- Examining the Investment in Caring for High-Needs Patients
Since 2013, VA has invested more than $22 million in fostering and testing interventions within patient-centered medical homes at five demonstration sites to improve care for Veterans at highest risk for hospitalizations or death. In this commentary, VA authors involved in this project, known as the VA PACT Intensive Management program, reflect on lessons learned about improving care for this population, including: using a combination of population management and clinician judgment is valuable for identifying patients best suited for intensive management; the top reasons for preventable emergency department visits and hospitalizations include treatment nonadherence and lack of patient engagement, rather than uncoordinated care; and intensive management efforts should focus on assessment for – and treatment of – modifiable risk factors among moderately high-risk patients, such as social needs and
caregiver issues. As intensive management programs did not decrease costs any more than patient-centered medical homes, VA’s Office of Primary Care plans to incorporate those intensive management practices that are feasible into existing patient-centered medical homes.
Date: September 10, 2021
- 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 enables enrollees to hire family members, friends, or neighbors as paid
caregivers and also provides
caregiver support, including
caregiver training and burden monitoring. 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. Findings showed that Veterans enrolled in VDC 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. Given VDC’s popularity among Veterans and
caregivers, it is a valuable model for supporting medically complex patients who are living in the community.
Date: June 1, 2019
- VA Experience with Implementing Intensive Primary Care Programs for Veterans at Highest Risk
This case study describes VA’s experience with implementing intensive primary care programs, as well as the program elements that appear to be necessary to meet the complex care needs of these high-risk Veterans. Findings showed that the PACT Intensive Management program (PIM) has been successfully implemented for more than three years at five demonstration sites in the VA healthcare system. The PIM program has evolved over time, eventually converging on implementation of the following elements: an interdisciplinary care team, chronic disease management, comprehensive patient assessment and evaluation, care and case management, transitional care support, preventive home visits, pharmaceutical services, chronic disease self-management,
caregiver support services, health coaching, and advanced care planning. PIM teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address the psychosocial needs of these complex patients. In addition, having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites.
Date: October 25, 2017
- Impact of Comprehensive
Caregiver Support Program on VA Healthcare Utilization and Cost
The Program of Comprehensive Assistance for Family
Caregivers (PCAFC) supports
caregivers of Veterans from the post-9/11 era who need assistance with activities of daily living (ADLs) or supervision or protection because of the residual effect of injuries sustained during their service. A monthly stipend is provided to
caregivers based on Veterans’ care needs. In this study, investigators examined the early impact of PCAFC on VA healthcare utilization and costs. Findings showed that Veterans in PCAFC had similar acute care utilization when compared with those in the control group, but significantly greater primary, specialty, and mental health outpatient care use at least 30 – and up to 36 months post-application. Compared with Veterans in the control group, over time, Veterans in the PCAFC group had about a 10 percentage point higher probability of receiving any VA primary care. In the first six months, Veterans in the PCAFC group had an increased probability of using any VA specialty care (75% vs. 64%). Veterans in the treatment group also had an increased probability of using mental healthcare in the first 6 months (84% vs. 77%) and this increase was sustained through 31-36 months. Estimated total healthcare costs for Veterans in the PCAFC group were $1,500 to $3,400 higher per Veteran per 6-month interval than for Veterans in the control group. Findings suggest that comprehensive supports for family
caregivers can increase patient engagement in outpatient care in the short term, which may enhance long-term health outcomes.
Date: April 1, 2017
- Benefits for Veterans with Dementia who Participate in VA Program Integrating Healthcare and Community Services
This study tested the effectiveness of a telephone-based care-coordination program – Partners in Dementia Care (PDC) – that integrated healthcare and community services through structured coaching and support. PDC targeted both Veterans and their primary informal
caregivers. Findings showed that compared to usual care, PDC was associated with significantly lower levels of self-reported adverse outcomes among Veterans. Improvements in all but one outcome (embarrassment about memory problems) were restricted to Veterans who were more cognitively impaired or had more difficulties with personal care. Beneficial effects after 6 months were evident in reduced relationship strain, depression, and unmet needs for more impaired Veterans – and reduced embarrassment about memory problems for all Veterans. In addition, between months 6 and 12, there were further reductions in unmet needs for more impaired Veterans.
