BACKGROUND/RATIONALE:
Dr. Thomas' long-term career goal is to conduct rigorous research that will inform policies and practices aimed at advancing the VA's home and community-based service delivery, thereby improving the quality of life and health outcomes of Veterans needing LTSS. The demand for LTSS within VA is expected to continue to grow dramatically as the Veteran population ages. This CDA will focus on understanding the role of participant-directed (PD) cash benefit programs provided by VA to meet the growing need for LTSS. The VA, through its Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA), offers separate and distinct PD cash benefit programs for LTSS. The VHA's Veteran-Directed Home and Community Based Services program (VD-HCBS) provides Veterans with a monthly budget based on the extent of their disability giving them the opportunity to purchase goods and services that best meet their needs. The VBA offers two enhanced monthly benefits to disabled and homebound Veterans receiving pension or compensation: the Aid and Attendance (A&A) and Housebound benefits. In non-VA populations, similar programs have been cost-effective and improved participants' outcomes. However, in VA, information about effectiveness and access to these programs is limited: there remains little to no understanding of who receives these PD cash benefits, how Veterans are utilizing these benefits, their satisfaction with the benefits, their consumption of medical and institutional care, nor the outcomes associated with receiving these cash benefits.

OBJECTIVE(S):
The objective of this application is to establish a foundation of research about the VA's PD cash benefit programs in order to develop interventions aimed at improving access to these benefits, promote a national understanding of Veterans' experiences with these benefits, and set the stage for a research career evaluating and improving the delivery of LTSS to Veterans. This CDA will provide Dr. Thomas with the support necessary to accomplish the following goals: (1) to become an expert in conducting rigorous, practical program evaluation and implementation research; (2) to achieve proficiency in comparative effectiveness research, primary data collection, and qualitative research methodologies (3) to become familiar with delivery of LTSS at VAMCs and (4) to reach research independence. These goals will be achieved through the training and applied, mixed methods formative research she has proposed in this award. Specifically, her research seeks to (1) use administrative data to determine which eligible Veterans being served by which Medical Centers enroll in VA's PD cash benefit programs, (2) explore reasons for variation in enrollment in VD-HCBS, A&A and Housebound benefits across VAMCs with interviews of VAMC personnel (3) conduct interviews with Veterans to describe their experiences with the VA's PD cash benefit programs and (4) establish the effectiveness of the VA's PD cash benefit programs in controlling healthcare costs by using sophisticated methodologies to compare Veterans' healthcare utilization to that of Veterans receiving traditional LTSS.

METHODS:
Drawing on the Behavioral Model for Vulnerable Populations, this study will identify predisposing, enabling, and need characteristics associated with enrollment in VD-HCBS, Housebound, and A&A using secondary, administrative VA and CMS data. It will also compare utilization and costs of (a) Veterans receiving VD-HCBS to Veterans receiving Home-Based Primary Care (HBPC) and/or Homemaker and Home Health Aide Services (H/HHA) (b) Veterans receiving A&A to Veterans receiving HBPC or H/HHA and (c) Veterans receiving Housebound benefits to Veterans receiving HBPC or H/HHA. Building on previous research and preliminary studies, the hypothesis is that Veterans receiving VA's PD cash benefits will have a decreased likelihood of hospitalization, emergency department use, and nursing home admission compared to similar Veterans receiving traditional LTSS.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
This research is significant because it will provide a critical understanding of who receives VA cash benefits for PD care, causes for variation, Veterans' perceptions of PD programs, and knowledge of their outcomes. The experience and skills gained through the integrated training and research plan will accelerate progress toward Dr. Thomas' long-term research goal and will set the stage for implementing innovative solutions to increase the access to cash benefits and obtaining a national picture of Veterans' experiences with these benefits, to be proposed in future Merit award applications. Dr. Thomas' current and future research will evaluate programs and implement innovative solutions to integrate VHA and VBA, creating a "One VA" system to enable older, vulnerable Veterans to receive appropriate, Veteran-centered, and cost-effective LTSS in the setting of their choice.

