Maximizing the Value of VA Homemaker/Home Health Aide (H/HHA) Services to Veterans, Caregivers and VA: Supporting Older Veterans’ Pathways to Stable H/HHA Care

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Background: Home health aides (HHAs) advance VA’s priority to honor Veterans’ desire to age in place by improving health outcomes, reducing family caregiver burden and strain, and delaying or avoiding costly institutional placement. Lack of adequate, stable HHA support for older Veterans is associated with loneliness, depression and mortality. Improving access to HHA services is an urgent VA and legislative priority, and VA’s HHA benefit is the health system’s most widely used and fastest growing home and community-based service (HCBS). But because HHA care is purchased from community providers, navigating care can be complex and fragmented. Ensuring stable, continuous HHA care thus demands a stakeholder-engaged systems approach to better understand how Veterans navigate roadblocks and to identify potential interventions at the individual, organizational and policy levels. My extensive research and professional experience with HHAs and my qualitative training prepares me for this work. With mentorship and additional training in process improvement, intervention development, implementation science, and trial design, I will leverage this CDA’s findings into a bundle of actionable, multi-level interventions and advance my VA career. Specific Aims: This proposed CDA simultaneously fills the gaps in my training and provides VA with rigorous research on which to ground future interventions to strengthen Veterans’ caregiving teams in the home. This work is guided by a theory-driven framework and supported by operational partners in GEC, Caregiver Support, and Primary Care. Aims will: (1) Systematically describe the process of receiving and maintaining VA- paid HHA services by identifying steps; individual, organizational and policy-level roadblocks; and promising points of intervention. (2) Collaboratively adapt VA’s established Caregivers FIRST family caregiver curriculum for VA-paid HHAs. (3) Conduct a pilot and formative evaluation of the intervention at the Bronx VA. Methods: Aim 1: At 4 VAMCs diverse in geography, size, and HHA benefit structure, I will create process maps using participatory methods with Veterans, caregivers, VA primary care teams, VA HCBS coordinators, home health agencies and HHAs to prioritize potentially modifiable organizational factors to improve HHA access. Aim 2: Through a stakeholder-engaged co-design process informed by previous pilot data and the needs and barriers identified in Aim 1, I will develop an intervention to better prepare HHAs to provide Veteran- centered care. Aim 3: I will use mixed methods to assess implementation outcomes (feasibility, acceptability, usefulness) and HHA outcomes (preparedness). I will also examine potential downstream measures (caregiver burden, Veteran days at home). Expected Results and Next Steps: Throughout this study, I will provide my operational partners with key deliverables, including HHA process maps and priorities for organizational-level interventions, and a scalable, stakeholder-designed training program for VA-paid HHAs. Knowledge and skills developed through this CDA will help me develop multi-site studies to more rigorously evaluate the effectiveness of this intervention and address individual and organizational-level interventions through two proposed multi-site IIRs. Findings will inform future research and action to improve the delivery and stability of HHA services and leverage the skills of this critical workforce. Significance and Relevance to Veterans’ Health: My study is innovative, timely, and responsive to VA and legislative priorities. It addresses multiple HSR&D priority areas in Long-term Care/Aging and Disability, with a focus on health systems issues and cross-cutting HSR methods, and shines light on a critical yet understudied anchor of VA HCBS. This work comes at a critical juncture for VA as long-term care shifts to the community. This study seizes these opportunities, systematically identifying needed improvements and launching a promising intervention as a first step toward leveraging VA resources to support Veterans’ caregiving teams.