Date: February 28, 2014
- Home Safety Intervention Improves
Caregiver Competence for Individuals with Alzheimer’s Disease
This trial sought to give informal
caregivers the knowledge and resources to prevent risky behaviors and accidents in the homes of persons with dementia of the Alzheimer’s type (DAT) or a related dementia. Investigators designed a Home Safety Toolkit that includes a booklet on high-frequency/high-severity risks for accidents and injuries in the home, and sample items (i.e., smoke alarm, night lights, slide bolt lock, medicine case) that allow
caregivers to make easy home safety modifications. Findings showed that all outcome variables improved more for
caregivers in the Home Safety Toolkit intervention group than for
caregivers in the control group. For example,
caregivers in the intervention group had significantly improved home environmental safety compared to those in the control group, and patients in the intervention group had fewer risky behaviors and accidents compared to patients in the control group. The intervention group had 80% overall confidence in their ability to make a home safer compared to 75% for
caregivers in the control group.
Caregivers in the intervention group also had lower perceived strain in caregiving compared to
caregivers in the control group.
Date: October 1, 2013
- Study Assesses VA/Alzheimer’s Association Care Coordination Program for Informal
Caregivers of Veterans with Dementia
A new initiative targeting
caregivers of Veterans with dementia is “Partners in Dementia Care” (PDC) — a care-coordination program delivered via a partnership between VA and Alzheimer’s Association chapters. This study assessed the effectiveness of the PDC program. Findings showed that the PDC program is a promising model that improves linkages between VA healthcare services and community services for informal
caregivers of Veterans with dementia. Compared to comparison
caregivers, those who participated in the PDC program had significant improvement in outcomes representing unmet needs, all three types of
caregiver strains, depression, and support resources. Most improvements were evident after six months, with more limited improvements from months 6 – 12. However, improvements after the first six months were maintained during the entire study. Some outcomes improved for all
caregivers, while others improved for
caregivers with more initial difficulties – or those who were caring for Veterans with more severe impairments.
Date: August 1, 2013
- Issues for Sexual and Gender Minority Veterans Receiving VA Healthcare
This article summarizes emergent research findings regarding sexual and gender minority (SGM) Veterans, and the first initiatives that have been implemented by VA to promote quality care. Being a member of both the Veteran and SGM communities may contribute to a higher level of risk for poor health than membership in just one of these populations. A recent VA study indicated that only 33% of SGM Veterans reported open communication about their sexual orientation with VA healthcare providers, while 25% reported avoiding certain VA services because of concerns about stigma. In another study of 202 VA providers and 58 SGM Veterans, less than one-third of all participants viewed VA as welcoming to SGM Veterans. To address these issues, VA has created new programs, such as the Office of Health Equity LGBT Workgroup, which works to address inequities in the healthcare environment for SGM Veterans. VA also created two new part-time LGBT Program Coordinator positions, through the Office of Patient Care Services, who advise leadership on policy and practice issues related to SGM Veterans. In June 2011, VA released the first national policy to describe the services that are available to transgender Veterans. Other recent VA policy changes include “sexual orientation” and “gender identity and expression” now being included in VA non-discrimination and
caregiver policies. Educational resources and trainings have been developed for VA staff about culturally appropriate care for SGM Veterans. Further research is needed to better understand the SGM population, their healthcare needs, and how these needs vary in relation to gender, race/ethnicity, and other factors, as well as in evaluation of provider training and policies.
Date: July 1, 2013
- Significant Financial Burden for
Caregivers of Veterans with Polytrauma and Traumatic Brain Injury
This study (conducted prior to the implementation of stipends from the
Caregivers and Veterans Omnibus Health Services Act) evaluated the prevalence of financial strain as measured by asset depletion and/or debt accumulation, and labor force exit among
caregivers of Veterans with polytrauma and traumatic brain injury (TBI). Findings showed that financial strain is common for
caregivers: 62% reported depleted assets and/or accumulated debt, and 41% reported leaving the labor force. The latter finding stands in sharp contrast to studies in other populations internationally, where between 2% to 27% of
caregivers left the labor force. If a severely injured Veteran needed intensive help with activities of daily living, the primary
caregiver faced 4.6 higher odds of leaving the labor force, and used $27,576 more assets and/or debt to help care for the Veteran compared to
caregivers of Veterans needing little or no help. Male
caregivers, those providing care since the time of injury, and those providing care to Veterans with high-intensity needs and with the lowest overall functioning at time of discharge experienced significantly higher amounts of asset depletion and/or debt accumulation compared to female
caregivers relatively new to their role, and those providing care to higher functioning Veterans with low-intensity care needs. Spouses did not face higher financial strain compared to parents; financial strain was no higher for
caregivers of those injured in Iraq, Afghanistan or the Middle East compared to those injured in the U.S., and the timing of injury was not associated with greater financial strain.
