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CRE 12-029 – HSR&D Study

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CRE 12-029
Medical Foster Homes: A Safe, Cost Effective Substitute for Nursing Homes?
Cari R. Levy MD PhD
Rocky Mountain Regional VA Medical Center, Aurora, CO
Aurora, CO
Funding Period: August 2013 - July 2016

BACKGROUND/RATIONALE:
Medical Foster Home (MFH) is a program for Veterans who meet nursing home (NH) level of care because they cannot live independently due to complex medical, psychological, or functional impairments and inadequate family support. MFH merges care in a personal home with interdisciplinary home care, such as VA Home Based Primary Care which provides comprehensive home care and caregiver training. Veterans pay the MFH caregiver approximately $2500 per month. MFH programs are expanding rapidly, but why the program is chosen over traditional NH care, the safety and costs are unknown.

OBJECTIVE(S):
Aim 1. Describe what leads Veterans to select or reject MFHs over traditional NH care by:
1A. Comparing Veterans residing in three high-enrollment and one growing MFH program to Veterans residing in NHs
1B. Conducting interviews with Veterans who either recently enrolled or declined enrollment in one of three high-enrollment MFH programs
1C. Performing qualitative examinations of three high- and three low-enrollment MFH programs to understand how MFH program attributes promote or thwart access to MFH enrollment
Aim 2. Assess safety of the MFH program
Aim 3. Calculate VA budgetary costs for care in MFH compared to traditional NH care


METHODS:
Minimum Data Set data are available for NH residents, but are not routinely collected for MFH residents. Thus, on-site research nurses conducted MDS assessments directly for Veterans at three high-enrollment and one growing MFH program to allow for comparisons of the MFH cohort to Veterans residing in NHs at the same VAMC (Sub-Aim 1A). Veterans or their families who recently entered or declined MFH were interviewed using a semi-structured protocol followed by a general inductive analysis to understand the basis of their choices (Sub -Aim 1B). To understand why MFH programs flourished in some areas and not in others, interviews were conducted with VAMC administrative and clinical program officials at three high- and three low-enrollment MFH programs and analyzed using a general inductive approach (Sub-Aim 1C). To address the issue of relative safety of the MFH program, potentially avoidable hospitalization rates were calculated in a pre-post analysis comparing the six months prior and following MFH enrollment. Additionally, adverse events were compared between MFH Veterans propensity matched to Veterans residing in VA NHs (Aim 2). Administrative datasets, nearest neighbor matching and generalized linear models (GLM) were used to analyze secondary data to estimate budget impacts of exclusive use of MFH (N=212) compared to traditional NH care (N=511) between 2008 and 2012 (Aim 3).

FINDINGS/RESULTS:
Aim 1. What lead Veterans to select/reject MFH placement?

i.Sub-Aim 1A: A distinct subset of Veterans who were unmarried and of Hispanic ethnicity (N=388) with levels of comorbidity and frailty similar to those of Veterans in traditional NH settings (N=10,872) were more likely to be cared for in MFHs. (Levy, 2016)

ii.Sub-Aim 1B: Successful MFH placement depended upon (N=35): 1) The Environment - Veterans needed appropriate and comfortable physical space that ensured safety and was in a desirable geographic location; 2) The Match - a collaborative relationship between Veterans, caregivers, and the medical team providing care within the home; and 3) Perceptions and Expectations about the ability for needs to be adequately addressed in MFHs related to health concerns, relocation to the MFH, and costs of care. (Levy, 2014)

iii.Sub-Aim 1C: Program attributes promoting access to MFHs included (N=47): 1. A full-time MFH coordinator in each medical center; 2. Unmitigated Home-Based Primary Care team engagement; 3. Pursuit and receipt of appropriate referrals; and 4. Match between caregiver, home, and Veteran. (Haverhals, 2017)

Aim 2. Safety in MFHs appeared to be favorable based on a reduction in hospitalization rates following enrollment and in a comparison of adverse event rates to Veterans in VA NHs. Among 22 adult ambulatory care sensitive conditions, the overall rate of avoidable hospitalizations declined from 18.5 to 14.9 per 100 enrollees (p<0.01) and the number of bed days used declined by 39% (p<0.01) in the first six months following MFH enrollment compared to the six months prior to MFH enrollment . (Pracht, 2016) MFH cases and matched VA NH controls did not differ in rates of suicide/ self-injury, urinary tract infections, pneumonia, septicemia, history of injury, delirium/dementia/cognitive impairments, falls, and adverse drug events but MFH residents were less likely to be hospitalized for adverse care events (OR = 0.13, 95% CI = 0.03-0.53), anxiety disorders (OR = 0.52, 95% CI = 0.33-0.80), mood disorders (OR = 0.57, 95% CI = 0.42- 0.79), bacterial infections (OR = 0.54, 95% CI = 0.31- 0.92), skin infections (OR = 0.22, 95% CI = 0.10-0.51) and skin ulcers (OR = 0.22, 95% CI = 0.09-0.50). (Levy, 2016)

