Study Evaluates Home Care Model for Older Veterans

A retrospective cohort study evaluated outcomes of a multidisciplinary model of care developed to serve the primary care needs of low-income older adults that was adopted by the Department of Veterans Affairs (VA) in 1 facility.

Compared with younger veterans, older veterans are more likely to use more health care services, have more impairments that hinder daily functioning, have comorbidities, and have a higher risk of adverse health outcomes. This trend will accelerate as by 2028 one-third of the veteran population is expected to be 75 years or older.

The Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care was initially developed and implemented more than a decade ago by the Indiana University School of Medicine's Center for Aging Research. The program aims to improve health outcomes and functioning while reducing health care use and preventing long-term nursing home placement. In a randomized controlled trial, GRACE improved quality and reduced health care utilization compared with usual care.

A 1999 veterans health care law required access to geriatric assessments. The authors said the VA-GRACE program pairs nurse practitioners with social workers who conduct home assessments with veterans to screen for common geriatric syndromes and conduct a physical examination as well as 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 VA-GRACE multidisciplinary team during weekly rounds, including a geriatrician, a psychologist, and a pharmacist. A care plan is established and is shared via the electronic medical record with the patient's primary care provider.

Once enrolled, patients remain in VA-GRACE until discharge, which means long-term care placement; patient or caregiver request discharge; nonadherence to VA-GRACE recommendations; functional and clinical improvement that disqualifies them from the program; or death.

A prior study of VA-GRACE found that it cut emergency department visits by 7.1%, lowered 30-day readmissions by nearly 15%, and slashed hospital admissions by nearly 40%. That study, which also found that it saved an estimated $200,000 per year after program costs in the first 14 months, was limited to a 16-month period.

This retrospective cohort study aimed to evaluate the program since it began. It included patients admitted to the Richard L. Roudebush VA hospital (2010–2019) who received VA-GRACE services post discharge. Veterans who were potentially eligible for VA-GRACE but did not receive services served as controls and received usual care.

Primary outcomes in the study included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and provider satisfaction. To adjust for differences in characteristics between groups, researchers used propensity score modeling with overlapping weighting.

Patients in VA-GRACE (n = 683) were older than controls (n = 4313) (mean age, 78.3 [8.2] vs 72.2 [6.9] years; P < .001). Their comorbidity score was higher (median Charlson Comorbidity Index, 3 vs 0; P < .001).

Results showed that patients in the program:

• Had lower 90-day mortality: adjusted odds ratio (aOR), 0.31; 95% CI, 0.11-0.92
• Had no statistically significant difference in 1-year mortality: 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 1-year readmissions, 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.

The VA-GRACE home visits reduced travel concerns and connected veterans and caregivers to resources. And the primary care model reduced the workload of providers, improved medication management, and gave 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 outcomes may reflect unmeasured confounding.

“Widespread deployment of programs like VA-GRACE will be required to support Veterans aging 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