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Nadash P, Tell EJ, Jansen T. What do Family Caregivers Want? Payment for Providing Care. J Aging Soc Policy 2024; 36:547-561. [PMID: 36688324 DOI: 10.1080/08959420.2022.2127599] [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: 02/15/2022] [Accepted: 03/12/2022] [Indexed: 01/24/2023]
Abstract
Although the primary goal of self-directed programs providing long term services and supports (LTSS) is to maximize choice and control for service recipients, such programs may also benefit family caregivers by compensating them for providing supportive services. This study draws on qualitative data from research supporting the RAISE Family Caregiver Advisory Council, finding that family caregivers themselves see the expansion of self-directed programs as a policy priority due to their need for financial security. The request for compensation was the strongest finding, with respondents highlighting the incompatibility of work with caregiving and their inability to rely on the existing paid workforce due to supply and quality issues; the consequences of this loss of earned income were reported as severe. Ultimately, respondents saw payment for providing care as an issue of fairness. This evidence supports the policy case for expanding access to self-directed programs that permit the employment of family caregivers.
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Affiliation(s)
- Pamela Nadash
- Department of Gerontology and Gerontology Institute, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts, Boston, Massachusetts, USA
| | - Eileen J Tell
- Department of Gerontology and Gerontology Institute, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts, Boston, Massachusetts, USA
- ET Consulting, LLC
| | - Taylor Jansen
- Department of Gerontology and Gerontology Institute, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts, Boston, Massachusetts, USA
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2
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Tyagi P, Bouldin ED, Hathaway WA, D'Arcy D, Nasr SZ, Intrator O, Dang S. Preimplementation Evaluation of a Self-Directed Care Program in a Veterans Health Administration Regional Network: Protocol for a Mixed Methods Study. JMIR Res Protoc 2024; 13:e57341. [PMID: 38875003 PMCID: PMC11214023 DOI: 10.2196/57341] [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: 02/13/2024] [Revised: 04/18/2024] [Accepted: 05/08/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND The Veteran-Directed Care (VDC) program serves to assist veterans at risk of long-term institutional care to remain at home by providing funding to hire veteran-selected caregivers. VDC is operated through partnerships between Department of Veterans Affairs (VA) Medical Centers (VAMCs) and third-party Aging and Disability Network Agency providers. OBJECTIVE We aim to identify facilitators, barriers, and adaptations in VDC implementation across 7 VAMCs in 1 region: Veterans Integrated Service Network (VISN) 8, which covers Florida, South Georgia, Puerto Rico, and the US Virgin Islands. We also attempted to understand leadership and stakeholder perspectives on VDC programs' reach and implementation and identify veterans served by VISN 8's VDC programs and describe their home- and community-based service use. Finally, we want to compare veterans served by VDC programs in VISN 8 to the veterans served in VDC programs across the VA. This information is intended to be used to identify strategies and propose recommendations to guide VDC program expansion in VISN 8. METHODS The mixed methods study design encompasses electronically delivered surveys, semistructured interviews, and administrative data. It is guided by the Consolidated Framework for Implementation Research (CFIR version 2.0). Participants included the staff of VAMCs and partnering aging and disability network agencies across VISN 8, leadership at these VAMCs and VISN 8, veterans enrolled in VDC, and veterans who declined VDC enrollment and their caregivers. We interviewed selected VAMC site leaders in social work, Geriatrics and Extended Care, and the Caregiver Support Program. Each interviewee will be asked to complete a preinterview survey that includes information about their personal characteristics, experiences with the VDC program, and perceptions of program aspects according to the CFIR (version 2.0) framework. Participants will complete a semistructured interview that covers constructs relevant to the respondent and facilitators, barriers, and adaptations in VDC implementation at their site. RESULTS We will calculate descriptive statistics including means, SDs, and percentages for survey responses. Facilitators, barriers, number of patients enrolled, and staffing will also be presented. Interviews will be analyzed using rapid qualitative techniques guided by CFIR domains and constructs. Findings from VISN 8 will be collated to identify strategies for VDC expansion. We will use administrative data to describe veterans served by the programs in VISN 8. CONCLUSIONS The VA has prioritized VDC rollout nationwide and this study will inform these expansion efforts. The findings from this study will provide information about the experiences of the staff, leadership, veterans, and caregivers in the VDC program and identify program facilitators and barriers. These results may be used to improve program delivery, facilitate growth within VISN 8, and inform new program establishment at other sites nationwide as the VDC program expands. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/57341.
