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Edwards ST, O'Neill A, Niederhausen M, Salvi A, Laliberte A, Saha S, Hynes DM, Pizer S, Kinosian B. Trajectories of care and outcomes of Veterans receiving home-based primary care. J Am Geriatr Soc 2024; 72:80-90. [PMID: 37772617 DOI: 10.1111/jgs.18607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described. METHODS We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015. We extracted demographics, comorbidities, functional status, and social supports from VA and Medicare data and examined patterns of care and clinical outcomes, including hospital, nursing home (NH), hospice use and mortality from FY2015-2017. We present results using descriptive statistics, alluvial plots, and heat maps. RESULTS We identified 10,571 HBPC enrollees in FY2015; mean age was 77.7. HBPC patients commonly had chronic medical conditions with high self-management burden (e.g., diabetes 48.2%) and disabling conditions such as dementia (39.3%). Over half had ≥2 deficits in activities of daily living, 46% had caregivers with functional limitations or no caregiver, and 25% resided in a socially deprived area. Patients experienced variable care trajectories. Mean time enrolled in HBPC was 331 days, 8.3% of patients were discharged after 3 months, and 22.8% stayed enrolled for over 2 years. Institutional health care use declined in the 6 months after initial enrollment: (e.g., hospital: 41%-25%, NH: 34%-11%). At 2 years, 36% of patients had died; among decedents, 58% received hospice and 72% died in a non-institutional setting. In the last 180 days of life, 84% of time was spent at home, and once enrolled in hospice, 97% of time was spent outside of institutional care. CONCLUSIONS HBPC patients experience highly variable care trajectories but on average have reductions in acute care use and spend a majority of time in non-institutional settings. These data allow for a nuanced understanding of HBPC, providing a platform for monitoring, evaluating, and improving program function.
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Affiliation(s)
- Samuel T Edwards
- Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon, USA
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Allison O'Neill
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Oregon Health and Science University - Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Apoorva Salvi
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Avery Laliberte
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Somnath Saha
- Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Health Management and Policy Program, School of Public Health and Nutrition, College of Health, Oregon State University, Corvallis, Oregon, USA
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Steven Pizer
- Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- Partnered Evidence-Based Policy Resource Center, Department of Veterans Affairs, Boston, Massachusetts, USA
| | - Bruce Kinosian
- Division of Geriatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Geriatrics and Extended Care Data Analysis Center, Cpl Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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2
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Raj M, Stephenson AL, DePuccio MJ, Sullivan EE, Tarver W, Fleuren B, Thomas SC, Scheck McAlearney A. Conceptual Framework for Integrating Family Caregivers Into the Health Care Team: A Scoping Review. Med Care Res Rev 2023; 80:131-144. [PMID: 36000495 DOI: 10.1177/10775587221118435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
More than 80% of family care partners of older adults are responsible for coordinating care between and among providers; yet, their inclusion in the health care delivery process lacks recognition, coordination, and standardization. Despite efforts to include care partners (e.g., through informal or formal proxy access to their care recipient's patient portal), policies and procedures around care partner inclusion are complex and inconsistently implemented. We conducted a scoping review of peer-reviewed articles published from 2015 to 2021 and reviewed a final sample of 45 U.S.-based studies. Few articles specifically examine the inclusion of care partners in health care teams; those that do, do not define or measure care partner inclusion in a standardized way. Efforts to consider care partners as "partners" rather than "visitors" require further consideration of how to build health care teams inclusive of care partners. Incentives for health care organizations and providers to practice inclusive team-building may be required.
