TY - JOUR
AU - A. Tuepker
AU - E. J. Miech
AU - E. C. Hulen
AU - M. Niederhausen
AU - C. S. Hwang
AU - B. Kinosian
AU - A. O'Neill
AU - S. G. Wiederholt
AU - C. Penn
AU - D. Cooper
AU - S. T. Edwards
A1 - 
AB - BACKGROUND: The Department of Veterans Affairs (VA) is the largest integrated healthcare system in the United States and serves a rapidly aging patient population. The VA's Home-Based Primary Care (HBPC) program is a home care model for older, complex, high-risk Veterans that provides comprehensive, longitudinal primary care delivered by an interdisciplinary team of VA staff, with plans for expansion by 2027. HBPC program implementation varies considerably across local sites and contexts. Accordingly, these characteristics offer a unique opportunity to investigate real-world, cross-case heterogeneity and identify crucial factors that may lead to improved patient outcomes. METHODS: Patient home time in the last 180 days of life will serve as the primary outcome measure, calculated at the patient-level as the total days not in an acute care (e.g., emergency department [ED], hospital), post-acute care (e.g., skilled nursing facility), or institutional long-term care setting (e.g., nursing home) in the 180 days prior to death. Secondary outcomes include patient satisfaction and other utilization outcomes: ED visits, hospitalizations, days in long term care, care transitions, hospice use prior to death, and site of death. Multiple datasets will be combined to obtain a comprehensive view of HBPC site characteristics. This study will use an exploratory sequential mixed methods design to describe the heterogeneity in HBPC program implementation and evaluate how contextual factors and program delivery patterns influence home time and other patient outcomes. Analyses will identify difference-making configurations of contextual, operational, cultural, and care delivery factors that distinguish high- versus low-home time sites. Analytic methods include quantitative descriptive analyses, regression analyses, in-depth qualitative case studies at 10 high and 10 low home time sites, qualitative cross-case analysis, and the application of Coincidence Analysis to identify successful HBPC program configurations. DISCUSSION: Health care systems can take advantage of real-world heterogeneity in program implementation across sites that vary in context and setting to identify the key difference-makers and use these findings to inform future program expansion. By understanding which HBPC program features lead to improved outcomes for older adults in specific contexts, the VA can learn where site variation is a positive sign of adaptation versus a sign of inefficiency and an opportunity for improvement. CLINICAL TRIAL NUMBER: Not applicable.
AD - Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd, R&D 66, Portland, OR, 97239, USA.; Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.; Indiana University School of Medicine, Indianapolis, IN, USA.; Veterans Rural Health Resource Center, VA Office of Rural Health, Portland, OR, USA.; OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA.; Section of General Internal Medicine, VA Portland Health Care System, Portland, OR, USA.; Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA.; Geriatrics and Extended Care Data Analysis Center (GECDAC), Cpl. Michael J Crescenz VA Medical Center, Philadelphia, PA, USA.; Center for Health Equity Research and Promotion, Cpl. Michael J Crescenz VA Medical Center, Philadelphia, PA, USA.; Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.; Office of Geriatrics and Extended Care, Veterans Health Administration, Washington DC, USA.; Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd, R&D 66, Portland, OR, 97239, USA. samuel.edwards@va.gov.; Section of General Internal Medicine, VA Portland Health Care System, Portland, OR, USA. samuel.edwards@va.gov.; Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA. samuel.edwards@va.gov.
AN - 41291477
BT - BMC Geriatr
C5 - Healthcare Disparities
CP - 1
DA - Nov 25
DO - 10.1186/s12877-025-06502-7
DP - NLM
ET - 20251125
IS - 1
JF - BMC Geriatr
LA - eng
N2 - BACKGROUND: The Department of Veterans Affairs (VA) is the largest integrated healthcare system in the United States and serves a rapidly aging patient population. The VA's Home-Based Primary Care (HBPC) program is a home care model for older, complex, high-risk Veterans that provides comprehensive, longitudinal primary care delivered by an interdisciplinary team of VA staff, with plans for expansion by 2027. HBPC program implementation varies considerably across local sites and contexts. Accordingly, these characteristics offer a unique opportunity to investigate real-world, cross-case heterogeneity and identify crucial factors that may lead to improved patient outcomes. METHODS: Patient home time in the last 180 days of life will serve as the primary outcome measure, calculated at the patient-level as the total days not in an acute care (e.g., emergency department [ED], hospital), post-acute care (e.g., skilled nursing facility), or institutional long-term care setting (e.g., nursing home) in the 180 days prior to death. Secondary outcomes include patient satisfaction and other utilization outcomes: ED visits, hospitalizations, days in long term care, care transitions, hospice use prior to death, and site of death. Multiple datasets will be combined to obtain a comprehensive view of HBPC site characteristics. This study will use an exploratory sequential mixed methods design to describe the heterogeneity in HBPC program implementation and evaluate how contextual factors and program delivery patterns influence home time and other patient outcomes. Analyses will identify difference-making configurations of contextual, operational, cultural, and care delivery factors that distinguish high- versus low-home time sites. Analytic methods include quantitative descriptive analyses, regression analyses, in-depth qualitative case studies at 10 high and 10 low home time sites, qualitative cross-case analysis, and the application of Coincidence Analysis to identify successful HBPC program configurations. DISCUSSION: Health care systems can take advantage of real-world heterogeneity in program implementation across sites that vary in context and setting to identify the key difference-makers and use these findings to inform future program expansion. By understanding which HBPC program features lead to improved outcomes for older adults in specific contexts, the VA can learn where site variation is a positive sign of adaptation versus a sign of inefficiency and an opportunity for improvement. CLINICAL TRIAL NUMBER: Not applicable.
PY - 2025
SN - 1471-2318
SP - 1049
ST - Defining successful program configurations in VA home-based primary care: a study protocol to identify key difference-makers through investigating cross-case heterogeneity in program implementation
T1 - Defining successful program configurations in VA home-based primary care: a study protocol to identify key difference-makers through investigating cross-case heterogeneity in program implementation
T2 - BMC Geriatr
TI - Defining successful program configurations in VA home-based primary care: a study protocol to identify key difference-makers through investigating cross-case heterogeneity in program implementation
U1 - Healthcare Disparities
U3 - 10.1186/s12877-025-06502-7
VL - 25
VO - 1471-2318
Y1 - 2025
ER -