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

背景：家庭健康助理（HHAs）通过以下方式推进VA优先考虑荣誉退伍军人的愿望： 改善健康结果，减轻家庭照顾者的负担和压力， 机构安置。缺乏足够的，稳定的HHA支持老年退伍军人是与孤独， 抑郁症和死亡率。改善获得HHA服务的机会是一个紧迫的VA和立法优先事项，VA的 HHA福利是卫生系统中使用最广泛、增长最快的家庭和社区服务 （HCBS）。但是，由于HHA护理是从社区提供者购买的，因此导航护理可能很复杂， 支离破碎因此，确保稳定、持续的HHA护理需要一种由患者参与的系统方法， 更好地了解退伍军人如何克服障碍，并确定对个人的潜在干预措施， 组织和政策层面。我对HHA的广泛研究和专业经验以及我的 素质训练使我为这项工作做好准备。通过在流程改进方面的指导和额外培训， 干预开发，实施科学和试验设计，我将利用CDA的发现， 一系列可操作的多层次干预措施，推动我的退伍军人事务部职业生涯。 具体目标：这一拟议的CDA同时填补了我的培训空白，并为VA提供了严格的 研究，以巩固未来的干预措施，以加强退伍军人的家庭护理团队。这 工作由理论驱动的框架指导，并得到GEC、Caregiver 支持和初级保健。目的是：（1）系统地描述接收和维护VA的过程， 通过确定步骤;个人，组织和政策层面的障碍;和有前途的 干预点。(2)协作适应VA的既定照顾者第一家庭照顾者课程 对于VA支付的HHA。(3)在布朗克斯弗吉尼亚州对干预措施进行试点和形成性评估。 方法：目标1：在4个地理位置、规模和HHA利益结构不同的VAMC中，我将创建流程 地图使用参与式方法与退伍军人，照顾者，VA初级保健团队，VA HCBS协调员， 家庭卫生机构和HHA优先考虑潜在的可修改的组织因素，以改善HHA access.目标2：通过一个由股东参与的共同设计过程， 目标1中确定的需求和障碍，我将制定干预措施，以更好地准备HHA，为退伍军人提供 中心护理目标3：我将使用混合方法评估实施结果（可行性、可接受性、 有用性）和HHA结果（准备）。我还将研究潜在的下游措施（护理人员 （重定向自Veteran Days at Home） 预期结果和后续步骤：在整个研究过程中，我将为我的运营合作伙伴提供关键的 可交付成果，包括HHA流程图和组织级干预的优先级，以及可扩展的， 为VA付费的HHA设计的培训计划。通过本CDA开发的知识和技能 将帮助我开展多中心研究，以更严格地评估这种干预的有效性， 通过两个拟议的多地点综合投资报告处理个人和组织一级的干预措施。发现将 为未来的研究和行动提供信息，以改善HHA服务的交付和稳定性，并利用 这个关键的劳动力。 对退伍军人健康的意义和相关性：我的研究是创新的，及时的，对VA和 立法优先。它涉及长期护理/老龄化和残疾的多个HSR&D优先领域， 重点关注卫生系统问题和跨领域的HSR方法，并揭示了一个关键的，但研究不足的 VA HCBS的锚。这项工作是在弗吉尼亚州的一个关键时刻，因为长期护理转移到社区。 本研究抓住了这些机会，系统地确定了需要改进的地方， 有希望的干预作为第一步，利用退伍军人事务部的资源，以支持退伍军人的康复团队。

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.