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Health Services Research & Development

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2023 HSR&D/QUERI National Conference Abstract

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1121 — Natural History of Veterans Affairs Home-Based Primary Care

Lead/Presenter: Samuel Edwards,  COIN - Portland
All Authors: Edwards ST (Center to Improve Veteran Involvement in Care), Niederhausen M (Center to Improve Veteran Involvement in Care) O'Neill A (Center to Improve Veteran Involvement in Care) Salvi A (Center to Improve Veteran Involvement in Care) Laliberte A (Center to Improve Veteran Involvement in Care) Leng Q (Center to Improve Veteran Involvement in Care) Kinosian B (University of Pennsylvania)

Objectives:
Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal primary care at home to patients with complex, chronic disabling disease, with an interdisciplinary team. While HBPC enrollment is associated with lower hospitalization rates and health care costs, a comprehensive examination of patient characteristics, length of HBPC enrollment and trajectories of care settings and outcomes over time is lacking.

Methods:
We performed a descriptive quantitative study of patients newly enrolled in HBPC in fiscal year (FY) 2015. We extracted information on demographics, comorbidities, functional status, social supports from VA and Medicare data in FY2015 and examined length of HBPC enrollment, hospitalization, long term care use, hospice enrollment and mortality from FY2015-17. We present results using descriptive statistics, and present longitudinal outcomes across care settings using color coded heat maps and Sankey plots.

Results:
We identified 10,942 new HBPC enrollees in FY 2015, mean age was 77.7 years (standard deviation [SD] 11.4), and mean HCC score of 2.93 (SD 1.79). Most common diagnoses included diabetes (48.4%), depression/anxiety (44.3%), pulmonary disease (40.0%), and dementia (39.4%). 64% of patients required assistance with mobility or were bed disabled, and 53% had two or more deficits in activities of daily living (ADLs). 45.9% have caregiver limitations or no caregiver, 29.6% of patients lived alone and 24.5% resided in a socially deprived area. Mean time enrolled in HBPC was 221.8 days (SD 54.4). Comparing acute health care usage in the six months prior to HBPC enrollment to the six months after enrollment, any hospital use decreased from 40.8% to 24.9%, any ED use decreased from 24.6% to 17.9%, and nursing home use (including Community Living Centers) decreased from 34.5% to 11.0%. After enrollment, the proportion of patient time alive spent in a community-based setting (i.e., not in institutional care) was 86.0% (SD 22.0%). After 3 months, 21.6% of patients had been discharged to community settings and these early discharge patients were younger (mean age 75.8, SD 11.8), more medically complex (mean HCC 3.5, SD 2.1) and had more functional deficits (proportion with 2+ ADL deficiencies 55.7%) than the overall group. At six months after enrollment, 3.5% of new HBPC enrollees were in a nursing home, 10.2% had died, and among decedents, 60.2% had received hospice care.

Implications:
HBPC patients are older, have a high prevalence of chronic disabling conditions, significant functional deficits, limited social supports, and often live in deprived settings. After enrollment, HBPC patients have reductions in acute care use, spend a large majority of time in non-institutional settings, and a most HBPC decedents receive hospice care. A substantial portion of new HBPC enrollees are discharged to community settings by 3 months, and these patients are more medically complex, likely demonstrating a “best fit” patient selection process where patient needs are matched to HBPC program capabilities over time.

Impacts:
A better understanding of how individual HBPC programs select patients for admission and discharge based on patient’s evolving needs across complex care trajectories is needed.