Inter-Disciplinary Outpatient Care Model Providing Comprehensive Geriatric Assessment, Care-Coordination & Co-management

Summary

The Department of Veterans Affairs' (VA) Home Based Primary Care (HBPC) program provides comprehensive care to its sickest, frailest Veterans with multiple complex chronic diseases. The HBPC program is a resource intensive non-institutional care program where Veterans, who are not able to receive primary care at the VA, are closely monitored and care is provided using an interdisciplinary team that coordinates the care through multi-professional home visits.

The Geriatric Extended Care recommended that Miami Veteran Affairs Healthcare System (VAHS) HBPC enroll from a list of over 2,000 pre-identified High Need High Risk (HNHR) Miami Veterans for whom HBPC enrollment would have a high likelihood of clinical and economic benefits. HNHR Veterans have the greatest need for care but face the steepest challenges with access. However, despite best of intentions, the Miami HBPC program does not have the capacity to enroll the large numbers of Veterans on this new HNHR list. Therefore, innovative strategies are needed to provide appropriate needed care for this HNHR Veteran population.

Goal: Maintain older Veterans in their homes for as long as possible.

Aims: Design and pilot test an evidence-based, outpatient, Comprehensive geriatric assessment, Care plan based, Care-coordination, Co-management (C4) model, for 100 HBPC eligible HNHR older Veterans who are not enrolled in the HBPC program.

The investigators will develop, implement and evaluate a VA model to provide a comprehensive geriatric assessment of HNHR Veterans, design a structured care plan that includes care coordination to link their needs to appropriate referrals, home and community based services, monitor and coach patients and caregivers, and coordinate their care across VA and non-VA providers and settings.

Objectives:

1. Characterize the needs of the HNHR group of Veterans
2. Evaluate the feasibility and processes of the Geri C4 model
3. Evaluate the impact of the model on patient, healthcare utilization, and other Geriatric Extended Care (GEC) outcomes
4. Determine the facilitators and barriers for implementing the intervention

Conditions

• Veterans
• Geriatric Assessment
• Care-Coordination
• Outpatient Care

Interventions

OTHER

Comprehensive Care

1. Comprehensive Geriatric Assessment (3 visits with a geriatrician alternating with 3 primary provider visits over 6 months) 2. Care Planning with Interdisciplinary Team 3. Care coordination 4. Co-management with Primary care 5. Social work needs assessment 6. Patient-centered telehealth using phone, home telehealth, patient portal, Video 7. Transportation provided for all visits 8. Referral to Geriatric primary care clinic and mental health per Veteran need 9. Goals of Care and Veteran preferences conversation 10. Educate primary care providers about HNHR population, home and community based services, collaboration

OTHER

Standard Care

No intervention or treatment will be provided.

Sponsors & Collaborators

• Miami VA Healthcare System

  lead FED

Principal Investigators

• Stuti Dang, MD,MPH · Miami VA Healthcare System

Eligibility

Min Age

65 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2018-04-16

Primary Completion

2022-03-31

Completion

2022-03-31

Countries

• United States

Study Locations