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CDA 19-120 – HSR Study

CDA 19-120
Helping VA optimize its long-term care services
Josephine C. Jacobs, PhD MSc
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: July 2020 - December 2025


By 2023, it is expected that the number of VHA enrollees aged 65 and over will increase from 4.1 million to 4.7 million. To meet the growing demand for long-term care services, VA has attempted to expand its home and community-based services (HCBS) through measures such as the 1999 Millennium Health Care and Benefits Act (the Millennium Act). These expansion efforts were based on the premise that HCBS provide care in Veterans’ setting of choice for a lower cost than in institutional settings and with comparable outcomes. Since passing the Millennium Act, however, VA still lags significantly behind other health systems with respect to rebalancing its long-term care expenditures away from institutional care and towards HCBS. VA’s 21 percentage point increase in the proportion of its long-term care expenditures spent on HCBS between 1999 and 2016 (from 5% to 26%) can be compared to Medicaid’s 42 percentage point increase over the same period (from 15% o 57%). VA needs to examine the empirical evidence to understand why this transformation remains elusive. A health system’s ability to rebalance towards HCBS is determined by a combination of patient, system, and family level factors. Precise patient targeting, local home health market conditions, and adequate supply of and support for informal caregivers all contribute to how successful health systems will be in rebalancing towards HCBS. However, these factors remain under-explored in the VA context – in part due to gaps in VA’s structured data and in part due to the limited application of methods that enable these types of analyses. My long-term goal is to become an independent investigator focused on leading research initiatives that help VA to achieve its long-term care rebalancing aims and to fill these gaps in the existing evidence base. The proposed research will strengthen VA’s knowledge of how patient, system, and family level factors are affecting its rebalancing efforts. Specifically, the research aims of this CDA-2 are to: 1) use natural language processing to extract patient functional status from free-text notes and use the constructed measures to improve prediction of Veterans’ one-year risk of institutionalization; 2) build a geospatial database of VA and VA-contracted home health providers and conduct analyses evaluating the association between distance to and market supply of home health agencies and long-term care utilization patterns; and 3) quantify the impact of informal care receipt on VA health care utilization and costs. I will achieve these aims by receiving mentorship and training in natural language processing, risk adjustment, geospatial econometrics, and causal modeling. These new skills will contribute to my overall career development and, in collaboration with my mentors and operational partners, enable me to submit two merit review proposals focused on developing enhanced HCBS patient targeting tools and improved caregivers supports. They will also enable me to submit an application for a partnered evaluation initiative with the Office of Connected Care aimed at developing a geospatial tool to help regional offices efficiently identify prospective partners for new home health service contracts. Overall, this CDA will help me to become an independent investigator focused on leading research initiatives that help VA achieve its long-term care rebalancing aims. The results of this CDA project will be relevant to Veterans, their caregivers, and VA policy makers involved in allocating long-term care funding and will be an innovative contribution to the broader literature on the determinants of successful HCBS expansion strategies.

External Links for this Project

NIH Reporter

Grant Number: IK2HX002860-01A1

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Journal Articles

  1. Barnett PG, Jacobs JC, Jarvik JG, Chou R, Boothroyd D, Lo J, Nevedal A. Assessment of Primary Care Clinician Concordance With Guidelines for Use of Magnetic Resonance Imaging in Patients With Nonspecific Low Back Pain in the Veterans Affairs Health System. JAMA Network Open. 2020 Jul 1; 3(7):e2010343. [view]
  2. Wagner TH, Yoon J, Jacobs JC, So A, Kilbourne AM, Yu W, Goodrich DE. Estimating Costs of an Implementation Intervention. Medical decision making : an international journal of the Society for Medical Decision Making. 2020 Nov 1; 40(8):959-967. [view]
  3. Gujral K, Van Campen J, Jacobs J, Kimerling R, Zulman DM, Blonigen D. Impact of VA's video telehealth tablets on substance use disorder care during the COVID-19 pandemic. Journal of substance use and addiction treatment. 2023 Jul 1; 150:209067. [view]
  4. Jacobs JC, Wagner TH, Trivedi R, Lorenz K, Van Houtven CH. Long-term care service mix in the Veterans Health Administration after home care expansion. Health services research. 2021 Dec 1; 56(6):1126-1136. [view]
  5. Jacobs JC, Jarvik JG, Chou R, Boothroyd D, Lo J, Nevedal A, Barnett PG. Observational Study of the Downstream Consequences of Inappropriate MRI of the Lumbar Spine. Journal of general internal medicine. 2020 Dec 1; 35(12):3605-3612. [view]
  6. Jacobs J, Ferguson JM, Van Campen J, Yefimova M, Greene L, Heyworth L, Zulman DM. Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2022 Feb 1; 28(2):199-211. [view]
  7. Slightam C, Gregory AJ, Hu J, Jacobs J, Gurmessa T, Kimerling R, Blonigen D, Zulman DM. Patient Perceptions of Video Visits Using Veterans Affairs Telehealth Tablets: Survey Study. Journal of medical Internet research. 2020 Apr 15; 22(4):e15682. [view]
  8. Jacobs JC, Bowling CB, Brown T, Smith VA, Decosimo K, Wilson SM, Hastings SN, Shepherd-Banigan M, Allen K, Van Houtven C. Racial inequality in functional trajectories between Black and White U.S. veterans. Journal of the American Geriatrics Society. 2023 Apr 1; 71(4):1081-1092. [view]
  9. Stanfors M, Jacobs J. Unpaid caregiving and stress among older working-age men and women in Sweden. SSM - population health. 2023 Sep 1; 23:101458. [view]
  10. Ferguson JM, Wray CM, Jacobs J, Greene L, Wagner TH, Odden MC, Freese J, Van Campen J, Asch SM, Heyworth L, Zulman DM. Variation in initial and continued use of primary, mental health, and specialty video care among Veterans. Health services research. 2023 Apr 1; 58(2):402-414. [view]
  11. Jacobs JC, Hu J, Slightam C, Gregory A, Zulman DM. Virtual Savings: Patient-Reported Time and Money Savings from a VA National Telehealth Tablet Initiative. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2020 Sep 1; 26(9):1178-1183. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: TRL - Applied/Translational
Keywords: Care Coordination, Career Development, Caregiving, Decision Support
MeSH Terms: None at this time.

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