Aim 3. Among the 203 cases of Veterans in MFHs matched to 1,483 controls in VA NHs, use of MFH instead of a VA NH reduced budget impacts to the VA by at least $2,645/Veteran/month. When average out-of-pocket payments made by MFH residents ($2,500) were included in the analysis, the net reduction of budget impact declines to $145/Veteran/month.



IMPACT:
Expenditures for community-based NH care in the VA in fiscal year 2016 were estimated at $970 million, nearly a three-fold increase (from $385 million in FY06) over 10 years. These costs are expected to accelerate as the number of Priority 1a Veterans over the age of 65 years of age, for whom the VA is obligated to pay for long-term care increases, from approximately 600,000 in 2016 to over 1 million by 2025. These data have been used in legislative efforts (H.R. 294) aimed at extending eligibility for MFH to Veterans currently eligible for NH care.



PUBLICATIONS:

Journal Articles

  1. Kennedy LC, Binswanger IA, Mueller SR, Levy C, Matlock DD, Calcaterra SL, Koester S, Frank JW. "Those Conversations in My Experience Don't Go Well": A Qualitative Study of Primary Care Provider Experiences Tapering Long-term Opioid Medications. Pain medicine (Malden, Mass.). 2018 Nov 1; 19(11):2201-2211.
  2. Dang S, Ruiz DI, Klepac L, Morse S, Becker P, Levy CR, Kinosian B, Edes TE. Key Characteristics for Successful Adoption and Implementation of Home Telehealth Technology in Veterans Affairs Home-Based Primary Care: An Exploratory Study. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2018 Jul 3.
  3. Holman E, Levy C, Kennedy B. Palliative Care Matters: Lessons From the Loss of a Facility Dog. The American journal of hospice & palliative care. 2018 Oct 1; 35(10):1362-1364.
  4. Burke RE, Hess E, Barón AE, Levy C, Donzé JD. Predicting Potential Adverse Events During a Skilled Nursing Facility Stay: A Skilled Nursing Facility Prognosis Score. Journal of the American Geriatrics Society. 2018 May 1; 66(5):930-936.
  5. Gilman C, Haverhals L, Manheim C, Levy C. A qualitative exploration of veteran and family perspectives on medical foster homes. Home health care services quarterly. 2018 Jan 2; 37(1):1-24.
  6. Master Z, Martinson BC, Resnik DB. Expanding the Scope of Research Ethics Consultation Services in Safeguarding Research Integrity: Moving Beyond the Ethics of Human Subjects Research. The American journal of bioethics : AJOB. 2018 Jan 1; 18(1):55-57.
  7. Lum HD, Sudore RL, Matlock DD, Juarez-Colunga E, Jones J, Nowels M, Schwartz RS, Kutner JS, Levy CR. A Group Visit Initiative Improves Advance Care Planning Documentation among Older Adults in Primary Care. Journal of the American Board of Family Medicine : JABFM. 2017 Jul 1; 30(4):480-490.
  8. Martinson BC, Thrush CR, Gunsalus CK. Comment on "Improving research misconduct policies" by Redman & Caplan. EMBO reports. 2017 Jun 1; 18(6):866.
  9. Levy C. Bereaved or Relieved Caregivers? Commentary on Events Leading to Hospital-Related Disenrollment of Hospice Patients: A Study of Primary Caregivers' Perspectives. Journal of palliative medicine. 2017 Mar 1; 20(3):214-215.
  10. Haverhals LM, Levy CR, Manheim C. Launching Medical Foster Home Programs: Key Components to Growing this Alternative to Nursing Home Placement. Journal of housing for the elderly. 2017 Feb 16; 31(1):14-33.
  11. Levy C, Whitfield EA. Medical Foster Homes: Can the Adult Foster Care Model Substitute for Nursing Home Care? Journal of the American Geriatrics Society. 2016 Dec 1; 64(12):2585-2592.
  12. Pracht EE, Levy CR, Williams A, Alemi F, Williams AE. The VA Medical Foster Home Program, Ambulatory Care Sensitive Conditions, and Avoidable Hospitalizations. American journal of medical quality : the official journal of the American College of Medical Quality. 2016 Nov 1; 31(6):536-540.
  13. Alemi F, Levy CR, Kheirbek RE. The Multimorbidity Index: A Tool for Assessing the Prognosis of Patients from Their History of Illness. EGEMS (Washington, DC). 2016 Oct 13; 4(1):1235.
  14. Arnett K, Sudore RL, Nowels D, Feng CX, Levy CR, Lum HD. Advance Care Planning: Understanding Clinical Routines and Experiences of Interprofessional Team Members in Diverse Health Care Settings. The American journal of hospice & palliative care. 2017 Dec 1; 34(10):946-953.
  15. Haverhals LM, Manheim CE, Gilman CV, Jones J, Levy C. Caregivers Create a Veteran-Centric Community in VHA Medical Foster Homes. Journal of gerontological social work. 2016 Aug 1; 59(6):441-457.
  16. Dehmer SP, Baker-Goering MM, Maciosek MV, Hong Y, Kottke TE, Margolis KL, Will JC, Flottemesch TJ, LaFrance AB, Martinson BC, Thomas AJ, Roy K. Modeled Health and Economic Impact of Team-Based Care for Hypertension. American journal of preventive medicine. 2016 May 1; 50(5 Suppl 1):S34-44.
  17. Sutton BS, Pracht É, Williams AR, Alemi F, Williams AE, Levy C. Budget Impact Analysis of Veterans Affairs Medical Foster Homes versus Community Living Centers. Population health management. 2017 Feb 1; 20(1):48-54.
  18. Levy CR, Alemi F, Williams AE, Williams AR, Wojtusiak J, Sutton B, Giang P, Pracht E, Argyros L. Shared Homes as an Alternative to Nursing Home Care: Impact of VA's Medical Foster Home Program on Hospitalization. The Gerontologist. 2016 Feb 1; 56(1):62-71.
  19. Manheim CE, Haverhals LM, Jones J, Levy CR. Allowing Family to be Family: End-of-Life Care in Veterans Affairs Medical Foster Homes. Journal of Social Work in End-of-Life & Palliative Care. 2016 Jan 1; 12(1-2):104-25.
Journal Other

