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Veterans Health Administration Models of Community-Based Long-Term Care: State of the Science

Published:November 09, 2022DOI:https://doi.org/10.1016/j.jamda.2022.10.012

      Abstract

      The complex care needs of older adults arising at the intersection of age-related illnesses, military service, and social barriers have presented challenges to the US Department of Veterans Affairs (VA) for decades. In response, the VA has invested in centers that integrate research, education, and clinical innovation, using approaches aligned with a learning health care system, to create, evaluate, and implement new care models. This article presents an integrative review of 6 community care models developed within the VA to manage multimorbidity, complex social needs, and avoid institutional care, examining how these models address complex care needs among older adults. The models reviewed include Home Based Primary Care, Medical Foster Home, the VA Caregiver Support Program, the Resources Enhancing Alzheimer's Caregiver Health (REACH)-VA program, the Caregivers of Older Adults Cared for at Home (COACH) program, and Veteran Directed Care. Core components and evaluation outcomes for each model are summarized, along with implications for more widespread implementation and research. Each model promotes coordinated care, integrates behavioral health, and leverages interprofessional expertise. All models are cost-neutral or incur only modest cost increases to improve outcomes. Broader implementation will require interprofessional workforce development, payment model realignment, and infrastructure to evaluate outcomes in new settings. The VA provides a blueprint for infrastructure that could be adapted to other domestic and international settings. Care models successfully implemented within the VA's single-payer system hold promise to address persistent dilemmas in long-term care, such as management of multimorbidity and social drivers of health, integration and support of family caregivers, and mental health integration. These models also demonstrate the value of incorporating care approaches that have been developed or tested outside the United States and argue for greater cross-fertilization of ideas from different health systems.

