Study evaluates home care model for older veterans

A multidisciplinary home care program aims to improve health outcomes and functioning while reducing health care utilization and preventing long-term nursing home placement.

A retrospective cohort study evaluated the outcomes of a multidisciplinary model of care developed to serve the primary care needs of low-income older adults that was adopted by the Department of Veterans Affairs (VA) at 1 facility.

Compared to younger veterans, older veterans are more likely to use more health services, have more disabilities that interfere with daily functioning, have comorbidities, and have a higher risk of adverse health outcomes. This trend will accelerate as by 2028, one-third of the veteran population is expected to be 75 or older.

The Geriatric Resource Assessment and Care for the Elderly (GRACE) Team Care was originally developed and implemented more than a decade ago by the Center for Research on Aging at the Indiana School of Medicine. The program aims to improve health outcomes and functioning while reducing health care utilization and preventing long-term nursing home placement. In a randomized controlled trial, GRACE improved quality and reduced health care utilization compared with usual care.

The Veterans Health Care Act of 1999 required access to geriatric evaluations. The authors say the VA-GRACE program connects nurse practitioners with social workers who perform home assessments with veterans to screen for common geriatric syndromes and conduct a physical exam as well as comprehensive medication reconciliation. The visit includes a psychosocial assessment and involves family and caregivers.

The nurse practitioner and social worker present their findings to the VA-GRACE multidisciplinary team during weekly rounds, including a geriatrician, psychologist, and pharmacist. A care plan is created and shared via the electronic medical record with the patient’s primary care provider.

Once enrolled, patients remain in VA-GRACE until discharge, which means long-term care placement; the patient or caregiver requested discharge; failure to comply with VA-GRACE recommendations; functional and clinical improvement disqualifying them from the program; or death.

A previous VA-GRACE study found it reduced emergency department visits by 7.1%, reduced 30-day readmissions by nearly 15%, and reduced hospital admissions by nearly 40%. That study, which also found savings of about $200,000 a year after program costs in the first 14 months, was limited to a 16-month period.

This retrospective cohort study aimed to evaluate the program from its inception. Includes patients admitted to the Richard L. Roudebush VA Hospital (2010–2019) who received VA-GRACE services after discharge. Veterans who were potentially eligible for VA-GRACE but did not receive services served as controls and received usual care.

Primary study outcomes included 90-day and 1-year all-cause readmissions and mortality, as well as patient, caregiver, and provider satisfaction. To adjust for differences in characteristics between groups, the researchers used propensity score modeling with overlapping weights.

Patients in VA-GRACE (n = 683) were older than controls (n = 4313) (mean age 78.3 [8.2] against 72.2[6.9]years; P < 0.001). Their comorbidity score was higher (mean Charlson comorbidity index, 3 vs. 0; P < 0.001).

Results show that patients in the program:

  • There was a lower 90-day mortality: adjusted odds ratio (aOR), 0.31; 95% CI, 0.11–0.92
  • There was no statistically significant difference in 1-year mortality: aOR, 0.88; 95% CI, 0.55–1.41
  • Had higher 90-day readmissions, aOR, 1.55; 95% CI, 1.01–2.38
  • Had higher 1-year readmissions, aOR, 1.74; 95% CI, 1.22–2.48

As part of the study, researchers interviewed patients, caregivers and primary care providers, and very high satisfaction with the program was reported.

VA-GRACE home visits reduced travel concerns and connected veterans and caregivers with resources. And the primary care model reduced provider workload, improved medication management and provided insight into patients’ daily lives, providers reported.

The study had several limitations, including the fact that interviews were conducted with a limited number of stakeholders; the VA-GRACE program exists at only 1 location and results may vary at other locations; and differences in results may reflect unmeasured confounding.

“Widespread implementation of programs such as VA-GRACE will be necessary to support aging veterans,” the authors note.

reference

Schubert CS, Perkins AJ, Myers LJ, et al. Effectiveness of the VA-Geriatric Resources for Assessment and Care of the Elderly (VA-GRACE) program: an observational cohort study. J Am Geriatr Soc. Published online 29 August 2022 doi:10.1111/jgs.18013

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