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Affiliation(s)
| | | | | | | | | | | | - Samuel C Thomas
- Stanford School of Medicine and Intermountain Healthcare, USA
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3
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McConnell ES, Xue TM, Levy CR. Veterans Health Administration Models of Community-Based Long-Term Care: State of the Science. J Am Med Dir Assoc 2022; 23:1900-1908.e7. [PMID: 36370751 DOI: 10.1016/j.jamda.2022.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
The complex care needs of older adults arising at the intersection of age-related illnesses, military service, and social barriers have presented challenges to the US Department of Veterans Affairs (VA) for decades. In response, the VA has invested in centers that integrate research, education, and clinical innovation, using approaches aligned with a learning health care system, to create, evaluate, and implement new care models. This article presents an integrative review of 6 community care models developed within the VA to manage multimorbidity, complex social needs, and avoid institutional care, examining how these models address complex care needs among older adults. The models reviewed include Home Based Primary Care, Medical Foster Home, the VA Caregiver Support Program, the Resources Enhancing Alzheimer's Caregiver Health (REACH)-VA program, the Caregivers of Older Adults Cared for at Home (COACH) program, and Veteran Directed Care. Core components and evaluation outcomes for each model are summarized, along with implications for more widespread implementation and research. Each model promotes coordinated care, integrates behavioral health, and leverages interprofessional expertise. All models are cost-neutral or incur only modest cost increases to improve outcomes. Broader implementation will require interprofessional workforce development, payment model realignment, and infrastructure to evaluate outcomes in new settings. The VA provides a blueprint for infrastructure that could be adapted to other domestic and international settings. Care models successfully implemented within the VA's single-payer system hold promise to address persistent dilemmas in long-term care, such as management of multimorbidity and social drivers of health, integration and support of family caregivers, and mental health integration. These models also demonstrate the value of incorporating care approaches that have been developed or tested outside the United States and argue for greater cross-fertilization of ideas from different health systems.
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Affiliation(s)
- Eleanor S McConnell
- Duke University School of Nursing, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA.
| | - Tingzhong Michelle Xue
- Duke University School of Nursing, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Cari R Levy
- University of Colorado School of Medicine, Aurora, CO, USA; Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
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4
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Haverhals LM. How Social Determinants of Health of Individuals Living or Working in U.S. Department of Veterans Affairs Home-Based Long-Term Care Programs in Puerto Rico Influenced Recovery after Hurricane Maria. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13243. [PMID: 36293827 PMCID: PMC9603221 DOI: 10.3390/ijerph192013243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/07/2022] [Accepted: 10/09/2022] [Indexed: 06/16/2023]
Abstract
In September 2017, Hurricane Maria devastated Puerto Rico, causing extensive infrastructure damage and a significant number of deaths. In the months and years since, recovery from Maria has been slow, hampered by delayed delivery of fiscal aid, corruption, economic hardships, and Puerto Rico's colonial status. Simultaneously, Puerto Rico's population is rapidly aging and hundreds of thousands of mostly younger Puerto Ricans are migrating out of Puerto Rico for more opportunities. Many Puerto Ricans who are older or disabled and need long-term care receive this care in home-based environments, as Puerto Rico has minimal institutionalized long-term care infrastructure and limited funding to expand it. The Department of Veterans Affairs (VA) offers several home-based long-term care options for Veterans in Puerto Rico. In this qualitative case study, veterans, VA staff, veterans' caregivers, caregivers' family members, and veterans' family members receiving or involved with providing this care were interviewed regarding their experiences during and after Hurricane Maria. Specifically, this study highlights how social determinants of health of those residing in or involved with VA home-based long-term care programs influenced recovery from Hurricane Maria, and how findings can inform disaster recovery and provision of home-based long-term care going forward.
