3 - (IOP 9) Applying Designing for Dissemination to Optimize VA Psychiatric Advance Directives for Veteran-centered Care

Psychiatric advance directives (PADs) are legal documents intended to communicate mental health preferences during psychiatric crises. A recent meta-analysis showed that PADs and similar crisis planning strategies reduced involuntary admissions by 25% compared to usual care. In the VA, PADs are integrated with medical advance directives. Our recent EHR study of >5000 Veterans with serious mental illness (SMI) identified that only 3.2% of these Veterans have PADs and 10% have medical advance directives. We identified no explicit evidence of PAD implementation during these Veterans’ subsequent psychiatric hospitalizations. The goal of this study is to use designing for dissemination and sustainability (D4DS) strategies to understand the current fit of the PAD concept with the actual product in terms of its design and workflow so that future work can identify methods to improve PAD prevalence and implementation in VA settings.

We completed informant interviews using a customer discovery approach including 15 total informants (11 providers, 3 patients, 1 principal investigator). We utilized the Fit to Context Framework (F2C), an iterative approach to planning studies using D4DS to support context-relevant, equitable, and implementation-ready design of research products. Specifically, this study used the first phase, conceptualization, to assess context, priorities, and product demand.

We identified that the PAD is integrated within medical service workflows, policies, and documentation, with limited integration within VA mental health services for screening or completion. VA providers report varied perceptions of the PAD’s utility. Some were unaware of its existence or purpose, despite using the integrated medical/psychiatric directive in their clinical practice. The primary or sole use of PADs for many clinicians was to identify Veterans’ power of attorney for end-of-life decision-making. Veterans report investment in the concept of PADs for communicating preferences during crises but had poor experiences (e.g., being screened during psychiatric crises in ER settings). All informant groups reported that stigma and discomfort decreased willingness to complete PADs.

Therefore, VA PADs have a fundamental lack of fit across all elements: the product itself, its perceived value, and workflows including screening, completion, and use. This lack of fit is by design; the product and workflow are intended for older and very ill Veterans to support end-of-life care. However, Veterans with SMI still experience disparities in terms of medical directives (10% vs. ~37% in community samples). This suggests multilevel barriers for Veterans with SMI regardless of the directive’s stated purpose. Increasing prevalence and implementation of VA PADs requires broad changes in design and workflow. Dissemination strategies might increase the PAD’s perceived value among clinicians and others. However, it may also be effective to consider different strategies to increase Veteran-centered care during psychiatric crises given varied perspectives on the current product. In this case, it is still important to tailor current workflows to increase medical directive prevalence among Veterans with SMI to eliminate current disparities.