Aligning VA Home‐Based Primary Care Interdisciplinary Team Structure with Veterans’ Needs

Abstract

Research ObjectiveDepartment of Veterans Affairs (VA) Home‐Based Primary Care (HBPC) employing mobile interdisciplinary teams (IDT: physician/nurse practitioner, nurse, therapist, social worker, dietician, pharmacist, and psychologist) has been reported to be effective at improving care and lowering cost for frail, high‐risk Veterans. The full IDT represents a significant investment in care for complex Veterans. Some VA Medical Centers (VAMCs) employ HBPC without providing mobile primary care but use an enhanced home health team. The Program for All Inclusive Care for the Elderly (PACE) employs a similar IDT to care for frail older adults. The updated Centers for Medicare & Medicaid Services (CMS) PACE addresses the cost of a full IDT by regulating a “core” team (primary care, nursing, social work, and therapy), with additional team members as needed. We examined the variability of IDT care by frailty of HBPC Veterans.Study DesignUsing discipline‐specific visit codes, we classified staffing patterns by IDT involvement: full IDT (all 7 members), core (primary care, nursing, social work, and therapy), core+ (core and one or more noncore disciplines), home health (nursing, social work, and therapy), home health + (home health and one or more noncore disciplines), and housecalls (mobile primary care). We clustered the 13 domains of frailty identified from diagnoses codes in the JEN Frailty Index domains (JFI=sum of domains, range 0‐13) to identify clusters of high and low frailty. Chi‐square goodness of fit tested the association of HBPC service teams with the frailty profiles among all HBPC Veterans and the subset with high frailty (JFI > 6).Population StudiedVeterans enrolled in HBPC in fiscal year 2018 across 139 VA Medical Centers (VAMCs) (N = 55 197) of whom 35 876 (65%) were high frailty (JFI > 6).Principal FindingsForty‐one percent of all HBPC Veterans received care from a full IDT, 22% received care from a Core IDT, 16% received care from a Core+ IDT, 4% received care from a Home Health IDT, while 16% received care from a Home Health+ IDT and 1% received housecalls. Ten clusters of teams were identified ranging from high risk to low risk and an “Other” risk formed the 11th cluster. Among high frailty Veterans, 71% were in the top 2 high‐risk clusters, among whom 62% received Full IDT or Core+ IDT. Among lower risk Veterans, 74% were in clusters 1‐10, among whom 28% were in the 3 lowest risk clusters, and 38.9% received HH/HH+ IDT. The 15 VAMCs with the greatest share of a HH or HH+ teams had between 34 and 100% of Veterans receiving mobile primary care. The chi‐square with 66 degrees of freedom (11 clusters * 6 IDT models) of the global association of care patterns and Veteran frailty was 1487 (P < .0001).ConclusionsDifferent compositions of HBPC IDT provide care aligning with Veteran complexity. Among programs with a higher prevalence of a HH/HH+ IDT, there was a wide range of mobile primary care.Implications for Policy or PracticeThe Centers for Medicare & Medicaid Services PACE regulation centered on a Core IDT with selective additional members might be a more efficient standard for HBPC, while providing for the variability in patient frailty.Primary Funding SourceDepartment of Veterans Affairs.