PUBLICATIONS:

Journal Articles

1. Cohen AJ, Dosa DM, Rudolph JL, Halladay CW, Heisler M, Thomas KS. Risk factors for Veteran food insecurity: findings from a National US Department of Veterans Affairs Food Insecurity Screener. Public Health Nutrition. 2022 Apr 1; 25(4):819-828.
2. Evans E, Krebill C, Gutman R, Resnik L, Zonfrillo MR, Lueckel SN, Zhang W, Kumar RG, Dams-O'Connor K, Thomas KS. Functional motor improvement during inpatient rehabilitation among older adults with traumatic brain injury. PM & R : the journal of injury, function, and rehabilitation. 2022 Apr 1; 14(4):417-427.
3. Hua CL, Thomas KS, Bunker J, Gozalo PL, Teno JM. Changes in the agreement between the Minimum Data Set and hospital Medicare claims measures of dementia. Journal of the American Geriatrics Society. 2021 Sep 1; 69(9):2672-2675.
4. Durfey SNM, Gadbois EA, Meyers DJ, Brazier JF, Wetle T, Thomas KS. Health Care and Community-Based Organization Partnerships to Address Social Needs: Medicare Advantage Plan Representatives' Perspectives. Medical care research and review : MCRR. 2022 Apr 1; 79(2):244-254.
5. Thomas KS, Corneau E, H Van Houtven C, Cornell P, Aron D, M Dosa D, M Allen S. Inequities in access to VA'S aid and attendance enhanced pension benefit to help Veterans pay for long-term care. Health services research. 2021 Jun 1; 56(3):389-399.
6. Fabius CD, Cornell PY, Zhang W, Thomas KS. State Medicaid Financing and Access to Large Assisted Living Settings for Medicare-Medicaid Dual-Eligibles. Medical care research and review : MCRR. 2022 Feb 1; 79(1):69-77.
7. Thomas KS, Wretman CJ, Sloane PD, Carder P, Schwartz L, Beeber AS, Zimmerman S. To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living? Journal of The American Medical Directors Association. 2021 Sep 1; 22(9):1813-1818.e3.
8. Hua CL, Thomas KS, Peterson LJ, Hyer K, Dosa DM. Emergency Department Use Among Assisted Living Residents After Hurricane Irma. Journal of The American Medical Directors Association. 2021 Apr 1; 22(4):918-922.e1.
9. Downer B, Pritchard K, Thomas KS, Ottenbacher K. Improvement in Activities of Daily Living during a Nursing Home Stay and One-Year Mortality among Older Adults with Sepsis. Journal of the American Geriatrics Society. 2021 Apr 1; 69(4):938-945.
10. Travis LJ, Thomas KS, Clark MA, Belanger E. Organizational Characteristics of Assisted Living Communities With Policies Supportive of Admitting and Retaining Residents in Need of End-of-Life Care. The American journal of hospice & palliative care. 2021 Aug 1; 38(8):947-953.
11. Hua CL, Cornell PY, Zimmerman S, Winfree J, Thomas KS. Trends in Serious Mental Illness in US Assisted Living Compared to Nursing Homes and the Community: 2007-2017. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2021 May 1; 29(5):434-444.
12. Teshale SM, Schwartz ML, Thomas KS, Mroz TM. Early Effects of Home Health Value-Based Purchasing on Quality Star Ratings. Medical care research and review : MCRR. 2021 Dec 1; 78(6):747-757.
13. Hua CL, Zhang W, Cornell PY, Rahman M, Dosa DM, Thomas KS. Characterizing Emergency Department Use in Assisted Living. Journal of The American Medical Directors Association. 2021 Apr 1; 22(4):913-917.e2.
