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Wyman MF, Jacobs J, Stalter L, Venkatesh M, Voils CI, Trivedi RB, Gleason CE, Byers AL. Association of Caregiving Receipt With Mental Health Utilization in a National Cohort of Older Adults. Am J Geriatr Psychiatry 2024:S1064-7481(24)00378-6. [PMID: 39030145 DOI: 10.1016/j.jagp.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/21/2024]
Abstract
OBJECTIVE There exist significant age disparities in mental health (MH) utilization, such that older adults, including older veterans, are much less likely to use MH services. In-home caregivers represent a novel, yet understudied, pathway to increase appropriate utilization. We sought to examine the association between receiving caregiving assistance and MH utilization and test moderation effects of cognitive status and depression severity in a sample of older veterans. METHODS Cross-sectional, mixed effects logistic regression with moderation analyses was used with a unique data resource combining survey data from the 2000-2012 U.S. Health and Retirement Study with Veterans Affairs (VA) healthcare administrative records. The analytic sample included N=1,957 Community-dwelling veterans (mean age 68.2 [9.7]), primarily male (96.5%) and non-Hispanic white (77.0%). Measures included MH utilization extracted from VA records or self-report; CESD-8 for depressive symptoms; and the Langa-Weir cognitive status classification using the modified TICS. RESULTS After accounting for demographics, spousal caregiver availability, health factors, and socioeconomic status, caregiving receipt was associated with two-fold odds of MH utilization, compared to receiving no assistance (8,839 person-year observations; OR = 2.02; 95% CI 1.54-2.65) and remained similar following VA policy changes to enhance MH access. Exploratory analyses revealed that categories of cognition and depressive symptoms may moderate the association. CONCLUSION Receipt of any in-home caregiving is associated with increased likelihood of MH use by older adults. Caregivers may represent an underutilized resource to reduce age-related mental health access disparities.
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Affiliation(s)
- Mary F Wyman
- Geriatric Research, Education and Clinical Center and Research Service, W.S. Middleton Memorial Veterans Hospital (MFW, CIV, CEG), Madison, WI; Department of Medicine, Division of Geriatrics (MFW, CEG), University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Psychiatry (MFW), University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Josephine Jacobs
- Health Economics Resource Center (JJ), VA Palo Alto Health Care System, Menlo Park, CA; Department of Health Policy (JJ), Stanford University School of Medicine, Stanford, CA
| | - Lily Stalter
- Department of Surgery (LS, MV, CIV), University of Wisconsin, Madison, WI
| | - Manasa Venkatesh
- Department of Surgery (LS, MV, CIV), University of Wisconsin, Madison, WI
| | - Corrine I Voils
- Geriatric Research, Education and Clinical Center and Research Service, W.S. Middleton Memorial Veterans Hospital (MFW, CIV, CEG), Madison, WI; Department of Surgery (LS, MV, CIV), University of Wisconsin, Madison, WI
| | - Ranak B Trivedi
- HSR and D Center for Innovation to Implementation (RBT), Palo Alto VA Medical Center, Palo Alto, CA; Department of Psychiatry and Behavioral Sciences (RBT), Stanford University, Palo Alto, CA
| | - Carey E Gleason
- Geriatric Research, Education and Clinical Center and Research Service, W.S. Middleton Memorial Veterans Hospital (MFW, CIV, CEG), Madison, WI; Department of Medicine, Division of Geriatrics (MFW, CEG), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Amy L Byers
- Department of Medicine, Division of Geriatrics (ALB), University of California, San Francisco CA; Research Service, San Francisco VA Health Care System (ALB), San Francisco, CA; Department of Psychiatry and Behavioral Sciences (ALB), University of California, San Francisco CA
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Van Houtven CH, Smith VA, Miller KEM, Berkowitz TSZ, Shepherd-Banigan M, Hein T, Penney LS, Allen KD, Kabat M, Jobin T, Hastings SN. Comprehensive Caregiver Supports and Ascertainment and Treatment of Veteran Pain. Med Care Res Rev 2024; 81:107-121. [PMID: 38062735 DOI: 10.1177/10775587231210026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Disabled Veterans commonly experience pain. The Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides training, a stipend, and services to family caregivers of eligible Veterans to support their caregiving role. We compared ascertainment of veteran pain and pain treatment through health care encounters and medications (pain indicators) of participants (treated group) and non-participants (comparison group) using inverse probability treatment weights. Modeled results show that the proportion of Veterans with a pain indicator in the first year post-application was higher than that pre-application for both groups. However, the proportion of Veterans with a pain indicator was substantially higher in the treatment group: 76.1% versus 63.9% in the comparison group (p < .001). Over time, the proportion of Veterans with any pain indicator fell and group differences lessened. However, differences persisted through 8 years post-application (p < .001). PCAFC caregivers appear to help Veterans engage in pain treatment at higher rates than caregivers not in PCAFC.
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Affiliation(s)
- Courtney H Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Duke Margolis Center for Health Policy, Duke University
| | - Valerie A Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Department of General Internal Medicine, Duke University
| | - Katherine E M Miller
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Medical Ethics and Health Policy, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Theodore S Z Berkowitz
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Megan Shepherd-Banigan
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
| | - Tyler Hein
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs
| | - Lauren S Penney
- The Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System
- Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio
| | - Kelli D Allen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Margaret Kabat
- Office of the Secretary US Department of Veterans Affairs
| | - Timothy Jobin
- Caregiver Support Program, Veterans Health Administration, US Department of Veterans Affairs
| | - S Nicole Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine
- Center for the Study of Aging and Human Development, Duke University School of Medicine
- Geriatrics Research, Education and Clinical Center, Durham VA Health Care System
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Jacobs JC, Lo J, Van Houtven CH, Wagner TH. The impact of informal caregiving on U.S. Veterans Health Administration utilization and expenditures. Soc Sci Med 2024; 344:116625. [PMID: 38324974 DOI: 10.1016/j.socscimed.2024.116625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
Few studies have examined the effect of informal care receipt on health care utilization and expenditures while accounting for the potentially endogenous relationship between informal and formal care, and none have examined these relationships for U.S. Veterans. With rapidly increasing investments in caregiver supports over the past decade, including stipends for caregivers, the U.S. Department of Veterans Affairs (VA) needs to better understand the costs and benefits of informal care provision. Using a unique data linkage between the 1998-2010 Health and Retirement Study and VA administrative data (n = 2083 Veterans with 9511 person-wave observations), we applied instrumental variable techniques to understand the effect of care from an adult child on Veterans' two-year VA utilization and expenditures. We found that informal care decreased overall utilization by 53 percentage points (p < 0.001) and expenditures by $19,977 (p < 0.01). These reductions can be explained by informal care decreasing the probability of inpatient utilization by 17 percentage points (p < 0.001), outpatient utilization by 57 percentage points (p < 0.001), and institutional long-term care by 3 percentage points (p < 0.05). There were no changes in the probability of non-institutional long-term care use, though these expenditures decreased by $882 (p < 0.05). Expenditure decreases were greatest amongst medically complex patients. Our results indicate relative alignment between VA's stipend payments, which are based on replacement cost methods, and the monetary benefits derived through VA cost avoidances due to informal care. For health systems considering similar caregiver stipend payments, our findings suggest that the cost of these programs may be offset by informal care substituting for formal care, particularly for higher need patients.
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Affiliation(s)
- Josephine C Jacobs
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park CA, USA; Department of Health Policy, Stanford University School of Medicine, Stanford, CA, USA.
| | - Jeanie Lo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park CA, USA
| | - Courtney H Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA; Department of Population Health Sciences, Duke University, Durham, NC, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Todd H Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park CA, USA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Harrod M, Hauschildt K, Kamphuis LA, Korpela PR, Rouse M, Nallamothu BK, Iwashyna TJ. Disrupted Lives: Caregivers' Experiences of In-Hospital Cardiac Arrest Survivors' Recovery 5 Years Later. J Am Heart Assoc 2023; 12:e028746. [PMID: 37671627 PMCID: PMC10547269 DOI: 10.1161/jaha.122.028746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 04/25/2023] [Indexed: 09/06/2023]
Abstract
Background Survivors of in-hospital cardiac arrest (IHCA) experience ongoing physical and cognitive impairments, often requiring support from a caregiver at home afterwards. Caregivers are important in the survivor's recovery, yet there is little research specifically focused on their experiences once the survivor is discharged home. In this study, we highlight how caregivers for veteran IHCA survivors described and experienced their caregiver role, the strategies they used to fulfill their role, and the additional needs they still have years after the IHCA event. Methods and Results Between March and July 2019, semistructured telephone interviews were conducted with 12 caregivers for veteran IHCA survivors. Interviews were transcribed, and content analysis was performed. Patterns within the data were further analyzed and grouped into themes. A predominant theme of "disruption" was identified across 3 different domains including the following: (1) disruption in caregiver's life, (2) disruption in caregiver-patient relationship, and (3) disruption in caregiver's well-being. Disruption was associated with both positive and negative caregiver experiences. Strategies caregivers used and resources they felt would have helped them adjust to their caregiver role were also identified. Conclusions Caregivers for veteran IHCA survivors experienced a disruption in many facets of their lives. Caregivers felt the veterans' IHCA impacted various aspects of their lives, and they continued to need additional support in order to care for the IHCA survivor and themselves. Although some were able to procure coping strategies, such as counseling and engaging in stress-relieving activities, most indicated additional help and resources were still needed.
