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IIR 12-152 – HSR&D Study

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IIR 12-152
Factors Associated with Institutional Use by Veterans in Home Based Primary Care
Suzanne Gillespie MD
Canandaigua VA Medical Center, Canandaigua, NY
Canandaigua, NY
Funding Period: July 2015 - March 2019

BACKGROUND/RATIONALE:
The quality of VA's Home Based Primary Care (HBPC) program has been established along several institutional utilization dimensions, such as fewer hospitalizations for ambulatory care-sensitive conditions and fewer inpatient days following enrollment in HBPC. However, research has shown substantial variation in the utilization of institutional care across HBPC programs that is not fully explained by Veterans' disease complexity.

OBJECTIVE(S):
The primary goal of this study is to identify factors contributing to variations in the utilization of institutional care services across HBPC program sites. We will empirically test the relationships between HBPC organizational characteristics, work environment, team effectiveness, and variations in eight risk-adjusted quality measures (QMs) of institutional use: hospital and community living center admission rates and days; 30-day and 90-day rehospitalizations; emergency department visits; and Veterans' site of death.

The specific objectives are:
1) Describe the organizational characteristics of HBPC programs (e.g., MD/NP provider model, staffing, available technology);
2) Identify effective team-based practices among HBPC sites on multiple functional dimensions (e.g., leadership, culture, communication, coordination, conflict management, team cohesion, and team effectiveness);
3) Examine associations between HBPC organizational characteristics, work environment, and team effectiveness; and
4) Identify more effective HBPC organizational characteristics, work environment, and team effectiveness associated with utilization of institutional care services.

METHODS:
To address these objectives, we are conducting a four phase explanatory sequential design study.
- In Phase 1, HBPC Program Directors were recruited to complete an online HBPC Background Structure Profile (HBPC-BSP) survey detailing the organizational characteristics of individual HBPC program sites.
- In Phase II, HBPC team members from the Phase I programs were recruited to complete an online organizational assessment questionnaire (HBPC-OAQ) survey to measure HBPC work environment and perceived work effectiveness.
- In Phase III, HBPC-BSP data is being analyzed with data from the HBPC-OAQ survey to test associations between program characteristics, work environment, and team effectiveness.
- In Phase IV, the influence of HBPC organizational characteristics, work environment, and team effectiveness is being examined with respect to the risk-adjusted QMs of institutional use.
- In addition, questions raised by quantitative data analysis will be examined in more depth by semi-structured interviews and observational data collected during 8 HBPC program site visits.

FINDINGS/RESULTS:
We identified 394 unique HBPC sites and received surveys detailing the structure and practice characteristics of 236 sites (60% response rate). Overall, HBPC sites typically reported a focus of comprehensive primary care to home-based Veterans with complex chronic illness. Interdisciplinary teams with nurses, social workers and registered dietitians were reported by over 90% of sites. Most often nurse practitioners were the primary care providers, typically working with nurse case managers. Nearly all sites provided access to a core set of comprehensive services. Some variation across sites was observed including size, use of non-VA hospitals, and primary care models used. Overall, rural and urban HBPC sites have similar reported structures and perceived team effectiveness, but vary with respect to interdisciplinary team care planning participation.

Psychometric analysis of the responses provided by 1403 HBPC team members from 221 sites confirmed the reliability and validity of the HBPC-OAQ. Leadership, communication/care coordination and conflict management were significant predictors of team cohesion and perceived team effectiveness. Overall perceived team effectiveness was significantly influenced by the respondent's profession, group/developmental predominant culture of the team, the workplace environment, and availability of resources and staffing.

Eight site visits were completed, generating 41 hours of interviews from 103 team members. As part of that work, we studied the provision of mental health care to HBPC Veterans from the perspective of HBPC team members. Content analysis revealed four themes: the majority of Veterans have complex physical and mental health care needs; HBPC psychologists play multi-faceted roles on their teams; collaboration between medical and mental health providers is important to caring for Veterans in HBPC; gaps are perceived in providing mental health care in HBPC.

IMPACT:
Overall, reported HBPC structure and processes reflect a high degree of fidelity to the rationale and mission of HBPC. Overall, the identification of organizational characteristics and team-based practices that are associated with QMs for institutional use will improve understanding of how HBPC programs can serve Veterans at home with even higher levels of quality.

From the perspective of HBPC team members, the need for mental health care in HBPC is significant and mental health providers are an essential component of HBPC teams. Understanding HBPC mental health provider models will be important to optimizing care of homebound adults.


PUBLICATIONS:

Journal Articles

  1. Gillespie SM, Manheim C, Gilman C, Karuza J, Olsan TH, Edwards ST, Levy CR, Haverhals L. Interdisciplinary Team Perspectives on Mental Health Care in VA Home-Based Primary Care: A Qualitative Study. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2019 Feb 1; 27(2):128-137.
  2. Gillespie S, Karuza J, Olsan TH, Cai X, Intrator O, Li J, Gao S, Szydlowski J, Temkin-Greener H, Kinosian B, Edes T. A Comparison of Rural and Urban Veterans Health Administration's Home Based Primary Care. Journal of The American Medical Directors Association. 2018 Feb 21; 19(3):B24-41.
  3. Gillespie S, Temkin-Greener H, Szydlowski J, Intrator O, Olsan TH, Karuza J, Cai X, Gao S. Measuring Team Effectiveness in the Veterans Health Administration's Home-Based Primary Care Program. Journal of The American Medical Directors Association. 2018 Feb 21; 19(3):B27-B28.
  4. Karuza J, Gillespie SM, Olsan T, Cai X, Dang S, Intrator O, Li J, Gao S, Kinosian B, Edes T. National Structural Survey of Veterans Affairs Home-Based Primary Care Programs. Journal of the American Geriatrics Society. 2017 Dec 1; 65(12):2697-2701.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Quality Improvement, Best Practices, Management and Human Factors, Organizational Structure, Practice Patterns/Trends, Risk Factors
MeSH Terms: none