Expanding Home-Based Primary Care to American Indian Reservations and Other Rural Communities: An Observational Study.

Abstract

Home-based primary care (HBPC) is a comprehensive, interdisciplinary program to meet the medical needs of community-dwelling populations needing long-term care (LTC). The U.S. Department of Veterans Affairs (VA) expanded its HBPC program to underserved rural communities, including American Indian reservations, providing a "natural laboratory" to study change in access to VA LTC benefits and utilization outcomes for rural populations that typically face challenges in accessing LTC medical support. Pretest-Posttest quasi-experimental approach with interrupted time-series design using linked VA, Medicare, and Indian Health Service (IHS) records. American Indian reservations and non-Indian communities in rural HBPC catchment areas. 376 veterans (88 IHS beneficiaries, 288 non-IHS beneficiaries) with a HBPC length of stay of 12months or longer. Baseline demographic and health characteristics, activities of daily living (ADL), previous VA enrollment, and hospital admissions and emergency department (ED) visits as a function of time, accounting for IHS beneficiary and functional statuses. For HBPC users, VA enrollment increased by 22%. At baseline, 30% of IHS and non-IHS beneficiaries had 2 or more ADLs impairments; IHS populations were younger (P<.001) and had more diagnosed chronic diseases (P=.007). Overall, hospital admissions decreased by 0.10 (95% confidence interval (CI)=-0.14 to -0.05) and ED visits decreased by 0.13 (95% CI=-0.19 to -0.07) in the 90days after HBPC admission (Ps<.001) and these decreases were maintained over 1year follow-up. Before HBPC, probability of hospital admission was 12% lower for IHS than non-IHS beneficiaries (P=.02). Introducing HBPC to rural areas increased access to LTC and enrollment for healthcare benefits, with equitable outcomes in IHS and non-IHS populations.