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Affiliation(s)
- Molly Harrod
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
| | - Katrina Hauschildt
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
- Department of SociologyPopulation Studies CenterUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineThe Johns Hopkins University School of MedicineBaltimoreMDUSA
| | - Lee A. Kamphuis
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
| | - Peggy R. Korpela
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
| | - Marylena Rouse
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
| | - Brahmajee K. Nallamothu
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
- Center for Healthcare Outcomes and PolicyUniversity of MichiganAnn ArborMIUSA
- Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Theodore J. Iwashyna
- Lieutenant Colonel Charles S. Kettles VA Medical CenterCenter for Clinical Management ResearchAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineThe Johns Hopkins University School of MedicineBaltimoreMDUSA
- Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Health Policy and Management, School of Public HealthThe Johns Hopkins UniversityBaltimoreMDUSA
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Miller KEM, Van Houtven CH, Kent EE, Gilleskie D, Holmes GM, Smith VA, Stearns SC. Short-term effects of comprehensive caregiver supports on caregiver outcomes. Health Serv Res 2023; 58:140-153. [PMID: 35848763 PMCID: PMC10501334 DOI: 10.1111/1475-6773.14038] [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: 01/17/2023] Open
Abstract
OBJECTIVE To estimate the association of the Veterans Health Administration (VHA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) implemented in 2011 with caregiver health and health care use. DATA SOURCES VHA claims and electronic health records from May 2009 to May 2018. STUDY DESIGN Using a retrospective, pre-post study design with inverse probability of treatment weights to address selection into treatment, we examine the association of PCAFC on caregivers who are veterans: (1) outpatient primary, specialty, and mental health care visits; (2) probability of uncontrolled hypertension and anxiety/depression; and (3) VHA health care costs. We compare outcomes for caregivers approved for PCAFC (treatment) to caregivers denied PCAFC (comparison). DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS In the year pre-application, we observe similar probabilities of having any VHA primary care (~36%), VHA specialty care (~24%), and VHA or VHA-purchased mental health care (~22%) for treatment and comparison caregivers. In the year post-application, treated caregivers had a 5.89 percentage point larger probability of any outpatient VHA primary care (p = 0.002) and 4.34 percentage points larger probability of any outpatient mental health care use (p = 0.014). Post-application, probabilities of having uncontrolled hypertension or diagnosed anxiety/depression were higher for both treated and comparison groups. In the second year post-application, treated caregivers had a 1.88 percentage point larger probability of uncontrolled hypertension (p = 0.019) and 4.68 percentage points larger probability of diagnosed anxiety/depression (predicted probabilities: treated = 0.30; comparison = 0.25; p = 0.005). We find no evidence of differences in VHA total costs by PCAFC status. CONCLUSIONS Our findings that PCAFC enrollment is associated with increased health care diagnosis and service use may reflect improved access for previously unmet needs in the population of veteran caregivers for veterans in PCAFC. The costs and value of these increases can be weighed against other effects of the program to inform national policies supporting caregivers.
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Affiliation(s)
- Katherine E. M. Miller
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham Virginia Health Care SystemDurhamNorth CarolinaUSA
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Courtney H. Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham Virginia Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Duke Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Erin E. Kent
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Lineberger Comprehensive Cancer CenterThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Donna Gilleskie
- Department of EconomicsThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - G. Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Valerie A. Smith
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham Virginia Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Brickell TA, French LM, Varbedian NV, Sewell JM, Schiefelbein FC, Wright MM, Lange RT. Relationship satisfaction among spouse caregivers of service members and veterans with comorbid mild traumatic brain injury and post-traumatic stress disorder. FAMILY PROCESS 2022; 61:1525-1540. [PMID: 34859431 DOI: 10.1111/famp.12731] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 06/13/2023]
Abstract
This study examined relationship satisfaction and health-related quality of life (HRQOL) among spouse caregivers assisting service members and veterans (SMV) with comorbid uncomplicated mild traumatic brain injury (MTBI) and post-traumatic stress disorder (PTSD). Spouse caregivers (N = 205) completed the Couples Satisfaction Index (CSI), 12 HRQOL measures, and the Mayo-Portland Adaptability Inventory 4th Edition (MPAI-4). T-scores were classified as "clinically elevated" using a cutoff of ≥60T. The sample was also classified into "Satisfied" (≥13.5, n = 113, 55.0%) or "Dissatisfied" (<13.5, n = 92, 44.0%) relationship categories. Using stepwise regression analysis, Anxiety, Family Disruption, Vigilance, Emotional Support, Feeling Trapped, and MPAI-4 Adjustment were identified as the strongest predictors of CSI total scores (p < 0.001), accounting for 41.6% of the variance. Squared semi-partial correlations revealed that 18.1% of the variance was shared across all six measures, with 7.8% to 1.5% of unique variance accounted for by each measure separately. When comparing the number of clinically elevated measures simultaneously, the Dissatisfied group consistently had a higher number of clinically elevated scores compared to the Satisfied group (e.g., 3-or-more clinically elevated scores: Dissatisfied = 40.2%, Satisfied = 8.8%, OR = 6.93, H = 0.76). Caring for a SMV with comorbid TBI and PTSD can have a profound impact on the spouse caregiver's HRQOL, relationship satisfaction, and family functioning. The findings from the current study continue to support the need for family involvement in the SMV's treatment plan, but more effort is needed to integrate behavioral health treatment that focuses on the family member's own issues into military TBI and PTSD systems of care.
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Affiliation(s)
- Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
- Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada
| | - Louis M French
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Nicole V Varbedian
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
| | - Jessie M Sewell
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
| | - Faith C Schiefelbein
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
| | - Megan M Wright
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
| | - Rael T Lange
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
- Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada
- University of British Columbia, Vancouver, BC, Canada
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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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MILLER KATHERINEEM, STEARNS SALLYC, VAN HOUTVEN COURTNEYH, GILLESKIE DONNA, HOLMES GEORGEM, KENT ERINE. The Landscape of State Policies Supporting Family Caregivers as Aligned With the National Academy of Medicine Recommendations. Milbank Q 2022; 100:854-878. [PMID: 35579187 PMCID: PMC9576229 DOI: 10.1111/1468-0009.12567] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Policy Points In the absence of federal policy, states adopted policies to support family caregivers, but availability and level of support varies. We describe, compare, and rank state policies to support family caregivers as aligned with National Academy of Medicine recommendations. Although the landscape of state policies supporting caregivers has improved over time, few states provide financial supports as recommended, and benefit restrictions hinder accessibility for all types of family caregivers. Implementing policies supporting family caregivers will become more critical over time, as the reliance on family caregivers as essential providers of long-term care is only expected to grow as the population ages. CONTEXT In the United States in 2020, approximately 26 million individuals provided unpaid care to a family member or friend. On average, 60% of caregivers were employed, and they provided 20.4 hours of care per week on top of employment. Although a handful of patchwork laws exist to aid family caregivers, systematic supports, including comprehensive training, respite, and financial support, remain limited. In the absence of federal supports, states have adopted policies to provide assistance, but they vary in availability and level of support provided. Our objectives were to describe, compare, and rank state policies to support family caregivers over time. METHODS We used publicly available data from the AARP Long-Term Services and Supports State Scorecard, the National Academy for State Health Policy, and Tax Credits for Workers and Families for all 50 states and the District of Columbia (2015-2019). FINDINGS We found that states had increased supports to family caregivers over this five-year period, although significant variability in adoption and implementation of policies persists. Approximately 20% of states had enacted policies that exceed the federal Family and Medical Leave Act requirements, and 18% offered paid family leave. However, most states had not improved spousal impoverishment protections for Medicaid beneficiaries. For example, from 2016 to 2019, 24% of states provided fewer or no protections, while 71% of states did not improve spousal impoverishment protections over time. Access to training for caregivers varied based on eligibility criteria (e.g., select populations and/or only co-residing caregivers). CONCLUSIONS Overall, state approaches to support family caregivers vary by eligibility and scope of services. Substantial gaps in support of caregivers, particularly economic supports, persist. Although the landscape of state policies supporting caregivers has improved over time, few states provide financial supports as recommended by the National Academy of Medicine, and benefit restrictions hinder accessibility for all family caregivers.
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Affiliation(s)
- KATHERINE E. M. MILLER
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham VA Health Care System
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel Hill
- Author affiliation at time work was conducted
| | - SALLY C. STEARNS
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel Hill
- University of North Carolina at Chapel Hill
| | - COURTNEY H. VAN HOUTVEN
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham VA Health Care System
- Population Health SciencesDuke University School of Medicine
- Duke Margolis Center for Health PolicyDuke University
| | | | - GEORGE M. HOLMES
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill
| | - ERIN E. KENT
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel Hill
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Is Traumatic Brain Injury Severity in Service Members and Veterans Related to Health-Related Quality of Life in Their Caregivers? J Head Trauma Rehabil 2022; 37:338-349. [PMID: 35862894 DOI: 10.1097/htr.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To examine the relationship between service member/veteran (SM/V) traumatic brain injury (TBI) severity with caregiver health-related quality of life (HRQOL). SETTING Military treatment facility. PARTICIPANTS Caregivers (N = 316) of SM/Vs following a TBI divided into 2 groups based on SM/V TBI severity: (1) caregivers of SM/Vs following an uncomplicated mild TBI (UnMTBI Caregiver group, n = 246), and (2) caregivers of SM//Vs following a complicated mild, moderate, severe, or penetrating TBI (STBI Caregiver group, n = 70). The STBI Caregiver group was further divided into 2 subgroups: Parent (n = 21) versus Intimate Partner (n = 49). The UnMTBI Caregiver group consisted of intimate partners. DESIGN Prospective cohort. MAIN MEASURES Caregivers completed 15 HRQOL measures. RESULTS Using analysis of variance and chi-square analysis, the UnMTBI Caregiver group reported worse scores on 12 HRQOL measures and more clinically elevated scores for 6 of 15 comparisons than the STBI Caregiver group. The UnMTBI Caregiver group also reported worse scores on 10 HRQOL measures than intimate partners in the STBI Caregiver group and 5 measures than parents in the STBI Caregiver group. Parents reported worse scores on 3 measures than intimate partners in the STBI Caregiver group. The UnMTBI Caregiver group reported more clinically elevated scores for 7 of 15 comparisons than intimate partners in the STBI Caregiver group. CONCLUSION Intimate partner caregivers of an SM/V following a remote uncomplicated MTBI reported worse HRQOL than intimate partners and parent caregivers of an SM/V following a more severe TBI, mostly likely due to SM/V physical and mental health comorbidities. Interventions that focus on the SM/V's TBI and other comorbidities, the caregiver's behavioral health problems, and the relationship and family factors that interact with each other will likely have the most success in improving individual and family outcomes for military families.