Date: February 1, 2013
- Factors Associated with Increased Aggression in Veterans with Dementia
This study sought to examine the factors predicting the development of aggression among Veterans with dementia. Findings show that potentially mutable factors were associated with the development of aggression in Veterans with newly diagnosed dementia. Mutable factors that predicted increased risk of aggression included: higher levels of baseline
caregiver burden, worst patient pain, declining patient-
caregiver relationship, and increasing non-aggressive physical agitation. Baseline dementia severity and depression were indirectly related to the onset of aggression.
Date: October 26, 2012
Caregiver Satisfaction with VA Dementia Care
caregivers reported about 17 unmet care needs, indicating that they needed more information about or help with approximately one-third of the care needs used in the study analyses. Total unmet need was the only significant predictor of satisfaction with physician care, indicating that as the number of unmet needs increase, satisfaction with physician care suffers. Similarly, total unmet need was the strongest predictor of satisfaction with VA care, indicating that as the number of unmet needs increase, satisfaction with VA healthcare also suffers. Behavior problems and VA site were additionally predictive of satisfaction with VA care.
Date: April 1, 2012
- Multi-Component Support Program Helps Lessen Burden for
Caregivers of Aging Veterans with Disabilities
A multi-component support services program that allowed Veterans aging with a disability to remain in the home, while also addressing the unmet needs of
caregivers, was implemented and evaluated in one VA facility in 2009.
Caregivers experienced meaningful improvements in burden after support services were rendered. Although there were no changes in
caregivers’ physical health status, the support services program had a positive impact on mental health that was reflected in significant improvements in
caregiver scores on the mental health components of the SF-12 health status scale. Satisfaction with services increased from baseline to follow-up.
Date: February 1, 2012
- Prevalence and Risk Factors for Non-Fatal Injuries among Veterans with TBI – Post-Discharge from VA Polytrauma Care
This study examined the prevalence of, and potential risk factors for, non-fatal injuries among Veterans with TBI after discharge from VA inpatient polytrauma rehabilitation programs.
Caregivers reported that nearly one-third (32%) of Veterans discharged from VA Polytrauma Rehabilitation Centers had incurred subsequent, medically treated injuries; most were associated with falls (49%) and motor vehicles (37%). Factors associated with Veterans’ increased odds of subsequent injury included poor or fair general health and requiring assistance with activities of daily living or instrumental activities of daily living. A number of
caregiver-reported ongoing symptoms/health problems among Veterans (e.g., depression, vision loss, hearing loss) were also associated with greater injury odds. Moreover, the odds of subsequent injury increased as the number of reported symptoms/comorbid health problems increased. Compared to male Veterans, the small proportion of female Veterans (n=23) had approximately four and a half times the odds of sustaining subsequent injury.
Caregivers who reported their own health as poor or fair were more likely to report subsequent injuries for Veterans compared to
caregivers who reported their own health as excellent, very good, or good.
Caregivers with higher than average or average depressive or anxiety symptoms, or lower than average physical functioning scores, also were more likely to report injuries among Veterans compared to
caregivers without these symptoms.
Date: January 1, 2012
- Majority of Veterans Interested in Sharing Personal Health Record Information with
Caregivers and non-VA Healthcare Providers
This study explored patient preferences regarding shared access to electronic health information by surveying individuals who used VA’s personal health record, My HealtheVet. Findings showed that a majority (79%) of My HealtheVet users were interested in sharing access to their personal health record with someone outside the VA healthcare system: 62% with a spouse/partner, 23% with a child, 15% with another family member, and 25% with a non-VA healthcare provider. Preferences regarding degree of access varied based on the type of information being shared, the type of activity being performed, and the respondent’s relationship with the person. Interest in sharing access to My HealtheVet was modestly, but significantly, greater among older Veterans and men, but did not vary by health status.
Date: December 20, 2011
Caregivers of Veterans with Chronic Illness
This study sought to identify predictors of
caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of
caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction.
Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted
caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower
caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher
caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both
caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However,
caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse
caregivers in this sample, who are available for caregiving around the clock. A majority of
caregivers expressed a need to know more about the Veteran’s medication.
Date: November 22, 2011
- Profile of
Caregivers and Care Provided for OEF/OIF Veterans Following Acute Rehabilitation for TBI and Polytrauma
The Family and
Caregiver Experience Study (FACES) sought to describe the care and support needs of OEF/OIF Veterans with moderate to severe polytrauma after they received acute rehabilitation – and to describe the providers of that care. Findings showed that a significant portion of
caregivers provide time-consuming, unpaid care for Veterans, years after injury. Policymakers may need to target additional resources to meet the long-term needs of
caregivers who may not be eligible for support mandated by the
Caregivers and Veterans Omnibus Health Services Act of 2010.
Date: August 25, 2011
- Successful Translation of Behavioral Intervention for
Caregivers of Veterans with Dementia
This study assessed the translation of the NIA/NINR Resources for Enhancing Alzheimer’s
Caregivers Health (REACH II) intervention into REACH VA – a behavioral intervention for
caregivers of Veterans with dementia that ran from 9/07 through 8/09. Findings show that the REACH VA intervention provided clinically significant benefits for
caregivers of Veterans with progressive dementia.
Caregivers reported significantly decreased burden, depression, impact of depression on daily life, frustrations associated with caregiving, and number of troubling dementia-related behaviors. Also, a decrease of two hours per day “on duty” trended toward significance. Of the
caregivers who participated in the REACH VA intervention, 96% believed that the program should be provided by VA to
Date: February 28, 2011
- Telephone-based Care Coordination Intervention Complements Care for Veterans with Dementia and Supports their
This article provides a detailed description of a telephone-based care coordination intervention – Partners in Dementia Care (PDC) – developed for Veterans with dementia and their family
caregivers across all stages of the disease. Findings show that, overall, the PDC intervention addresses the diverse needs of Veterans with dementia and their
caregivers, including non-medical care issues such as understanding VA benefits, accessing community resources, and addressing
caregiver strain. The authors also note that the PDC intervention incorporates several unique features that distinguish it from most other services and programs for dementia caregiving, such as the delivery of the intervention through formal partnerships between VAMCs and local Alzheimer’s Association Chapters, the inclusion of family
caregivers, and the breadth of issues addressed for both Veterans and their
caregivers. The consumer-directed philosophy of the program enabled Care Coordinators to serve a large number of families in a cost-efficient way, since Veterans and families were taking action on their own with support and guidance from both VA and Alzheimer’s Association care coordinators.
Date: January 17, 2011
- Aggressive Behavior Prevalent in Veterans with Dementia
This study examined aggressive behavior in 400 community-dwelling Veterans, 60 years or older and newly diagnosed with dementia at one VAMC, who were non-aggressive at the beginning of the study. Findings show that 40.9% of initially non-aggressive Veterans with dementia became aggressive within the 24-month study period, and most aggression was verbal. Verbal aggression was associated with the highest levels of disruptiveness, with 69.3% of verbally aggressive behaviors considered moderately or extremely disruptive, while 39.8% of physically aggressive behaviors and 12.5% of sexually aggressive behaviors were considered moderately or extremely disruptive. Results also show that most
caregivers were women (94%), and there were no significant differences found in aggressive vs. non-aggressive Veterans with dementia in terms of demographics.
Date: October 1, 2009
- Physicians May Need More Education about Long-Term Care Options for Veterans
The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and
caregiver needs, may help to increase those referrals.
Date: February 1, 2009
- Fall Prevention and Management for Older Adults
This article describes fall prevention and management activities from a chronic care perspective that may help researchers, practitioners, and policymakers better understand existing programs and services. The authors propose a "no wrong door" approach to fall prevention and management, in which older adults at risk of falls are evaluated across three domains -- physical activity, medical risks, and home safety. Trained providers would then connect the patients and their
caregivers to programs and services that address the identified risk in the most appropriate manner.
Date: August 1, 2008
- Parkinson Disease:
Caregiver Needs and Experiences
caregivers felt prepared for their role, one-third or more were unprepared for the stress and physical strain they encountered. Typical
caregivers were older female spouses who rated tasks involving physical effort the most difficult.
Date: July 1, 2008