Potential of Team-Based Approaches to Improve Goals of Care Conversations in Primary Care Settings

Key Message : Primary care is an important setting for goals of care conversations (GoCCs). However, rates may be limited by clinician-specific and system-specific barriers. Our qualitative study of primary care clinicians and leaders across VA medical centers that improved GoCC rates suggests potential for interdisciplinary team-based strategies in supporting primary palliative care.

Abstract:

Background:
Goals of care conversations (GoCCs) can help align medical treatment with patient preferences and values (1, 2). Primary care settings offer a prime opportunity for initiating GoCCs in patients with serious illness, given both continuity and trust in patient-provider relationships and ability for proactive timing of such conversations (3, 4). Yet, GoCC rates in primary care remain suboptimal due to barriers such as clinicians’ time constraints, competing priorities, and limited experience conducting GoCCs (5). We explored approaches that might have successfully improved GoCC rates in the Veterans Health Administration (VA).

Objective:
To identify and characterize approaches that support GoCC implementation in primary care.

Methods:
We conducted qualitative interviews with 67 clinicians and leaders from 10 VA medical centers across the US that had each improved their outpatient rates of GoCCs from 2019 to 2023. Interviews explored factors influencing decisions to initiate GoCCs, barriers to implementation, and approaches explicitly used to improve GoCC rates. Data analysis was based on the constant comparative method, using primarily deductive coding but also informed by new concepts that emerged.

Results:
We identified three distinct approaches anchored to primary care settings: 1) Discrete interventional components within primary care (e.g., dedicated appointments); 2) Multi-component team-based approaches within primary care (e.g., social workers complete preparatory GoCC steps); 3) Interdisciplinary and multi-specialty collaboration (e.g., with Palliative Care).

Conclusion:
Interdisciplinary, team-based strategies may increase initiation of GoCCs in primary care. Multi-component approaches may be the most promising by maximizing existing team structures while addressing provider time limitations. Integration into clinical workflows can optimize implementation while nurturing collaboration. Our findings have the potential to inform strategies within the VA and broader healthcare systems that promote primary palliative care and increase GoCC rates to ensure engagement of more patients in the necessary conversations to align their care with their values.

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2.Krejci LP, Carter K, Gaudet T. Whole health: the vision and implementation of personalized, proactive, patient-driven health care for veterans. Med Care 2014;52:S5-8.
3. Munday D, Pastrana T, Murray SA. Defining and developing primary palliative care as an essential element of primary health care. Palliat Med. 2024 Sep;38(8):766-769. doi: 10.1177/02692163241270915. Epub 2024 Aug 19. PMID: 39155820; PMCID: PMC11528942.
4. A National Framework and Preferred Practices for Palliative and Hospice Care Quality. The National Quality Forum. Washington, DC. 2006.
5. Haverhals LM, Gilman C, Manheim C, Bauers C, Kononowech J, Levy C. Implementation of VA's Life Sustaining Treatment Decisions Initiative: Facilitators and Barriers to Early Implementation Across Seven VA Medical Centers. J Pain Symptom Manage 2020 Nov 3:S0885-3924(20)30863-0.