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Affiliation(s)
- Pranjal Tyagi
- South Florida Veteran Affairs Foundation for Research & Education, Miami, FL, United States
| | - Erin D Bouldin
- Division of Epidemiology, Department of Internal Medicine, University of Utah Eccles School of Medicine, Salt Lake City, UT, United States
| | - Wendy A Hathaway
- Providence Veterans Affairs Medical Center, Providence, RI, United States
| | - Derek D'Arcy
- Canandaigua VA Medical Center, Department of Veterans Affairs, Canandaigua, NY, United States
| | - Samer Zacharia Nasr
- VISN 8 Network Office, Department of Veterans Affairs, St. Petersburg, FL, United States
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester, Rochester, NY, United States
- Geriatrics and Extended Care Data Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, United States
| | - Stuti Dang
- Miami VA GRECC, Miami VA Healthcare System, Miami, FL, United States
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3
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Zimmerman S, Stone R, Carder P, Thomas K. Does Assisted Living Provide Assistance And Promote Living? Health Aff (Millwood) 2024; 43:674-681. [PMID: 38709966 DOI: 10.1377/hlthaff.2023.00972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have worsened; regulations have become complex; the need for consumer support, education, and advocacy has grown; and financing and accessibility have become insufficient. Together, these factors have limited the extent to which today's assisted living adequately provides assistance and promotes living, with negative consequences for aging in place and well-being. This Commentary provides recommendations in four areas to help assisted living meet its promise: workforce; regulations and government; consumer needs and roles; and financing and accessibility. Policies that may be helpful include those that would increase staffing and boost wages and training; establish staffing standards with appropriate skill mix; promulgate state regulations that enable greater use of third-party services; encourage uniform data reporting; provide funds supporting family involvement; make community disclosure statements more accessible; and offer owners and operators incentives to facilitate access for consumers with fewer resources. Attention to these and other recommendations may help assisted living live up to its name.
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Affiliation(s)
- Sheryl Zimmerman
- Sheryl Zimmerman , University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Paula Carder
- Paula Carder, Portland State University, Portland, Oregon
| | - Kali Thomas
- Kali Thomas, Johns Hopkins University, Baltimore, Maryland
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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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5
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Yuan Y, Thomas KS, Van Houtven CH, Price ME, Pizer SD, Frakt AB, Garrido MM. Fewer potentially avoidable health care events in rural veterans with self-directed care versus other personal care services. J Am Geriatr Soc 2022; 70:1418-1428. [PMID: 35026056 PMCID: PMC9106846 DOI: 10.1111/jgs.17656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 12/02/2021] [Accepted: 12/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rural residents face more barriers to healthcare access, including challenges in receiving home- and community-based long-term services, compared to urban residents. Self-directed services provide flexibility and choice in care options and may be particularly well suited to help older adults with multiple chronic conditions and functional limitations who reside in rural areas remain independent and live in the community. METHODS We conducted a retrospective observational study to understand whether differences in health outcomes between Veteran-Directed Care (VDC), a self-directed Veterans Health Administration (VHA)-paid care program, and other VHA-paid home- and community-based personal care services vary in rural/urban location. The sample included 37,395 veterans receiving VHA-paid home- and community-based long-term care services in FY17. Our primary outcomes were changes in monthly incidence of VHA or VHA-paid community acute care admissions, nursing home admissions, and emergency department (ED) visits. We used fixed effects logistic regression models on unmatched and coarsened exact matched cohorts, stratified by rural/urban location. RESULTS Both urban and rural VDC recipients were significantly less likely to be admitted to VHA-paid nursing homes, compared to those receiving other VHA-paid personal care services (rural: incremental effect = -0.22, [-0.30, -0.14]; urban: incremental effect = -0.14, [-0.20, -0.07]). Rural, but not urban, VDC enrollees had significantly fewer VHA-paid acute care admissions and ED visits, relative to recipients of other VHA-paid personal care services (acute care, rural: incremental effect = -0.07, 95% CI = [-0.14, -0.01], urban: incremental effect = -0.01, [-0.06, 0.03]; ED, rural: incremental effect = -0.08, [-0.14, -0.02], urban: incremental effect = 0.01, [-0.03, 0.05]). CONCLUSIONS VDC recipients had fewer incidents of potentially avoidable VHA-paid health care use, compared to similar veterans receiving other VHA-paid personal care services. These differences were more pronounced among rural VDC recipients than urban VDC recipients.
