• Caitlin S Chan, Darlene Davis, Dayna Cooper, Thomas Edes, Ciaran S Phibbs, Orna Intrator, and Bruce Kinosian.
• Geriatrics and Extended Care Data Analysis Center, Palo Alto, California; Canandaigua, New York, Philadelphia, Pennsylvania, USA.
• J Am Geriatr Soc. 2021 Jul 1; 69 (7): 1729-1737.

BackgroundInterdisciplinary 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.DesignCross-sectional analysis.SettingAll 139 VA HBPC programs administered across 379 sites.ParticipantsAbout 55,173 Veterans enrolled in HBPC during fiscal year 2018.MeasurementsPatients' 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.ResultsHBPC 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 (X2 2863.5 [66 df], p < 0.0001). High-risk Veterans (72% of sample) were more likely to receive Full IDT care (X2 62.9, 1 df), p < 0.0001), while low-risk Veterans (28%) were more likely to receive HHA+ care (X2 314.8, 1 df, p < 0.0001).ConclusionThere is a strong association between HBPC team patterns and patient frailty, indicating tailoring of care to match Veteran needs.© Published 2021. This article is a U.S. Government work and is in the public domain in the USA.

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