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Affiliation(s)
- Leah M. Haverhals
- Denver-Seattle VA Center of Innovation for Value Driven & Veteran-Centric Care, Rocky Mountain Regional VA Medical Center at VA Eastern Colorado Health Care System, 1700 N. Wheeling St., Aurora, CO 80045, USA; ; Tel.: +1-720-331-4176
- Department of Health Care Policy & Research, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
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5
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Hulen E, Lafferty M, Laliberte A, Saha S, Edwards ST. Balancing the benefits of patient-clinician relationships with professional boundaries in Home-based Primary Care. Home Health Care Serv Q 2022; 41:330-340. [PMID: 35348032 DOI: 10.1080/01621424.2022.2056106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In the home care setting, boundaries may be difficult to identify when behavioral changes are made to accommodate the nature of care being delivered. In this secondary qualitative study, we examined how Home-based Primary Care (HBPC) clinicians understand role and relationship boundaries with patients and how these dynamics support patient care. The data set consisted of 14 semi-structured interviews with HBPC clinicians representing multiple disciplines and field observations of 6 HBPC team meetings. Using a directed approach to content analysis, we identified and described how HBPC clinicians worked to build relationships with patients, experienced challenges with emotional attachment, and negotiated boundaries in the patient-clinician relationship. Our findings illustrate how the home care setting is a site for which strong, therapeutic patient-clinician relationships can be developed while also highlighting the work that clinicians must do to balance addressing patient needs stemming from social isolation and adherence to their own professional boundaries.
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Affiliation(s)
- Elizabeth Hulen
- Center to Improve Veteran Involvement in Care, Va Portland Health Care System, Portland, USA
| | - Megan Lafferty
- Center to Improve Veteran Involvement in Care, Va Portland Health Care System, Portland, USA
| | - Avery Laliberte
- Center to Improve Veteran Involvement in Care, Va Portland Health Care System, Portland, USA
| | - Somnath Saha
- Center to Improve Veteran Involvement in Care, Va Portland Health Care System, Portland, USA
- Section of General Internal Medicine, Va Portland Health Care System, Portland Oregon, USA
- General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, USA
| | - Samuel T Edwards
- Center to Improve Veteran Involvement in Care, Va Portland Health Care System, Portland, USA
- Section of General Internal Medicine, Va Portland Health Care System, Portland Oregon, USA
- General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, USA
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6
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Wyte-Lake T, Manheim C, Gillespie SM, Dobalian A, Haverhals LM. COVID-19 Vaccination in VA Home Based Primary Care: Experience of Interdisciplinary Team Members. J Am Med Dir Assoc 2022; 23:917-922. [PMID: 35443215 PMCID: PMC8977493 DOI: 10.1016/j.jamda.2022.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/15/2022] [Accepted: 03/26/2022] [Indexed: 11/19/2022]
Abstract
Objectives Describe how Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) team members discussed the COVID-19 vaccine with Veteran patients and their caregivers; describe HBPC team members' experiences providing care during the pandemic; identify facilitators and barriers to vaccinating HBPC Veterans during the COVID-19 pandemic. Design Online survey that included 3 open-ended COVID-19 vaccine-related questions. Setting and Participants HBPC Program Directors from 145 VA Medical Centers were invited to participate and share the survey invitation with team members. The survey was open from March to May 2021. We collected N = 573 surveys from 73 sites. Methods We analyzed demographic data using descriptive frequencies and open-ended questions using thematic analysis. Results Respondents from all HBPC roles were included in the study: Registered Nurses, Psychologists, Advanced Registered Nurse Practitioners, Social Workers, Dieticians, Occupational Therapists, Pharmacists, Physical Therapists, HBPC Program Directors, HBPC Medical Directors, MDs, Physician Assistants, Other. Qualitative thematic analysis revealed 3 themes describing VA HBPC team members' experiences discussing and administering the COVID-19 vaccine: communication and education, advocating for prioritization of HBPC Veterans to receive the vaccine, and logistics of delivering and administering the vaccine. Conclusions and Implications Our study findings highlight the multifaceted experiences of VA HBPC team members discussing and administering initial doses of the COVID-19 vaccine to primarily homebound Veterans. Although the VA's HBPC program offers an example of a singular health care system, insights from more than 70 sites from across the United States reveal key lessons around the internal and external structures required to successfully support programs and their staff in providing these key activities. These lessons include proactively addressing the needs of homebound populations in national vaccine rollouts and developing vaccine education and training programs for HBPC team members specifically aligned to HBPC program needs. These lessons can extend to non-VA organizations who care for similar homebound populations.
