VHA and Indian Health Service (IHS) entered into a Memorandum of Understanding (MOU) in 2010 to improve access to healthcare and clinical collaborations for American Indian Veterans, citing collaborations between VA facilities and IHS for Home Based Primary Care (HBPC) as an example. HBPC is a VA longitudinal non-institutional long-term care (NILTC) benefit provided in the home and designed to meet the healthcare needs of Veterans with complex chronic conditions. Our aims were to use the "natural laboratory" of these innovative collaborative HBPC programs to investigate outcome correlates. The study also addresses a gap in the HBPC literature on rural populations.
Phase I characterized the organizational contexts and processes of care that account for variation in the HBPC expansion models. Phase II described the rural HBPC patient population and outcomes of HBPC expansion at the patient-level (i.e., use of hospital and emergency departments) and organizational-level (i.e., enrollment for VA medical benefits).
This was a mixed methods observational study. Phase I used multiple qualitative methods (i.e., key respondent interviews, focus group discussions) to collect original data to characterize innovative HBPC collaborations. Phase II used a quantitative approach with a retrospective pre/post comparative design to analyze outcome correlates based on linked and merged secondary data from VA, IHS and Medicare administrative records. The study population was determined by identifying the American Indian reservations that received HBPC during Phase I and included 157 zipcodes on or nearby these American Indian reservations where IHS eligible populations might reside. 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.
Six innovative expansion models independently emerged at 12 VAMC reflecting different staffing patterns and strategies for providing access to NILTC in rural communities and federally or state recognized Indian reservations: 1) program expansion at a satellite site, such as a CBOC, 2) streamlined staffing, including nurses working out of their own home, 3) purchased-care from community home health nursing to supplement HBPC, 4) use of a mobile clinic to reach remote locations and provide a home base for HBPC, 5) integrated partnerships with joint privileging of key medical staff and 6) reimbursed-care for IHS or Tribal primary care to enrolled HBPC users. The latter two were used exclusively with IHS/Tribal health programs (THP) that retained responsibility as primary care provider of record. Some HBPC programs with multiple teams or service areas used more than one organizational model
Most of these HBPC programs were successful in building and/or restoring trust in VA and improving access to quality care. There were two keys to this success. First, were program coordinators who had previous knowledge about interacting in Native communities or who were willing to engage and learn from Tribal members. Second, goodwill was maintained by program clinical staff that became known to 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. A number of localized strategies were used to coordinate care including joint privileging, templates for referral to VA HBPC from IHS/THP or ad hoc case management.
HBPC rural expansion included non-Indian communities as well as Tribal communities that are served by IHS. IHS beneficiaries are American Indian or Alaska Native (n=88) and the race/ethnicity of non-IHS beneficiaries (n=288) could not be confirmed. Both subpopulations were assessed and characterized by >30% impairments in 2 Activities of Daily Living (ADL) and similar rates of chronic disease. However, IHS beneficiaries were a significantly younger population of HBPC users than non-IHS beneficiaries (p < 0.001).
Initiation of HBPC programs in rural areas increased enrollment for 83 (22.1%) 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%) than for Non-IHS beneficiaries (15.6%, 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 same pattern was found when accounting for IHS versus non-IHS beneficiary status or for 2 ADL versus 1 ADL impairments.
Expansions of HBPC to rural American Indian reservations demonstrates opportunities to coordinate clinical care between federal healthcare organizations and are models for delivery of patient-centered care in rural areas. Strategies for clinical care coordination might be widely disseminated beyond these 12 VAMC. The success of HBPC programs also establishes groundwork to expand other programs, including telehealth to distant communities or improve coordination of care that is performed by IHS and 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.
- Kramer BJ, Creekmur B, Mitchell MN, Saliba D. Expanding Home-Based Primary Care to American Indian Reservations and Other Rural Communities: An Observational Study. Journal of the American Geriatrics Society. 2018 Apr 1; 66(4):818-824.
- Kramer BJ, Cote SD, Lee DI, Creekmur B, Saliba D. Barriers and facilitators to implementation of VA home-based primary care on American Indian reservations: a qualitative multi-case study. Implementation science : IS. 2017 Sep 2; 12(1):109.
- Kramer BJ, Creekmur B, Cote S, Saliba D. Improving access to noninstitutional long-term care for American Indian veterans. Journal of the American Geriatrics Society. 2015 Apr 1; 63(4):789-96.
HSR&D or QUERI Publications
- Kramer BJ, Creekmur B, Saliba D. VHA-Indian Health Service Collaborations Reveal Opportunities to Improve Rural Health Care. Forum: Research Highlight, Summer 2017 Issue. 2017 Aug 1.