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Miller KEM, Van Houtven CH, Smith VA, Lindquist JH, Gray K, Richardson C, Shepherd-Banigan M. Family Caregivers of Veterans Experience Clinically Significant Levels of Distress Prepandemic and During Pandemic: Implications for Caregiver Support Services. Med Care 2022; 60:530-537. [PMID: 35471419 PMCID: PMC9187587 DOI: 10.1097/mlr.0000000000001726] [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: 11/26/2022]
Abstract
BACKGROUND Of the 26.4 million family caregivers in the United States, nearly 40% report high levels of emotional strain and subjective burden. However, for the 5 million caregivers of Veterans, little is known about the experiences of caregivers of Veterans during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE The aim was to examine pandemic-related changes of caregiver well-being outcomes. RESEARCH DESIGN, SUBJECTS, AND MEASURES Using a pre/post design and longitudinal data of individual caregivers captured pre-COVID-19 and during COVID-19, we use multilevel generalized linear mixed models to examine pandemic-related changes to caregiver well-being (n=903). The primary outcome measures include Zarit Subjective Burden, Center for Epidemiologic Studies Short Depression Scale, perceived financial strain, life chaos, and loneliness. RESULTS During the pandemic, we observe slight improvements for caregivers across well-being measures except for perceived financial strain. Before the pandemic, we observed that caregivers screened positive for clinically significant caregiver burden and probable depression. While we do not observe worsening indicators of caregiver well-being during the COVID-19 pandemic, the average predicted values of indicators of caregiver well-being remain clinically significant for caregiving subjective burden and depression. CONCLUSIONS These findings illuminate pandemic-related impacts of caregivers receiving support through the Veterans Affairs (VA) pre-COVID and during the COVID-19 pandemic while caring for a population of frail, older care-recipients with a high burden of mental illness and other chronic conditions. Considering the long-term impacts of the pandemic to increase morbidity and the expected increased demand for caregivers in an aging population, these consistently high levels of distress despite receiving support highlight the need for interventions and policy reform to systematically support caregivers more broadly.
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Affiliation(s)
- Katherine E M Miller
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University Medical Center
- Duke-Margolis Center for Health Policy
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University Medical Center
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Jennifer H Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Kaileigh Gray
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | | | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University Medical Center
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11
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Abstract
OBJECTIVE To describe the self-reported needs of family caregivers of service members and veterans (SMVs) who sustained a traumatic brain injury (TBI) and to identify predictors of the unmet family caregiver needs. SETTING Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS Family caregivers of SMVs enrolled in the VA PRC TBI Model Systems (TBIMS) national database who were within their first 5 years post-TBI (n = 427). DESIGN Observational study. MAIN OUTCOME MEASURE The Family Needs Questionnaire-Revised (FNQ-R) was completed by each SMV's designated caregiver. ANALYSES Descriptive analyses were conducted on the FNQ-R responses at the item, domain, and total score levels. Unadjusted univariable and adjusted multivariable regression models were fitted to identify predictors of total unmet needs and unmet family need domains. RESULTS FNQ-R item-level and domain-level descriptive results indicated that health information was the most frequently met need domain. In contrast, emotional and instrumental support domains were the least often met. On average, family caregivers reported that 59.2% of the 37 FNQ-R needs were met at the time of the follow-up assessment. Regression models indicated that both the number of SMV-perceived environmental barriers and whether the SMV received mental health treatment within the past year predicted the number of unmet FNQ-R needs. SMV-reported environmental barriers predicted increased unmet needs in all 6 family caregiver domains, and SMV mental health treatment in the past year predicted more unmet family caregiver emotional support, community support, and professional support needs. CONCLUSIONS The current findings can be used to inform policy and programming for VA and Department of Defense to proactively address the specific needs of families and caregivers experienced in the first 5 years post-TBI.
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12
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Shepherd-Banigan M, Jones KA, Sullivan C, Wang K, Clark AG, Van Houtven C, Olsen JM. Individual and program Characteristics May Drive Variability in Outcomes After Caregivers Participate in a Tailored Support Intervention. J Appl Gerontol 2022; 41:1960-1970. [PMID: 35575158 PMCID: PMC9364230 DOI: 10.1177/07334648221091564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Critically needed programs designed to support family caregivers have shown
inconsistent reductions in stress and burden. To explore drivers of improvement
in caregiver outcomes after participation in a support intervention we analyzed
data from a one-on-one, tailored problem-solving intervention targeting
caregiver wellbeing (2015–2019, n = 503). We explored data
patterns across 21 individual, household, and program-level variables using
elastic net regression to identify drivers of improvements, and their relative
importance. Baseline subjective burden, baseline depressive symptom scores,
baseline caregiver problem solving, African American race, and site and coach
fixed effects were the most consistent drivers of changes across the explored
caregiver outcomes. Caregiver and program characteristics may be promising
avenues to target to decrease distress and burden during intervention design.
Interventions focusing on highly distressed caregivers may lead to greater
improvements. More research is needed to identify how site or interventionists
characteristics drive positive intervention effects.
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Duke-Margolis Center for Health Policy, Durham, NC, USA
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Caitlin Sullivan
- Durham VA Health Care System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Ke Wang
- Rosalynn Carter Institute for Caregivers, Georgia Southwestern State University, Americus, GA, USA
| | - Amy G Clark
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Courtney Van Houtven
- Durham VA Health Care System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Duke-Margolis Center for Health Policy, Durham, NC, USA
| | - Jennifer M Olsen
- Rosalynn Carter Institute for Caregivers, Georgia Southwestern State University, Americus, GA, USA
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13
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Kuntz AA, Wanninger E, Lewis B. Caregiver Support in a Case of Posttraumatic Stress Disorder and Lewy Body Dementia. Fed Pract 2022; 39:226-231. [PMID: 35935923 PMCID: PMC9351732 DOI: 10.12788/fp.0239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The US Department of Veterans Affairs (VA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides assistance for at-home caregiving of veterans and defers the costs of care for veterans. In October 2020, PCAFC eligibility expanded to include Vietnam-era veterans. CASE PRESENTATION We present the case of a Vietnam-era veteran with posttraumatic stress disorder (PTSD) and Lewy body dementia (LBD) who over years of care developed worsening symptoms from his illnesses, including behaviors and psychological symptoms of dementia. Recurrent behavioral episodes and issues with home safety, along with his caregiver's financial need to continue working, led the patient to being placed in a VA-contracted skilled nursing facility. However, expanded PCAFC eligibility enabled a transfer back to in-home living. We discuss PCAFC expansion and examine trends in veteran health that point to a large burden of dementia and PTSD on both veterans and their caregivers. CONCLUSIONS This case demonstrates how the PCAFC expansion is likely to benefit other older veterans with service-connected disability, PTSD, and/or dementia. These veterans may now be eligible for a service and funds that may enable at-home living. This expansion has policy implications as the VA manages the budget of this program and institutes measures to limit abuse and waste, as well as research implications as the PCAFC is used to enable at-home aging as an alternative to aging with dementia in a facility.
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Affiliation(s)
- Aaron A Kuntz
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Ellen Wanninger
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Brian Lewis
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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14
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Kolodziej IWK, Coe NB, Van Houtven CH. The Impact of Care Intensity and Work on the Mental Health of Family Caregivers: Losses and Gains. J Gerontol B Psychol Sci Soc Sci 2022; 77:S98-S111. [PMID: 35191980 PMCID: PMC9122646 DOI: 10.1093/geronb/gbac031] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES We estimate the causal impact of intensive caregiving, defined as providing at least 80 h of care per month, and work on the mental health of caregivers while considering possible sources of endogeneity in these relationships. METHODS We use 2 linked data sources from the United States by matching caregivers in the National Study of Caregiving with corresponding care recipients in the National Health and Aging Trends Study for years 2011-2017. We address possible sources of endogeneity in the relationships between caregiving, work, and mental health by using instrumental variables methodology, instrumenting for both caregiving and work behavior. We examine 2 measures used to screen for depression (PHQ-2, psychodiagnostic test) and anxiety (GAD-2, generalized anxiety disorders screening instrument), a composite measure that combines these measures (PHQ-4), and positive well-being variables to ascertain possible gains from caregiving. RESULTS Providing at least 80 h of care per month to a parent compared to less intensive caregiving increases the PHQ-4 scale for anxiety and depression disorders. This is driven by the screening score for anxiety and not psychodiagnostic test scores for depression. Relationship quality decreases substantially for intensive caregivers, and intensive caregiving leads to less satisfaction that the care recipient is well-cared for. We do not find offsetting mental health gains for intensive caregivers compared to nonintensive caregivers. Work does not independently affect the mental health of caregivers. DISCUSSION Caregiver interventions that reduce objective demands or support intensive caregivers could reduce or prevent well-being losses and improve the caregiver's relationship with the recipient.