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Affiliation(s)
- Tamar Wyte-Lake
- Veterans Emergency Management Evaluation Center, North Hills, CA, USA; Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Chelsea Manheim
- VA Eastern Colorado Health Care System Denver-Seattle Center of Innovation, Aurora, CO, USA
| | - Suzanne M Gillespie
- VA Finger Lakes Healthcare System, Canandaigua, NY, USA; Division of Geriatrics/Aging, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Aram Dobalian
- Veterans Emergency Management Evaluation Center, North Hills, CA, USA; Health Services Management and Policy, College of Public Health, The Ohio State University, Colombus, OH, USA
| | - Leah M Haverhals
- VA Eastern Colorado Health Care System Denver-Seattle Center of Innovation, Aurora, CO, USA; Health Care Policy & Research, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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7
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Haverhals LM, Magid KH, Kononowech J. Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration. FRONTIERS IN HEALTH SERVICES 2022; 2:935341. [PMID: 36925825 PMCID: PMC10012641 DOI: 10.3389/frhs.2022.935341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022]
Abstract
In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.
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Affiliation(s)
- Leah M Haverhals
- Denver-Seattle VA Center of Innovation for Value Driven and Veteran-Centric Care, Rocky Mountain Regional VA Medical Center at VA Eastern Colorado Health Care System, Aurora, CO, United States.,Health Care Policy and Research, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kate H Magid
- Denver-Seattle VA Center of Innovation for Value Driven and Veteran-Centric Care, Rocky Mountain Regional VA Medical Center at VA Eastern Colorado Health Care System, Aurora, CO, United States
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8
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Zimbroff RM, Ornstein KA, Sheehan OC. Home-based primary care: A systematic review of the literature, 2010-2020. J Am Geriatr Soc 2021; 69:2963-2972. [PMID: 34247383 DOI: 10.1111/jgs.17365] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/07/2021] [Accepted: 06/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although more than seven million older adults struggle or are unable to leave their homes independently, only a small minority access home-based primary care (HBPC). Despite substantial growth of HBPC, fueled by growing evidence supporting positive patient outcomes and cost savings, the population remains dramatically underserved and many evidence gaps still exist around scope of practice and key issues in care delivery and quality. Understanding the current state of the field is critical to the delivery of high-quality home-based care. METHODS We conducted a systematic search of the peer-reviewed literature on HBPC, published between January 2010 and January 2020, using Medline, CINAHL, Embase, Web of Science, and Scopus online libraries. All studies were evaluated by two members of the research team, and key findings were extracted. RESULTS The initial search yielded 1730 unique studies for screening. Of these initial results, 1322 were deemed not relevant to this review. Of the 408 studies deemed potentially relevant, 79 were included in the study. Researchers identified five overarching themes: the provision of HBPC, the composition of care teams, HBPC outcomes, the role of telehealth, and emergency preparedness efforts. CONCLUSION The need and desire for growth of HBPC has been highlighted by the recent COVID-19 pandemic. Current research on HBPC finds a diverse scope of practice, successful use of interdisciplinary teams, positive outcomes, and increasing interest in telehealth with many areas ripe for further research.
