Helping VA optimize its long-term care services

到2023年，预计65岁及以上的VHA注册人数将从410万增加到470万 百万美元。为了满足对长期护理服务日益增长的需求，退伍军人管理局试图扩大其家庭和 通过1999年千年保健和福利等措施提供以社区为基础的服务 法案(千年法案)。这些扩展努力是基于以下前提：母婴健康中心在 退伍军人的选择，成本比机构环境低，结果可比。自.以来 然而，通过《千年法案》，退伍军人事务部在以下方面仍然大大落后于其他卫生系统 重新平衡其长期护理支出，从机构护理转向卫生保健服务。弗吉尼亚州21岁 1999年间，其长期护理支出中用于母婴保健服务的比例增加了一个百分点 2016年(从5%到26%)可以与同期医疗补助计划42个百分点的增长相比较 (由15%或57%)。退伍军人管理局需要检查经验证据，以理解为什么这种转变 仍然难以捉摸。 卫生系统向HCBS重新平衡的能力取决于患者、系统和 家庭层面的因素。准确的患者目标，当地的家庭健康市场状况，以及充足的 对非正式照顾者的支持都有助于卫生系统在实现再平衡方面取得多大的成功 HCBS。然而，这些因素在退伍军人管理局的背景下仍然没有得到充分的探索--部分原因是退伍军人管理局的差距 这在一定程度上是由于能够进行这类分析的方法应用有限。我的 长期目标是成为一名独立调查员，专注于领先的研究计划，帮助退伍军人管理局 实现其长期护理再平衡目标，并填补现有证据基础中的这些空白。 拟议的研究将加强退伍军人管理局对患者、系统和家庭层面因素的了解 影响其再平衡努力。具体地说，CDA-2的研究目的是：1)使用自然语言 从自由文本注释中提取患者功能状态的处理，并使用构建的措施 改进对退伍军人一年住院风险的预测；2)建立退伍军人和退伍军人的地理空间数据库 与退伍军人管理局签约的家庭保健提供者，并进行分析，评估距离和 家庭健康机构的市场供应和长期护理利用模式；以及3)量化 退伍军人医疗服务利用和费用的非正式护理收据。我将通过接受指导来实现这些目标 以及自然语言处理、风险调整、地理空间计量经济学和因果建模方面的培训。 这些新技能将有助于我的整体职业发展，并与我的导师和 业务合作伙伴，使我能够提交两项功绩审查建议，重点是开发增强型协调一致方案 患者定位工具和改进的护理人员支持。它们还将使我能够提交申请 与互联关怀办公室合作的评估倡议，旨在开发地理空间工具以帮助 区域办事处有效地为新的家庭健康服务合同寻找潜在的合作伙伴。 总体而言，这个CDA将帮助我成为一名专注于领先研究计划的独立调查员 这有助于退伍军人管理局实现其长期护理再平衡目标。该CDA项目的结果将与 退伍军人、他们的照顾者和退伍军人政策制定者参与分配长期护理资金，并将成为 对更广泛的关于成功的母婴健康保险扩张战略决定因素的文献作出了创新性的贡献。

By 2023, it is expected that the number of VHA enrollees aged 65 and over will increase from 4.1 million to 4.7 million. To meet the growing demand for long-term care services, VA has attempted to expand its home and community-based services (HCBS) through measures such as the 1999 Millennium Health Care and Benefits Act (the Millennium Act). These expansion efforts were based on the premise that HCBS provide care in Veterans’ setting of choice for a lower cost than in institutional settings and with comparable outcomes. Since passing the Millennium Act, however, VA still lags significantly behind other health systems with respect to rebalancing its long-term care expenditures away from institutional care and towards HCBS. VA’s 21 percentage point increase in the proportion of its long-term care expenditures spent on HCBS between 1999 and 2016 (from 5% to 26%) can be compared to Medicaid’s 42 percentage point increase over the same period (from 15% o 57%). VA needs to examine the empirical evidence to understand why this transformation remains elusive. A health system’s ability to rebalance towards HCBS is determined by a combination of patient, system, and family level factors. Precise patient targeting, local home health market conditions, and adequate supply of and support for informal caregivers all contribute to how successful health systems will be in rebalancing towards HCBS. However, these factors remain under-explored in the VA context – in part due to gaps in VA’s structured data and in part due to the limited application of methods that enable these types of analyses. My long-term goal is to become an independent investigator focused on leading research initiatives that help VA to achieve its long-term care rebalancing aims and to fill these gaps in the existing evidence base. The proposed research will strengthen VA’s knowledge of how patient, system, and family level factors are affecting its rebalancing efforts. Specifically, the research aims of this CDA-2 are to: 1) use natural language processing to extract patient functional status from free-text notes and use the constructed measures to improve prediction of Veterans’ one-year risk of institutionalization; 2) build a geospatial database of VA and VA-contracted home health providers and conduct analyses evaluating the association between distance to and market supply of home health agencies and long-term care utilization patterns; and 3) quantify the impact of informal care receipt on VA health care utilization and costs. I will achieve these aims by receiving mentorship and training in natural language processing, risk adjustment, geospatial econometrics, and causal modeling. These new skills will contribute to my overall career development and, in collaboration with my mentors and operational partners, enable me to submit two merit review proposals focused on developing enhanced HCBS patient targeting tools and improved caregivers supports. They will also enable me to submit an application for a partnered evaluation initiative with the Office of Connected Care aimed at developing a geospatial tool to help regional offices efficiently identify prospective partners for new home health service contracts. Overall, this CDA will help me to become an independent investigator focused on leading research initiatives that help VA achieve its long-term care rebalancing aims. The results of this CDA project will be relevant to Veterans, their caregivers, and VA policy makers involved in allocating long-term care funding and will be an innovative contribution to the broader literature on the determinants of successful HCBS expansion strategies.