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Publication Briefs

Veteran-Directed Care Adds to Options for Medically Complex Veterans Living in the Community – Without Raising Costs

One way in which VA facilitates independence and supports caregivers is through the Veteran-Directed Care (VDC) program, part of VA's Office of Geriatrics and Extended Care Services. VDC provides flexibility to enrollees and enables them to hire family members, friends, or neighbors as paid caregivers. VDC also provides support to caregivers, including caregiver training and burden monitoring. Family caregivers value VDC, but evidence is lacking regarding its impact on healthcare costs and use. This study evaluated the incidence of VA hospital admissions, ambulatory care-sensitive admissions, and costs associated with inpatient care in the year after the initial receipt of a VDC service. Investigators compared outcomes among 965 Veterans who had their first VDC visit recorded in FY17 to 36,442 Veterans who received at least one VA purchased-care service other than VDC (homemaker or home health aide, home respite, and/or contract adult day healthcare). Patients were followed for 360 days after their first VDC or other purchased care visit – or until death.


  • Veterans enrolled in Veteran-Directed Care had indicators of higher chronic disease burden and more functional limitations than Veterans enrolled in other purchased-care service programs, but experienced similar decreases in hospital use and costs from before to after enrollment in services.
  • During the 6th month before receiving services, mean monthly hospital costs were $2,131 for VDC patients, $1,054 for comparison group patients at sites with an active VDC program, and $974 for comparison group patients at sites without an active VDC program. In the 6th month after receiving services, mean monthly costs were $1,569, $1,170, and $1,049, respectively. In the 12th month after receiving services, VDC patients still had higher mean monthly hospital costs ($1,331) than patients in the active or inactive comparison group ($1,007 and $1,027, respectively), but the difference between costs among VDC patients and comparison-group patients had decreased.


  • VDC is "non-inferior" to other purchased-care services in terms of hospital use and cost trajectories, despite being targeted to Veterans with greater care needs.
  • Given VDC's popularity among Veterans and caregivers, it is a valuable model for supporting medically complex patients who are living in the community. However, to allocate resources more efficiently, future work should identify the optimal target population for VDC – and the optimal methods for using the stipend to facilitate independent community living and support caregivers.


  • Investigators did not examine care received outside VA (i.e., Medicare, Medicaid).
  • The number of Veterans enrolled in VDC is relatively small, which limited the ability of investigators to detect significant associations between VDC participation and outcomes.

This study was funded by HSR&D/QUERI. Ms. Yuan and Drs. Frakt, Pizer, and Garrido are with QUERI's Partnered Evidence-Based Policy Resource Center (PEPReC); Dr. Thomas is with HSR&D's Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans.

PubMed Logo Yuan Y, Thomas K, Frakt A, Pizer S, and Garrido M. Users of Veteran-Directed Care and Other Purchased Care have Similar Hospital Use and Costs Over Time. Health Affairs. June 2019;38(6):1037-1045.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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