Evaluating the Impact of Medical Foster Home Coordinator Effort and Experience on Costs

This project will address the HSR&D Long-Term Care and Aging priority by investigating Medical Foster Homes (MFHs) as a community-based long-term care (LTC) alternative, and in particular compared to Community Nursing Home (CNH) care, the primary program serving LTC needs in institutions. MFH care is

provided in private residences with trained and licensed caregivers, who live on the premises, that serve up to three Veterans who receive VA Home Based Primary Care (HBPC) services. The need for 24 hour per day care is increasing as the Veteran population ages. The GAO has projected that, by the year 2037, Veterans’

use of CNHs will increase 80%, and corresponding expenditures will increase approximately 150%, from a 2017 benchmark. Medical Foster Homes care is potentially less expensive for the VA. However, as the VA considers expanding coverage of direct room & board cost of the MFH to more Veterans, the cost advantage is

unclear and understanding the implications of the MFH environment on Veteran cost and utilization becomes more important. Across the VA, MFH programs vary in the effort and experience of the coordinators that manage them. Although there is evidence that MFH programs cost less than CNH in the past, current

estimates are lacking, and the extent to which such cost savings is related to MFH program coordinator effort and experience has not been established, nor is it understood whether saving is facilitated by VA patient safety culture. To provide a cost saving alternative to institutional care, it is important to understand coordinator

impact on efficiency of operations. This project will determine the impact of dedicated coordinator effort and experience, on overall MFH Veteran direct healthcare costs. Additionally, to be a high reliability organization, the VA emphasizes the development of a patient safety culture among its facilities. This project will determine

whether a patient safety culture moderates the impact of coordinators on program efficiency and will inform decisions regarding program coordinator coverage and training as impacted by patient safety culture. Research on MFHs (see HSR&D CRE 12-029, PI Cari Levy, and subsequent publications) have shown

that VA costs and were lower among Veterans after MFH and costs were lower than Community Nursing Homes using FY2011 data. Moreover, qualitative work has explored the role of more experienced programs. However, there has not been quantitative research explicitly on MFH program coordinator effort and

experience in relation to cost or utilization. This project will address this gap. This project includes, in addition to standard evaluation of expected outcomes, the evaluation of reliability of outcomes, which is expected to improve with dedicated coordinator effort and experience guided by goals established by a patient safety

culture. The project is therefore also methodologically innovative, as it will evaluate the scale function (representing the mean-independent variation of outcomes) in addition to the regression function. The project has 3 aims: (1) To evaluate the VA cost and utilization of MFH Veterans and compare to (a) similar non-MFH

community-dwelling Veterans and (b) similar Veterans in CNH. (2) To evaluate the effect of coordinator effort and experience on the VA costs and utilization for MFH Veterans and compare to similar non-MFH community- dwelling Veterans and similar Veterans in CNH. (3) To evaluate whether the effect of coordinator effort and

experience on the VA costs and utilization for MFH Veterans is moderated by patient safety culture. Each aim will be analyzed using fiscal years 2021 through 2023 data from the CDW, SAIL, and GECDAC core files data sets. Data will also incorporate the monthly MFH coordinator survey, and the Patient Safety

Culture Survey. Data will include all MFH Veterans and similar non-MFH Veterans who use VA healthcare resources. Parametric and non-parametric methods will be used for evaluation of regression and scale functions. The primary outcome will be total VA direct costs. Secondary outcomes will include Emergency

Department visit rates and hospitalization rates.