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SDR 16-194 – HSR&D Study

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SDR 16-194
Evaluation of Veteran Directed Home and Community Based Services
James L. Rudolph MD
Providence VA Medical Center, Providence, RI
Providence, RI
Funding Period: April 2016 - March 2020

In the next decade, the number of older high priority (P1a) Veterans will double. The VA has a statutory obligation to purchase or provide institutional care to all P1a Veterans. GEC has implemented many innovative programs to postpone or prevent institutionalization all together. GEC leadership implemented a program for Veterans to self-direct their care thereby enabling them to maintain community residence and avoid institutionalization: Veteran-Directed Home and Community Based Services (VD-HCBS).

GEC is planning to expand VD-HCBS to an additional 90 VAMCs over the next 3 years and has partnered with the Program Evidenced-based Policy Resource Center (PEPReC) for a randomized, stepped-wedge dissemination and an evaluation of utilization outcomes. This proposal will provide important outcomes and context to the VD-HCBS expansion. The specific aims of this proposal are: Aim 1: To describe the impact of VD-HCBS on Veterans' satisfaction, unmet need for services, quality of life and independence using mixed methods. Aim 2: To understand the effect of VD-HCBS on Caregivers' well-being. Aim 3: To examine the implementation of the VD-HCBS program expansion.

Aim 1 will utilize operations data to describe the change in Veteran-reported satisfaction, unmet needs, and independence from enrollment in VD-HCBS to 3 and 12 months. Additionally, we will conduct interviews with Veterans to capture their experiences with the program. Aim 2 will compare Caregivers' financial strain, depressive symptoms, caregiving stress, and health status and positive caregiver experiences to a propensity matched population from existing VA data to determine the impact of the VD-HCBS program on Caregivers. Aim 3 will utilize the Consolidated Framework for Implementation Research and Expert Recommendations for Implementing Change to interview coordinators, and other key informants, from VA and ADNA VD-HCBS pairs. The analysis will shed light on how contextual factors and implementation strategies relate to implementation and Veteran outcomes.

The VD-HCBS program was planned to expand to 90 VAMCs over the three years of this program. With GEC support, the randomization of facilities was planned by PEPReC. The expansion has not proceeded at the rate expected due to external factors including VA leadership changes, budget, Community care legislation, and modernization.

VD-HCBS is a complex program that involves the VA Offices of GEC, the VA Office of Community Care, QUERI, & PEPReC, as well as, the Administration for Community Living, their Aging and Disability Network Agencies (ADNAs), and contractors from Lewin and Applied Self Direction (Formerly the National Center for Participant Directed Care). We have been effective at coordinating with the multiple parties as the program has evolved through bi-weekly phone calls. Data collection and analysis are ongoing. The Veteran and Caregiver enrollment at new sites is slower than expected. We have been aggressive about changing our protocol to address this delay.

Interviews completed with program coordinators about two months after starting the program revealed some specific differences in communication style between VA and ADNA partners and desire from the ADNA partners for more transparency from the VA about their program start-up process. Interviews completed with these same coordinators about four months later revealed that although interviewees continued to remain positive about the VD-HCBS program, there were differences between VA and ADNA coordinators about the ways in which they were proceeding with program implementation and variability between ADNA and VA dyads in terms of the way that they communicated with each other.

We have worked with a collaborative to begin the roll-out of VD-HCBS that consists of GEC, Administration for Community Living, PEPReC, VAMCs, and the contractor Lewin. The collaboration among the many parties has produced important components of VD-HCBS for all programs, not just the randomized. These include:
-Veteran interview guides
-Unified caregiver survey which has been coordinated with changes to the national survey administered by the VA Caregiver Support Program
-VA and ADNA implementation interview guides
-Collaborative AARP, ACL, and VA White Paper on lessons learned


Journal Articles

  1. Garrido MM, Allman RM, Pizer SD, Rudolph JL, Thomas KS, Sperber NR, Van Houtven CH, Frakt AB. Innovation in a Learning Health Care System: Veteran-Directed Home- and Community-Based Services. Journal of the American Geriatrics Society. 2017 Nov 1; 65(11):2446-2451.
Journal Other

  1. Clary AS, Perry KR, Edwards-Orr M, Miech EJ, VanHoutven C, Rudolph JL, Thomas KS, Sperber N. Interorganizational Context When Implementing Multisector Partnered Programs: A Qualitative Analysis of Veteran Directed Care. [Abstract]. Journal of gerontological social work. 2020 Nov 9; 1-15.

  1. Rudolph JL, Thomas K, Fox-Grage W, Neill-Bowen CN. No Wrong Door: Supporting Community Living for Veterans. Washington DC: AARP Public Policy Institute, the Commonwealth Fund, the SCAN Foundation, AARP Public Policy Institute; 2017 Oct 24. 1-25 p.

DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: TRL - Applied/Translational
Keywords: Aging, Models of Care, Self-Care
MeSH Terms: none

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