• Leah M Haverhals, Chelsea Manheim, Carrie Gilman, Jurgis Karuza, Tobie Olsan, Samuel T Edwards, Cari R Levy, and Suzanne M Gillespie.
• Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, Colorado.
• J Am Geriatr Soc. 2019 Dec 1; 67 (12): 2511-2518.

Background/ObjectivesThe US Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) Program provides interdisciplinary, long-term primary care for frail, disabled, or chronically ill veterans. This research identifies strategies used by HBPC teams to support veterans in their homes, rather than in institutionalized care.DesignFocus groups and semistructured interviews were conducted with HBPC interdisciplinary team (IDT) members, including program directors, medical directors, and key staff, from September 2017 to March 2018. Field observations were gathered during visits to veterans' homes and IDT meetings.SettingIn-person site visits were conducted at eight HBPC Programs across the United States. Sites varied in location, setting, and primary care model.ParticipantsA total of 105 HBPC professionals.MeasurementQualitative thematic content analysis.ResultsFour main strategies drive and support the shared mission of IDTs to support veterans at home: fostering frequent communication among IDT members, veterans, caregivers, and outside agencies; development of longitudinal, trusting, reliable relationships within IDTs and with veterans and caregivers; ongoing, consistent education for IDT members and veterans and caregivers; and collaboration within and outside IDTs. Adhering to this mission meant providing timely and efficient care that kept veterans in their homes and minimized the need for acute hospitalizations and nursing home placement.ConclusionHBPC IDTs studied worked together across disciplines to effectively create a dedicated culture of caring for veterans, caregivers, and themselves, leading to keeping veterans at home. Focusing on the strategies identified in this research may be useful to achieve similar positive outcomes when caring for medically complex, homebound patients within and outside the VA. J Am Geriatr Soc 67:2511-2518, 2019.© 2019 The American Geriatrics Society.

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