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      References

        • Fontana A.
        • Rosenheck R.
        Treatment-seeking veterans of Iraq and Afghanistan: comparison with veterans of previous wars.
        J Nerv Ment Dis. 2008; 196: 513-521
        • Gabrielian S.
        • Yuan A.H.
        • Andersen R.M.
        • et al.
        VA health service utilization for homeless and low-income veterans.
        Med Care. 2014; 52: 454-461
        • Song W.
        • Intrator O.
        • Twersky J.
        • et al.
        Utilization and cost effects of the VHA Caring for Older Adults and Caregivers at Home (COACH) Program.
        Med Care Res Rev. 2021; 78: 736-746
        • Nichols L.O.
        • Martindale-Adams J.
        • Burns R.
        • et al.
        Translation of a dementia caregiver support program in a health care system—REACH VA.
        Arch Intern Med. 2011; 171: 353-359
        • Bruening R.
        • Sperber N.
        • Miller K.
        • et al.
        Connecting caregivers to support: Lessons learned from the VA Caregiver Support Program.
        J Appl Gerontol. 2020; 39: 368-376
        • Sullivan J.L.
        • Eisenstein R.
        • Price T.
        • et al.
        Implementation of the Geriatric Patient-Aligned Care Team Model in the Veterans Health Administration (VA).
        J Am Board Fam Med. 2018; 31: 456-465
        • Atkins D.
        • Kilbourne A.M.
        • Shulkin D.
        Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration.
        Annu Rev Public Health. 2017; 38: 467-487
        • United States Department of Veterans Affairs Office of Rural Health
        Enterprise-Wide Initiatives.
        • United States Government Accountability Office
        VA Health Care: Veterans’ Use of Long-Term Care is Increasing, and VA Faces Challenges in Meeting the Demand.
        https://www.gao.gov/assets/gao-20-284.pdf
        Date: 2020
        Date accessed: July 31, 2022
        • Centers for Medicare & Medicaid Services
        Home & Community Based Services Final Regulation.
        • Edes T.
        • Kinosian B.
        • Vuckovic N.H.
        • et al.
        Better access, quality, and cost for clinically complex veterans with home-based primary care.
        J Am Geriatr Soc. 2014; 62: 1954-1961
        • Hughes S.L.
        Effectiveness of Team-Managed Home-Based Primary Care: A randomized multicenter trial.
        JAMA. 2000; 284: 2877
        • Levy C.
        • Whitfield E.A.
        • Gutman R.
        Medical foster home is less costly than traditional nursing home care.
        Health Serv Res. 2019; 54: 1346-1356
        • Levy C.
        • Whitfield E.A.
        • Foster Homes Medical
        Can the Adult Foster Care Model substitute for nursing home care?.
        J Am Geriatr Soc. 2016; 64: 2585-2592
        • Miller S.C.
        • Intrator O.
        • Scott W.
        • et al.
        Increasing veterans' hospice use: The Veterans Health Administration's focus on improving end-of-life care.
        Health Aff (Millwood). 2017; 36: 1274-1282
        • McConeghy K.W.
        • Curyto K.
        • Jedele J.
        • et al.
        Impact of an interdisciplinary intervention for distress behaviors in dementia on psychotropic drug use in Veterans Health Administration Community Living Centers: STAR-VA impact on psychotropic drug utilization.
        Geriatr Nurs. 2021; 42: 1533-1540
        • Hastings S.N.
        • Sloane R.
        • Morey M.C.
        • et al.
        Assisted early mobility for hospitalized older veterans: preliminary data from the STRIDE program.
        J Am Geriatr Soc. 2014; 62: 2180-2184
        • Hastings S.
        • Choate A.
        • Mahanna E.
        • et al.
        Early mobility in the hospital: Lessons learned from the STRIDE program.
        Geriatrics. 2018; 3: 61
        • Ouellet J.A.
        • Mecca M.C.
        • Tinetti M.E.
        • et al.
        Education outcomes of a multisite, virtual, interprofessional training in patient priorities aligned care.
        J Am Geriatr Soc. 2022; 70: E5-e7
        • Davenport C.
        • Ouellet J.
        • Tinetti M.E.
        Use of the patient-identified top health priority in care decision-making for older adults with multiple chronic conditions.
        JAMA Network Open. 2021; 4: e2131496
        • Kind A.J.H.
        • Jensen L.
        • Barczi S.
        • et al.
        Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital.
        Health Affairs. 2012; 31: 2659-2668
        • Morey M.C.
        • Lee C.C.
        • Castle S.
        • et al.
        Should structured exercise be promoted as a model of care? Dissemination of the Department of Veterans Affairs Gerofit Program.
        J Am Geriatr Soc. 2018; 66: 1009-1016
        • Whittemore R.
        • Knafl K.
        The integrative review: updated methodology.
        J Adv Nurs. 2005; 52: 546-553
        • Supiano M.A.
        • Alessi C.
        • Chernoff R.
        • et al.
        Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: Translating aging research into clinical geriatrics.
        J Am Geriatr Soc. 2012; 60: 1347-1356
        • Haverhals L.M.
        • Manheim C.
        • Gilman C.
        • et al.
        Dedicated to the mission: Strategies US Department of Veterans Affairs Home-Based Primary Care teams apply to keep veterans at home.
        J Am Geriatr Soc. 2019; 67: 2511-2518
        • Gillespie S.M.
        • Li J.
        • Karuza J.
        • et al.
        Factors associated with hospitalization by veterans in Home-Based Primary Care.
        J Am Med Dir Assoc. 2021; 22: 1043-1051.e1
        • Karuza J.
        • Gillespie S.M.
        • Olsan T.
        • et al.
        National structural survey of Veterans Affairs Home-Based Primary Care programs.
        J Am Geriatr Soc. 2017; 65: 2697-2701
        • Levy C.R.
        • Alemi F.
        • Williams A.E.
        • et al.
        Shared homes as an alternative to nursing home Care: Impact of VA’s Medical Foster Home Program on hospitalization.
        Gerontologist. 2016; 56: 62-71
        • Haverhals L.M.
        • Manheim C.E.
        • Jones J.
        • Levy C.
        Launching Medical Foster Home Programs: Key components to growing this alternative to nursing home placement.
        J Hous Elderly. 2017; 31
        • Manheim C.E.
        • Haverhals L.M.
        • Jones J.
        • Levy C.R.