14. Thomas KS, Zhang W, Cornell PY, Smith L, Kaskie B, Carder PC. State Variability in the Prevalence and Healthcare Utilization of Assisted Living Residents with Dementia. Journal of the American Geriatrics Society. 2020 Jul 1; 68(7):1504-1511.
15. Cornell PY, Zhang W, Thomas KS. Changes in Long-Term Care Markets: Assisted Living Supply and the Prevalence of Low-Care Residents in Nursing Homes. Journal of The American Medical Directors Association. 2020 Aug 1; 21(8):1161-1165.e4.
16. Zullo AR, Moyo P, Jutkowitz E, Zhang W, Thomas KS. Opioid Use Disorder Among Hospitalized Older Adults: Prevalence, Characteristics, and Discharge Status. Journal of The American Medical Directors Association. 2020 Apr 1; 21(4):557-559.
17. Fashaw S, Chisholm L, Mor V, Meyers DJ, Liu X, Gammonley D, Thomas K. Inappropriate Antipsychotic Use: The Impact of Nursing Home Socioeconomic and Racial Composition. Journal of the American Geriatrics Society. 2020 Mar 1; 68(3):630-636.
18. Cohen AJ, Rudolph JL, Thomas KS, Archambault E, Bowman MM, Going C, Heisler M, O'Toole TP, Dosa DM. Food Insecurity Among Veterans: Resources to Screen and Intervene. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2020 Jan 1; 37(1):16-23.
19. Thomas KS, Belanger E, Zhang W, Carder P. State Variability in Assisted Living Residents' End-of-Life Care Trajectories. Journal of The American Medical Directors Association. 2020 Mar 1; 21(3):415-419.
20. Fashaw SA, Thomas KS, McCreedy E, Mor V. Thirty-Year Trends in Nursing Home Composition and Quality Since the Passage of the Omnibus Reconciliation Act. Journal of The American Medical Directors Association. 2020 Feb 1; 21(2):233-239.
21. Thomas KS, Durfey SNM, Gadbois EA, Meyers DJ, Brazier JF, McCreedy EM, Fashaw S, Wetle T. Perspectives of Medicare Advantage Plan Representatives on Addressing Social Determinants of Health in Response to the CHRONIC Care Act. JAMA Network Open. 2019 Jul 3; 2(7):e196923.
22. Morris AM, Engelberg JK, Schmitthenner B, Dosa D, Gadbois E, Shield RR, Akobundu U, Thomas KS. Leveraging Home-Delivered Meal Programs to Address Unmet Needs for At-Risk Older Adults: Preliminary Data. Journal of the American Geriatrics Society. 2019 Sep 1; 67(9):1946-1952.
23. Meyers DJ, Durfey SNM, Gadbois EA, Thomas KS. Early Adoption of New Supplemental Benefits by Medicare Advantage Plans. JAMA. 2019 Jun 11; 321(22):2238-2240.
24. Yuan Y, Thomas KS, Frakt AB, Pizer SD, Garrido MM. Users Of Veteran-Directed Care And Other Purchased Care Have Similar Hospital Use And Costs Over Time. Health affairs (Project Hope). 2019 Jun 1; 38(6):1037-1045.
25. Nazareno J, Zhang W, Silver B, Dosa D, Gozalo P, Thomas K. Home Health Utilization in Assisted Living Settings. Medical care research and review : MCRR. 2020 Dec 1; 77(6):620-629.
26. Bélanger E, Thomas KS, Jones RN, Epstein-Lubow G, Mor V. Measurement validity of the Patient-Health Questionnaire-9 in US nursing home residents. International journal of geriatric psychiatry. 2019 May 1; 34(5):700-708.
27. Shan M, Gutman R, Dosa D, Gozalo PL, Ogarek JA, Kler S, Thomas KS. A New Data Resource to Examine Meals on Wheels Clients' Health Care Utilization and Costs. Medical care. 2019 Mar 1; 57(3):e15-e21.
