Beyond implementation: what drives long-term sustainment of life-sustaining treatment documentation in VA home based...

Sustaining evidence-based practices in health care systems remains a persistent challenge. While many implementation efforts successfully achieve adoption and short-term outcomes, these gains may diminish once external support is withdrawn. Understanding organizational and contextual factors influencing sustainability is necessary for long-term success. We designed the Preferences Elicited and Respected for Seriously Ill Veterans (PERSIVED) United States Department of Veterans Affairs (VA) quality improvement project to support documentation of life-sustaining treatment (LST) preferences aimed to identify and explain determinants impacting sustainment following the end of active implementation strategies.

Eleven Home-Based Primary Care (HBPC) programs participated in the stepped-wedge design that included pre-implementation, implementation, and sustainability phases. During the implementation phase, programs received monthly coaching and audit with feedback showing rates of LST documentation. During sustainability, coaching calls ceased with audit with feedback continuing. To explore contextual determinants of sustainability, semi-structured group interviews were conducted with site champions and leadership at months 4 and 12 of sustainability. Qualitative data were analyzed using a matrixed multiple case study approach guided by the Clinical Sustainability Assessment Tool.

All participating sites sustained or exceeded LST documentation rates reached during the implementation phase throughout the sustainability phase. Enabling factors included embedding LST documentation into clinical visit processes, viewing documentation as standard of care, clear team expectations, use of feedback reports to motivate change, and inclusion of LST documentation in provider performance evaluations. Differentiating factors included leadership engagement, mechanisms for monitoring performance data, and team awareness and beliefs regarding the importance of LST documentation. Hindering factors included staff shortages, competing demands, and limited time to engage in conversations regarding preferences and time to document preferences. Program expansion had a mixed impact depending on staffing capacity and workflow integration. Continuing education and use of PERSIVED resources had limited impact on sustainability.

Embedding LST documentation into routine workflows, maintaining visibility of performance data, and reinforcing expectations by leadership and organizational processes led to sustainment of LST documentation in VA HBPC programs. These findings inform strategies for future studies emphasizing systems change and encourage the examination of sustainability over a longer period to assess which determinants are most influential for maintaining evidence-based practices after implementation ends.