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Affiliation(s)
- Ingo W K Kolodziej
- Address correspondence to: Ingo W. K. Kolodziej, RWI — Leibniz Institute for Economic Research, 45128 Essen, Germany. E-mail:
| | - Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Courtney H Van Houtven
- Department of Population Health Sciences and Duke-Margolis Center for Health Policy, Duke VA HCS, Durham, North Carolina, USA,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
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15
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King HA, Shepherd-Banigan M, Chapman JG, Bruening R, Decosimo KP, Van Houtven CH. Use of motivational techniques to enhance unpaid caregiver engagement in a tailored skills training intervention. Aging Ment Health 2022; 26:337-344. [PMID: 33325259 PMCID: PMC10424086 DOI: 10.1080/13607863.2020.1855103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES) evaluated a skills training program to support family caregivers of cognitively or functionally impaired persons. HI-FIVES demonstrated sustained improvements in caregivers' and patients' experiences of VA care. The aim of this distinct, secondary qualitative study was to explore the potential processes related to the individual tailored skills-based telephone training underpinning HI-FIVES intervention effects. We explored topics caregivers selected, characteristics of action items created, patterns of action or inaction, and barriers to action item completion across topics. METHODS Qualitative data was analysed from 118 dyads randomized into the HI-FIVES intervention which included three weekly facilitated training calls covering five education topics and action items developed by caregivers for each topic. Qualitative analysis of text responses to questions from the training calls was used. RESULTS Three of the top four most selected topics were caregiver-oriented and caregivers created an action item most often for self-care topics. Caregiver-oriented topics also had the highest action item completion rates. The majority of action items created met SMART guidelines for goal setting and simple structure. With regard to barriers to action item completion, caregivers commonly reported still contemplating/pending. CONCLUSION Our findings identify motivational interviewing as an effective technique to identify critical intervention content and address barriers to achieving caregiving goals. We suggest that caregivers felt more empowered to create and complete an action item when they had more control over completing the action item, such as in topics related to their own self-care.
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Affiliation(s)
- Heather A. King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | | | - Rebecca Bruening
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Kasey P. Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Courtney H. Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
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16
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Truskinovsky Y, Finlay JM, Kobayashi LC. Caregiving in a Pandemic: COVID-19 and the Well-Being of Family Caregivers 55+ in the United States. Med Care Res Rev 2022; 79:663-675. [PMID: 35001714 DOI: 10.1177/10775587211062405] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is known about the effects of Coronavirus disease 2019 (COVID-19) on older family caregivers. Using data from a national sample of 2,485 U.S. adults aged ≥55, we aimed to describe the magnitude of disruptions to family care arrangements during the initial wave of the COVID-19 pandemic, and the associations between these disruptions and the mental health outcomes (depression, anxiety, loneliness, and self-rated health) and employment outcomes (job loss or furlough, hours or wages reduced, transition to work-from-home) of family caregivers. We found that COVID-19 disrupted over half of family caregiving arrangements, and that care disruptions were associated with increased depression, anxiety, and loneliness among caregivers, compared with both noncaregivers and caregivers who did not experience disruptions. Family caregivers who experienced pandemic-related employment disruptions were providing more care than caregivers who did not experience disruptions. These findings highlight the impact of the pandemic on an essential and vulnerable health care workforce.
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17
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Shepherd-Banigan ME, Boucher NA, McKenna K, Delgado RE, Whitaker C, Christensen L, Sperber NR. Family Caregiver and Provider Perspectives on Inclusive Care: Aligning Needs and Expectations. Med Care 2021; 59:961-969. [PMID: 34348392 DOI: 10.1097/mlr.0000000000001622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Home-based and community-based health care for individuals with complex medical conditions is often provided by family caregivers. Yet caregivers often are not meaningfully included in interactions with clinical health care teams. Inclusive care means inviting the caregiver to participate in shared decision-making and treatment planning. For aging or medically vulnerable adults, caregiver inclusion is an important facet of patient-centered care. METHODS We apply a mixed-methods approach using a survey (n=50) and semistructured interview data (n=13) from a national sample of caregivers of veterans and semistructured interview data from (n=24) providers from 3 Veterans Affairs regional networks. We elicited data from caregivers about their experiences with inclusive care and how providers communicate with them and assess their capacity. We juxtaposed these data with provider perspectives to see where there was alignment. FINDINGS We determined that caregivers play important roles in trust-building, communications management, implementation of care plans at home or in the community, and improving the care of care recipients-while maintaining a balance between competing tensions. CONCLUSIONS Our findings suggest that expanding inclusive care could improve care quality and health outcomes of individuals with complex health care needs. Further, our findings bolster recent policy efforts at the federal and state levels to increase recognition of caregivers as key members of the health care team.
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Affiliation(s)
- Megan E Shepherd-Banigan
- Duke University Department of Population Health Sciences
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System
- Duke-Margolis Center for Health Policy
| | - Nathan A Boucher
- Duke University Department of Population Health Sciences
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System
- Duke-Margolis Center for Health Policy
- Sanford School of Public Policy, Duke University
- Duke University School of Medicine, Center for the Study of Aging and Human Development, Durham, NC
| | - Kevin McKenna
- Duke University Department of Population Health Sciences
| | - Roxana E Delgado
- General and Hospital Medicine Division, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | | | - Leah Christensen
- National Caregiver Support Program, Department of Veterans Affairs, Washington, DC
| | - Nina R Sperber
- Duke University Department of Population Health Sciences
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System
- Duke-Margolis Center for Health Policy
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18
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Shepherd-Banigan M, Pogoda TK, McKenna K, Sperber N, Van Houtven CH. Experiences of VA vocational and education training and assistance services: Facilitators and barriers reported by veterans with disabilities. Psychiatr Rehabil J 2021; 44:148-156. [PMID: 32597666 PMCID: PMC9677616 DOI: 10.1037/prj0000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To understand the experiences of veterans with disabilities and caregiving needs who use Department of Veterans Affairs (VA) vocational and education services, including Supported Employment, the Post-9/11 GI Bill, and Vocational Rehabilitation and Employment. METHOD We conducted 26 joint semistructured interviews with post-9/11 veterans who had used at least one of three vocational and education services, and their family members who were enrolled in a VA Caregiver Support Program. RESULTS VA vocational and education services helped veterans with disabilities transition from the military into civilian life by providing skills and incremental exposure to engaging in everyday life tasks. Veteran motivation, caregiver support, and engaged staff at VA and academic institutions were key drivers of veteran success. Veterans who experienced challenges cited the following barriers: health problems, concerns about benefits loss if they became employed, and VA and academic programs that did not accommodate the needs of nontraditional veteran learners. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE There is a need to bolster VA vocational and educational services for veterans with disabilities in several domains, including modifying the roles of frontline staff and increasing communication between vocational counselors and health care teams to better accommodate the veteran's health-related limitations. Providing a vocational rehabilitation navigator to help veterans identify opportunities within VA and work/educational settings that are a good match for the veteran's goals and abilities could also be beneficial across vocational and educational services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham Veterans Affairs Health Services Research and Development (HSR&D), Center of Innovation to Accelerate Discovery and Practice Transformation(ADAPT),VA Durham Healthcare System
| | - Terri K Pogoda
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System
| | - Kevin McKenna
- Department of Population Health Sciences, Duke School of Medicine
| | - Nina Sperber
- Durham Veterans Affairs Health Services Research and Development (HSR&D), Center of Innovation to Accelerate Discovery and Practice Transformation(ADAPT),VA Durham Healthcare System
| | - Courtney H Van Houtven
- Durham Veterans Affairs Health Services Research and Development (HSR&D), Center of Innovation to Accelerate Discovery and Practice Transformation(ADAPT),VA Durham Healthcare System
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19
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Shepherd-Banigan M, Smith VA, Stechuchak KM, Van Houtven CH. Informal Caregiver Support Policies Change Use of Vocational Assistance Services for Individuals With Disabilities. Med Care Res Rev 2021; 79:218-232. [PMID: 34053345 DOI: 10.1177/10775587211018548] [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: 11/15/2022]
Abstract
Support policies for caregivers improves care-recipient access to care and effects may generalize to nonhealth services. Using administrative data from the U.S. Department of Veterans Affairs (VA) for veterans <55 years, we assessed the association between enrollment in a VA caregiver support program and veteran use of vocational assistance services: the post-9/11 GI Bill, VA vocational rehabilitation and employment (VR&E), and supported employment. We applied instrumental variables to Cox proportional hazards models. Caregiver enrollment in the program increased veteran supported employment use (hazard ratio = 1.35, 95% confidence interval [1.14, 1.53]), decreased VR&E use (hazard ratio = 0.84, 95% confidence interval [0.76, 0.92]), and had no effect on the post-9/11 GI Bill. Caregiver support policies could increase access to some vocational assistance for individuals with disabilities, particularly supported employment, which is integrated into health care. Limited coordination between health and employment sectors and misaligned incentives may have inhibited effects for the post-9/11 GI Bill and VR&E.
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, Durham, NC, USA
- Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
| | - Valerie A Smith
- Durham VA Health Care System, Durham, NC, USA
- Duke University, Durham, NC, USA
| | | | - Courtney H Van Houtven
- Durham VA Health Care System, Durham, NC, USA
- Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
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20
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Takvorian SU, Balogh E, Nass S, Valentin VL, Hoffman-Hogg L, Oyer RA, Carlson RW, Meropol NJ, Sheldon LK, Shulman LN. Developing and Sustaining an Effective and Resilient Oncology Careforce: Opportunities for Action. J Natl Cancer Inst 2021; 112:663-670. [PMID: 31868912 DOI: 10.1093/jnci/djz239] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/04/2019] [Accepted: 12/13/2019] [Indexed: 12/12/2022] Open
Abstract
Advances in cancer care have led to improved survival, which, coupled with demographic trends, have contributed to rapid growth in the number of patients needing cancer care services. However, with increasing caseload, care complexity, and administrative burden, the current workforce is ill equipped to meet these burgeoning new demands. These trends have contributed to clinician burnout, compounding a widening workforce shortage. Moreover, family caregivers, who have unique knowledge of patient preferences, symptoms, and goals of care, are infrequently appreciated and supported as integral members of the oncology "careforce." A crisis is looming, which will hinder access to timely, high-quality cancer care if left unchecked. Stemming from the proceedings of a 2019 workshop convened by the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine, this commentary characterizes the factors contributing to an increasingly strained oncology careforce and presents multilevel strategies to improve its efficiency, effectiveness, and resilience. Together, these will enable today's oncology careforce to provide high-quality care to more patients while improving the patient, caregiver, and clinician experience.
