» Back to Table of Contents

Research Highlight

VHA-Indian Health Service Collaborations Reveal Opportunities to Improve Rural Health Care

VA Home Based Primary Care (HBPC) is an interdisciplinary, longitudinal program for Veterans who are vulnerable to poor outcomes because of complex, intertwined functional and medical needs. HBPC thrived in urban settings, but the feasibility and patient-level impact was unknown in rural areas where access is limited for all types of noninstitutional long-term care (NILTC). In 2009, VA Office of Rural Health funded expansion of HBPC to rural areas and to American Indian reservations, where health care is also provided by Indian Health Service (IHS) or Tribal Health Programs (THP) in accordance with a Memorandum of Understanding between VA and IHS. By using the "natural laboratory" of these expansion programs, the research team was able to identify the key barriers and facilitators to implementing NILTC for vulnerable rural populations.

This observational study used a mixed methods approach. In qualitative Phase I, we used key respondent interviews to characterize organizational contexts and processes of care for rural HBPC models. In quantitative Phase II, we used a retrospective pre/post comparative design to analyze outcome correlates at the patient-level (i.e., use of hospital and emergency departments) and organizational-level (i.e., enrollment for VA medical benefits) based on linked and merged secondary data from VA, IHS, and Medicare records. We compared utilization pre-admission to HBPC in two 90-day quarters with utilization post-admission to HBPC in four 90-day quarters for one year follow-up.

Phase I Findings

Six innovative expansion models independently emerged at 12 VA medical centers (VAMC) reflecting different staffing patterns and strategies for providing HBPC: 1) expansion to a satellite site, such as a community-based outpatient clinic; 2) streamlined staffing, including nurse working out of own home; 3) purchasedcare from community home health nursing to supplement HBPC; 4) use of a mobile clinic; 5) integrated partnerships with joint privileging of key medical staff by a VAMC and a partner IHS/THP facility; and 6) reimbursed-care for IHS or Tribal primary care to enrolled HBPC users.1 The latter two were used exclusively with IHS/THP, which retained responsibility as primary care provider of record. Some HBPC programs with multiple teams or service areas used more than one organizational model.

Qualitative analyses revealed that most of these HBPC programs were successful in building and restoring trust in VA and improving access to quality care. Two key elements contributed to this success. First, program coordinators either had previous knowledge about interacting in Native communities or were willing to engage and learn from Tribal members. Second, program clinical staff maintained goodwill within communities and their IHS/THP counterparts through multiple visits to care for elders, coordination of care to optimize resources, and, in some cases, participation in community activities. Program coordinators also used a number of localized strategies to coordinate care, including templates for referral to VA HBPC from IHS/ THP or ad hoc case management.

Phase II Findings

HBPC rural expansion included non- Indian communities as well as Tribal communities that are served by IHS. Like IHS beneficiaries (n=88), non-IHS beneficiaries (n=288) were characterized by >30 percent impairments in ≥2 Activities of Daily Living (ADL); further, both subpopulations had similar rates of chronic disease. However, IHS beneficiaries were a significantly younger population of HBPC users than non-IHS beneficiaries (p < 0.001).

Hospital admissions and emergency department visits decreased significantly (p < 0.001) in the quarter following admission to HBPC, and these improvements were maintained over one year. The study detected the same pattern when accounting for IHS versus non-IHS beneficiary status or for > 2 ADL versus < 1 ADL impairments.

Initiation of HBPC programs in rural areas increased enrollment for 83 (22.1 percent of the sample) Veterans who met criteria as new users of the VA medical benefit. The proportion of new VA enrollees was significantly greater for IHS beneficiaries (43.2 percent) than for non-IHS beneficiaries (15.6 percent, p < 0.001).

Expansion of HBPC to rural American Indian reservations demonstrates opportunities to coordinate clinical care between federal health care organizations; this expansion also serves as a model for delivery of patient-centered care in rural areas. VA Office of Rural Health has recently funded the expansion of an additional 50 HBPC programs for rural areas to aid broader dissemination of strategies for clinical care coordination. The success of HBPC programs also establishes groundwork to expand other programs, including telehealth to distant communities or improved coordination of care that is performed by IHS/THP under reimbursement agreements with VAMC. This study also begins to address a gap in the literature on rural populations and HBPC that was noted in a recent Agency for Healthcare Quality and Research evidence synthesis review.

References

1. Kramer BJ, Creekmur B, Cote S, Saliba D. "Improving Access to Noninstitutional Long-Term Care for American Indian Veterans," Journal of the American Geriatric Society 2015; 63(4):789-96.