Fewer potentially avoidable health care events in rural veterans with self‐directed care versus other personal care services

Abstract

Background Rural residents face more barriers to healthcare access, including challenges in receiving home‐ and community‐based long‐term services, compared to urban residents. Self‐directed services provide flexibility and choice in care options and may be particularly well suited to help older adults with multiple chronic conditions and functional limitations who reside in rural areas remain independent and live in the community. Methods We conducted a retrospective observational study to understand whether differences in health outcomes between Veteran‐Directed Care (VDC), a self‐directed Veterans Health Administration (VHA)‐paid care program, and other VHA‐paid home‐ and community‐based personal care services vary in rural/urban location. The sample included 37,395 veterans receiving VHA‐paid home‐ and community‐based long‐term care services in FY17. Our primary outcomes were changes in monthly incidence of VHA or VHA‐paid community acute care admissions, nursing home admissions, and emergency department (ED) visits. We used fixed effects logistic regression models on unmatched and coarsened exact matched cohorts, stratified by rural/urban location. Results Both urban and rural VDC recipients were significantly less likely to be admitted to VHA‐paid nursing homes, compared to those receiving other VHA‐paid personal care services (rural: incremental effect = −0.22, [−0.30, −0.14]; urban: incremental effect = −0.14, [−0.20, −0.07]). Rural, but not urban, VDC enrollees had significantly fewer VHA‐paid acute care admissions and ED visits, relative to recipients of other VHA‐paid personal care services (acute care, rural: incremental effect = −0.07, 95% CI = [−0.14, −0.01], urban: incremental effect = −0.01, [−0.06, 0.03]; ED, rural: incremental effect = −0.08, [−0.14, −0.02], urban: incremental effect = 0.01, [−0.03, 0.05]). Conclusions VDC recipients had fewer incidents of potentially avoidable VHA‐paid health care use, compared to similar veterans receiving other VHA‐paid personal care services. These differences were more pronounced among rural VDC recipients than urban VDC recipients.

Rural former service members participate in meaningful occupations to ‘fill the void’ after military service

“…Given military cultural values and ideals such as comradery, support, self-determination, and respect, consumer-led approaches may also provide opportunities to enhance consumer participation and engagement through culturally relative practice. Previous research indicates that rural former service members who accessed self-directed care had fewer hospital admissions than those with other types of services (Yuan et al, 2022). The Canadian Occupational Therapy Inter-Relationship Practice Process Framework could be used to promote rights-based selfdetermination and co-design of occupation-based programs with rural former service members (Restall et al, 2022).…”

Preimplementation Evaluation of a Self-Directed Care Program in a Veterans Health Administration Regional Network: Protocol for a Mixed Methods Study

“…[12-17] VDC enrollees were less likely to have a VA-paid nursing home admission compared to Veterans using other personal care services paid for by VA. [14] In addition, there were fewer potentially-avoidable acute care admissions and emergency department visits among rural Veterans enrolled in VDC (but not among urban VDC enrollees). [14] Moreover, there is qualitative evidence that the VDC program is acceptable, and satisfaction among enrolled Veterans is high with participants expressing that it has given them purpose and meaning. [18] Given current workforce shortages in the healthcare sector and especially in rural areas, the ability to hire family members and neighbors as paid caregivers through self-directed services may be a particularly effective way to surmount access challenges for Veterans.…”

“…Compared to other HCBS enrollees, VDC enrollees were more likely to receive aid and attendance benefits, to have a spinal cord injury, and to have higher health care costs [ 12 - 17 ]. VDC enrollees were less likely to have a VA-paid nursing home admission compared to veterans using other personal care services paid for by VA [ 14 ]. In addition, there were fewer potentially avoidable acute care admissions and emergency department visits among rural veterans enrolled in VDC (but not among urban VDC enrollees) [ 14 ].…”