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Affiliation(s)
- Samuel U Takvorian
- Division of Hematology & Oncology, Perelman School of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Erin Balogh
- National Cancer Policy Forum, National Academies of Sciences, Engineering, and Medicine, Washington DC, USA
| | - Sharyl Nass
- National Cancer Policy Forum and Board on Health Care Services, National Academies of Sciences, Engineering, and Medicine, Washington DC, USA
| | - Virginia L Valentin
- Division of Physician Assistant Studies, Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lori Hoffman-Hogg
- Office of Nursing Services, Department of Veterans Affairs, Prevention Policy National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Washington DC, USA
| | - Randall A Oyer
- Lancaster General Health, Penn Medicine, Lancaster, PA, USA
| | - Robert W Carlson
- National Comprehensive Cancer Network, Plymouth Meeting, PA, USA
| | | | | | - Lawrence N Shulman
- Division of Hematology & Oncology, Perelman School of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
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21
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Wyman MF, Voils CI, Trivedi R, Boyle L, Goldman D, Umucu E, Zuelsdorff M, Johnson AL, Gleason CE. Perspectives of Veterans Affairs mental health providers on working with older adults with dementia and their caregivers. GERONTOLOGY & GERIATRICS EDUCATION 2021; 42:114-125. [PMID: 32420824 PMCID: PMC7671942 DOI: 10.1080/02701960.2020.1764356] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Continuing education directed at building providers' skills and knowledge in geriatrics represents a practical approach to addressing the geriatric mental health (MH) care workforce shortage. To inform the development of professional training curricula, we surveyed MH providers (N = 65) at a Veterans Affairs medical center on working with older persons with dementia (PwD) and informal caregivers. Providers rated service provision to PwD and caregivers as highly important but endorsed modest self-efficacy. Half of respondents were minimally confident in managing risk of harm to self or others in a PwD. Respondents believed PwD can benefit from MH treatments, yet identified several barriers to providing care, including inadequate time and staffing resources. Interest in geriatric training topics was high. Findings demonstrate that MH providers at this site value care provision to PwD and caregivers, and desire additional training to serve this population. System-level barriers to MH care for PwD should also be identified and addressed.
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Affiliation(s)
- Mary F. Wyman
- W.S. Middleton Memorial Veterans Hospital, Madison, WI
- University of Wisconsin School of Medicine & Public Health
| | - Corrine I. Voils
- W.S. Middleton Memorial Veterans Hospital, Madison, WI
- University of Wisconsin School of Medicine & Public Health
| | - Ranak Trivedi
- Stanford University, Palo Alto, CA
- VA Palo Alto Health Care System, Palo Alto, CA
| | - Lisa Boyle
- W.S. Middleton Memorial Veterans Hospital, Madison, WI
- University of Wisconsin School of Medicine & Public Health
| | | | - Emre Umucu
- University of Texas, El Paso, El Paso, TX
| | - Megan Zuelsdorff
- University of Wisconsin School of Medicine & Public Health
- School of Nursing, University of Wisconsin
| | - Adrienne L. Johnson
- W.S. Middleton Memorial Veterans Hospital, Madison, WI
- UW Center for Tobacco Research and Intervention, Madison, WI
| | - Carey E. Gleason
- W.S. Middleton Memorial Veterans Hospital, Madison, WI
- University of Wisconsin School of Medicine & Public Health
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22
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Hirschman KB, Bowles KH, Garcia-Gonzalez L, Shepard B, Walser TJ, Thomas GL, Stawnychy MA, Riegel B. Lessons learned from the implementation of a video health coaching technology intervention to improve self-care of family caregivers of adults with heart failure. Res Nurs Health 2020; 44:250-259. [PMID: 33341950 DOI: 10.1002/nur.22100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 11/13/2020] [Accepted: 12/06/2020] [Indexed: 12/18/2022]
Abstract
Individuals with heart failure (HF) typically live in the community and are cared for at home by family caregivers. These caregivers often lack supportive services and the time to access those services when available. Technology can play a role in conveniently bringing needed support to these caregivers. The purpose of this article is to describe the implementation of a virtual health coaching intervention with caregivers of HF patients ("Virtual Caregiver Coach for You"-ViCCY). A randomized controlled trial is currently in progress to test the efficacy of the intervention to improve self-care. In this trial, 250 caregivers will be randomly assigned to receive health information via a tablet computer (hereafter, tablet) plus 10 live health coaching sessions delivered virtually (intervention group; n = 125) or health information via a tablet only (control group; n = 125). Each tablet has specific health information websites preloaded. To inform others embarking on similar technology projects, here we highlight the technology challenges encountered with the first 15 caregivers who received the ViCCY intervention and the solutions used to overcome those challenges. Several adaptations to the implementation of ViCCY were needed to address hardware, software, and network connectivity challenges. Even with a well-designed research implementation plan, it is important to re-examine strategies at every step to solve implementation barriers and maximize fidelity to the intervention. Researcher and interventionist flexibility in adapting to new strategies is essential when implementing a technology-based virtual health coaching intervention.
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Affiliation(s)
- Karen B Hirschman
- NewCourtland Center for Transitions and Health, Philadelphia, Pennsylvania, USA.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathryn H Bowles
- NewCourtland Center for Transitions and Health, Philadelphia, Pennsylvania, USA.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, New York, USA
| | | | - Brooke Shepard
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tracie J Walser
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gladys L Thomas
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael A Stawnychy
- NewCourtland Center for Transitions and Health, Philadelphia, Pennsylvania, USA.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Barbara Riegel
- NewCourtland Center for Transitions and Health, Philadelphia, Pennsylvania, USA.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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23
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Shepherd‐Banigan M, Sherman SR, Lindquist JH, Miller KEM, Tucker M, Smith VA, Van Houtven CH. Family Caregivers of Veterans Experience High Levels of Burden, Distress, and Financial Strain. J Am Geriatr Soc 2020; 68:2675-2683. [DOI: 10.1111/jgs.16767] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/07/2020] [Accepted: 07/12/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Megan Shepherd‐Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System Durham North Carolina USA
- Department of Population Health Sciences Duke University Medical Center Durham North Carolina USA
| | - Sophia R. Sherman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System Durham North Carolina USA
| | - Jennifer H. Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System Durham North Carolina USA
| | - Katherine E. M. Miller
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System Durham North Carolina USA
- Department of Health Policy and Management University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Matthew Tucker
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System Durham North Carolina USA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System Durham North Carolina USA
- Department of Population Health Sciences Duke University Medical Center Durham North Carolina USA
- Department of General Internal Medicine Duke University Durham North Carolina USA
| | - Courtney Harold Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System Durham North Carolina USA
- Department of Population Health Sciences Duke University Medical Center Durham North Carolina USA
- Duke‐Margolis Center for Health Policy Durham North Carolina USA
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24
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Song W, Intrator O, Twersky J, Davagnino J, Kinosian B, Wieland D. Utilization and Cost Effects of the VHA Caring for Older Adults and Caregivers at Home (COACH) Program. Med Care Res Rev 2020; 78:736-746. [PMID: 32646276 DOI: 10.1177/1077558720929592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since 2010, the Veterans Health Administration has initiated a home-based Caring for Older Adults and Caregivers at Home (COACH) program to provide clinical support to dementia patients and family caregivers. But its impact on health care utilization and costs is unknown. We compared 354 COACH care recipients with a propensity score weighted comparison group of 9,857 community-dwelling Veterans during fiscal years 2010-2015. In 1-year follow-up, COACH program was associated with a lower rate of long-term nursing home placement (average treatment effect on the treated [ATT] -3%; p = .01). The program increased utilization of emergency services (ATT 6%; p = .01), hospitals (ATT 10%; p < .001), and personal care services (ATT 31%; p < .001). Health care costs were also significantly increased. Improved access to services may have enabled COACH Veterans to stay at home longer. As one of Veterans Health Administration's top priorities to expand caregiver assistance programs, COACH seems to be a promising model for a nationwide implementation.
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Affiliation(s)
- Wei Song
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Public Health Sciences, University of Rochester, Rochester, NY, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Public Health Sciences, University of Rochester, Rochester, NY, USA
| | - Jack Twersky
- Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
| | - Judith Davagnino
- Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
| | - Bruce Kinosian
- Geriatrics and Extended Care Data Analysis Center and Center for Health Equity Research and Promotion, Cpl. Michael J Crescenz VA Medical Center, Philadelphia, USA.,Department of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Darryl Wieland
- Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
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25
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Van Houtven CH, Smith VA, Stechuchak KM, Berkowitz TSZ, Miller KEM, Shepherd-Banigan M, Kabat M, Henius J. Comprehensive support of family caregivers: Are there health system cost offsets? Health Serv Res 2020; 55:710-721. [PMID: 32621548 DOI: 10.1111/1475-6773.13312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To examine the effect of the Department of Veterans Affairs' (VA) Program of Comprehensive Assistance for Caregivers (PCAFC) on total VA health care costs for Veterans. DATA SOURCES VA claims. STUDY DESIGN Using a pre-post cohort design with nonequivalent control group, we estimated the effect of PCAFC on total VA costs up through 6 years. The treatment group included Veterans (n = 32 394) whose caregivers enrolled in PCAFC. The control group included an inverse probability of treatment weighted sample of Veterans whose caregivers were denied PCAFC enrollment (n = 38 402). DATA EXTRACTION May 2009-September 2017. PRINCIPAL FINDINGS Total VA costs pre-PCAFC application date were no different between groups. Veterans in PCAFC were estimated to have $13 227 in VA costs in the first 6 months post-PCAFC application, compared to $10 806 for controls. Estimated VA costs for both groups decreased in the first 3 years with a narrowing, but persistent and significant, difference, through 5.5 years. No significant difference in VA health care costs existed at 6 years, approximately $10 000 each, though confidence intervals reflect significant uncertainty in cost differences at 6 years. CONCLUSIONS Increased costs arose from increased outpatient costs of participants. Sample composition changes may explain lack of significance in cost differences at 6 years because these costs comprise of early appliers to PCAFC. Examining 10-year costs could elucidate whether there are long-term cost offsets from increased engagement in outpatient care.
