Geriatric Research Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.
Division of Geriatric Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California.
J Am Geriatr Soc. 2018 Apr;66(4):818-824. doi: 10.1111/jgs.15193. Epub 2018 Mar 12.
BACKGROUND/OBJECTIVES: Home-based primary care (HBPC) is a comprehensive, interdisciplinary program to meet the medical needs of community-dwelling populations needing long-term care (LTC). The U.S. Department of Veterans Affairs (VA) expanded its HBPC program to underserved rural communities, including American Indian reservations, providing a "natural laboratory" to study change in access to VA LTC benefits and utilization outcomes for rural populations that typically face challenges in accessing LTC medical support.
Pretest-Posttest quasi-experimental approach with interrupted time-series design using linked VA, Medicare, and Indian Health Service (IHS) records.
American Indian reservations and non-Indian communities in rural HBPC catchment areas.
376 veterans (88 IHS beneficiaries, 288 non-IHS beneficiaries) with a HBPC length of stay of 12 months or longer.
Baseline demographic and health characteristics, activities of daily living (ADL), previous VA enrollment, and hospital admissions and emergency department (ED) visits as a function of time, accounting for IHS beneficiary and functional statuses.
For HBPC users, VA enrollment increased by 22%. At baseline, 30% of IHS and non-IHS beneficiaries had 2 or more ADLs impairments; IHS populations were younger (P < .001) and had more diagnosed chronic diseases (P = .007). Overall, hospital admissions decreased by 0.10 (95% confidence interval (CI) = -0.14 to -0.05) and ED visits decreased by 0.13 (95% CI = -0.19 to -0.07) in the 90 days after HBPC admission (Ps < .001) and these decreases were maintained over 1 year follow-up. Before HBPC, probability of hospital admission was 12% lower for IHS than non-IHS beneficiaries (P = .02).
Introducing HBPC to rural areas increased access to LTC and enrollment for healthcare benefits, with equitable outcomes in IHS and non-IHS populations.
背景/目的：家庭初级保健（HBPC）是一项综合的、跨学科的计划，旨在满足需要长期护理（LTC）的社区居民的医疗需求。美国退伍军人事务部（VA）将其 HBPC 计划扩展到服务不足的农村社区，包括美国印第安人保留地，为研究农村人口获得 VA LTC 福利的变化和利用结果提供了一个“天然实验室”，这些农村人口在获得 LTC 医疗支持方面通常面临挑战。
使用链接的 VA、医疗保险和印度卫生服务（IHS）记录的预测试-后测试准实验方法和中断时间序列设计。
美国印第安人保留地和农村 HBPC 集水区的非印第安社区。
376 名退伍军人（88 名 IHS 受益人，288 名非 IHS 受益人），HBPC 停留时间为 12 个月或更长时间。
基线人口统计学和健康特征、日常生活活动（ADL）、以前的 VA 登记以及医院入院和急诊部（ED）就诊情况，这些都与 IHS 受益人和功能状态有关。
对于 HBPC 用户，VA 登记增加了 22%。在基线时，30%的 IHS 和非 IHS 受益人有 2 项或更多 ADL 损伤；IHS 人群更年轻（P<0.001），患有更多诊断出的慢性疾病（P=0.007）。总体而言，HBPC 入院后 90 天内，医院入院次数减少了 0.10（95%置信区间（CI）=-0.14 至 -0.05），急诊就诊次数减少了 0.13（95% CI=-0.19 至 -0.07）（P<0.001），并且这些减少在 1 年的随访中得到了维持。在 HBPC 之前，IHS 受益人的医院入院概率比非 IHS 受益人低 12%（P=0.02）。
将 HBPC 引入农村地区增加了对 LTC 和医疗保健福利的获得，IHS 和非 IHS 人群的结果均等。
