Putting the puzzle together: Leveraging dual use to improve care for Veterans living with dementia

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Background: The number of Veterans living with dementia (VLWD) will increase by 2030 to nearly 340,000; these VLWD and their caregivers often have complex psychosocial and health needs. Coordinating this care is complicated by the fact that most VLWD are Medicare-eligible and therefore use care both through the VA and Medicare. Unfortunately, dual use is often associated with duplication of services and potentially inappropriate care. In light of these complexities, VHA Directive 1140.12 from October 2019 mandated that VA facilities establish a Dementia System of Care to provide person-centered services for these VLWD. Because the design of dementia care services is left to individual VA facilities, national variation affords a unique opportunity to learn from particularly successful facilities. Significance: The proposed study will provide important new knowledge to advance the HSR&D priorities of long-term care/aging, access to care, and primary care practice. This knowledge will be achieved by linking patient-level VA data, Medicare claims, and the GECDAC Residential History File, enacting the VA Office of Research and Development’s Research Priority of putting VA data to work for Veterans. Innovation and Impact: This will be the first: (1) comprehensive analysis of non-VA care used by VLWD, including both Medicare- and VA-reimbursed community care; (2) analysis of dual use at the VA facility level, which is critical data for operational purposes; and (3) analysis of dementia care since the VHA Dementia System of Care directive. Finally, we will include the voice of VLWD and caregivers in both facility interviews and as Stakeholder Panel members. Specific Aims: (1) Characterize the associations of dual use and continuity of care with the Veteran-centered outcome of home time and how home time varies across VA facilities. (2) Assess facility-level strategies that promote home time and the acceptability of these strategies to Veterans and caregivers. (3) Develop a toolkit of dementia care strategies that facilities can use to enhance VLWD care delivery. Methodology: In this explanatory sequential mixed methods study, we will first identify community-dwelling VLWD and link their VA data and Medicare claims with the GECDAC Residential History File. Then, we will examine the association of dual use of outpatient and prescription medications with home time, and whether this is moderated by continuity of care. We will collapse these findings to examine dual use, continuity of care, and home time at the facility level. With input from a Stakeholder & Expert Panel, we will identify four high- and four low-performing VA facilities and conduct semi-structured interviews focused on local dementia care strategies with VA providers, VLWD-caregiver dyads, and a non-VA community care coordinator (n=9 interviews per facility). Finally, we will integrate our Aims 1 and 2 findings and, with Stakeholder & Expert Panel input, develop a dementia care toolkit consisting of strategies and tools that VA facilities can use to help implement their local Dementia System of Care. Next Steps/Implementation: The 2019 VHA Directive directing VA facilities to establish a local Dementia System of Care was not optional, but some facilities may have launched their systems more successfully than others. The toolkit developed during Aim 3 will provide additional guidance for challenging work facilities are already doing to improve the quality of care provided to VLWD.