  1. Sales AE, Ersek M, Intrator OK, Levy C, Carpenter JG, Hogikyan R, Kales HC, Landis-Lewis Z, Olsan T, Miller SC, Montagnini M, Periyakoil VS, Reder S. Correction to: Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol. Implementation science : IS. 2018 Feb 9; 13(1):29.
  2. Gillespie SM, Levy CR, Katz PR. What Exactly Is an "SNF-ist?". [Letter to the Editor]. JAMA internal medicine. 2018 Jan 1; 178(1):153-154.
  3. Levy C. Expectation conversations about the very predictable events in advanced dementia. [Editorial]. Journal of The American Medical Directors Association. 2015 Sep 1; 16(9):724-7.
Conference Presentations

  1. Levy CR, Manheim C, Haverhals LM, Jones J. VHA Medical Foster home: The Coordinator is the Key. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2016 Oct 29; Denver, CO.
  2. Haverhals LM, Levy CR, Manheim C. Providing concurrent care to Veterans: Perspectives from VHA providers and hospice providers. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  3. Levy CR, Haverhals LM. Applying the RE-AIM framework to describe implementation of the VHA Medical Foster Home program. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  4. Levy CR, Haverhals LM, Manheim C, Jones J. Factors affecting growth of VHA Medical Foster Home programs. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  5. Levy CR, Manheim C, Haverhals LM. Can adult foster care substitute for nursing home care? Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  6. Levy CR, Haverhals LM, Manheim C. Can Adult Foster Care Substitute for Nursing Home Care? Poster session presented at: Academic and Health Policy Conference on Correctional Health; 2016 Jun 10; Boston, MA.
  7. Levy CR, Alemi F, Williams AR, Wojtusiak J, Sutton B, Giang P, Pracht E, Argyros L, Williams AE. Does Medical Foster Home Placement Prevent Hospitalization? Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  8. Levy CR, Haverhals LM, Manheim C, Jones J. Housing Our Heroes: Facilitators to Growth of VA Medical Foster Home Programs. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  9. Levy CR, Curseen KA. Providing Palliative Care within the Unique Framework of Medical Foster Homes, Assisting Livings, and Group Homes. Presented at: American Geriatrics Society Annual Meeting; 2015 May 4; National Harbor, MD.


DRA: Aging, Older Veterans' Health and Care
DRE: none
Keywords: Home Care, Outcomes - Patient, Patient Preferences
MeSH Terms: none