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Affiliation(s)
- Robert M Zimbroff
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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9
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Chan CS, Davis D, Cooper D, Edes T, Phibbs CS, Intrator O, Kinosian B. VA home-based primary care interdisciplinary team structure varies with Veterans' needs, aligns with PACE regulation. J Am Geriatr Soc 2021; 69:1729-1737. [PMID: 33834504 DOI: 10.1111/jgs.17174] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/26/2021] [Accepted: 03/22/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Interdisciplinary team (IDT) care is central to home-based primary care (HBPC) of frail elders. Traditionally, all HBPC disciplines managed a patient (Full IDT), a costly approach to maintain. The recent PACE (Program of All-inclusive Care for the Elderly) regulation provides for a flexible approach of annual assessments from a core team with involvement of additional disciplines dependent upon patient needs (Core+). Current Department of Veterans Affairs (VA) HBPC guidance specifies Full IDTs care for medically complex and functionally impaired Veterans similar to PACE participants. We evaluated whether VA HBPC has adopted the flexible structure of the PACE regulation, aligned to Veteran needs. DESIGN Cross-sectional analysis. SETTING All 139 VA HBPC programs administered across 379 sites. PARTICIPANTS About 55,173 Veterans enrolled in HBPC during fiscal year 2018. MEASUREMENTS Patients' HBPC physician, nurse, psychologist/psychiatrist, social worker, therapist, dietitian, and pharmacist visits were grouped into interdisciplinary team types. Patient frailty was classified using VA HNHR v2 (High-Need High-Risk version 2, a measure of high, medium, and low risk of long-term institutionalization). Medical complexity was measured by clusters of impairment in the JEN frailty index (JFI). JFI clusters were validated by VA's Nosos measure to project cost and Care Assessment Need (CAN) measure of hospitalization and mortality risk. RESULTS HBPC provided Full IDT care to 21%, Core+ care to 54%, and Home Health+ (HHA+) care (skilled home health services plus additional disciplines, without primary care) to 16% of Veterans. Team type was associated with medical complexity (X2 2863.5 [66 df], p < 0.0001). High-risk Veterans (72% of sample) were more likely to receive Full IDT care (X2 62.9, 1 df), p < 0.0001), while low-risk Veterans (28%) were more likely to receive HHA+ care (X2 314.8, 1 df, p < 0.0001). CONCLUSION There is a strong association between HBPC team patterns and patient frailty, indicating tailoring of care to match Veteran needs.
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Affiliation(s)
- Caitlin S Chan
- Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.,VA Palo Alto Health Economics Resource Center (HERC), Menlo Park, California, USA.,Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Darlene Davis
- Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Dayna Cooper
- Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Thomas Edes
- Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Ciaran S Phibbs
- Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.,VA Palo Alto Health Economics Resource Center (HERC), Menlo Park, California, USA.,Department of Veterans Affairs, Washington, District of Columbia, USA.,Stanford University, Stanford, California, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.,Department of Veterans Affairs, Washington, District of Columbia, USA.,University of Rochester, Rochester, New York, USA
| | - Bruce Kinosian
- Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.,Department of Veterans Affairs, Washington, District of Columbia, USA.,Center for Health Equity Research and Promotion (CHERP), Philadelphia, Pennsylvania, USA.,Cpl. Michael J Crescenz VA Medical Center (Philadelphia), Philadelphia, Pennsylvania, USA.,University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Hulen E, Laliberte A, Ono S, Saha S, Edwards ST. "Eyes in the Home": Addressing Social Complexity in Veterans Affairs Home-Based Primary Care. J Gen Intern Med 2021; 36:894-900. [PMID: 33432431 PMCID: PMC8042101 DOI: 10.1007/s11606-020-06356-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 11/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Home-Based Primary Care (HBPC) has demonstrated success in decreasing risk of hospitalization and improving patient satisfaction through patient targeting and integrating long-term services and supports. Less is known about how HBPC teams approach social factors. OBJECTIVE Describe HBPC providers' knowledge of social complexity among HBPC patients and how this knowledge impacts care delivery. DESIGN, SETTING, AND PARTICIPANTS Between 2018 and 2019, we conducted in-person semi-structured interviews with 14 HBPC providers representing nursing, medicine, physical therapy, pharmacy, and psychology, at an urban Veterans Affairs (VA) medical center. We also conducted field observations of 6 HBPC team meetings and 2 home visits. APPROACH We employed an exploratory, content-driven approach to qualitative data analysis. RESULTS Four thematic categories were identified: (1) HBPC patients are socially isolated and have multiple layers of medical and social complexity that compromise their ability to use clinic-based care; (2) providers having "eyes in the home" yields essential information not accessible in outpatient clinics; (3) HBPC fills gaps in instrumental support, many of which are not medical; and (4) addressing social complexity requires a flexible care design that HBPC provides. CONCLUSION AND RELEVANCE HBPC providers emphasized the importance of having "eyes in the home" to observe and address the care needs of homebound Veterans who are older, socially isolated, and have functional limitations. Patient selection criteria and discharge recommendations for a resource-intensive program like VA HBPC should include considerations for the compounding effects of medical and social complexity. Additionally, staffing that provides resources for these effects should be integrated into HBPC programming.
