Objectives: To elicit perspectives from specialist palliative care (SPC) and cardiology clinicians on the necessary components, delivery characteristics, and implementation strategies of successful ambulatory SPC for people with heart failure (HF). Background: Palliative care is a recommended component of guideline-directed care for people with HF. However, optimal strategies to implement SPC within ambulatory settings are unknown. Methods: Following a positive deviance frame, we conducted a qualitative study comprising interviews with SPC and cardiology clinicians at Veterans Affairs Medical Centers (VAMCs) with the highest number of ambulatory SPC consultations within the VA system among people with HF from 2021-2022. Clinicians were asked how they provided ambulatory SPC and what they felt were the necessary components, delivery characteristics, and implementation strategies of care delivery. Interviews were analyzed using content analysis. Results: We interviewed 14 SPC clinicians and 9 cardiology clinicians at seven national VAMCs; 43% were physicians 48% were advanced practice registered nurses/physician associates, and 10% were psychologists or social workers. Discussion of goals of care (e.g., prognosis, advance directives) and connecting patients/caregivers to resources (e.g., homecare) were essential components of ambulatory SPC provided at participating facilities. Clinicians preferred and used integrated (i.e., embedded) approaches to SPC delivery, employed standardized patient selection and referral procedures, and formalized procedures for handoffs to and from SPC. Necessary strategies to address barriers to ambulatory SPC implementation included deploying palliative champions, educating non-SPC clinicians on the value of ambulatory SPC for people with HF, and developing ambulatory models through leadership support. Conclusions/Implications: Facilitating the broader adoption of ambulatory SPC may be achieved by prioritizing these mutually valued and necessary features of delivery.

The authors have declared no competing interest.

This material is the result of work supported with resources at the VA Connecticut Healthcare System. SLF received funding for this work from the Palliative Care Research Cooperative and the National Institutes of Nursing Research (5U2CNR014637).

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

West Haven Department of Veterans Affairs and Yale University.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

The availability of data from this manuscript is in accordance with the West Haven Department of Veterans Affairs Institutional Review Board and VA research polices.