Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization.
Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization.
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DOI：
10.1097/md.0000000000028864
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发表时间：
2022-02-18
期刊：
影响因子：
1.6
通讯作者：
Zulman, Donna M.
中科院分区：
文献类型：
--
作者：
Vanneman, Megan E.;Yoon, Jean;Singer, Sara J.;Wagner, Todd H.;Goldstein, Mary K.;Hu, Jiaqi;Boothroyd, Derek;Greene, Liberty;Zulman, Donna M.
美国退伍军人事务部（VA）患者的多系统使用可能会给负责协调退伍军人使用非VA护理（包括VA购买的护理（“社区护理”）和医疗保险）的VA临床医生带来挑战。研究驾驶距离和时间之间的关系社区护理和VA依赖（在VA与医疗保险和社区护理中接受的护理比例）的关键资格标准退伍军人在高风险住院。我们使用政策前数据来预测2014年选择法案和2018年维护内部系统和加强综合外部网络法案（使命法案）的影响，该法案扩大了社区护理的可及性。采用分数逻辑回归的横断面分析，以检查退伍军人对VA门诊初级，心理健康和其他专业护理的依赖与他们到VA设施的驾驶距离/时间之间的关系。在2014年联邦财政年度，65岁以上的13703名退伍军人参加了退伍军人事务部和按服务收费的医疗保险，他们的住院风险排在前10个百分位。关键的解释变量是患者到VA的驾驶距离> 40英里（选择法案标准），到VA的驾驶时间≥ 30分钟（初级和精神卫生保健）和≥60分钟（专业护理）（使命法案标准）。 与不符合选择法案资格标准的退伍军人相比，具有驾车距离资格的住院高风险退伍军人在VA进行门诊专科护理访视的几率增加（比值比= 1.10，95%置信区间1.05-1.15）。 然而，驾驶时间合格性（使命Act标准）与VA发生门诊专科护理访视的几率显著降低相关（比值比= 0.69，95%置信区间0.67，0.71）。 驾驶距离和驾驶时间与依赖门诊初级保健或精神卫生保健无关。尽管可以获得外部服务，但住院风险高的VA患者可能会继续依赖VA进行门诊初级保健和心理健康护理，但在使命时代，可能会增加社区门诊专科护理的使用，增加对多系统护理协调的需求。
U.S. Veterans Affairs (VA) patients’ multi-system use can create challenges for VA clinicians who are responsible for coordinating Veterans’ use of non-VA care, including VA-purchased care (“Community Care”) and Medicare. To examine the relationship between drive distance and time—key eligibility criteria for Community Care—and VA reliance (proportion of care received in VA versus Medicare and Community Care) among Veterans at high risk for hospitalization. We used prepolicy data to anticipate the impact of the 2014 Choice Act and 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded access to Community Care. Cross-sectional analysis using fractional logistic regressions to examine the relationship between a Veteran's reliance on VA for outpatient primary, mental health, and other specialty care and their drive distance/time to a VA facility. Thirteen thousand seven hundred three Veterans over the age of 65 years enrolled in VA and fee-for-service Medicare in federal fiscal year 2014 who were in the top 10th percentile for hospitalization risk. Key explanatory variables were patients’ drive distance to VA > 40 miles (Choice Act criteria) and drive time to VA ≥ 30 minutes for primary and mental health care and ≥60 minutes for specialty care (MISSION Act criteria). Veterans at high risk for hospitalization with drive distance eligibility had increased odds of an outpatient specialty care visit taking place in VA when compared to Veterans who did not meet Choice Act eligibility criteria (odds ratio = 1.10, 95% confidence interval 1.05–1.15). However, drive time eligibility (MISSION Act criteria) was associated with significantly lower odds of an outpatient specialty care visit taking place in VA (odds ratio = 0.69, 95% confidence interval 0.67, 0.71). Neither drive distance nor drive time were associated with reliance for outpatient primary care or mental health care. VA patients who are at high risk for hospitalization may continue to rely on VA for outpatient primary care and mental health care despite access to outside services, but may increase use of outpatient specialty care in the community in the MISSION era, increasing demand for multi-system care coordination.