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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.
VA Home Based Primary Care (HBPC) is an interdisciplinary, longitudinal program for Veterans who are vulnerable to poor outcomes because of complex, intertwined functional and medical needs. HBPC thrived in urban settings, but the feasibility and patient-level impact was unknown in rural areas where access is limited for all types of noninstitutional long-term care (NILTC). In 2009, VA Office of Rural Health funded expansion of HBPC to rural areas and to American Indian reservations, where health care is also provided by Indian Health Service (IHS) or Tribal Health Programs (THP) in accordance with a Memorandum of Understanding between VA and IHS. By using the "natural laboratory" of these expansion programs, the research team was able to identify the key barriers and facilitators to implementing NILTC for vulnerable rural populations. This observational study used a mixed methods approach. In qualitative Phase I, we used key respondent interviews to characterize organizational contexts and processes of care for rural HBPC models. In quantitative Phase II, we used a retrospective pre/post comparative design to analyze outcome correlates at the patient-level (i.e., use of hospital and emergency departments) and organizational-level (i.e., enrollment for VA medical benefits) based on linked and merged secondary data from VA, IHS, and Medicare records. 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.