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INV 19-171 – HSR Study

INV 19-171
Targeting and Improving Long Term Care Services and Support for High Need Veterans
Stuti Dang, MD MPH
Miami VA Healthcare System, Miami, FL
Miami, FL
Funding Period: October 2019 - March 2022


Background: Using a predictive analytic model with national Veterans Affairs (VA) data, the Geriatrics and Extended Care Data Analysis Center (GECDAC) identifies “High Need High Risk” (HNHR) Veterans every quarter. These Veterans are at high risk for hospitalization and institutionalization, and GEC recommends that they be enrolled in the VA Home Based Primary Care (HBPC) program. However, VA is currently providing HBPC to less than 25% of the identified >200,000 HNHR Veterans because the HBPC program’s reach is constrained by limited program capacity. Significance/potential impact: We expect that our transformative project will shift current clinical practice paradigm in VA by utilizing a novel potential alternative approach for improving care and outcomes of HNHR Veterans, using peer specialists. Peer Specialists are Veterans trained to provide support by drawing on their own personal recovery experience. This timely model capitalizes on the VA MISSION Act of 2018, which supports the development of peer specialists in Patient Aligned Care Teams (PACTs) through the Peers in PACT program. We will develop and pilot test this innovative model for HNHR Veterans specifically, using peer specialists hired through the Peers in PACT program. Specific goal(s) for Phase I: (1) Develop and pilot an innovative care model for HNHR Veterans who cannot get HBPC, by using Peer Specialists as home extenders of the primary care PACTs. This model will use trained Peer Specialists to conduct in-person and virtual home visits with HNHR Veterans for targeted data gathering regarding health, function, social determinants of health, unmet needs, and barriers to care. We will develop a protocol to stratify HNHR veterans into those that are home-limited and frail and in high need of HBPC, vs. non-frail high utilizing with low need for HBPC. The low need HNHR group will receive an integrated PACT clinic/ home intervention supplemented by Peer Specialists. The Peer Specialists will integrate themselves into the PACT to engage HNHR Veterans and connect them with needed GEC services and Long-Term Services and Support. This will also help identify a process to improve HBPC targeting and identify the right HNHR patients for HBPC enrollment. (2) Formalize partnerships with National VA operational partners and recruit additional VA sites for Phase II hybrid implementation trial. (3) Finalize an implementation plan and submit proposal for a Phase II hybrid implementation trial. Long-term goal(s) for Phase II: (1) Conduct a hybrid implementation trial at additional VA sites via Health Service Research and D Phase II funding, working with National VA operational partners. (2) Use the results from the Phase II trial to fine tune the model and partner with the operational partners to disseminate the peer specialist model for HNHR veterans at additional VA sites. Innovation: Although peer specialists have been shown to be beneficial in certain populations and are part of some comprehensive VA programs, to our knowledge, use of peer specialists integrated with VA primary care PACT to conduct home visits for pre-identified HNHR Veterans gather data and identify unmet needs has not been explored. This model offers a new way to engage HNHR Veterans who have the greatest need for care but often face the steepest challenges with access. Information from this pilot will enable VA primary care PACTs to use Peer Specialists to provide care to Veterans with greatest need, enhancing optimal use of available resources by matching services to patients and population subgroups. It will also provide data to help GECDAC refine criteria to identify appropriate HNHR patients for HBPC. Moreover, this innovative timely model capitalizes on the VA MISSION Act of 2018, which supports the development of peer specialists in VA primary care PACTs.

External Links for this Project

NIH Reporter

Grant Number: I01HX003026-01

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None at this time.

DRA: Aging, Older Veterans' Health and Care, Health Systems, Other Conditions
DRE: Treatment - Preclinical, TRL - Development
Keywords: Best Practices, Medication Management, Practice Patterns/Trends
MeSH Terms: None at this time.

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