退伍军人团体高级护理计划试点

无干预：Usual Care

The patient will continue to receive as normal and usual care. The participant will also receive educational materials in writing regarding advance care planning mailed to their preferred mailing address. The participants will complete surveys and interviews at baseline at again at 2 months post-enrollment.

实验性的：Group Advance Care Planning

The participant will receive normal and usual care which also consists of educational materials in writing regarding advance care planning mailed to their preferred mailing address. They will also engage in 2 group educational sessions with 4-5 participants which will last 60-90 minutes regarding advance care planning. They participants will complete surveys and interviews at baseline and again at 2 months post-enrollment.

行为的：Group Advance Care Planning Education

Those assigned to the group ACP arm will receive usual care and the intervention which consists of 2 virtual or in-person 60-90 minute sessions by a trained community health worker/health educator. Sessions will introduce advanced care planning, help veterans discuss their goals of care with their care teams and learn how to discuss with their families and oncologist, and filing an advanced directive. Participants will be surveyed and interviewed at baseline and again at 2 months post-enrollment.

Goals of Care Documentation

Documentation of goals of care discussions will be analyzed for each patient at 8 weeks after patient enrollment.

Feeling Heard and Understood

Each patient will receive a validated Heard and Understood assessment survey. 4-item National Quality Forum-endorsed survey assessing self-perceived quality of communication with clinical care team. Each question is scored with a range of 0 to 4, with analyses comparing the proportion of patients reporting a top score (4) for a given question. The measure's reliability and validity has been assessed in a large study of outpatients with serious illness. It will be collected by self-report and self-administered assessment for each patient at Baseline and Week 8.

Change in patient activation using the Patient Activation Measure

Each patient will receive a validated patient activation survey (PAM-10) to assess their activation. This is a validated measure from Insignia Health. Responses are: disagree strongly, disagree, agree, agree strongly with higher activation correlated with responses of agree and agree strongly. Each item is rated on 4-point scale (1 strongly disagree to 4 strongly agree, with additional "not applicable" option). Higher scores indicate greater patient activation. It will be collected for each patient by self-assessment at Baseline and Week 8.

Change in patient satisfaction with decision using the Satisfaction with Decision Measure

Each patient will receive a validated satisfaction with decision survey to assess their satisfaction with decision. It will be analyzed for each patient at Baseline and Week 8.

Palliative Care Use (Self-reported and Chart Review)

Palliative care use will be analyzed for each patient at month 6.

Hospice Care Use (Self-reported and Chart Review)

Hospice care use will be analyzed at month 6.

Hospitalization Visits (Self-reported and Chart Review)

Hospital use for each patient will be self-reported by each patient or abstracted by electronic medical record at month 6.