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CDA 16-152 – HSR&D Study

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CDA 16-152
Optimizing Outcomes in Home-Based Primary Care
Samuel T. Edwards MD MPH
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: July 2018 - June 2023

The Veterans Health Administration is facing increasing numbers of older Veterans suffering from multiple chronic conditions, who are frequently hospitalized for ambulatory care sensitive conditions (ACSC) at high cost. While many efforts to redesign outpatient care for this vulnerable group have failed to reduce health care utilization, VA Home-Based Primary Care (HBPC) has recently been demonstrated to reduce rates of hospitalization for ACSCs by 27%. However there is substantial variation in HBPC implementation across sites, and the key mechanisms that drive reduced hospitalizations are unknown.

The purpose of this research is to explore what features of HBPC drive its success in reducing hospitalizations for ambulatory care sensitive conditions, and use these insights to develop an intervention to promote best practices in HBPC. The aims of this proposal are 1) Characterize patterns of enrollment and care delivery within HBPC, and determine clinical and systems correlates of preventable hospitalizations, 2) Assess HBPC provider perceptions of appropriate patient selection and care delivery patterns, core functions of HBPC, and barriers and facilitators to HBPC performance, and 3) Develop and test a pilot intervention to promote best practices in HBPC

Aim 1 is a quantitative study consisting of four secondary analyses of national VHA data to (1) determine predictors of enrollment in HBPC, (2) define clinical subgroups of HBPC patients, (3) describe care delivery patterns within HBPC, and (4) determine association of patient subgroups and care delivery patterns with ambulatory care sensitive hospitalizations. Aim 2 is a two phase qualitative study. The first phase is an in depth study of the Portland HBPC program using interviews, focus groups and structured observation. In the second phase, program directors at other HBPC sites will be to gain an understanding of differences across sites. Finally, Aim 3 will be the development of a pilot intervention to promote best practices in HBPC learned from Aims 1 and 2, which will be tested locally in a trial.

Not yet available.

The research has the potential to improve the quality and efficiency of the HBPC program nationally, leading to improved care for older medically complex Veterans, and reduced rates of hospitalization and long term institutionalization.


Journal Articles

  1. Edwards ST, O'Neill A, Niederhausen M, Salvi A, Laliberte A, Saha S, Hynes DM, Pizer S, Kinosian B. Trajectories of care and outcomes of Veterans receiving home-based primary care. Journal of the American Geriatrics Society. 2024 Jan 1; 72(1):80-90.
  2. Hulen E, Laliberte A, Saha S, Edwards ST. Relational Coordination in Veterans Affairs Home-Based Primary Care. Journal of interprofessional education & practice. 2023 Sep 1; 32:
  3. Edwards ST, Johnson A, Park B, Eiff P, Guzman CEV, Gordon L, Taylor C, Tuepker A. "What We're Doing Now…Is More Than Water Cooler": Perspectives of Primary Care Leaders on Leading Through (and Beyond) COVID-19. Journal of general internal medicine. 2023 Aug 15.
  4. Lindner SR, Balasubramanian B, Marino M, McConnell KJ, Kottke TE, Edwards ST, Cykert S, Cohen DJ. Estimating the Cardiovascular Disease Risk Reduction of a Quality Improvement Initiative in Primary Care: Findings from EvidenceNOW. Journal of the American Board of Family Medicine : JABFM. 2023 May 8; 36(3):462-476.
  5. Rotenstein LS, Cohen DJ, Marino M, Bates DW, Edwards ST. Association of Clinician Practice Ownership With Ability of Primary Care Practices to Improve Quality Without Increasing Burnout. JAMA health forum. 2023 Mar 3; 4(3):e230299.
  6. Rotenstein LS, Edwards ST, Landon BE. Adult Primary Care Physician Visits Increasingly Address Mental Health Concerns. Health affairs (Project Hope). 2023 Feb 1; 42(2):163-171.
  7. Govier DJ, Hickok A, Edwards ST, Weaver FM, Gordon H, Niederhausen M, Hynes DM. Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time. Journal of general internal medicine. 2023 Mar 1; 38(4):889-897.
  8. Edwards ST, Greene L, Chaudhary C, Boothroyd D, Kinosian B, Zulman DM. Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care. JAMA Network Open. 2022 Sep 1; 5(9):e2230036.
  9. Chan B, Geduldig A, Korthuis T, Hulen E, Nicolaidis C, Kansagara D, Edwards S. "The SUMMIT Team is All I Got": perspectives of medically and socially complex patients seen in intensive primary care. Annals of Family Medicine. 2022 Apr 1; 20(20 Suppl 1).
  10. Hulen E, Lafferty M, Laliberte A, Saha S, Edwards ST. Balancing the benefits of patient-clinician relationships with professional boundaries in Home-based Primary Care. Home health care services quarterly. 2022 Mar 29; 41(4):330-340.
  11. Edwards ST, Marino M, Solberg LI, Damschroder L, Stange KC, Kottke TE, Balasubramanian BA, Springer R, Perry CK, Cohen DJ. Cultural And Structural Features Of Zero-Burnout Primary Care Practices. Health affairs (Project Hope). 2021 Jun 1; 40(6):928-936.
  12. Montano AR, Ge A, Halladay CW, Edwards ST, Rudolph JL, Cornell PY. Association of Home-Based Primary Care Enrollment with Social Determinants of Health for Older Veterans. Rhode Island medical journal (2013). 2021 May 3; 104(4):32-38.
  13. Hulen E, Laliberte A, Ono S, Saha S, Edwards ST. "Eyes in the Home": Addressing Social Complexity in Veterans Affairs Home-Based Primary Care. Journal of general internal medicine. 2021 Apr 1; 36(4):894-900.
  14. Manheim C, Haverhals L, Gilman C, Karuza J, Olsan T, Edwards S, Levy C, Gillespie S. VA Home Based Primary Care Teams: Partnering with and Acting as Caregivers for Veterans. Home health care services quarterly. 2021 Jan 1; 40(1):1-15.
  15. Chan B, Hulen E, Edwards S, Mitchell M, Nicolaidis C, Saha S. "It's Like Riding Out the Chaos": Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU). Annals of Family Medicine. 2019 Nov 1; 17(6):495-501.
  16. Haverhals LM, Manheim C, Gilman C, Karuza J, Olsan T, Edwards ST, Levy CR, Gillespie SM. Dedicated to the Mission: Strategies US Department of Veterans Affairs Home-Based Primary Care Teams Apply to Keep Veterans at Home. Journal of the American Geriatrics Society. 2019 Dec 1; 67(12):2511-2518.
  17. 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.

DRA: Health Systems
DRE: TRL - Applied/Translational
Keywords: Home Care, Models of Care, Practice Patterns/Trends
MeSH Terms: none

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