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Affiliation(s)
- Elizabeth Hulen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA. .,Department of Sociology, Portland State University, Portland, OR, USA.
| | - Avery Laliberte
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Sarah Ono
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,Veterans Rural Health Resource Center-Portland, Veterans Health Administration Office of Rural Health, Portland, OR, USA
| | - Somnath Saha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA
| | - Samuel T Edwards
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA
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11
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Gillespie SM, Li J, Karuza J, Levy C, Dang S, Olsan T, Kinosian B, Intrator O. Factors Associated With Hospitalization by Veterans in Home-Based Primary Care. J Am Med Dir Assoc 2021; 22:1043-1051.e1. [PMID: 33524340 DOI: 10.1016/j.jamda.2020.12.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/12/2020] [Accepted: 12/19/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study examined the extent to which program site-based and Veteran characteristics were associated with potentially avoidable hospitalizations or other hospitalization of Veterans enrolled in the Veterans Affairs (VA) Home-Based Primary Care (HBPC). DESIGN Retrospective claims-based study. SETTING AND PARTICIPANTS HBPC programs that responded to a national survey of HBPC programs (n = 189) in fiscal year (FY) 2016 were studied. Veterans in the analysis cohort were identified as having been enrolled in VA-HBPC in FY2016 who had not received care by VA-HBPC within 1 year prior to their first HBPC enrollment in FY2016 (N = 8497). METHODS Multinomial logistic regression analysis with 5 outcome categories within the 6 months following the first HBPC enrollment date: (1) any potentially avoidable hospitalizations for ambulatory care-sensitive conditions (ACSC) as identified by AHRQ Prevention Quality Indicator (PQI), (2) any other hospitalizations for non-ACSC conditions, (3) died during study period, (4) discharged from HBPC, or (5) remained at home with HBPC. Average marginal effects (AME) of veteran-level and VA-HBPC-level covariates are reported for each of the outcome categories. RESULTS More frail Veterans and Veterans 85 years old or older were more likely to have potentially preventable ACSC hospitalizations (AME = 5.4%, 1.8%, respectively). Veterans who were younger than 75 years, functionally impaired, bed-bound, or frail were more likely to have non-ACSC hospitalization (AME = 3.0%, 2.2%, 3.5%, and 9.0%, respectively). Veterans with low frailty index scores were less likely to have non-ACSC hospitalizations (AME = -17.1%). Six-month hospitalization patterns were not associated with reported HBPC site characteristics. CONCLUSIONS AND IMPLICATIONS Within the framework of the national VA HBPC program, variations in the structural model used at HBPC sites are not significantly associated with hospitalizations. Tailoring of HBPC care, based on individual patient factors and clinical judgment rather than standard protocols, may be central to the success of HBPC in reducing ACSC hospitalizations.
