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 expanded its home and community- based services (HCBS) through the Millennium Health Care and Benefits 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. However, there is sparse evidence about the ability of HCBS to reduce long-term care costs in VA or in other settings. Further, previous VA evidence on HCBS expansion has been unable to: 1) look at a time horizon over which cost savings are likely to be realized, 2) identify a well-matched control group; or 3) employ robust methods that enable causal assessments of the impact of HCBS on subsequent outcomes. Strengthening this evidence base will help VA understand Veteran and system-level effects of HCBS expansion and achieve an appropriate level of HCBS investment. In this pilot study, we will conduct a longitudinal cohort analysis using the Health and Retirement Study (HRS) to evaluate the effect of VA HCBS expansion on Veterans' quality of life, the probability of nursing home entry, and the use of formal and informal home care services. Recent linkages between the HRS and VA and Medicare administrative data present a unique opportunity to test the appropriateness of using non-Veteran Medicare users, who were not exposed to HCBS expansion efforts, as an innovative control group. With HRS data, we will use previously unavailable information on functional status and formal and informal home care use to address differences between Veterans who are VHA users and non-Veteran Medicare users. We will also assess outcomes over a much longer time horizon than previous studies to overcome the abovementioned limitations of existing literature. Specifically, in this pilot we will 1) compare the functional status and other characteristics of VHA users and non-Veteran Medicare groups; 2) identify the best methods to match the two groups on observable characteristics; 3) describe trends in quality of life, nursing home use, and formal and informal home care service use for these groups pre- and post- HCBS expansion; and 4) identify the most appropriate methods to determine the causal effects of HCBS expansion on each outcome. These analyses will inform a future IIR that will use the linked HRS-VA and Medicare administrative data to determine the effect of HCBS expansion on Veteran and caregiver outcomes and VA system-level costs. This will allow us to assess whether HCBS expansion has been cost-effective from a VA perspective. The results of this pilot 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 value of HCBS expansion.

Public Health Relevance

To meet the growing demand for long-term care services while enabling veterans to receive care in their setting of choice, VA has expanded home and community-based services (HCBS) over the past two decades. Data limitations have made it difficult to understand the effect of these expansion efforts on Veteran outcomes and system level costs. This study will use newly available data linkages to determine how veterans' quality of life, nursing home care, and formal and informal home care use have been impacted by VA's HCBS expansion efforts. These findings will lay the groundwork to assess the value of VA HCBS expansion in terms of veteran and caregiver quality of life outcomes and potential cost-offsets. The proposed research addresses a key HSR&D Cross-Cutting Priority Area, Long-term Care and Caregiving, and will help VA operations make informed decisions about how to maximize the effectiveness and reach of scarce long-term care dollars.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (I21)
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Veterans Admin Palo Alto Health Care Sys
Palo Alto
United States
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