title: Barriers and Facilitators to Scaling Up Outpatient Palliative Care.
abstract: BACKGROUND
  The Institute of Medicine recommends people with serious advanced illness have access to skilled palliative care. However, the predominant delivery model of nonhospice palliative care is inpatient, consultative care focused on the end of life, with a small specialist palliative care workforce.
  
  
  OBJECTIVE
  The study objective was to understand organizational factors that could influence the adoption and scale-up of outpatient palliative care in chronic advanced illness, using the example of heart failure.
  
  
  METHODS
  This was a cross-sectional qualitative study. Participants were 17 health care providers and local, regional, and national health system leaders from the Veterans Health Administration (VHA) who were considering whether and how to adopt and sustain outpatient palliative care. Individual interviews using semistructured questions assessed domains of the Consolidated Framework for Implementation Science.
  
  
  RESULTS
  Most providers and leaders perceived outpatient palliative care as high priority in the VHA given its patient-centeredness and potential to decrease health care use and costs associated with conditions like heart failure. They also supported a collaborative care team model of outpatient palliative care delivery where a palliative care specialist collaborates with medical nurses and social workers. They reported lack of performance measures/incentives for patient-centered care processes and outcomes as a potential barrier to implementation. Features of outpatient palliative care viewed as important for successful adoption and scale-up included coordination and communication with other providers, ease of integration into existing programs, and evidence of improving quality of care while not substantially increasing overall health care costs.
  
  
  CONCLUSIONS
  Incentives such as performance measures and collaboration with local VHA providers and leaders could improve adoption and scale-up of outpatient palliative care.
authors.affiliation: 1 Department of Veterans Affairs, Eastern Colorado Health Care System , Denver, Colorado.|2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado.
authors.forename: David B
authors.initials: DB
authors.lastname: Bekelman
authors.affiliation: 3 Department of Family Medicine and Colorado Health Outcomes Program, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado.
authors.forename: Borsika A
authors.initials: BA
authors.lastname: Rabin
authors.affiliation: 2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado.
authors.forename: Carolyn T
authors.initials: CT
authors.lastname: Nowels
authors.affiliation: 4 VA Palo Alto Health Care System , Palo Alto, California.
authors.forename: Anju
authors.initials: A
authors.lastname: Sahay
authors.affiliation: 4 VA Palo Alto Health Care System , Palo Alto, California.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Heidenreich
authors.affiliation: 2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado.
authors.forename: Stacy M
authors.initials: SM
authors.lastname: Fischer
authors.affiliation: 5 Department of Health and Behavioral Sciences, University of Colorado , Denver, Colorado.
authors.forename: Deborah S
authors.initials: DS
authors.lastname: Main
mesh_terms: D000553:Ambulatory Care / Q000458:organization & administration*; D003430:Cross-Sectional Studies; D005260:Female; D006292:Health Priorities; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D008297:Male; D017146:Models, Organizational; D010166:Palliative Care / Q000458:organization & administration*; D036301:Qualitative Research; D014481:United States; D014493:United States Department of Veterans Affairs