Study assesses home care model for older veterans

The 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 meet 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 care services, have more impairments that interfere with daily functioning, have comorbidities, and have a higher risk of adverse health effects. This trend will accelerate since by 2028, one-third of the veteran population is expected to be 75 or older.

The GRACE (Geriatric Resources for Assessment and Care of Elders) team was originally developed and implemented over a decade ago by the University of Indiana. The program aims to improve health outcomes and functioning while reducing health care utilization and preventing long-term placement in a nursing home. In a randomized controlled trial, GRACE improved quality and reduced healthcare utilization compared to usual care.

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

A nurse practitioner and social worker present their findings to the multidisciplinary VA-GRACE team during weekly rounds, including a geriatrician, psychologist and pharmacist. A care plan is established 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 placement in long-term care; the patient or carer requests discharge; non-compliance with VA-GRACE recommendations; a functional and clinical improvement that disqualifies them from the program; or death.

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

This retrospective cohort study aimed at evaluating the program since its inception. It included patients admitted to 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 readmissions and all-cause mortality at 90 days and 1 year, as well as patient, caregiver, and provider satisfaction. To adjust for differences in characteristics between the groups, the researchers used propensity score modeling with overlapping weighting.

VA-GRACE patients (n=683) were older than controls (n=4313) (mean age, 78.3 [8.2] against 72.2[6.9]years; P P

The results showed that patients in the program:

  • Lower 90-day mortality: adjusted odds ratio (aOR), 0.31; 95% CI, 0.11-0.92
  • No statistically significant difference in mortality at 1 year: 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 readmissions at 1 year, 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 was reported with the program.

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

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

“Wide deployment of programs like VA-GRACE will be needed to help veterans age in place,” the authors noted.

Reference

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

Denise W. Whigham