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Affiliation(s)
- Courtney Harold Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC.,Duke-Margolis Center for Health Policy, Durham, NC
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Theodore S Z Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Katherine E M Miller
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, NC
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC
| | - Margaret Kabat
- Caregiver Support Program, VA Central Office, Washington, DC
| | - Jennifer Henius
- Caregiver Support Program, VA Central Office, Washington, DC
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26
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Shepherd-Banigan M, Sperber N, McKenna K, Pogoda TK, Van Houtven CH. Leveraging institutional support for family caregivers to meet the health and vocational needs of persons with disabilities. Nurs Outlook 2019; 68:184-193. [PMID: 31570147 DOI: 10.1016/j.outlook.2019.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/09/2019] [Accepted: 08/25/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Family caregivers might enhance veteran engagement in health and nonhealth services (i.e., vocational/educational assistance). PURPOSE To describe how veterans with disabilities perceive their recovery needs, identify types of social support from caregivers that help veterans engage in Veterans Affairs (VA) health and nonhealth services, and explore participant views of VA institutional support for caregivers to help veterans engage in these services. METHODS Joint in-depth qualitative interviews with U.S. veterans and family caregivers (n = 26). FINDINGS Caregivers performed social support functions that helped veterans engage in health and vocational/educational services and institutional support from VA enhanced caregivers' capacity. DISCUSSION Caregivers are well positioned to align health and nonhealth services with patient needs to enhance recovery. Staffing a point person for caregivers within the health system is key to help families develop a coordinated plan of treatment and services to improve patient success across health and nonhealth domains. Nurses are well suited to perform this role.
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Affiliation(s)
- Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.
| | - Nina Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Kevin McKenna
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Terri K Pogoda
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA; Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Duke-Margolis Center for Health Policy, Duke University, Durham, NC
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27
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Shepherd-Banigan M, Kaufman BG, Decosimo K, Dadolf J, Boucher NA, Mahanna EP, Bruening R, Sullivan C, Wang V, Hastings SN, Allen KD, Sperber N, Coffman CJ, Van Houtven CH. Adaptation and Implementation of a Family Caregiver Skills Training Program: From Single Site RCT to Multisite Pragmatic Intervention. J Nurs Scholarsh 2019; 52:23-33. [PMID: 31497935 DOI: 10.1111/jnu.12511] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES). DESIGN Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework. FINDINGS Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention. CONCLUSIONS The emphasis on flexible intervention delivery and standardized materials has been identified as strengths of the adaptation process. Two key challenges have been identifying feasible impact measures and reaching eligible caregivers for intervention recruitment. CLINICAL RELEVANCE This systematic implementation process can be used to rapidly adapt an intervention to diverse clinical sites and contexts. Nursing professionals play a significant role in educating and supporting caregivers and care recipients and can take a leading role to implement interventions that address skills and unmet needs for caregivers.
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Affiliation(s)
- Megan Shepherd-Banigan
- Research Health Scientist, Durham VA Health Care System, and Assistant Professor, Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Brystana G Kaufman
- Postdoctoral Research Fellow, Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Kasey Decosimo
- Research Health Scientist Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Joshua Dadolf
- Clinical Social Worker/Intervention Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Nathan A Boucher
- Research Health Scientist, Durham VA Health Care System, and Assistant Research Professor, Sanford School of Public Policy, Duke University, Durham, NC, USA.,Core Faculty, Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Elizabeth P Mahanna
- Research Health Scientist Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Rebecca Bruening
- Research Health Scientist Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Caitlin Sullivan
- Research Health Scientist Specialist, Durham VA Health Care System, Durham, NC, USA
| | - Virginia Wang
- Research Health Scientist, Durham VA Health Care System, and Associate Professor, Department of Population Health Sciences, Duke University, and Associate Professor, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - S Nicole Hastings
- Research Health Scientist, Durham VA Health Care System, and Associate Professor, Division of Geriatrics, Department of Medicine, Duke University, and Associate Professor, Department of Population Health Sciences, Duke University, and Senior Fellow, Center for the Study of Aging, Duke University School of Medicine, Durham, NC, USA
| | - Kelli D Allen
- Research Health Scientist, Durham VA Health Care System, Durham, NC, and Professor, Division of Rheumatology, Allergy, and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nina Sperber
- Research Health Scientist, Durham VA Health Care System, and Assistant Professor, Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Cynthia J Coffman
- Research Health Scientist, Durham VA Health Care System, and Associate Professor, Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Courtney H Van Houtven
- Core Faculty, Margolis Center for Health Policy, Duke University, Durham, NC, USA.,Research Health Scientist, Durham VA Health Care System, and Professor, Department of Population Health Sciences, Duke University, Durham, NC, USA
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28
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Riegel B, Hanlon AL, Coe NB, Hirschman KB, Thomas G, Stawnychy M, Wald JW, Bowles KH. Health coaching to improve self-care of informal caregivers of adults with chronic heart failure - iCare4Me: Study protocol for a randomized controlled trial. Contemp Clin Trials 2019; 85:105845. [PMID: 31499227 DOI: 10.1016/j.cct.2019.105845] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/23/2019] [Accepted: 09/04/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Persons with chronic heart failure are living longer. These patients typically live in the community and are cared for at home by informal caregivers. These caregivers are an understudied and stressed group. METHODS We are conducting a two-arm, randomized controlled trial of 250 caregivers of persons with chronic heart failure to evaluate the efficacy of a health coaching intervention. A consecutive sample of participants is being enrolled from both clinic and hospital settings at a single institution affiliated with a large medical center in the northeastern US. Both the intervention and control groups receive tablets programmed to provide standardized health information. In addition, the intervention group receives 10 live coaching sessions delivered virtually by health coaches using the tablets. The intervention is evaluated at 6-months, with self-care as the primary outcome. Cost-effectiveness of the intervention is evaluated at 12-months. We are also enrolling heart failure patients (dyads) whenever possible to explore the effect of caregiver outcomes (self-care, stress, coping, health status) on heart failure patient outcomes (number of hospitalizations and days in the hospital) at 12-months. DISCUSSION We expect the proposed study to require 5 years for completion. If shown to be efficacious and cost-effective, our virtual health coaching intervention can easily be scaled to. support millions of caregivers worldwide.
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Affiliation(s)
| | | | - Norma B Coe
- University of Pennsylvania, United States of America
| | | | - Gladys Thomas
- University of Pennsylvania, United States of America
| | | | - Joyce W Wald
- Hospital of the University of Pennsylvania, United States of America
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29
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Goldstein KM, Duan-Porter W, Alkon A, Olsen MK, Voils CI, Hastings SN. Enrollment and Retention of Men and Women in Health Services Research and Development Trials. Womens Health Issues 2019; 29 Suppl 1:S121-S130. [PMID: 31253236 PMCID: PMC8489188 DOI: 10.1016/j.whi.2019.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 02/26/2019] [Accepted: 03/01/2019] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Sex- and gender-specific science is essential to inform patient-centered, evidence-based care. Developing such evidence requires adequate inclusion of both women and men in trials. We sought to describe study participation of women and men in Department of Veterans Affairs Health Services Research and Development trials. METHODS We identified recent health services research trials from one Health Services Research and Development Center of Innovation and compared the participation of women and men from trial recruitment to study completion. We also calculated the participation to prevalence ratio (PPR) by sex for each trial. RESULTS We included eight trials that started recruitment between 2011 and 2014. Only one study purposefully attempted to boost the recruitment of women. Overall, the PPR for women ranged from 0.2 to 4.5, with seven studies having a PPR of greater than 1, indicating that women participated in these trials at proportions greater than their prevalence in the disease population within the Department of Veterans Affairs. The PPR for men ranged from 0.8 to 1.1. Retention was best with those studies that used administrative data for final outcomes assessment. No studies provided results stratified by sex or conducted analyses to explore treatment effect by sex. CONCLUSIONS At a single site, women participated in Health Services Research and Development trials at similar or greater rates to men without cross-study efforts to enrich the recruitment or retention of women. Adding strategic recruitment approaches could further boost the proportion of women in Department of Veterans Affairs trials and enable adequately powered sex-based analyses.
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Affiliation(s)
- Karen M Goldstein
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Wei Duan-Porter
- University of Minnesota Medical School, Minneapolis, Minnesota; Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Aviel Alkon
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Maren K Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Corrine I Voils
- Department of Surgery, University of Wisconsin, Madison, Wisconsin; William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Susan N Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina; Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, North Carolina; Center for the Study of Human Aging and Development, Duke University, Durham, North Carolina
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30
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Yuan Y, Thomas KS, Frakt AB, Pizer SD, Garrido MM. Users Of Veteran-Directed Care And Other Purchased Care Have Similar Hospital Use And Costs Over Time. Health Aff (Millwood) 2019; 38:1037-1045. [PMID: 31158026 PMCID: PMC6781229 DOI: 10.1377/hlthaff.2019.00020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Veteran-Directed Care (VDC) program facilitates independent community living among adults with multiple chronic conditions and functional limitations. Family caregivers value the choice and flexibility afforded by VDC, but rigorous evidence to support its impact on health care costs and use is needed. We identified veterans enrolled in VDC in fiscal year 2017 and investigated differences in hospital admissions and costs after initial receipt of VDC services. We compared VDC service recipients to a matched comparison group of veterans receiving homemaker or home health aide, home respite, and adult day health care services and found similar decreases in hospital use and costs from before to after enrollment in the groups. Further investigation into trends of nursing home use, identification of veterans most likely to benefit from VDC, and relative costs of operating VDC versus other purchased care programs is needed, but our results suggest that VDC remains a valuable option for supporting veterans and caregivers.
