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Publication Briefs

Assessing Expansion of VA's Home-Based Primary Care Program for American-Indian Veteran Patient Population


Little is known about the population characteristics or outcomes of patients using home-based primary care (HBPC) in rural areas with limited access to non-institutional long-term care. This knowledge gap is particularly salient for American Indians who reside in predominantly rural areas and have been characterized by inequities in healthcare access, health status, and outcomes. VA provides HBPC in rural communities with American Indian reservations, where prospective patients may qualify for healthcare from VA, Medicare (CMS), and/or the Indian Health Service (IHS). This multi-site study of the effectiveness of HBPC expansion to these rural areas also describes the characteristics of patients who meet the requirements for admission to rural HBPC. Investigators sought to answer two key questions: 1) Does implementation of rural HBPC programs increase access to VA health benefits for American Indians? 2) Are outcomes equitable for HBPC-enrolled American Indians and non-Indians living in rural areas? Using VA, CMS, and IHS data, investigators identified 376 Veterans (88 IHS beneficiaries and 288 non-IHS beneficiaries) with >12 months length of stay in home-based primary care. To observe the impact of HBPC over time, a timeline was constructed for each patient from the date of HBPC admission, including a 360 day post-HBPC period. Measures included demographics, health status, activities of daily living (ADLs), VA enrollment, VA hospital admissions, and ED visits.


  • Expansion of the HBPC program was effective in introducing non-institutional home-based primary medical care to populations residing in American Indian reservations and other rural communities. Among HBPC users, VA enrollment increased by 22%.
  • The proportion of new VA enrollees was significantly greater for IHS beneficiaries (43%) than non-IHS beneficiaries (16%).
  • Overall, hospital admissions and ED visits decreased, respectively, by 0.10 and 0.13, in the 90 days following HBPC admission and were maintained over the one-year follow-up. Reductions occurred equally for IHS and non-IHS beneficiaries.
  • In both IHS and non-IHS beneficiaries, 30% had impairments in 2+ activities of daily living (ADLs) [greater ADL impairment is a risk factor for hospital admission].


  • Results suggest opportunities to identify new clients for services that support aging in rural settings.


  • Potential biases included the relatively small sample size (12 VAMCs) that agreed to participate in the HBPC expansion program – and possible bias in patient selection by these new programs.
  • Additional potential biases are inherent in administrative data.

This study was funded by HSR&D (IIR 12-063). Drs. Kramer and Saliba are part of the VA Greater Los Angeles Healthcare System; Dr. Saliba also is part of HSR&D's Center for Healthcare Innovation, Implementation and Policy (CSHIIP) located in Los Angeles, CA.

PubMed Logo Kramer BJ, Creekmur B, Mitchell M, and Saliba D. Expanding Home-Based Primary Care to American Indian Reservations and Other Rural Communities: An Observational Study. Journal of the American Geriatrics Society. April 2018;66(4):818-24.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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