        Allowing family to be family: End-of-life care in Veterans Affairs Medical Foster Homes.
        J Soc Work End Life Palliat Care. 2016; 12: 104-125
        • VA Caregiver Support Program
        Caregiver Support Program-Two Programs: What’s the Difference?.
        (Updated May 13, 2022)
        • Van Houtven C.H.
        • Smith V.A.
        • Stechuchak K.M.
        • et al.
        Comprehensive Support for Family Caregivers: Impact on veteran health care utilization and costs.
        Med Care Res Rev. 2019; 76: 89-114
        • Griffin J.M.
        • Malcolm C.
        • Wright P.
        • et al.
        U.S. veteran health care utilization increases after caregivers' use of National Caregiver Telephone Support Line.
        Health Soc Work. 2017; 42: e111-e119
        • Nichols L.O.
        • Martindale-Adams J.
        • Burns R.
        • et al.
        REACH VA: Moving from translation to system implementation.
        Gerontologist. 2016; 56: 135-144
        • D'Souza M.F.
        • Davagnino J.
        • Hastings S.N.
        • et al.
        Preliminary data from the Caring for Older Adults and Caregivers at Home (COACH) Program: A care coordination program for home-based dementia care and caregiver support in a Veterans Affairs Medical Center.
        J Am Geriatr Soc. 2015; 63: 1203-1208
        • United States Department of Veterans Affairs Office of Rural Health
        Rural Promising Practice Issue Brief: Caring for Older Adults and Caregivers at Home.
        • Garrido M.M.
        • Allman R.M.
        • Pizer S.D.
        • et al.
        Innovation in a learning health care system: Veteran-Directed Home- and Community-Based Services.
        J Am Geriatr Soc. 2017; 65: 2446-2451
        • Yuan Y.
        • Thomas K.S.
        • Van Houtven C.H.
        • et al.
        Fewer potentially avoidable health care events in rural veterans with self-directed care versus other personal care services.
        J Am Geriatr Soc. 2022; 70: 1418-1428
        • Yuan Y.
        • Thomas K.S.
        • Frakt A.B.
        • et al.
        Users of Veteran-Directed Care and other purchased care have similar hospital use and costs over time.
        Health Aff. 2019; 38: 1037-1045
      1. Administration for Community Living. Veteran Directed Care Program.
        • Gillespie S.M.
        • Manheim C.
        • Gilman C.
        • et al.
        Interdisciplinary team perspectives on mental health care in VA Home-Based Primary Care: A qualitative study.
        Am J Geriatr Psychiatry. 2019; 27: 128-137
        • Gilman C.
        • Haverhals L.
        • Manheim C.
        • Levy C.
        A qualitative exploration of veteran and family perspectives on medical foster homes.
        Home Health Care Serv Q. 2018; 37: 1-24
        • Office of Public and Intergovernmental Affairs
        VA Amplifies Access to Home, Community-Based Services for Eligible Veterans.
        (Updated Jan 24, 2022)
        • Levy C.
        • Haverhals L.
        • Gilman C.
        • Manheim C.
        The Veterans Health Administration's Medical Foster Home Program: Where heroes meet (older) angels.
        Generations. 2018; 42: 47-50
        • Haverhals L.M.
        • Manheim C.E.
        • Gilman C.V.
        • et al.
        Caregivers create a veteran-centric community in VHA Medical Foster Homes.
        J Gerontol Soc Work. 2016; 59: 441-457
        • Magid K.
        • Manheim C.
        • Haverhals L.M.
        • et al.
        Who receives care in VA Medical Foster Homes?.
        Federal Practitioner. 2021; 38
        • Sutton B.S.
        • Pracht É.
        • Williams A.R.
        • et al.
        Budget Impact analysis of Veterans Affairs Medical Foster Homes versus Community Living Centers.
        Popul Health Manag. 2017; 20: 48-54
        • Pracht E.E.
        • Levy C.R.
        • Williams A.
        • et al.
        The VA Medical Foster Home Program, ambulatory care sensitive conditions, and avoidable hospitalizations.
        Am J of Med Qual. 2016; 31: 536-540
        • Levy C.R.
        • Jones J.
        • Haverhals L.M.
        • Nowels C.T.
        A qualitative evaluation of a new community living model: medical foster home placement.
        J Nurs Educ Pract. 2013; 4
        • Jones J.
        • Haverhals L.M.
        • Manheim C.E.
        • Levy C.
        Fostering excellence: An examination of high-enrollment VHA Medical Foster Home Programs.
        Home Health Care Manag Pract. 2018; 30: 16-22
        • Lorig K.
        • Ritter P.L.
        • Laurent D.D.
        • Yank V.
        Building better caregivers: A pragmatic 12-month trial of a community-based workshop for caregivers of cognitively impaired adults.
        J Appl Gerontol. 2019; 38: 1228-1252
        • Sperber N.
        • Van Houtven C.
        • Andrews S.
        • et al.
        Family caregiver use and value of support services in the VA Program of Comprehensive Assistance for Family Caregivers.
        J Long-Term Care. 2018; : 41-50
        • Doty P.
        • Mahoney K.J.
        • Simon-Rusinowitz L.
        Designing the Cash and Counseling Demonstration and Evaluation.
        Health Services Research. 2007; 42: 378-396
        • Kramer B.J.
        The VA Geriatric Scholars Program.
        Fed Pract. 2015; 32: 46-48
        • Meyer E.M.
        • Zapatka S.
        • Brienza R.S.
        The development of professional identity and the formation of teams in the Veterans Affairs Connecticut Healthcare System's Center of Excellence in Primary Care Education Program (CoEPCE).
        Acad Med. 2015; 90: 802-809
        • Centers for Medicare & Medicaid Services
        Independence at Home Demonstration.
        (Updated August 4, 2022)
        • Leinonen E.
        Time to care? Temporal variations of agency of the Finnish adult foster carers.
        J Aging Stud. 2020; 52: 100830
        • Xu H.
        • Intrator O.
        • Bowblis J.R.
        Shortages of staff in nursing homes during the COVID-19 pandemic: What are the driving factors?.
        J Am Med Dir Assoc. 2020; 21: 1371-1377
        • Nyman J.A.
        • Finch M.
        • Kane R.A.
        • et al.
        The substitutability of adult foster care for nursing home care in Oregon.
        Med Care. 1997; 35: 801-813
        • Kane R.A.
        • Kane R.L.
        • Illston L.H.
        • et al.
        Adult foster care for the elderly in Oregon: a mainstream alternative to nursing homes?.
        Am J Public Health. 1991; 81: 1113-1120