Evaluating the Impact of COVID-19 on Case Management, Health Care Utilization, and Housing Outcomes for HUD-VASH Veterans

背景：美国住房和城市发展部-退伍军人事务部支持住房 （HUD-VASH）计划提供永久，补贴独立住房和案件管理， 每年有6万名退伍军人。为了应对COVID-19，HUD-VASH将病例管理从面对面转变为 电话/视频互动。本项目的目标是检查HUD-VASH向虚拟 关心退伍军人参与和方案的成果。我们的建议是由一个工作理论， 虚拟护理增加了获得病例管理、初级保健和改善行为质量措施的机会 有助于电话/视频交互（例如，精神病住院后的随访），但获得 专科护理和不利于电话/视频交互的恶化的质量测量（例如，阿片类药物 使用障碍）。意义：退伍军人事务部致力于改善退伍军人的住房和健康。我们的项目 将通过帮助国家无家可归者项目办公室了解虚拟护理的影响， HUD-VASH旨在最大限度地提高项目覆盖面、参与度和成果。该项目涉及VA的2018财年- 2024年战略目标2.2（“VA确保处于风险和服务不足的退伍军人获得他们需要的东西， 消除退伍军人自杀、无家可归和贫困”），RFA HX-21-025的目标（虚拟护理的变更 和HSR&D的目标（虚拟护理和健康的社会决定因素）。具体 目标：目标1。确定在COVID-19大流行期间HUD-VASH转向虚拟护理对病例的影响 管理服务：假设：HUD-VASH在大流行期间转向虚拟护理， 与大流行前相比，电话和视频案件管理的总数。二次分析： 确定退伍军人因素之间的关联（例如，心理健康诊断）与病例管理 在转向虚拟护理之前和之后，以及与不参与任何虚拟护理相关的退伍军人因素。 目标二。评估HUD-VASH在大流行期间转向虚拟护理对退伍军人医疗保健的影响 护理的利用和连续性。假设：HUD-VASH在大流行期间向虚拟护理的转变增加 初级保健的使用，改善了一些行为质量指标，同时降低了其他行为质量指标， 质量措施不利于虚拟护理和使用门诊专家护理。二次分析： 检查与HUD-VASH计划退出相关的退伍军人因素以及当年的医疗保健利用率 程序退出后。目标3：在HUD中检查退伍军人和提供商的虚拟案例管理体验- VASH。半结构化访谈VA领导，案例经理，和退伍军人谁经历了HUD- VASH向虚拟护理的转变，将使人们了解虚拟护理的障碍和促进因素。 实施虚拟案件管理。方法：一个收敛的并行混合方法设计将 被利用来自退伍军人事务部企业数据仓库（CDW）的数据将与无家可归者行动联系起来 管理和评价系统（HOMES）进行分析。利用这些数据，目标1和2将使用 采用分段回归的中断时间序列设计，以检查前后的利用结果 HUD-VASH转向虚拟护理。对于目标3，与VA领导层、案例经理和 退伍军人将捕捉实施和接受虚拟护理的经验，并为我们的 定量的发现。下一步/实施：我们的研究结果将为虚拟医疗的发展提供信息， HUD-VASH计划。该项目还将向无家可归者方案办公室通报其影响， 在大流行期间过渡到虚拟护理的经验以及这种过渡和大流行的程度 对无家可归的退伍军人的照顾。

Background: The US Department of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program offers permanent, subsidized independent housing and case management to over 60,000 Veterans annually. In response to COVID-19, HUD-VASH shifted case management from in-person to telephone/video interactions. The goal of this project is to examine the effect of HUD-VASH’s shift to virtual care on Veteran engagement and outcomes in the program. Our proposal is motivated by a working theory that virtual care increased access to case management, primary care, and improved behavioral quality measures conducive to phone/video interactions (e.g., follow-up after a psych hospitalization), but decreased access to specialist care and worsened quality measures not conducive to phone/video interactions (e.g., meds for opioid use disorder). Significance: The VA is dedicated to improving the housing and health of Veterans. Our project will advance policy by helping the National Homeless Programs Office understand the impact of virtual care in HUD-VASH to maximize program reach, engagement, and outcomes. The project addresses VA’s FY 2018- 2024 Strategic Objective 2.2 (“VA ensures at-risk and underserved Veterans receive what they need to eliminate Veteran suicide, homelessness, and poverty”), objectives of RFA HX-21-025 (changes to virtual care on Veteran outcomes), and objectives of HSR&D (virtual care and social determinants of health). Specific Aims: Aim 1. Determine the effect of HUD-VASH’s shift to virtual care during the COVID-19 pandemic on case management services: Hypothesis: HUD-VASH’s shift to virtual care during the pandemic resulted in more total, telephone and video case management as compared to a pre-pandemic period. Secondary analysis: Identify associations between Veteran factors (e.g., mental health diagnosis) with the use of case management before and after the shift to virtual care, and Veteran factors associated with not engaging in any virtual care. Aim 2. Evaluate the effect of HUD-VASH’s shift to virtual care during the pandemic on Veteran’s health care utilization and continuity of care. Hypothesis: HUD-VASH’s shift to virtual care during the pandemic increased the use of primary care and improved some behavioral quality measures while decreased other behavioral quality measures not conducive to virtual care and the use of outpatient specialist care. Secondary analysis: Examine Veteran factors associated with HUD-VASH program exits and utilization of health care in the year after program exit. Aim 3. Examine Veteran and provider experiences with virtual case management in HUD- VASH. Semi-structured interviews with VA leadership, case managers, and Veterans who experienced HUD- VASH’s shift to virtual care, will provide an understanding of the barriers to and facilitators of the implementation of virtual case management. Methodology: A convergent parallel mixed-methods design will be used. Data from the VA’s Corporate Data Warehouse (CDW) will be linked with Homeless Operations Management and Evaluation System (HOMES) for analysis. Using these data, Aims 1 and 2 will use an interrupted time series design with segmented regression to examine utilization outcomes before and after HUD-VASH’s shift to virtual care. For Aim 3, qualitative interviews with VA leadership, case managers and Veterans will capture the experience of implementing and receiving virtual care and give context to our quantitative findings. Next Steps/ Implementation: Our findings will inform the evolution of virtual care within the HUD-VASH program. This project will also inform the Homeless Programs Office of the impact and experience of transitioning to virtual care during the pandemic and the extent this transition and pandemic disrupted VA care of homeless Veterans.