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Affiliation(s)
- Yingzhe Yuan
- Yingzhe Yuan is a data analyst at the Partnered Evidence-Based Policy Resource Center at the Veterans Affairs (VA) Boston Healthcare System and a research assistant at the Boston University School of Public Health, both in Massachusetts
| | - Kali S Thomas
- Kali S. Thomas is a research health scientist in the Center of Innovation in Long-Term Services and Supports at the Providence VA Medical Center and an associate professor in the Center for Gerontology and Healthcare Research, Brown University School of Public Health, all in Providence, Rhode Island
| | - Austin B Frakt
- Austin B. Frakt is director of the Partnered Evidence-Based Policy Resource Center at the VA Boston Healthcare System; an associate professor in the Boston University School of Public Health; and an adjunct associate professor at the Harvard T. H. Chan School of Public Health, all in Boston
| | - Steven D Pizer
- Steven D. Pizer is chief economist of the Partnered Evidence-Based Policy Resource Center at the VA Boston Healthcare System and an associate professor of health law, policy, and management, Boston University School of Public Health
| | - Melissa M Garrido
- Melissa M. Garrido ( ) is associate director of the Partnered Evidence-Based Policy Resource Center at the VA Boston Healthcare System and an associate professor of health law, policy, and management, Boston University School of Public Health
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31
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Smith VA, Lindquist J, Miller KEM, Shepherd-Banigan M, Olsen M, Campbell-Kotler M, Henius J, Kabat M, Van Houtven CH. Comprehensive Family Caregiver Support and Caregiver Well-Being: Preliminary Evidence From a Pre-post-survey Study With a Non-equivalent Control Group. Front Public Health 2019; 7:122. [PMID: 31179259 PMCID: PMC6538764 DOI: 10.3389/fpubh.2019.00122] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 04/30/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: In May 2010, the Caregivers and Veterans Omnibus Health Services Act of 2010, was signed into law in the United States, establishing the Program of Comprehensive Assistance for Family Caregivers (PCAFC) provided through the VA Caregiver Support Program (CSP). Prior to this program, over half of family caregivers reported being untrained for the tasks they needed to provide. The training through PCAFC represents the largest effort to train family caregivers in the U.S., and the features of the program, specifically a monthly stipend to caregivers and access to a Caregiver Support Coordinator at each VA medical center nationally, make it the most comprehensive caregiver support program ever enacted in the U.S. Methods: The purpose of this study is to examine the association between PCAFC participation and caregiver well-being following enrollment, comparing participating PCAFC caregivers to caregivers who applied to but were not approved for PCAFC participation (non-participants). Well-being is defined using three diverse but related outcomes: depressive symptoms, perceived financial strain, and perceived quality of the Veteran's health care. Additional well-being measures also examined include the Zarit Burden Inventory and positive aspects of caregiving. Results: The survey sample comprised of 92 caregivers approved for PCAFC and 66 caregivers not approved. The mean age of responding caregivers was 45; over 90% of caregivers were female; and over 80% of caregivers were married in both groups. We find promising trends in well-being associated with PCAFC participation. First, the perception of financial strain declined among participants compared to non-participants. Second, while depressive symptoms did not improve for the PCAFC caregivers, depressive symptoms increased among non-participants. Third, perceived quality of the Veteran's VA healthcare was no different between participants and non-participants. However, the 158 returned surveys reflect only a 5% response rate; hence this evidence is preliminary. Conclusion: Despite cautioning that results be interpreted as preliminary, this study provides unique descriptive information about young caregivers of U.S. post-9/11 Veterans, and offers a first step in filling the evidence gap about how comprehensive caregiver support in the U.S. may affect caregiver well-being. These preliminary findings should be explored and validated in a larger sample.
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Affiliation(s)
- Valerie A Smith
- Department of Population Health Sciences, Duke University, Durham, NC, United States.,Health Services Research and Development, Durham VA Health Care System, Durham, NC, United States.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, United States
| | - Jennifer Lindquist
- Health Services Research and Development, Durham VA Health Care System, Durham, NC, United States
| | - Katherine E M Miller
- Health Services Research and Development, Durham VA Health Care System, Durham, NC, United States.,Health Policy and Management, University of North Carolina, Chapel Hill, NC, United States
| | - Megan Shepherd-Banigan
- Department of Population Health Sciences, Duke University, Durham, NC, United States.,Health Services Research and Development, Durham VA Health Care System, Durham, NC, United States
| | - Maren Olsen
- Health Services Research and Development, Durham VA Health Care System, Durham, NC, United States.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States
| | - Margaret Campbell-Kotler
- Caregiver Support Program, United States Department of Veterans Affairs, Seattle, WA, United States
| | - Jennifer Henius
- Caregiver Support Program, United States Department of Veterans Affairs, Seattle, WA, United States
| | - Margaret Kabat
- Caregiver Support Program, United States Department of Veterans Affairs, Seattle, WA, United States
| | - Courtney Harold Van Houtven
- Department of Population Health Sciences, Duke University, Durham, NC, United States.,Health Services Research and Development, Durham VA Health Care System, Durham, NC, United States
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Wolff JL, Drabo EF, Van Houtven CH. Beyond Parental Leave: Paid Family Leave for an Aging America. J Am Geriatr Soc 2019; 67:1322-1324. [PMID: 30887494 DOI: 10.1111/jgs.15873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Emmanuel F Drabo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Courtney H Van Houtven
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
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Hanson KT, Carlson KF, Friedemann-Sanchez G, Meis LA, Van Houtven CH, Jensen AC, Phelan SM, Griffin JM. Family caregiver satisfaction with inpatient rehabilitation care. PLoS One 2019; 14:e0213767. [PMID: 30875411 PMCID: PMC6420024 DOI: 10.1371/journal.pone.0213767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 02/28/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Informal family caregivers play an increasingly important role in healthcare. Despite their role in ongoing management and coordination of care, caregiver satisfaction with the healthcare services care recipients receive has been understudied. We sought to assess what influences caregiver satisfaction with inpatient care provided to their care recipient among caregivers of veterans with traumatic brain injury (TBI) and polytrauma. METHODS Data from the Family and Caregiver Experience Survey, a national survey of caregivers of veterans with TBI and polytrauma, was used to explore factors associated with caregiver satisfaction with the care his/her care recipient received while an inpatient at a US Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center. Caregiver and care recipient demographic and injury factors and potential addressable factors including social support, caregiver training received, and caregiver perceptions of being valued by the VA were evaluated for their associations with caregivers' satisfaction with their care recipients' healthcare. RESULTS The majority of the 524 caregivers reported being mostly or very satisfied with their care recipient's inpatient care (75%, n = 393). Higher satisfaction with inpatient care was significantly associated with greater caregiver social support, receipt of training from the VA, and perceptions of being valued by the VA, both on univariate analysis and after controlling for care recipient TBI severity and caregiver's relationship to the care recipient. CONCLUSIONS Results suggest that supporting a strong social network for caregivers, providing caregiver training, and employing practices that communicate that family caregiving is valued by providers and healthcare organizations are promising avenues for improving caregiver satisfaction.
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Affiliation(s)
- Kristine T. Hanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kathleen F. Carlson
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, United States of America
- Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon, United States of America
| | - Greta Friedemann-Sanchez
- Hubert H. Humphrey School of Public Affairs, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Laura A. Meis
- University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, United States of America
| | - Courtney H. Van Houtven
- Durham VA Medical Center, Durham, North Carolina, United States of America
- Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Agnes C. Jensen
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, United States of America
| | - Sean M. Phelan
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Joan M. Griffin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, United States of America
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Miller KEM, Lindquist JH, Olsen MK, Smith V, Voils CI, Oddone EZ, Sperber NR, Shepherd‐Banigan M, Wieland GD, Henius J, Kabat M, Van Houtven CH. Invisible partners in care: Snapshot of well-being among caregivers receiving comprehensive support from Veterans Affairs. Health Sci Rep 2019; 2:e112. [PMID: 30937391 PMCID: PMC6427058 DOI: 10.1002/hsr2.112] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 10/22/2018] [Accepted: 12/07/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND AND AIMS Since May 2011, over 23 000 caregivers of Veterans seriously injured on or after September 11, 2001 have enrolled in the Program of Comprehensive Assistance for Family Caregivers (PCAFC). PCAFC provides caregivers training, a stipend, and access to health care. The aim of this study is to describe the characteristics of caregivers in PCAFC and examine associations between caregiver characteristics and caregiver well-being outcomes. METHODS We sent a web survey invitation to 10 000 PCAFC caregivers enrolled as of September 2015. Using linear and logistic regressions, we examine associations between PCAFC caregiver characteristics and caregiver outcomes: perceived financial strain, depressive symptoms (Center for Epidemiologic Studies Depression Scale [CESD-10]), perceived quality of Veteran's Veterans Health Administration (VHA) care, and self-reported caregiver health. RESULTS We had complete survey data for 899 respondents. Since becoming a caregiver, approximately 50% of respondents reported reducing or stopping work. Mean time spent providing care was 3.8 years (median 3, IQR 1-5) with an average of 4.9 weekdays (median 5, IQR 5-5) and 1.9 weekend days (median 2, IQR 2-2). The mean CESD-10 score was 8.2 (median 7, 4-12), at the cutoff for screening positive for depressive symptoms. A longer duration of caregiving was associated with having 0.08 increase in rating of financial strain (95% CI, 0.02-0.14). Caregiver rating of the Veteran's health status as "fair" or better was a strong predictor of better caregiver outcomes, ie, self-reported caregiver health. However, higher levels of education were associated with worse caregiver outcomes, ie, lower global satisfaction with VHA care, higher CESD-10 score, and higher rating of financial strain. CONCLUSIONS Higher depressive symptoms among longer duration caregivers, coupled with high rates of reductions in hours worked, suggest interventions are needed to address the long-term emotional and financial needs of these caregivers of post-9/11 Veterans and identify subpopulations at risk for worse outcomes.
