Medical Foster Homes: A Safe, Cost Effective Substitute for Nursing Homes?

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DESCRIPTION (provided by applicant): Project Background: Since the program began in 2008, 1245 Veterans have received care in a MFH. The program has expanded from three sites in 2008 to 32 sites in 2010; 67 total sites are currently in some phase of initiating a program. The overall goals of this study are to inform VA policies pertaining to community based alternatives for LTC by understanding (1) how Veterans decide to receive care in a private home in the community rather than a traditional institutional setting; (2) which program attributes support their decision; (3) whether MFH is a safe alternative to NH placement; and (4) the costs associated with this model of care. Characterizing successful high-enrollment programs will inform changes to the model as it is nationally disseminated Objectives: Aim 1. Describe what leads Veterans to select or reject MFH placement over NH placement with the goal of assisting VHAs efficiently target recruitment into MFH programs by: Sub-Aim 1A. Comparing characteristics of Veterans residing in 3 high-enrollment MFH programs to the demographic, diagnostic, functional and cognitive characteristics of Veterans residing in NHs in the same VAMC catchment area. Sub-Aim 1B. Conducting in-person interviews with Veterans who have either recently enrolled or declined to enroll in one of 3 high-enrollment MFH programs. Sub-Aim 1C. Performing in-depth qualitative examinations of 3 high and 3 low-enrollment MFH programs to understand how MFH program attributes promote or thwart access to MFH enrollment. Aim 2. Assess safety of the MFH program by comparing adverse event rates among MFH enrollees to propensity matched MFH-eligible Veterans residing in NHs. Aim 3. Calculate VA budgetary costs for care, including non-programmatic inpatient and outpatient cost to the VA, of MFH enrollees compared to propensity-matched MFH-eligible Veterans living in NHs, and estimate total costs of MFH compared to non-MFH care. Methods: MFH residents will be compared to Veterans residing in NHs using data from the Minimum Data Set (MDS) in an unadjusted analysis. MDS data are available for NH residents but are not routinely collected for MFH residents. Thus, on-site research nurses will conduct MDS assessments directly for residents at 3 high- enrollment MFH programs to allow for comparisons of the MFH cohort to Veterans residing in NHs at the same VAMC (Sub Aim1A). Additionally, these on-site nurse researchers will interview 30 Veterans who entered and 30 who declined MFH entry within the last 30 days using a semi-structured protocol to understand the basis of their choices and preferences for care (Sub Aim 1B). In order to better understand why MFH programs have flourished in some areas while not in others, a team of qualitative researchers will undertake in-depth interviews with relevant VAMC administrative and clinical program officials during 2-day site visits at 3 high- enrollment and at 3 low-enrollment MFH programs (Sub Aim 1C). To address the issue of the relative safety of the MFH program versus the alternative of care in a NH, we will identify MFH users and compare the rate at which they experience avoidable hospitalizations, ED visits for accidents and exacerbations of medical conditions, infections, medication adherence and incident use of antipsychotics with a propensity matched group of NH residents drawn from similar medical centers that either had not instituted an MFH or had done so very late (Aim 2). Programmatic and non-programmatic costs of care will then be compared among these propensity matched subjects (Aim 3).