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Affiliation(s)
- Suzanne M Gillespie
- Canandaigua Veterans Affairs Medical Center, Canandaigua, NY, USA; Division of Geriatrics, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.
| | - Jiejin Li
- Canandaigua Veterans Affairs Medical Center, Canandaigua, NY, USA; Geriatrics & Extended Care Data Analysis Center, Office of Geriatrics & Extended Care, Office of Geriatrics and Extended Care, U.S. Department of Veterans Affairs, Washington, DC, USA; Department of Public Health Sciences, University of Rochester, Rochester, NY, USA
| | - Jurgis Karuza
- Canandaigua Veterans Affairs Medical Center, Canandaigua, NY, USA; Division of Geriatrics, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA; Department of Psychology, SUNY at Buffalo State, Buffalo, NY, USA
| | - Cari Levy
- Veterans Health Administration, ECHCS, Denver-Seattle Center of Innovation for Veterans Centric & Value Driven Care, Aurora, CO, USA; University of Colorado, Anschutz Medical Campus, School of Medicine, Department of Medicine, Division of Health Care Policy and Research, Aurora, CO, USA
| | - Stuti Dang
- Miami Veterans Affairs Healthcare System, Miami, FL, USA; Miami Veterans Affairs Geriatric Research Education and Clinical Center, Miami, FL, USA; Division of Geriatrics and Palliative Care, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tobie Olsan
- Canandaigua Veterans Affairs Medical Center, Canandaigua, NY, USA; School of Nursing, University of Rochester, Rochester, NY, USA
| | - Bruce Kinosian
- Division of Geriatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Cpl Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Orna Intrator
- Canandaigua Veterans Affairs Medical Center, Canandaigua, NY, USA; Geriatrics & Extended Care Data Analysis Center, Office of Geriatrics & Extended Care, Office of Geriatrics and Extended Care, U.S. Department of Veterans Affairs, Washington, DC, USA; Department of Public Health Sciences, University of Rochester, Rochester, NY, USA
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12
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Manheim C, Haverhals L, Gilman C, Karuza J, Olsan T, Edwards S, Levy C, Gillespie S. VA Home Based Primary Care Teams: Partnering with and Acting as Caregivers for Veterans. Home Health Care Serv Q 2021; 40:1-15. [PMID: 33411588 DOI: 10.1080/01621424.2020.1869634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The U.S. Department of Veterans Affairs' Home-Based Primary Care (HBPC) Interdisciplinary Team (IDT) provides in-home, primary care for medically complex Veterans. This study explores how HBPC and Veterans' caregivers partner to provide care. Interviews, focus groups, and field observations were conducted during eight HBPC site visits. Qualitative thematic analysis was performed. Caregivers/IDT member partnerships are important to care. Effective partnerships include: ease of communication; caregiver-centered support; and when no caregiver is present, IDTs providing more monitoring/services to Veterans and connection to community services. As this model expands, understanding dynamics between IDT members and caregivers will optimize the success of HBPC programs.
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Affiliation(s)
- C Manheim
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centric & Value Driven Care , Aurora, Colorado, USA
| | - L Haverhals
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centric & Value Driven Care , Aurora, Colorado, USA
| | - C Gilman
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centric & Value Driven Care , Aurora, Colorado, USA
| | - J Karuza
- Geriatrics, Extended Care and Rehabilitation, Canandaigua VA Medical Center , Canandaigua, New York, USA.,Division of Geriatrics/Aging, Department of Medicine, University of Rochester School of Medicine , Rochester, New York, USA.,Department of Psychology, S.U.N.Y at Buffalo State , Buffalo, New York, USA
| | - T Olsan
- Geriatrics, Extended Care and Rehabilitation, Canandaigua VA Medical Center , Canandaigua, New York, USA.,School of Nursing, University of Rochester , Rochester, New York, USA
| | - S Edwards
- Section of General Internal Medicine, Portland VA Medical Center , Portland, Oregon, USA.,Division of General Internal Medicine and Geriatrics, Oregon Health and Science University , Portland, Oregon, USA
| | - C Levy
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centric & Value Driven Care , Aurora, Colorado, USA.,Department of Medicine, Division of Health Care Policy and Research, Anschutz Medical Campus, School of Medicine, University of Colorado , Aurora, Colorado, USA
