"Goals of Care Conversations Don't Fit in a Box": Hospice Staff Experiences and Perceptions of Advance Care Planning Quality Measurement

Content Analysis of Serious Illness Conversation Documentation: Structured vs. Free-Text Information

CONTEXT

Clear, accessible, and thorough documentation of serious illness conversations helps ensure that critical information patients share with clinicians is reflected in their future care.

OBJECTIVES

We sought to characterize and compare serious illness conversations recorded two different ways in the electronic health record to better understand patterns of serious illness conversation documentation.

METHODS

We performed content analysis of serious illness conversations documented in the electronic health record, whether documented via structured tab or free-text clinical notes, for patients (n=150) with advanced cancer who started a treatment associated with a poor prognosis between October 2020 and June 2022. A multidisciplinary team iteratively developed a codebook to classify serious illness conversation content (e.g., goals/hopes) on a preliminary sample (n=30), and two researchers performed mixed deductive-inductive coding on the remaining data (n=120). We reviewed documentation from 34 patients with serious illness conversations documentation in the structured tab only, 43 with documentation in only free-text clinical notes, and 44 with documentation of both types. We then compared content between documentation types.

RESULTS

Information documented more frequently in structured tabs included fears/worries and illness understanding; clinical notes more often included treatment preferences, deliberations surrounding advance directives, function, and trade-offs. Qualitative insights highlight a range of length and detail across documentation types, and suggest notable authorship by palliative and social work clinicians.

CONCLUSION

How serious illness conversations are documented in the electronic health record may impact the content captured. Future quality improvement efforts should seek to consolidate documentation sources to improve care and information retention.

Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia

Background: Racial and ethnic minoritized people with dementia (PWD) are at high risk of disenrollment from hospice, yet little is known about the relationship between hospice quality and racial disparities in disenrollment among PWD. Objective: To assess the association between race and disenrollment between and within hospice quality categories in PWD. Design/Setting/Subjects: Retrospective cohort study of 100% Medicare beneficiaries 65+ enrolled in hospice with a principal diagnosis of dementia, July 2012-December 2017. Race and ethnicity (White/Black/Hispanic/Asian and Pacific Islander [AAPI]) was assessed with the Research Triangle Institute (RTI) algorithm. Hospice quality was assessed with the publicly-available Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item on overall hospice rating, including a category for hospices exempt from public reporting (unrated). Results: The sample included 673,102 PWD (mean age 86, 66% female, 85% White, 7.3% Black, 6.3% Hispanic, 1.6% AAPI) enrolled in 4371 hospices nationwide. Likelihood of disenrollment was higher in hospices in the lowest quartile of quality ratings (vs. highest quartile) for both White (adjusted odds ratio [AOR] 1.12 [95% confidence interval 1.06-1.19]) and minoritized PWD (AOR range 1.2-1.3) and was substantially higher in unrated hospices (AOR range 1.8-2.0). Within both low- and high-quality hospices, minoritized PWD were more likely to be disenrolled compared with White PWD (AOR range 1.18-1.45). Conclusions: Hospice quality predicts disenrollment, but does not fully explain disparities in disenrollment for minoritized PWD. Efforts to improve racial equity in hospice should focus both on increasing equity in access to high-quality hospices and improving care for racial minoritized PWD in all hospices.

Front-Line Hospice Staff Perceptions of Barriers and Opportunities to Discussing Advance Care Planning With Hospice Patients and Their Families

OBJECTIVES

To understand the facilitators and barriers to hospice staff engagement of patients and surrogates in advance care planning (ACP) conversations.

DESIGN

Qualitative study conducted with purposive sampling and semistructured interviews using ATLAS.ti software to assist with template analysis.

SETTINGS AND PARTICIPANTS

Participants included 51 hospice professionals (31 clinicians, 13 leaders, and 7 quality improvement administrators) from 4 geographically distinct nonprofit US hospices serving more than 2700 people.

MEASURES

Interview domains were derived from the implementation science framework of Capability, Opportunity, Motivation, and Behavior (COM-B), with additional questions soliciting recommendations for behavior change. Differences in themes were reconciled by consensus. The facilitator, barrier, and recommendation themes were organized within the COM-B framework.

RESULTS

Capability was facilitated by interdisciplinary teamwork and specified clinical staff roles and inhibited by lack of self-perceived skill in engaging in ACP conversations. Opportunities for ACP occurred during admission to hospice, acute changes, or deterioration in patient condition. Opportunity-related environmental barriers included time constraints such as short patient stay in hospice and workload expectations that prevented clinicians from spending more time with patients and families. Motivation to discuss ACP was facilitated by the employee's goal of providing personalized, patient-centered care. Implicit assumptions about patients' and families' preferences reduced staff's motivation to engage in ACP. Hospice staff made recommendations to improve ACP discussions, including training and modeling practice sessions, earlier introduction of ACP concepts by clinicians in prehospice settings, and increasing workforce diversity to reflect the patient populations the organizations want to reach and cultural competency.

CONCLUSIONS AND IMPLICATIONS

Even hospice staff can be uncomfortable discussing death and dying. Yet staff were able to identify what worked well. Solutions to increase behavior of ACP engagement included staff training and modeling practice sessions, introducing ACP prior to hospice, and increasing workforce diversity to improve cultural competency.