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CDA 14-422 – HSR&D Study

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CDA 14-422
Evaluating Cash Benefit Programs for Veterans' Long Term Care
Kali Thomas PhD
Providence VA Medical Center, Providence, RI
Providence, RI
Funding Period: October 2016 - September 2021

BACKGROUND/RATIONALE:
Dr. Thomas' long-term career goal is to conduct rigorous research that will inform policies and practices aimed at advancing the VA's home and community-based service delivery, thereby improving the quality of life and health outcomes of Veterans needing LTSS. The demand for LTSS within VA is expected to continue to grow dramatically as the Veteran population ages. This CDA will focus on understanding the role of participant-directed (PD) cash benefit programs provided by VA to meet the growing need for LTSS. The VA, through its Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA), offers separate and distinct PD cash benefit programs for LTSS. The VHA's Veteran-Directed Home and Community Based Services program (VD-HCBS) provides Veterans with a monthly budget based on the extent of their disability giving them the opportunity to purchase goods and services that best meet their needs. The VBA offers two enhanced monthly benefits to disabled and homebound Veterans receiving pension or compensation: the Aid and Attendance (A&A) and Housebound benefits. In non-VA populations, similar programs have been cost-effective and improved participants' outcomes. However, in VA, information about effectiveness and access to these programs is limited: there remains little to no understanding of who receives these PD cash benefits, how Veterans are utilizing these benefits, their satisfaction with the benefits, their consumption of medical and institutional care, nor the outcomes associated with receiving these cash benefits.

OBJECTIVE(S):
The objective of this application is to establish a foundation of research about the VA's PD cash benefit programs in order to develop interventions aimed at improving access to these benefits, promote a national understanding of Veterans' experiences with these benefits, and set the stage for a research career evaluating and improving the delivery of LTSS to Veterans. This CDA will provide Dr. Thomas with the support necessary to accomplish the following goals: (1) to become an expert in conducting rigorous, practical program evaluation and implementation research; (2) to achieve proficiency in comparative effectiveness research, primary data collection, and qualitative research methodologies (3) to become familiar with delivery of LTSS at VAMCs and (4) to reach research independence. These goals will be achieved through the training and applied, mixed methods formative research she has proposed in this award. Specifically, her research seeks to (1) use administrative data to determine which eligible Veterans being served by which Medical Centers enroll in VA's PD cash benefit programs, (2) explore reasons for variation in enrollment in VD-HCBS, A&A and Housebound benefits across VAMCs with interviews of VAMC personnel (3) conduct interviews with Veterans to describe their experiences with the VA's PD cash benefit programs and (4) establish the effectiveness of the VA's PD cash benefit programs in controlling healthcare costs by using sophisticated methodologies to compare Veterans' healthcare utilization to that of Veterans receiving traditional LTSS.

METHODS:
Drawing on the Behavioral Model for Vulnerable Populations, this study will identify predisposing, enabling, and need characteristics associated with enrollment in VD-HCBS, Housebound, and A&A using secondary, administrative VA and CMS data. It will also compare utilization and costs of (a) Veterans receiving VD-HCBS to Veterans receiving Home-Based Primary Care (HBPC) and/or Homemaker and Home Health Aide Services (H/HHA) (b) Veterans receiving A&A to Veterans receiving HBPC or H/HHA and (c) Veterans receiving Housebound benefits to Veterans receiving HBPC or H/HHA. Building on previous research and preliminary studies, the hypothesis is that Veterans receiving VA's PD cash benefits will have a decreased likelihood of hospitalization, emergency department use, and nursing home admission compared to similar Veterans receiving traditional LTSS.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
This research is significant because it will provide a critical understanding of who receives VA cash benefits for PD care, causes for variation, Veterans' perceptions of PD programs, and knowledge of their outcomes. The experience and skills gained through the integrated training and research plan will accelerate progress toward Dr. Thomas' long-term research goal and will set the stage for implementing innovative solutions to increase the access to cash benefits and obtaining a national picture of Veterans' experiences with these benefits, to be proposed in future Merit award applications. Dr. Thomas' current and future research will evaluate programs and implement innovative solutions to integrate VHA and VBA, creating a "One VA" system to enable older, vulnerable Veterans to receive appropriate, Veteran-centered, and cost-effective LTSS in the setting of their choice.

PUBLICATIONS:

Journal Articles

  1. Shan M, Gutman R, Dosa D, Gozalo PL, Ogarek JA, Kler S, Thomas KS. A New Data Resource to Examine Meals on Wheels Clients' Health Care Utilization and Costs. Medical care. 2019 Mar 1; 57(3):e15-e21.
  2. Thomas KS, Ogarek JA, Teno JM, Gozalo PL, Mor V. Development and Validation of the Nursing Home Minimum Data Set 3.0 Mortality Risk Score (MRS3). The journals of gerontology. Series A, Biological sciences and medical sciences. 2019 Jan 16; 74(2):219-225.
  3. Lueckel SN, Teno JM, Stephen AH, Benoit E, Kheirbek T, Adams CA, Cioffi WG, Thomas KS. Population of Patients With Traumatic Brain Injury in Skilled Nursing Facilities: A Decade of Change. The Journal of head trauma rehabilitation. 2019 Jan 1; 34(1):E39-E45.
  4. Thomas KS, Gadbois EA, Shield RR, Akobundu U, Morris AM, Dosa DM. "It's Not Just a Simple Meal. It's So Much More": Interactions Between Meals on Wheels Clients and Drivers. Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2018 Dec 20; 733464818820226.
  5. Thomas KS, Boyd E, Mariotto AB, Penn DC, Barrett MJ, Warren JL. New Opportunities for Cancer Health Services Research: Linking the SEER-Medicare Data to the Nursing Home Minimum Data Set. Medical care. 2018 Dec 1; 56(12):e90-e96.
  6. Fabius CD, Thomas KS. Examining Black-White Disparities Among Medicare Beneficiaries in Assisted Living Settings in 2014. Journal of The American Medical Directors Association. 2018 Nov 14.
  7. Fabius CD, Thomas KS, Zhang T, Ogarek J, Shireman TI. Racial disparities in Medicaid home and community-based service utilization and expenditures among persons with multiple sclerosis. BMC health services research. 2018 Oct 12; 18(1):773.
  8. Mor V, Thomas KS, Rahman M. Defining and Measuring Nursing Home Placement. Journal of the American Geriatrics Society. 2018 Oct 4; 66(10):1866-1868.
  9. Silver BC, Grabowski DC, Gozalo PL, Dosa D, Thomas KS. Increasing Prevalence of Assisted Living as a Substitute for Private-Pay Long-Term Nursing Care. Health services research. 2018 Dec 1; 53(6):4906-4920.
  10. Kosar CM, Thomas KS, Gozalo PL, Mor V. Higher Level of Obesity Is Associated with Intensive Personal Care Assistance in the Nursing Home. Journal of The American Medical Directors Association. 2018 Nov 1; 19(11):1015-1019.
  11. Lueckel SN, Kosar CM, Teno JM, Monaghan SF, Heffernan DS, Cioffi WG, Thomas KS. Outcomes in nursing home patients with traumatic brain injury. Surgery. 2018 May 9.
  12. Singh T, BĂ©langer E, Thomas K. Is Fear of Falling the Missing Link to Explain Racial Disparities in Fall Risk? Data from the National Health and Aging Trends Study. Clinical Gerontologist. 2018 Apr 25; 1-6.
  13. Kosar CM, Thomas KS, Gozalo PL, Ogarek JA, Mor V. Effect of Obesity on Postacute Outcomes of Skilled Nursing Facility Residents with Hip Fracture. Journal of the American Geriatrics Society. 2018 Jul 1; 66(6):1108-1114.
  14. Rivera-Hernandez M, Kumar A, Epstein-Lubow G, Thomas KS. Disparities in Nursing Home Use and Quality Among African American, Hispanic, and White Medicare Residents With Alzheimer's Disease and Related Dementias. Journal of aging and health. 2018 Apr 1; 898264318767778.
  15. Keohane LM, Rahman M, Thomas KS, Trivedi AN. Effects of Caps on Cost Sharing for Skilled Nursing Facility Services in Medicare Advantage Plans. Journal of the American Geriatrics Society. 2018 May 1; 66(5):992-997.
  16. Ogarek JA, McCreedy EM, Thomas KS, Teno JM, Gozalo PL. Minimum Data Set Changes in Health, End-Stage Disease and Symptoms and Signs Scale: A Revised Measure to Predict Mortality in Nursing Home Residents. Journal of the American Geriatrics Society. 2018 May 1; 66(5):976-981.
  17. Thomas KS, Dosa D, Gozalo PL, Grabowski DC, Nazareno J, Makineni R, Mor V. A Methodology to Identify a Cohort of Medicare Beneficiaries Residing in Large Assisted Living Facilities Using Administrative Data. Medical care. 2018 Feb 1; 56(2):e10-e15.
  18. Thomas KS, Cote D, Makineni R, Intrator O, Kinosian B, Phibbs CS, Allen SM. Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community. Journal of Aging & Social Policy. 2018 Mar 1; 30(2):93-108.
  19. Lord J, Davlyatov G, Thomas KS, Hyer K, Weech-Maldonado R. The Role of Assisted Living Capacity on Nursing Home Financial Performance. Inquiry : A Journal of Medical Care Organization, Provision and Financing. 2018 Jan 1; 55:46958018793285.
  20. Harris D, McNicoll L, Epstein-Lubow G, Thomas KS. Association between anxious symptoms and sleeping medication use among US older adults. International journal of geriatric psychiatry. 2018 Feb 1; 33(2):e307-e313.
  21. 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.
  22. Kosar CM, Thomas KS, Inouye SK, Mor V. Delirium During Postacute Nursing Home Admission and Risk for Adverse Outcomes. Journal of the American Geriatrics Society. 2017 Jul 1; 65(7):1470-1475.
  23. Li Q, Keohane LM, Thomas K, Lee Y, Trivedi AN. Association of Cost Sharing With Use of Home Health Services Among Medicare Advantage Enrollees. JAMA internal medicine. 2017 Jul 1; 177(7):1012-1018.
  24. Downer B, Thomas KS, Mor V, Goodwin JS, Ottenbacher KJ. Cognitive Status of Older Adults on Admission to a Skilled Nursing Facility According to a Hospital Discharge Diagnosis of Dementia. Journal of The American Medical Directors Association. 2017 Aug 1; 18(8):726-728.
  25. Brostow DP, Gunzburger E, Thomas KS. Food Insecurity among Veterans: Findings from the Health and Retirement Study. The Journal of Nutrition, Health & Aging. 2017 Jan 1; 21(10):1358-1364.
  26. Thomas KS, Parikh RB, Zullo AR, Dosa D. Home-Delivered Meals and Risk of Self-Reported Falls: Results From a Randomized Trial. Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2018 Jan 1; 37(1):41-57.
Reports

  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
DRE: Treatment - Comparative Effectiveness
Keywords: none
MeSH Terms: none