Innovation in a Learning Health Care System: Veteran‐Directed Home‐ and Community‐Based Services

Abstract

A path-breaking example of the interplay between geriatrics and learning healthcare systems is the Veterans Health Administration's (VHA's) planned roll-out of a program for providing participant-directed home- and community-based services to veterans with cognitive and functional limitations. We describe the design of a large-scale, stepped-wedge, cluster-randomized trial of the Veteran-Directed Home- and Community-Based Services (VD-HCBS) program. From March 2017 through December 2019, up to 77 Veterans Affairs Medical Centers will be randomized to times to begin offering VD-HCBS to veterans at risk of nursing home placement. Services will be provided to community-dwelling participants with support from Aging and Disability Network Agencies. The VHA Partnered Evidence-based Policy Resource Center (PEPReC) is coordinating the evaluation, which includes collaboration from operational stakeholders from the VHA and Administration for Community Living and interdisciplinary researchers from the Center of Innovation in Long-Term Services and Supports and the Center for Health Services Research in Primary Care. For older veterans with functional limitations who are eligible for VD-HCBS, we will evaluate health outcomes (hospitalizations, emergency department visits, nursing home admissions, days at home) and healthcare costs associated with VD-HCBS availability. Learning healthcare systems facilitate diffusion of innovation while enabling rigorous evaluation of effects on patient outcomes. The VHA's randomized rollout of VD-HCBS to veterans at risk of nursing home placement is an example of how to achieve these goals simultaneously. PEPReC's experience designing an evaluation with researchers and operations stakeholders may serve as a framework for others seeking to develop rapid, rigorous, large-scale evaluations of delivery system innovations targeted to older adults.

Overcoming Challenges to Evidence‐Based Policy Development in a Large, Integrated Delivery System

“…A new, randomized program evaluation will develop evidence of changes in health care use, days at home, and health care costs associated with VD‐HCBS availability (see Garrido et al. and trial registries isrctn.com/ISRCTN12228144 and clinicaltrials.gov/ct2/show/NCT03145818). In 2016, PEPReC worked with the VHA's Office of Geriatrics and Extended Care, the Administration for Community Living and an interdisciplinary team of researchers from the Center of Innovation in Long Term Services and Supports at the VA Providence Medical Center and the Center for Health Services Research in Primary Care at the Durham VA Medical Center to design a cluster‐randomized, stepped wedge roll‐out of VD‐HCBS at 77 VHA medical centers.…”

VA Staff Perceptions of Barriers and Facilitators to Home-and Community-Based Placement Post–Hospital Discharge

“…They are also responsible for arranging financial management services to pay bills and manage payroll. Nationally, budgetary and personnel constraints have limited VD-HCBS growth, pending findings from a large randomized evaluation currently in progress (Garrido et al, 2017). Locally, factors facilitating program success include frequent and ongoing communication between the VAMC and ADNA, ADNA training in VAMC policies and billing practices, and VA personnel who have the time and commitment necessary to champion the program and serve as a reliable point of contact for the ADNA (Thomas & Allen, 2016).…”

“…They also include pilot programs with which to test innovative noninstitutional care models deemed successful in other settings but not yet widely unavailable within the VA. Notable examples are participant-directed services (known as Veteran-directed [VD]-HCBS; Garrido et al, 2017), medical foster home services (Levy et al, 2016), Program of All-Inclusive Care for the Elderly (Administration on Community Living, 2014), and rural adaptations of established programs (e.g., home-based primary care; Kramer, Cote, Lee, Creekmur, & Saliba, 2017). Beginning with its FY 2015 budget submission, the VHA sought to promote HCBS further by shifting 2% of funds initially designated for NH care to HCBS, a shift that has continued in each subsequent year.…”

The Indiana Learning Health System Initiative: Early experience developing a collaborative, regional learning health system

“…Examples include the national health systems of Switzerland 14 and Denmark, 15 the Veterans Health Administration (VHA), [3][4][5]13 or multi-site and single healthcare organizations such as Kaiser Permanente, 6,7 the Geisinger Health System, 8 and others. [9][10][11][12] While a common organizational foundation can promote the development of LHS approaches, significant cultural, and scalability challenges can impede their dissemination throughout all levels and sites.…”

“…The implementation of learning health systems (LHSs) is an area of strong interest for healthcare organizations, policymakers, and the public. 1 , 2 , 3 To date, however, many LHS efforts have been developed within single organizations, 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 not as collaborations among separate entities. Given the need to develop collaborative LHSs that are healthcare market‐centric, as opposed to organization‐centric, two questions are particularly relevant: (a) What are promising approaches to operationalizing an LHS across a regional healthcare market that spans different organizations?…”