Does VA Home-Based Primary Care Reduce Costs Among Veterans Eligible for Independence at Home?

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Anticipated Impacts on Veteran's Healthcare: The Medicare Independence-at-Home (IAH) demonstration which provides frail elderly patients with provider-managed integrated care and supportive services at home has shown reduced rates of hospitalizations, 30-day rehospitalizations, emergency department care, and an average $3,070 annual costs savings per patient. This study will examine if VA's Home Based Primary Care (HBPC) program, the inceptor of IAH, produces similar outcomes among Veterans who meet IAH qualifying criteria (IAH-Q). High HBPC program costs have limited the availability of HBPC and it is currently serving less than 25% of Veterans who meet IAH-Q. This project will provide the Offices of Geriatrics and Extended Care (GEC) Policy (10P4G) and Operations (10NC4) with information needed to make informed decisions about effective expansion of the HBPC program, and tools to target Veterans who will benefit from it most. Project Background: The IAH demo is associated with better outcomes and reduced healthcare costs compared to routine care. While VA has operated the HBPC program since the 1970s, it only serves a fraction of the Veterans who meet the Medicare IAH-Q. VA has expanded HBPC from operating in less than half its facilities in 2000 to almost all facilities today. However, the program's reach is still constrained because of the relatively large up-front costs and the lack of readily applicable admission criteria to identify those who would benefit from the program. Further, since over half of the current HBPC enrollees do not meet the IAH-Q, VA needs information on which Veterans should be considered for HBPC so that the program can be available to those Veterans who will likely achieve the most clinical and economic benefit. Project Objectives: One: Does VA's HBPC, when targeted to IAH-Q Veterans, achieve the same clinical outcomes and cost savings as Medicare's IAH-Q beneficiaries receiving Medicare HBPC? Two: Extend the evaluation methods to exploit VA data that was not available to the Medicare evaluation, and include alternative estimation methods to test the robustness of the findings. Three: VA currently provides HBPC to Veterans who do not meet IAH-Q criteria. What is the effectiveness of HBPC in these other groups? Are there non-IAH-Q groups of Veterans for whom HBPC would be cost- effective? Further, what is the variability in the effectiveness of HBPC among IAH-Q Veterans? Four: Develop targeting criteria equivalent to IAH-Q that use only VA data, without relying on data from CMS, to identify Veterans for HBPC enrollment, including refinement of IAH-Q criteria with VA risk measures such as JEN Frailty Index and CAN scores. Five: The CMS demonstration project considered only Medicare expenditures. How does HBPC care affect utilization and costs across Medicare, Medicaid and VA? Project Methods: This project will use Medicare, Medicaid and VA data to capture all relevant utilization and diagnoses. We will identify all Veterans who were potentially eligible for HBPC in 2011. The intervention cohort will be all Veterans who received HBPC in 2012. The control group will be determined from those potentially eligible Veterans who did not use HBPC in 2012 using a direct demographic match, with a propensity score matching based on diagnoses, health services utilization, treatments and prescriptions and MDS or OASIS frailty assessments. We will follow both groups through 2015, comparing functional status, utilization of services, and costs.