28. Brostow DP, Gunzburger E, Abbate LM, Brenner LA, Thomas KS. Mental Illness, Not Obesity Status, is Associated with Food Insecurity Among the Elderly in the Health and Retirement Study. Journal of nutrition in gerontology and geriatrics. 2019 Apr 1; 38(2):149-172.
29. Thomas KS, Ogarek JA, Teno JM, Gozalo PL, Mor V. Development and Validation of the Nursing Home Minimum Data Set 3.0 Mortality Risk Score (MRS3). The journals of gerontology. Series A, Biological sciences and medical sciences. 2019 Jan 16; 74(2):219-225.
30. Lueckel SN, Teno JM, Stephen AH, Benoit E, Kheirbek T, Adams CA, Cioffi WG, Thomas KS. Population of Patients With Traumatic Brain Injury in Skilled Nursing Facilities: A Decade of Change. The Journal of head trauma rehabilitation. 2019 Jan 1; 34(1):E39-E45.
31. Thomas KS, Gadbois EA, Shield RR, Akobundu U, Morris AM, Dosa DM. "It's Not Just a Simple Meal. It's So Much More": Interactions Between Meals on Wheels Clients and Drivers. Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2020 Feb 1; 39(2):151-158.
32. Loomer L, Downer B, Thomas KS. Relationship between Functional Improvement and Cognition in Short-Stay Nursing Home Residents. Journal of the American Geriatrics Society. 2019 Mar 1; 67(3):553-557.
33. Thomas KS, Boyd E, Mariotto AB, Penn DC, Barrett MJ, Warren JL. New Opportunities for Cancer Health Services Research: Linking the SEER-Medicare Data to the Nursing Home Minimum Data Set. Medical care. 2018 Dec 1; 56(12):e90-e96.
34. Fabius CD, Thomas KS. Examining Black-White Disparities Among Medicare Beneficiaries in Assisted Living Settings in 2014. Journal of The American Medical Directors Association. 2019 Jun 1; 20(6):703-709.
35. Fabius CD, Thomas KS, Zhang T, Ogarek J, Shireman TI. Racial disparities in Medicaid home and community-based service utilization and expenditures among persons with multiple sclerosis. BMC health services research. 2018 Oct 12; 18(1):773.
36. Mor V, Thomas KS, Rahman M. Defining and Measuring Nursing Home Placement. Journal of the American Geriatrics Society. 2018 Oct 4; 66(10):1866-1868.
37. Silver BC, Grabowski DC, Gozalo PL, Dosa D, Thomas KS. Increasing Prevalence of Assisted Living as a Substitute for Private-Pay Long-Term Nursing Care. Health services research. 2018 Dec 1; 53(6):4906-4920.
38. Kosar CM, Thomas KS, Gozalo PL, Mor V. Higher Level of Obesity Is Associated with Intensive Personal Care Assistance in the Nursing Home. Journal of The American Medical Directors Association. 2018 Nov 1; 19(11):1015-1019.
39. Singh T, Bélanger E, Thomas K. Is Fear of Falling the Missing Link to Explain Racial Disparities in Fall Risk? Data from the National Health and Aging Trends Study. Clinical Gerontologist. 2020 Jul 1; 43(4):465-470.
40. Lueckel SN, Kosar CM, Teno JM, Monaghan SF, Heffernan DS, Cioffi WG, Thomas KS. Outcomes in nursing home patients with traumatic brain injury. Surgery. 2018 May 9.
41. Rivera-Hernandez M, Kumar A, Epstein-Lubow G, Thomas KS. Disparities in Nursing Home Use and Quality Among African American, Hispanic, and White Medicare Residents With Alzheimer's Disease and Related Dementias. Journal of aging and health. 2019 Aug 1; 31(7):1259-1277.
