standard.
With its national advance care planning project, the VA is aiming to have advance care plans in place for 95 percent of its seriously ill patients. When the project began, about half of these patients had such plans. After three months of an intensive effort to increase patient-provider communication about pain management, advance directives, and other end-of-life issues, almost 70 percent of the most severely ill patients had made advance care plans.
The VA is also turning its attention to improving pain management with a project called "Pain as a Fifth Vital Sign" to ensure that all of its health care sites make pain assessment as routine as taking a patient's blood pressure or temperature. Coordinated by a multidisciplinary team representing various health care fields, the program features increased education for patients and providers, along with better documentation of pain assessment and treatment. Clinicians will learn how to interpret and respond to patient reports of severe pain; patients and families will learn the importance of talking to providers about pain; and the health care system will track pain scores in patients' medical records. The VA has earmarked more than $3 million for staff training and pain management research.
The VA has been a leader in improving care of the dying: In 1991, it issued an official policy that all veterans needing and choosing hospice care would be provided with such care, either through the VA or through referrals to community hospice resources. In the years since, the VA has mandated that each of its medical centers establish a hospice program according to its needs and resources.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].