| | - S Gillespie
- Geriatrics, Extended Care and Rehabilitation, Canandaigua VA Medical Center , Canandaigua, New York, USA.,Division of Geriatrics/Aging, Department of Medicine, University of Rochester School of Medicine , Rochester, New York, USA
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13
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Cheng MKW, Allison TA, McSteen BW, Cattle CJ, Lo DT. The Adoption of Video Visits During the COVID-19 Pandemic by VA Home Based Primary Care. J Am Geriatr Soc 2020; 69:318-320. [PMID: 33284996 DOI: 10.1111/jgs.16982] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/14/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Mike K W Cheng
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Theresa A Allison
- Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA.,Department of Family & Community Medicine, University of California San Francisco, San Francisco, California, USA
| | - Brian W McSteen
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Chloe J Cattle
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Daphne T Lo
- Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
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14
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Wyte-Lake T, Der-Martirosian C, Chu K, Johnson-Koenke R, Dobalian A. Preparedness and response activities of the US Department of Veterans Affairs (VA) home-based primary care program around the fall 2017 hurricane season. BMC Public Health 2020; 20:1796. [PMID: 33243229 PMCID: PMC7690102 DOI: 10.1186/s12889-020-09888-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Large-scale natural disasters disproportionally affect both the medically complex and the older old, groups that are responsible for most medical surge after a disaster. To understand how to ameliorate this surge, we examined the activities of the nine US Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) programs impacted during the 2017 Fall Hurricane Season. METHODS Convergent mixed methods design, incorporating independently conducted qualitative and quantitative analyses. Phase One: 34 clinical staff were interviewed from the nine VA HBPC programs impacted by Hurricanes Harvey, Irma, and Maria to examine the experiences of their HBPC programs in response to the Hurricanes. Phase Two: Secondary quantitative data analysis used the VA's Corporate Data Warehouse (CDW) to examine the electronic health records of patients for these same nine sites. RESULTS The emergency management activities of the HBPC programs emerged as two distinct phases: preparedness, and response and recovery. The early implementation of preparedness procedures, and coordinated post-Hurricane patient tracking, limited disruption in care and prevented significant hospitalizations among this population. CONCLUSIONS Individuals aged 75 or older, who often present with multiple comorbidities and decreased functional status, typically prefer to age in their homes. Additionally, as in-home medical equipment evolves, more medically vulnerable individuals are able to receive care at home. HBPC programs, and similar programs under Medicare, connect the homebound, medically complex, older old to the greater healthcare community. Engaging with these programs both pre- and post-disasters is central to bolstering community resilience for these at-risk populations.
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Affiliation(s)
- Tamar Wyte-Lake
- Veterans Emergency Management Evaluation Center (VEMEC), U.S. Department of Veterans Affairs, 16111 Plummer St. MS-152, North Hills, CA, 91343, USA. .,Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
| | - Claudia Der-Martirosian
- Veterans Emergency Management Evaluation Center (VEMEC), U.S. Department of Veterans Affairs, 16111 Plummer St. MS-152, North Hills, CA, 91343, USA
| | - Karen Chu
- Veterans Emergency Management Evaluation Center (VEMEC), U.S. Department of Veterans Affairs, 16111 Plummer St. MS-152, North Hills, CA, 91343, USA
| | - Rachel Johnson-Koenke
- Denver-Seattle Center of Innovation, Rocky Mountain Regional VA Medical Center, U.S. Department of Veterans Affairs, 1700 North Wheeling Street, Aurora, CO, 80045-7211, USA
| | - Aram Dobalian
- Veterans Emergency Management Evaluation Center (VEMEC), U.S. Department of Veterans Affairs, 16111 Plummer St. MS-152, North Hills, CA, 91343, USA.,Division of Health Systems Management and Policy, University of Memphis School of Public Health, 3720 Alumni Ave, Memphis, TN, 38152, USA
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