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Affiliation(s)
- Yingzhe Yuan
- Partnered Evidence-Based Policy Resource Center (PEPReC), VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Kali S Thomas
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine and Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Megan E Price
- Partnered Evidence-Based Policy Resource Center (PEPReC), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Steven D Pizer
- Partnered Evidence-Based Policy Resource Center (PEPReC), VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Austin B Frakt
- Partnered Evidence-Based Policy Resource Center (PEPReC), VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Melissa M Garrido
- Partnered Evidence-Based Policy Resource Center (PEPReC), VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
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Jacobs JC, Maciejeweski ML, Wagner TH, Van Houtven CH, Lo J, Greene L, Zulman DM. Improving Prediction of Long-Term Care Utilization Through Patient-Reported Measures: Cross-Sectional Analysis of High-Need U.S. Veterans Affairs Patients. Med Care Res Rev 2021; 79:676-686. [PMID: 34906010 DOI: 10.1177/10775587211062403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article examines the relative merit of augmenting an electronic health record (EHR)-derived predictive model of institutional long-term care (LTC) use with patient-reported measures not commonly found in EHRs. We used survey and administrative data from 3,478 high-risk Veterans aged ≥65 in the U.S. Department of Veterans Affairs, comparing a model based on a Veterans Health Administration (VA) geriatrics dashboard, a model with additional EHR-derived variables, and a model that added survey-based measures (i.e., activities of daily living [ADL] limitations, social support, and finances). Model performance was assessed via Akaike information criteria, C-statistics, sensitivity, and specificity. Age, a dementia diagnosis, Nosos risk score, social support, and ADL limitations were consistent predictors of institutional LTC use. Survey-based variables significantly improved model performance. Although demographic and clinical characteristics found in many EHRs are predictive of institutional LTC, patient-reported function and partnership status improve identification of patients who may benefit from home- and community-based services.
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Affiliation(s)
- Josephine C Jacobs
- VA Palo Alto Health Care System, Menlo Park, CA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | | | - Todd H Wagner
- VA Palo Alto Health Care System, Menlo Park, CA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | | | - Jeanie Lo
- VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Liberty Greene
- VA Palo Alto Health Care System, Menlo Park, CA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | - Donna M Zulman
- VA Palo Alto Health Care System, Menlo Park, CA, USA.,Stanford University School of Medicine, Stanford, CA, USA
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7
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Clary AS, Perry KR, Edwards-Orr M, Miech EJ, VanHoutven C, Rudolph JL, Thomas KS, Sperber N. Interorganizational Context When Implementing Multisector Partnered Programs: A Qualitative Analysis of Veteran Directed Care. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2020; 63:822-836. [PMID: 33167782 DOI: 10.1080/01634372.2020.1817828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 08/25/2020] [Accepted: 08/28/2020] [Indexed: 06/11/2023]
Abstract
As the number of Veterans enrolled in the Veterans Health Administration (VHA) and at risk for needing Long Term Services and Supports increases, VHA is shifting from institutional to Home and Community Based Services, such as the Veteran-Directed Care (VDC) program. VDC is a multi-sector program implemented as a collaboration between individual VHA medical centers (VAMCs) and Aging and Disability Network Agencies (ADNAs), entities that sit outside the VHA. Factors that affect establishment of effective multi-sector programs such as VDC are poorly understood, limiting ability to effectively deliver and scale programs. We conducted a qualitative study to describe factors affecting the interorganizational implementation context of VDC. Using constructs from the Consolidated Framework for Implementation Research (CFIR), we interviewed VDC coordinators from seven different VAMC-ADNA partnerships that initiated the VDC program between 2017 and 2018. We identified eight CFIR determinants which manifested similarly for the VAMCs and ADNAs: evidence strength and quality, relative advantage, adaptability, tension for change, access to knowledge and information, self-efficacy; engaging, and champions. We identified three CFIR determinants that varied dramatically across VAMCs and ADNAs: available resources, implementation climate, and relative priority. Our results suggest that interorganizational context plays a critical and dynamic role within multi-sector collaborations.
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Affiliation(s)
- Alecia S Clary
- Center for Healthcare Transformation, Avalere Health , Washington, DC, USA
| | - Kathleen R Perry
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | | | - Edward J Miech
- Health Services Research & Development Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- William M. Tierney Center for Health Services Research, Regenstrief Institute , Indianapolis, Indiana, USA
| | - Courtney VanHoutven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine , Durham, North Carolina, USA
- Duke Margolis Center for Health Policy , Durham, North Carolina, USA
| | - James L Rudolph
- VA Providence Healthcare System, Providence, Rhode Island, USA
| | - Kali S Thomas
- VA Providence Healthcare System, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health , Providence, Rhode Island, USA
| | - Nina Sperber
- Center for Healthcare Transformation, Avalere Health , Washington, DC, USA
- Department of Population Health Sciences, Duke University School of Medicine , Durham, North Carolina, USA
- Duke Margolis Center for Health Policy , Durham, North Carolina, USA
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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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