Exploring "What Works" in Veterans Affairs Home-Based Primary Care

Abstract

Home Based Primary Care (HBPC) is an interdisciplinary care model involving comprehensive primary care services for patients with chronic illness who are unable to access clinic-based care. The largest HBPC program in the United States is run by the Department of Veterans Affairs (VA) and provides team-based primary care service to Veterans with complex, chronic conditions. The VA HBPC model includes primary care visits from a physician, nurse practitioner, or physician assistant, nurse care management, service coordination by a social worker, mental health services from a social worker or psychologist, nutrition counseling from a dietician, and help with medication management. In both VA and non-VA settings, HBPC has demonstrated success in improving patient and system outcomes. It is largely unknown how and in what circumstances HBPC positively impacts patients' health outcomes but may be related to the integration of long-term services and supports, strong patient-provider relationships, and highly functioning interprofessional teams. Thus, the specific aims of this study are: 1) explore how HBPC providers understand and address concurrent medical and social needs; 2) examine the ways in which providers in the VA HBPC program understand and manage their relationships with patients with respect to patient power and decision-making; and 3) investigate HBPC team function and coordination between clinic-based primary care physicians. Aims 1 and 2 are qualitative studies and Aim 3 utilizes an explanatory mixed-methods design. Data collected for Aims 1 and 2 are based on 14 semi-structured interviews with HBPC providers and 6 field observations of HBPC team meetings. Data collected for Aim 3 involves a cross-sectional survey administered to 33 HBPC providers and 10 semi-structured interviews with clinic-based primary care providers. Additionally, data from the HBPC provider interviews is used for Aim 3. For Aims 1 and 2, an exploratory, content-driven approach and analytic expansion approach, respectively, is used for data analysis. For Aim 3, survey data is used to assess the strength of relational coordination within HBPC teams and between HBPC teams and clinic-based primary care providers and staff, while qualitative data from semi-structured interviews with HBPC providers and clinic-based providers are used to explicate survey results. Findings from this study drive three main conclusions. First, having the home visit component of VA HBPC gives providers unparalleled insight into the impact that overlapping medical and social complexity has on HBPC patients. The home visit combined with the flexible nature of HBPC programming allows for providers to directly