View clinical trials related to Veterans.
Filter by:The Department of Veterans Affairs' (VA) Home Based Primary Care (HBPC) program provides comprehensive care to its sickest, frailest Veterans with multiple complex chronic diseases. The HBPC program is a resource intensive non-institutional care program where Veterans, who are not able to receive primary care at the VA, are closely monitored and care is provided using an interdisciplinary team that coordinates the care through multi-professional home visits. The Geriatric Extended Care recommended that Miami Veteran Affairs Healthcare System (VAHS) HBPC enroll from a list of over 2,000 pre-identified High Need High Risk (HNHR) Miami Veterans for whom HBPC enrollment would have a high likelihood of clinical and economic benefits. HNHR Veterans have the greatest need for care but face the steepest challenges with access. However, despite best of intentions, the Miami HBPC program does not have the capacity to enroll the large numbers of Veterans on this new HNHR list. Therefore, innovative strategies are needed to provide appropriate needed care for this HNHR Veteran population. Goal: Maintain older Veterans in their homes for as long as possible. Aims: Design and pilot test an evidence-based, outpatient, Comprehensive geriatric assessment, Care plan based, Care-coordination, Co-management (C4) model, for 100 HBPC eligible HNHR older Veterans who are not enrolled in the HBPC program. The investigators will develop, implement and evaluate a VA model to provide a comprehensive geriatric assessment of HNHR Veterans, design a structured care plan that includes care coordination to link their needs to appropriate referrals, home and community based services, monitor and coach patients and caregivers, and coordinate their care across VA and non-VA providers and settings. Objectives: 1. Characterize the needs of the HNHR group of Veterans 2. Evaluate the feasibility and processes of the Geri C4 model 3. Evaluate the impact of the model on patient, healthcare utilization, and other Geriatric Extended Care (GEC) outcomes 4. Determine the facilitators and barriers for implementing the intervention
Objectives: The purpose of this proposal is to evaluate the impact of the CNH Dashboard implementation on the quality of VA Purchased CNH care relative to other CNH facilities, and to evaluate the quality of Veteran-specific care in purchased CNH facilities by transition and safety outcome measures derived from Veteran-specific CMS data. Methods: The investigators will evaluate the effect of the CNH Dashboard release in a randomized, stepped-wedge dissemination. This dissemination design allows us to determine the impact of the CNH Dashboard on the quality of purchased CNH facility more systematically than a single phase roll-out. In each of the 4 steps, The investigators will release the CNH Dashboard to a randomly selected set of VISNs. Dashboard release will be accompanied by education. Findings: The CNH Dashboard has actionable information to leaders in GEC at the local, regional, and national levels. Impact: When completed, this program will improve the quality of care Veterans receive in VA purchased CNH programs as demonstrated by improved selection of CNH facilities and Veteran-specific measures.