Post-Acute Home Health Care for Veterans: Examining Payer Source, Quality, and Outcomes

项目摘要/摘要 背景资料。退伍军人出院后不良后果的风险增加，包括 再住院、疗养院入院和死亡率。急性后熟练家庭保健(HHC)可以 为住院后的退伍军人提供关键支持。通过HHC提供的服务，包括 护理和治疗，可以帮助退伍军人实现他们的目标，改善功能，幸福感，并回到 独立生活在自己的家中。对于符合联邦医疗保险资格的退伍军人，通过1)退伍军人管理局提供熟练的HHC 从签约的HHC机构购买熟练的HHC或2)医疗保险资助的HHC(即，A部分福利， 联邦医疗保险优势)。初步工作表明，大多数(66%)退伍军人从 拥有熟练HHC的退伍军人医疗中心(VAMC)将获得退伍军人管理局签约的熟练HHC，其余的将获得 医疗保险资助的HHC。然而，对于熟练的HHC的资金在不同的VAMC之间有很大的差异，这是有影响的 对于HHC服务的提供和退伍军人的结果。在前期工作中，我们发现30天的重新入院 与接受医疗保险资助的HHC相比，接受退伍军人资助的HHC的比例更高，后者可能 与HHC机构质量有关。 重要性/影响力。更好地了解HHC推荐和融资，这一直是 由社区HHC机构购买和交付，可为退伍军人管理局提供关键见解 在社区照顾退伍军人方面。因为社区家庭健康机构一直在提供急性呼吸道感染后 HHC，这一背景为审查组织间伙伴关系和退伍军人的 结果。拟议的研究将表征急性HHC的使用、资金和护理质量，以及 这些因素如何与退伍军人从VAMC出院的结果以及提供者的 以及退伍军人在急性HHC后接送的经历。调查结果将为以下发展提供信息 为退伍军人管理局和HHC领导者提供的工具包，提供指导高价值HHC机构选择和协作的资源。 这项研究的贡献是重大的，因为研究结果将直接告知运营合作伙伴如何 选择HHC机构以纳入提供商网络，并为熟练的HHC推荐制定政策，并将 还为多个利益相关者提供实用工具，为退伍军人提供最佳的HHC。 创新。这是第一项全面研究退伍军人管理局合同、转介做法和融资情况的研究。 包括退伍军人管理局和联邦医疗保险--以了解它们对退伍军人结局的影响。利益相关者- 参与式、复杂的混合方法研究设计用于了解 从多个角度塑造急性后HHC的使用和结果。 明确的目标。1)在社区中确定VA与医疗保险资助的急性后熟练HHC的决定因素 居住参加联邦医疗保险的退伍军人；2)了解多个利益相关者对老年退伍军人的看法 急性期后熟练HHC的使用及影响HHC分娩的因素；3)决定家庭的影响 卫生机构质量和HHC支付者来源关于老年退伍军人接受后治疗结果的差异 急性HHC。 方法论。这项建议使用了复杂的混合方法研究设计和高级统计学 技术和全面的退伍军人管理局和医疗保险管理数据，以及稳健的定性方法 采访来自VAMC、HHC机构、退伍军人和照顾者的利益相关者，以实现我们的目标。 实施/后续步骤。这项工作的最终结果将被纳入一个工具包，以 促进高价值HHC的遴选和协作。此外，这项工作将为大型- 规模研究，以开发和测试共享决策模型的实施和有效性 退伍军人和VAMC人员推动高价值HHC。

PROJECT SUMMARY/ABSTRACT Background. Veterans are at increased risk of adverse outcomes after hospital discharge, including rehospitalization, nursing home admission, and mortality. Post-acute skilled home health care (HHC) can provide critical support for Veterans following a hospitalization. The services provided through HHC, including nursing and therapies, can help Veterans meet their goals to improve function, well-being, and return to independent living in their homes. For Medicare-eligible Veterans, skilled HHC is provided through 1) VA purchased skilled HHC from a contracted HHC agency or 2) Medicare-funded HHC (i.e., Part A benefit, Medicare Advantage). Preliminary work suggests that the majority (66%) of Veterans discharged home from VA Medical Centers (VAMCs) with skilled HHC receive VA-contracted skilled HHC and the remainder receive Medicare-funded HHC. However, funding for skilled HHC varies substantially across VAMCs, with implications both for HHC service delivery and Veterans’ outcomes. In preliminary work, we found that 30-day readmissions are higher among Veterans who receive VA-financed HHC compared to Medicare-financed HHC, which could be related to HHC agency quality. Significance/Impact. A better understanding of HHC referrals and financing, which has always been purchased and delivered by community HHC agencies, could provide key insights for the VA given the growth in community care for Veterans. Because community home health agencies have always provided post-acute HHC, this context provides an ideal opportunity to examine interorganizational partnerships and Veterans’ outcomes. The proposed research will characterize post-acute HHC use, financing, and quality of care, and how these factors are associated with outcomes for Veterans discharged from VAMCs, as well as providers’ and Veterans’ experiences of delivering and receiving post-acute HHC. Findings will inform the development of a toolkit for VA and HHC leaders with resources to guide high-value HHC agency selection and collaboration. The contribution of this research is significant because the results will directly inform how operational partners choose HHC agencies to include in provider networks and develop policy for skilled HHC referrals, and will also provide practical tools for multiple stakeholders to provide optimal HHC for Veterans. Innovation. This is the first comprehensive study to examine VA contracting, referral practices, and financing - including both VA and Medicare - to understand their influence on Veterans’ outcomes. A stakeholder- engaged, complex mixed-methods study design is used to understand the mechanisms and processes that shape the use and outcomes of post-acute HHC from multiple perspectives. Specific Aims. 1) Identify determinants of VA vs Medicare-financed post-acute skilled HHC among community dwelling Medicare-enrolled Veterans; 2) Understand multiple stakeholders’ perspectives on older Veterans’ use of post-acute skilled HHC and factors that influence the delivery of HHC; 3) Determine the impact of home health agency quality and HHC payer source on differences in outcomes for older Veterans receiving post- acute HHC. Methodology. This proposal uses a complex mixed-methods study design with advanced statistical techniques and comprehensive VA and Medicare administrative data, as well as a robust qualitative approach to interview stakeholders from VAMCs, HHC agencies, Veterans, and caregivers to accomplish our aims. Implementation/Next Steps. The culmination of findings from this work will be incorporated into a toolkit to promote high-value HHC selection and collaboration. In addition, this work will form the foundation for a large- scale study to develop and test implementation and effectiveness of a shared decision-making model for Veterans and VAMC personnel to promote high-value HHC.