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2023 HSR&D/QUERI National Conference Abstract

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4070 — Health care teams and access to home and community-based services for older Veterans with dementia: Do comorbidities matter?

Lead/Presenter: Emma Quach,  COIN - Bedford/Boston
All Authors: Quach ED (Center for Healthcare Organization and Implementation Research, Bedford), Franzosa E (Icahn School of Medicine at Mount Sinai, GRECC Bronx) Zhao S (Center for Healthcare Organization and Implementation Research) Ni P (Boston University, School of Public Health) Hartmann CW (Center for Healthcare Organization and Implementation Research, UMass Lowell, Zuckerberg College of Health Sciences) Moo LR (Center for Healthcare Organization and Implementation Research, Harvard Medical School, NE GRECC)

Objectives:
Home and community-based services (HCBS) are vital for allowing Veterans with dementia to remain in the community; yet access barriers persist. Case management has been incorporated into multiple VA care settings targeting patients with dementia, but it is unknown how different care settings contribute to patients’ use of HCBS, especially patients with the most complex medical needs.

Methods:
A cross-sectional cohort analysis of CDW data regarding VA-funded health care received by community-dwelling patients > 65 years of age with dementia. We specified HCBS use (outcome variable) as home care-only, adult day-only, dual use of home care and adult day, or no use (reference group). Four binary predictors denoted whether or not patients with dementia received case management in (1) home-based primary care (HBPC), (2) geriatrics-based primary care (GeriPACT), (3) dementia-focused specialty care (Dementia Clinics or DCs) and had (4) either < 4 or > = 4 additional comorbidities. We controlled for Veteran sociodemographic and insurance characteristics shown to influence health care use. In our multivariate, multinomial regressions, the reference group constituted Veterans who did not receive care from any of the aforementioned 3 care settings.

Results:
Descriptively, among 143,281 older patients with dementia, 16.3% of patients were in HBPC, 4.5% in GeriPACTs, and 2.1% in DCs, with patients having ? 4 comorbidities more prevalent in HBPC (50%) than in GeriPACT or DCs (30%). For each care setting (HBPC, GeriPACT, and DC), the predominant form of HCBS use was home care-only, followed by adult day-only and dual use, even though rates of no use ranged between 40-70%, depending on the care setting. In multivariate, subgroup analysis of patients with < 4 additional comorbidities, each care setting was significantly (P < .05) associated with higher odd ratios (ORs) of each form of HCBS use: home care-only (ORs = 1.12 – 4.66), adult day-only (ORs = 1.22 – 1.47), and dual use (ORs = 1.40 – 3.07). In contrast, in subgroup analysis of patients with > = 4 comorbidities, only HBPC was significantly associated with each form of HCBS use. DCs were associated with 2 out of 3 forms of HCBS use (adult day-only and dual use) while GeriPACT was associated with 1 out of 3 forms of HCBS use (dual use).

Implications:
Patients with more complex medical needs may face higher barriers to HCBS access, especially patients not enrolled in home based primary care.

Impacts:
VA needs to ensure different care teams serving patients with the most complex medical needs have sufficient case management resources to facilitate patients’ access to HCBS.