VA Home Based Primary Care (HBPC) is an interdisciplinary team-based home care program that serves a rapidly aging cohort of oldest old Veterans (85+) and younger OIF/OEF Veterans with complex chronic disabling conditions. In 2011, approximately 15,000 Veterans were enrolled in 139 VA Medical Center HBPC programs and an associated 101 community-based outpatient clinic locations nationwide. Although HBPC program quality has been established along a number of institutional utilization dimensions (e.g., inpatient days) and cost, the use of institutional care varies substantially across HBPC programs nationally. Lower utilization of institutional care may suggest tailored approaches that optimize a veteran's care. Higher utilization of institutional care may be an indicator of potentially inappropriate or mismanaged care that places vulnerable HBPC Veterans at risk for complications. The proposed study seeks to identify the factors contributing to these variations by investigating associations between HBPC organizational structures, team functioning, and eight risk adjusted quality measures (QMs) of institutional use for hospitals, emergency departments (ED), and nursing homes (NHs). The starting place for redesigning the health care system is to understand the organizational structural attributes of the settings in which care occurs. To that end, a structural survey is conducted to develop a profile of the organizational structure characteristics of HBPC programs. Structure refers to HBPC program characteristics that affect the system's capacity to deliver primary care services to Veterans in their home and includes HBPC program standards, team structures, and telehealth technology. The study will then evaluate differences in HBPC interdisciplinary team functioning with regard to seven dimensions: culture, leadership, communication, coordination, conflict management, team cohesion, and team effectiveness through administration and analysis of the organizational assessment questionnaire (OAQ) survey. Next, associations between HBPC organizational structures and team functioning will be analyzed to identify organizational structures associated with more effective team functioning. Finally, the influence of HBPC organizational structures and team functions on the quality of HBPC care will be examined with respect to risk-adjusted QMs of institutional use: hospital and NH admissions and days, 30-day and 90-day rehospitalizations, ED visits, and Veteran's site of death. Primary data for this proposed study will be obtained through surveys and on-site observational visits. Secondary data will include two years of VA and CMS patient databases (2013-2014). Findings from this study will identify organizational structures and team functions associated with lower use of institutional care that can be integrated as best practices into policies and system redesign initiatives to bring lower performing HBPC programs up to the level of the highest performing programs. Ultimately, reducing avoidable and costly institutional care advances HBPC program goals, and as such, enables HBPC Veterans to be treated at home and to retain their maximal independence.
The burgeoning cohort of aging Veterans and new younger OIF/OEF Veterans is increasing the demand for VA Home Based Primary Care (HBPC) to maximize Veterans' integration into the community and to minimize admissions to hospitals, emergency departments (EDs), and nursing homes (NHs). Although HBPC is associated with reducing institutional care and costs overall, substantial variations in institutional use have been found across HBPC programs nationally. The proposed study seeks to understand what is contributing to those variations by testing associations between HBPC organizational structures, team functioning, and eight risk adjusted measures of institutional use: hospital and NH admissions and days, 30-day and 90-day rehospitalizations, ED visits, and Veteran's site of death. Factors associated with lower use of institutional care can be integrated into policies and system redesign efforts to ensure that the delivery of HBPC is more uniformly excellent across all HBPC programs and as such enables Veterans to live independently at home.