Resilience to Covid-19 Disrupted Chronic Condition Care for Older Veterans At Risk of Hospitalization: Role of VA Ambulatory Care and VA Extended Care Home and Community-Based Care Supports

背景资料：新冠肺炎疫情扰乱了慢性阻塞性肺疾病退伍军人的门诊医疗 病情，包括最需要退伍军人管理局护理的情况。 意义/影响：本研究将研究退伍军人管理局医疗保健系统在提供 大流行期间的慢性病管理，包括办公室、视频和电话护理，以及评估 因慢性病加重而住院风险最高的老年退伍军人的临床结局 以及严重的坠落伤。此外，我们将探讨退伍军人事务部延长护理院和社区如何- 基于服务(HCBS)缓解了与新冠肺炎相关的医疗中断。 创新：这项研究将采用最新的分析工具来研究老年人的健康状况 退伍军人，衡量获得退伍军人保健服务计划的途径，并确定哪些人面临最高的中断风险 延误了慢性病的治疗。 具体目标：使用最先进的方法，我们将解决以下目标： 目标1A：检查中断的非卧床护理访问对慢性病管理的影响 (CCM)适用于年长的退伍军人。我们将随着时间的推移确定门诊护理的变化(“中断”)，包括 面对面和虚拟访问、视频和电话呼叫的数量，由门诊和初级患者提供 专科门诊诊所。我们将研究大约100万名年龄较大(≥65岁)的退伍军人，他们至少有三分之一患有慢性 医疗和老年疾病：高血压、充血性心力衰竭(CHF)或跌倒/活动障碍 在新冠肺炎危机期间(2020-21)。慢性病的管理将通过药物治疗来衡量 坚持、强度、实验室监测和物理治疗服务。服务中断的漏洞将 在VA患者中使用已建立的方法进行定义，以及专门为 老年患者群体，预测的长期住院(PLI)措施。接下来，在目标1B中，我们 将测试能够更好地访问HBCS的设施是否缓解了 非卧床护理对慢性病护理管理绩效的影响。这一关键目标将 重点关注5个家庭负担沉重的方案：以家庭为基础的初级保健、个人护理服务(家庭主妇和家庭 医疗助理、暂缓护理)、退伍军人指导护理、成人日间护理和熟练的家庭护理(例如，身体和 职业治疗、护理、社会工作) 目的2：检查慢性疾病管理中断对ACSCs住院的影响 以及严重的坠落伤。我们将确定老年退伍军人在最初的治疗过程中是否会受到较少的干扰 其次，新冠肺炎激增也降低了与ACSC相关的慢性住院风险 与充血性心力衰竭和高血压有关或与跌倒有关的伤害。这一目标将导致更好地理解 如何根据易损性预测老年退伍军人ACSCs的住院率。 方法：这是一项对国家退伍军人保健系统中老年退伍军人的纵向研究，使用退伍军人管理局 医疗数据与联邦医疗保险和医疗补助长期护理数据以及退伍军人事务部和 医疗保险。我们将与GEC数据分析中心合作使用风险分数和数据源。 下一步：我们将确定应优先为老年人提供的慢性病管理服务 退伍军人和未来退伍军人门诊护理和GEC医疗系统的潜在路线图 合作伙伴提供更好的慢性疾病管理，并为老年退伍军人实现更好的健康结果。

Background: The Covid-19 pandemic disrupted the ambulatory health care of Veterans with chronic conditions, including those with the highest need for VA care. Significance/Impact: This research will study the critical role of the VA healthcare system for delivering chronic disease management during the pandemic, including office, video, and telephone care, and assess clinical outcomes of older Veterans at the highest risk for hospitalizations for chronic disease exacerbations and acute fall injuries. In addition, we will explore how VA Geriatric Extended Care Home and Community- Based Services (HCBS) mitigated Covid-19 related healthcare disruptions. Innovation: This research will implement the newest analytic tools for studying health outcomes of older Veterans, approaches to measure access to VA HCBS programs, and identify those at highest risk of disrupted and delayed chronic disease care. Specific Aims: Using state-of-the-art methods, we will address the following Aims: Aim 1A: Examine the effect of disrupted ambulatory care visits on chronic condition management (CCM) for older Veterans. We will identify changes over time (“disruption”) in ambulatory care, including the volume of face-to-face and virtual visits, video and telephone calls, that are provided by outpatient primary and specialty care outpatient clinics. We will study ~ 1 million older (age ≥65) Veterans with at least 1 of 3 chronic medical and geriatric conditions: hypertension, congestive heart failure (CHF), or falls/mobility impairment during the Covid-19 crisis (2020-21). Management of chronic conditions will be measured by medication adherence, intensity, lab monitoring, and physical therapy services. Vulnerability to service disruption will be defined using the established method in VA patients and two other methods developed specifically for geriatric patient populations, the Predicted Long-term Institutionalization (PLI) measure. Next, in Aim 1B, we will test whether facilities who were able to maintain better access to HBCS mitigated the effect of disrupted ambulatory care on performance of chronic condition care management. This critical Aim will focus on 5 HBCS programs: Home-Based Primary Care, Personal Care Services (homemaker and home health aides, respite care), Veteran Directed Care, Adult Day Care, and Skilled Home Care (e.g., physical and occupational therapy, nursing, social work) Aim 2: Examine the effect of chronic condition management disruption on hospitalizations for ACSCs and acute fall injuries. We will determine whether older Veterans with less disrupted care during the initial and second Covid-19 surges also had a lower risk of hospitalization for chronic ACSC-related hospitalizations related to CHF and hypertension or for a fall-related injury. This Aim will result in a better understanding of how to predict hospitalization for ACSCs among older Veterans according to vulnerability. Methodology: This is a longitudinal study of older Veterans in the national VA healthcare system, using VA healthcare data merged with Medicare and Medicaid long-term care data, and pharmacy files from the VA and Medicare. We will use risk scores and data sources in partnership with the GEC Data Analysis Center. Next Steps: We will identify the chronic condition management services that should be prioritized for older Veterans and a potential roadmap for how the future VA ambulatory care and GEC healthcare systems can partner to provide better chronic condition management and attain better health outcomes for older Veterans.