December 2020

In This Issue: Enhancing Primary Care for Veterans with Chronic Illness
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Optimizing Outcomes in Home-Based Primary Care for Veterans with Multiple Chronic Conditions

Feature Article

Takeaway: This research has the potential to improve the quality and efficiency of the Home-Based Primary Care program nationally, leading to improved care for older medically complex Veterans, and reduced rates of hospitalization and long-term institutionalization.

The VA healthcare system faces increasing numbers of older Veterans suffering from multiple chronic conditions, who are frequently hospitalized for ambulatory care sensitive conditions (ACSC) at high cost. While many efforts to redesign outpatient care for this vulnerable group have failed to reduce healthcare use, VA Home-Based Primary Care (HBPC) has recently been demonstrated to reduce rates of hospitalization for ACSCs by 27%. The HBPC program is for Veterans who need team-based in-home support for ongoing diseases and illnesses that affect their health and daily activities. The program is also for Veterans who are isolated – or whose caregiver is experiencing a significant burden. However, there is substantial variation in HBPC implementation across VA sites, and the key mechanisms that drive reduced hospitalizations are unknown.  

This main objective of this ongoing HSR&D study (July 2018 – June 2023) is to explore what features of HBPC drive its success in reducing hospitalizations for ambulatory care sensitive conditions – and use these insights to develop an intervention to promote best practices in HBPC. Specific aims are to:

• Characterize patterns of enrollment and care delivery within HBPC, and determine clinical and systems correlates of preventable hospitalizations;
• Assess HBPC provider perceptions of appropriate patient selection and care delivery patterns, core functions of HBPC, and barriers and facilitators to HBPC performance, and
• Develop and test a pilot intervention to promote best practices in HBPC.

The first phase of this research is an in-depth study of the Portland HBPC program using interviews, focus groups, and structured observation. In the second phase, medical directors at other HBPC sites will be interviewed to gain an understanding of differences in HBPC programs across sites.

Findings

This qualitative study found four themes:

• HBPC patients are socially isolated and have multiple, overlapping, interacting layers of medical and social complexity that compromise their ability to use clinic-based care;
• Providers having “eyes in the home” yields essential information not accessible in outpatient clinics;
• HBPC fills gaps in instrumental support, many of which are not medical; and
• Addressing medical and social complexity requires a flexible care design that HBPC provides.

Impact

This research has the potential to improve the quality and efficiency of the HBPC program nationally, leading to improved care for older medically complex Veterans, and reduced rates of hospitalization and long-term institutionalization.

Principal Investigator: Samuel T. Edwards, MD, MPH, is an HSR&D Career Development Awardee and an investigator with HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC) and the VA Portland Health Care System.

Publications

None at this time.

View study abstract