42. Kosar CM, Thomas KS, Gozalo PL, Ogarek JA, Mor V. Effect of Obesity on Postacute Outcomes of Skilled Nursing Facility Residents with Hip Fracture. Journal of the American Geriatrics Society. 2018 Jul 1; 66(6):1108-1114.
43. Keohane LM, Rahman M, Thomas KS, Trivedi AN. Effects of Caps on Cost Sharing for Skilled Nursing Facility Services in Medicare Advantage Plans. Journal of the American Geriatrics Society. 2018 May 1; 66(5):992-997.
44. Ogarek JA, McCreedy EM, Thomas KS, Teno JM, Gozalo PL. Minimum Data Set Changes in Health, End-Stage Disease and Symptoms and Signs Scale: A Revised Measure to Predict Mortality in Nursing Home Residents. Journal of the American Geriatrics Society. 2018 May 1; 66(5):976-981.
45. Thomas KS, Dosa D, Gozalo PL, Grabowski DC, Nazareno J, Makineni R, Mor V. A Methodology to Identify a Cohort of Medicare Beneficiaries Residing in Large Assisted Living Facilities Using Administrative Data. Medical care. 2018 Feb 1; 56(2):e10-e15.
46. Thomas KS, Cote D, Makineni R, Intrator O, Kinosian B, Phibbs CS, Allen SM. Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community. Journal of Aging & Social Policy. 2018 Mar 1; 30(2):93-108.
47. Lord J, Davlyatov G, Thomas KS, Hyer K, Weech-Maldonado R. The Role of Assisted Living Capacity on Nursing Home Financial Performance. Inquiry : A Journal of Medical Care Organization, Provision and Financing. 2018 Jan 1; 55:46958018793285.
48. Harris D, McNicoll L, Epstein-Lubow G, Thomas KS. Association between anxious symptoms and sleeping medication use among US older adults. International journal of geriatric psychiatry. 2018 Feb 1; 33(2):e307-e313.
49. Garrido MM, Allman RM, Pizer SD, Rudolph JL, Thomas KS, Sperber NR, Van Houtven CH, Frakt AB. Innovation in a Learning Health Care System: Veteran-Directed Home- and Community-Based Services. Journal of the American Geriatrics Society. 2017 Nov 1; 65(11):2446-2451.
50. Kosar CM, Thomas KS, Inouye SK, Mor V. Delirium During Postacute Nursing Home Admission and Risk for Adverse Outcomes. Journal of the American Geriatrics Society. 2017 Jul 1; 65(7):1470-1475.
51. Li Q, Keohane LM, Thomas K, Lee Y, Trivedi AN. Association of Cost Sharing With Use of Home Health Services Among Medicare Advantage Enrollees. JAMA internal medicine. 2017 Jul 1; 177(7):1012-1018.
52. Downer B, Thomas KS, Mor V, Goodwin JS, Ottenbacher KJ. Cognitive Status of Older Adults on Admission to a Skilled Nursing Facility According to a Hospital Discharge Diagnosis of Dementia. Journal of The American Medical Directors Association. 2017 Aug 1; 18(8):726-728.
53. Brostow DP, Gunzburger E, Thomas KS. Food Insecurity among Veterans: Findings from the Health and Retirement Study. The Journal of Nutrition, Health & Aging. 2017 Jan 1; 21(10):1358-1364.
54. Thomas KS, Parikh RB, Zullo AR, Dosa D. Home-Delivered Meals and Risk of Self-Reported Falls: Results From a Randomized Trial. Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2018 Jan 1; 37(1):41-57.

Reports

1. Rudolph JL, Thomas K, Fox-Grage W, Neill-Bowen CN. No Wrong Door: Supporting Community Living for Veterans. Washington DC: AARP Public Policy Institute, the Commonwealth Fund, the SCAN Foundation, AARP Public Policy Institute; 2017 Oct 24. 1-25 p.

DRA: Aging, Older Veterans' Health and Care
DRE: Treatment - Comparative Effectiveness
Keywords: none
MeSH Terms: none