Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.
VA Palo Alto Health Economics Resource Center (HERC), Menlo Park, California, USA.
J Am Geriatr Soc. 2021 Jul;69(7):1729-1737. doi: 10.1111/jgs.17174. Epub 2021 May 10.
BACKGROUND: Interdisciplinary team (IDT) care is central to home-based primary care (HBPC) of frail elders. Traditionally, all HBPC disciplines managed a patient (Full IDT), a costly approach to maintain. The recent PACE (Program of All-inclusive Care for the Elderly) regulation provides for a flexible approach of annual assessments from a core team with involvement of additional disciplines dependent upon patient needs (Core+). Current Department of Veterans Affairs (VA) HBPC guidance specifies Full IDTs care for medically complex and functionally impaired Veterans similar to PACE participants. We evaluated whether VA HBPC has adopted the flexible structure of the PACE regulation, aligned to Veteran needs. DESIGN: Cross-sectional analysis. SETTING: All 139 VA HBPC programs administered across 379 sites. PARTICIPANTS: About 55,173 Veterans enrolled in HBPC during fiscal year 2018. MEASUREMENTS: Patients' HBPC physician, nurse, psychologist/psychiatrist, social worker, therapist, dietitian, and pharmacist visits were grouped into interdisciplinary team types. Patient frailty was classified using VA HNHR v2 (High-Need High-Risk version 2, a measure of high, medium, and low risk of long-term institutionalization). Medical complexity was measured by clusters of impairment in the JEN frailty index (JFI). JFI clusters were validated by VA's Nosos measure to project cost and Care Assessment Need (CAN) measure of hospitalization and mortality risk. RESULTS: HBPC provided Full IDT care to 21%, Core+ care to 54%, and Home Health+ (HHA+) care (skilled home health services plus additional disciplines, without primary care) to 16% of Veterans. Team type was associated with medical complexity (X 2863.5 [66 df], p < 0.0001). High-risk Veterans (72% of sample) were more likely to receive Full IDT care (X 62.9, 1 df), p < 0.0001), while low-risk Veterans (28%) were more likely to receive HHA+ care (X 314.8, 1 df, p < 0.0001). CONCLUSION: There is a strong association between HBPC team patterns and patient frailty, indicating tailoring of care to match Veteran needs.
背景：跨学科团队（IDT）护理是家庭初级保健（HBPC）中体弱老年人护理的核心。传统上，所有 HBPC 学科都管理一名患者（全 IDT），这是一种维持成本较高的方法。最近的 PACE（老年人全面关怀计划）法规规定了一种灵活的方法，即由核心团队进行年度评估，并根据患者需求（核心+）参与其他学科。目前，美国退伍军人事务部（VA）HBPC 指南规定，对类似于 PACE 参与者的医疗复杂和功能受损退伍军人进行全 IDT 护理。我们评估了 VA HBPC 是否采用了 PACE 法规的灵活结构，以满足退伍军人的需求。 设计：横断面分析。 设置：在 379 个地点管理的所有 139 个 VA HBPC 项目。 参与者：在 2018 财年，约有 55173 名退伍军人参加了 HBPC。 测量：将患者的 HBPC 医生、护士、心理学家/精神科医生、社会工作者、治疗师、营养师和药剂师就诊分组为跨学科团队类型。使用 VA HNHR v2（高需求高风险版本 2，一种衡量长期机构化高、中、低风险的方法）对患者的脆弱性进行分类。医疗复杂性通过 JEN 脆弱性指数（JFI）中的损伤簇来衡量。JFI 簇通过 VA 的 Nosos 措施进行验证，以预测成本和 Care Assessment Need（CAN）措施的住院和死亡风险。 结果：HBPC 为 21%的退伍军人提供全 IDT 护理，为 54%的退伍军人提供 Core+护理，为 16%的退伍军人提供家庭保健+（熟练家庭保健服务加其他学科，不包括初级保健）护理。团队类型与医疗复杂性相关（X 2863.5 [66 df]，p < 0.0001）。高风险退伍军人（样本的 72%）更有可能接受全 IDT 护理（X 62.9，1 df），p < 0.0001），而低风险退伍军人（28%）更有可能接受 HHA+护理（X 314.8，1 df，p < 0.0001）。 结论：HBPC 团队模式与患者脆弱性之间存在很强的关联，表明根据退伍军人的需求调整护理。
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