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Affiliation(s)
- Katherine E. M. Miller
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Health Policy and ManagementUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Jennifer H. Lindquist
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
| | - Maren K. Olsen
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Biostatistics and BioinformaticsDuke UniversityDurhamNorth CarolinaUSA
| | - Valerie Smith
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Corrine I. Voils
- Research ServiceWilliam S. Middleton Veterans Memorial HospitalMadisonWisconsinUSA
- Department of SurgeryUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Eugene Z. Oddone
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Nina R. Sperber
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
| | - Megan Shepherd‐Banigan
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
| | - G. Darryl Wieland
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
| | - Jennifer Henius
- Caregiver Support ProgramDepartment of Veterans AffairsWashington DCUSA
| | - Margaret Kabat
- Caregiver Support ProgramDepartment of Veterans AffairsWashington DCUSA
| | - Courtney Harold Van Houtven
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
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Shepherd-Banigan ME, Shapiro A, McDuffie JR, Brancu M, Sperber NR, Van Houtven CH, Kosinski AS, Mehta NN, Nagi A, Williams JW. Interventions That Support or Involve Caregivers or Families of Patients with Traumatic Injury: a Systematic Review. J Gen Intern Med 2018; 33:1177-1186. [PMID: 29736752 PMCID: PMC6025684 DOI: 10.1007/s11606-018-4417-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/17/2018] [Accepted: 03/21/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Almost 40 million family caregivers care for a loved one with severe physical or cognitive impairments. The purpose of this review is to summarize evidence about the benefits of interventions to support or involve family members/caregivers of patients with trauma-related injury on caregiver, patient, and household outcomes. METHODS English-language peer-reviewed publications in MEDLINE, CINAHL, and PsycINFO from 1995 through December 2016 were identified. Eligible studies included RCT or quasi-experimental studies evaluating interventions designed to support or involve caregivers or family members of patients with TBI, PTSD, or polytrauma. Abstractions were completed by one reviewer and checked by a second; two reviewers independently assessed risk of bias using the Cochrane Effective Practice and Organization of Care Review Criteria. RESULTS Thirteen studies (n = 9 TBI; n = 4 PTSD, n = 0 polytrauma) evaluated psychological or rehabilitation interventions involving caregivers. Interventions did not improve TBI patients' functional status (standardized mean difference [SMD], 0.29 [95% confidence interval [CI], - 0.51 to 1.08]) or psychological symptoms (SMD - 0.25, CI - 0.62 to 0.12). Qualitative analysis shows potential intervention benefit for TBI symptoms. Interventions did not improve TBI caregiver psychological symptoms (SMD - 0.26, CI - 0.57 to 0.05); however, qualitative analysis suggests mixed effects for caregiver burden and quality of life. Positive intervention effects on patients' PTSD symptoms, mental health service use, and PTSD caregivers' psychological symptoms were identified with certain interventions. Strength of evidence ranged from moderate to very low. DISCUSSION Studies showed mixed patterns of intervention effects on caregiver and patient outcomes; evidence about intervention impact is inconclusive. This review is the first to identify caregiving interventions for patients with TBI and polytrauma and extends past reviews about patients with PTSD. Limitations include a small evidence base, low study quality, disparate methods, varied outcome measures, and high heterogeneity. PROSPERO Registration CRD42017053516.
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Affiliation(s)
- Megan E Shepherd-Banigan
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
| | - Abigail Shapiro
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer R McDuffie
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center Durham, Durham, NC, USA
| | - Mira Brancu
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham VA Medical Center, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Nina R Sperber
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center Durham, Durham, NC, USA
| | - Courtney H Van Houtven
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center Durham, Durham, NC, USA
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Neha N Mehta
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center Durham, Durham, NC, USA
| | - Avishek Nagi
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - John W Williams
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center Durham, Durham, NC, USA
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Shepherd-Banigan M, Smith VA, Maciejewski ML, Stechuchak KM, Hastings SN, Wieland GD, Miller KEM, Kabat M, Henius J, Campbell-Kotler M, Van Houtven CH. The Effect of Support and Training for Family Members on Access to Outpatient Services for Veterans with Posttraumatic Stress Disorder (PTSD). ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 45:550-564. [PMID: 29374821 PMCID: PMC6688617 DOI: 10.1007/s10488-017-0844-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The VA Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides landmark support for family caregivers of post-9/11 veterans. This study examines PCAFC support for veterans with and without PTSD and assesses whether program effect differs by PTSD status using a pre-post, non-equivalent, propensity score weighted comparison group design (n = 24,280). Veterans with and without PTSD in PCAFC accessed more mental health, primary, and specialty care services than weighted comparisons. PCAFC participation had stronger effects on access to primary care for veterans with PTSD than for veterans without PTSD. For veterans with PTSD, PCAFC support might enhance health service use.
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Affiliation(s)
- Megan Shepherd-Banigan
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA.
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA.
| | - Valerie A Smith
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Matthew L Maciejewski
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Karen M Stechuchak
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
| | - Susan Nicole Hastings
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA
- Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - G Darryl Wieland
- Social Sciences Research Institute, Duke University, Durham, NC, USA
| | - Katherine E M Miller
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
| | - Margaret Kabat
- Caregiver Support Program, VA Central Office, Washington, DC, USA
| | - Jennifer Henius
- Caregiver Support Program, VA Central Office, Washington, DC, USA
| | | | - Courtney Harold Van Houtven
- Department of Veterans Affairs, Durham VA Medical Center Health Services Research and Development, Durham, NC, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
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Van Houtven CH. Bringing Invisible Partners in Care out of the Shadows: Employment Effects of Informal Care Provision in Europe and Implications for the United States. Health Serv Res 2018; 53:2011-2019. [PMID: 29740818 DOI: 10.1111/1475-6773.12863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Courtney Harold Van Houtven
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
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Shepherd-Banigan M, Smith VA, Stechuchak KM, Miller KEM, Hastings SN, Wieland GD, Olsen MK, Kabat M, Henius J, Campbell-Kotler M, Van Houtven CH. Comprehensive Support for Family Caregivers of Post-9/11 Veterans Increases Veteran Utilization of Long-term Services and Supports: A Propensity Score Analysis. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2018; 55:46958018762914. [PMID: 29591540 PMCID: PMC5882048 DOI: 10.1177/0046958018762914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 01/28/2018] [Accepted: 02/07/2018] [Indexed: 11/16/2022]
Abstract
Family caregivers are an important component of the long-term services and supports (LTSS) system. However, caregiving may have negative consequences for caregiver physical and emotional health. Connecting caregivers to formal short-term home- and community-based services (HCBS), through information resources and referrals, might alleviate family caregiver burden and delay nursing home entry for the patient. The aim of this study was to evaluate the early impact of the Program of Comprehensive Assistance for Family Caregivers (PCAFC) (established by P.L. 111-163 for family caregivers of seriously injured post-9/11 Veterans) on Veteran use of LTSS. A two-cohort pre-post design with a nonequivalent comparison group (treated n = 15 650; comparison n = 8339) was used to (1) examine the association between caregiver enrollment in PCAFC and any VA-purchased or VA-provided LTSS use among Veterans and (2) describe program-related trends in HCBS and institutional LTSS use. The comparison group was an inverse-propensity-score weighted sample of Veterans whose caregivers applied for, but were not accepted into, the program. From baseline through 24 months post application, use of any LTSS ranged from 13.1% to 17.8% for Veterans whose caregivers were enrolled in PCAFC versus from 3.8% to 5.3% for Veterans in the comparison group. Participation in PCAFC was associated with a statistically significant increased use of any LTSS from 1 to 24 months post application (over time odds ratios ranged from 2.71 [95% confidence interval: 2.31-3.17] to 4.86 [3.93-6.02]). Support for family caregivers may enhance utilization of LTSS for Veterans with physical, emotional, and/or cognitive conditions.
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Affiliation(s)
| | - Valerie A. Smith
- Durham VA Medical Center, NC, USA
- Duke University, Durham, NC, USA
| | | | | | | | | | - Maren K. Olsen
- Durham VA Medical Center, NC, USA
- Duke University, Durham, NC, USA
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Van Houtven CH, Miller KEM, O'Brien EC, Wolff JL, Lindquist J, Kabat M, Campbell-Kotler M, Henius J, Voils CI. Development and Initial Validation of the Caregiver Perceptions About Communication With Clinical Team Members (CAPACITY) Measure. Med Care Res Rev 2017; 76:784-806. [PMID: 29262757 DOI: 10.1177/1077558717747985] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the important role that family caregivers play managing the care of persons with complex health needs, little is known about how caregivers perceive themselves to be recognized and valued by health care professionals. Our objective was to develop and validate a novel measure, the CAregiver Perceptions About CommunIcation with Clinical Team members (CAPACITY) instrument. Questions focus on perceived quality of communication with the health care team and the extent to which caregivers believe that the health care team considers their capacity and preferences in decision making. A confirmatory factor analysis supported a two-factor solution addressing communication and capacity. Internal consistency reliability was .90 for the communication domain and .93 for the capacity domain. Correlations between these two subscales and individual difference measures provided evidence of convergent and discriminant validity. The CAPACITY instrument may be a useful performance measure that quantifies the extent to which caregivers' experience person- and family-centered health care.
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Affiliation(s)
| | | | | | - Jennifer L Wolff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | | | - Corrine I Voils
- William S, Middleton Veterans Memorial Hospital, Madison, WI, USA.,University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
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