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

背景：到2030年，患有痴呆症（VLWD）的退伍军人人数将增加， 近340，000人;这些极低体重妇女及其照顾者往往有复杂的心理社会和健康问题， 需求由于大多数VLWD都符合Medicare资格，因此协调这种护理变得复杂 因此通过退伍军人管理局和医疗保险来使用医疗服务。不幸的是，双重用途往往是 与重复服务和潜在的不当护理有关。鉴于这些 复杂性，VHA指令1140.12从2019年10月规定，VA设施建立一个 老年痴呆症护理系统为这些极低体重妇女提供以人为本的服务。因为 痴呆症护理服务的设计留给个别VA设施，国家差异提供了一个 从特别成功的设施中学习的独特机会。 意义：拟议的研究将提供重要的新知识， HSR&D的长期护理/老龄化、获得护理和初级护理实践的优先事项。这 通过将患者层面的VA数据、医疗保险索赔和GECDAC联系起来，可以获得相关知识 住宅历史档案，制定研究和发展的研究VA办公室 把退伍军人事务部的数据为退伍军人工作的优先事项。 创新和影响：这将是第一个：（1）全面分析非VA护理使用 VLWD，包括医疗保险和VA报销的社区护理;（2）双重分析 在VA设施级别使用，这是用于操作目的的关键数据;以及（3）分析 自VHA痴呆症护理系统指令以来，最后，我们将包括 在机构访谈中以及作为利益相关者小组成员时，VLWD和护理人员的声音。 具体目标：（1）描述双重用途和护理连续性与 退伍军人为中心的结果回家的时间和如何回家的时间不同的VA设施。（二） 评估促进家庭时间的设施级策略以及这些策略的可接受性 退伍军人和护理人员。(3)开发痴呆症护理策略工具包， 用于增强VLWD护理提供。 方法：在这个解释性的顺序混合方法研究中，我们将首先确定 社区居住的VLWD，并将他们的VA数据和Medicare索赔与GECDAC联系起来 住宅历史档案。然后，我们将研究门诊和住院的双重使用之间的关系， 处方药与家庭时间，以及这是否是由护理的连续性缓和。 我们将把这些发现分解，以检查双重使用，护理的连续性和家庭时间， 设施水平。根据利益相关者和专家小组的意见，我们将确定四个高级别和四个 低性能的VA设施，并进行半结构化的采访，重点是当地的痴呆症 与VA提供者、VLWD-护理者二元组和非VA社区护理的护理策略 协调员（n=9个访谈，每个设施）。最后，我们将结合我们的目标1和2的调查结果， 在利益相关者和专家小组的投入下，开发一个痴呆症护理工具包， 以及VA设施可以用来帮助实施当地痴呆症护理系统的工具。 下一步/实施：2019年VHA指令指示VA设施建立本地 老年痴呆症护理系统不是可选的，但一些设施可能已经启动了他们的 系统比其他系统更成功。目标3期间开发的工具包将提供 对具有挑战性的工作设施提供额外的指导，以提高 为VLWD提供的护理。

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.