As the senior population booms, agencies and health care systems continue to look for cost effective ways to provide quality in-home care. But even before industry giants were targeting innovation, an unlikely pioneer — the Department of Veterans Affairs (VA) — was leading the charge.
With reports of system-wide negligence and arbitrary caregiver dismissals making headlines over the years, VA has long been mired in controversy. But despite scandals and the challenges of bureaucracy, the department’s innovative home health services have been lauded for decades. In fact, at least one observer compares VA to Tesla, the Elon Musk-led electric car company that has become shorthand for ambitious innovation — despite some notable stumbles.
“We’re working in this environment of challenging budget constraints, and at the same time, we’re a very mission driven organization,” Thomas Edes, director of comprehensive geriatrics and palliative care programs for the Department of Veterans Affairs, told Home Health Care News. “Put those together and what happens? That really pushes us to innovate.”
Under Edes’ leadership since 2000, the number of veterans getting home-based primary care has quadrupled and every VA medical center across the country has added a palliative care program. Meanwhile, Medical Foster Home — which provides veterans housing and in-home care — has grown from a pilot to a national program used in at least 45 states.
VA is ahead of the curve, in part, because of demographics. Veterans have a median age of 64, compared to 44 for non-veterans, according to 2016 data from the National Center for Veterans Analysis and Statistics.
While the senior population as a whole is growing — with 10,000 baby boomers turning 65 every day and the nation’s aging population expected to double in the next 20 years — the aging veteran population is growing faster.
For example, nationwide, the 85-and-over population is expected to increase 70% between 2000 and 2020, according to projections from the U.S. Department of Health and Human Services (HHS).
“Meanwhile, VA population over 85 nearly tripled in half that time — between 2000 and 2010 — and doubled in the five years between 2000 and 2005,” Edes said. “We’re really in the position to lead the nation in the care of older Americans.”
Tesla of home care
As a trailblazer of several now popular practices — such as supporting social and behavioral components of health — some have compared VA’s innovation to that of Tesla.
“The thing about Tesla is that they’re tailored,” Dr. Christine Ritchie, professor in clinical translational research and aging in the division of geriatrics at the University of California San Francisco Department of Medicine, told HHCN. “They’re forward thinking, energy efficient and have [the] driver in mind, and that’s what I’ve observed in home care at the VA.”
In many areas, VA allows veterans to customize their care in ways that most other health care systems do not. For example, its Veteran-Directed Care program puts clients in the driver seat, giving them flexible budgets to use as they wish to finance their home- and community-based service needs.
Additionally, VA has made headlines recently for its open-access hospice and concurrent palliative care offerings. When appropriate, it allows disease-altering treatments to be administered alongside hospice care, which Medicare generally does not permit.
In the past, this has specifically caused a major dilemma for kidney-failure patients, who sometimes have to forgo dialysis in order to receive hospice care. But it’s not only kidney patients who can benefit from concurrent hospice and curative care.
“So that veteran with severe lung cancer getting hospice in the home can come back to VA and be treated in whatever way is appropriate and consistent for that veteran with their goals and values,” Scott Shreve, VA’s national director of palliative and hospice care, told HHCN. “That’s a really different approach than the current Medicare approach, which when you elect hospice care, you really forgo any disease-altering treatments.”
But Medicare’s approach could change, eventually following the VA’s lead. Colorado researchers are currently evaluating the worth and cost effectiveness of VA’s practice of concurrent care, which can lessen patients’ pain and ease their end-of-life transition.
“Now Medicare is exploring the possibility of concurrent treatment and hospice, and we said, ‘Wait. We’ve been doing this in the VA for a long time!’ Maybe our experience can inform Medicare’s experiment,” Dr. Cari Levy, a University of Colorado professor and geriatrician at the VA’s Eastern Colorado Health Care System helping with the research, told MedicalXpress, an online medical and health news source.
Return on investment
Just like Tesla, VA isn’t without challenges. A system-wide scandal rocked the Veterans Health Administration in 2014, with reports detailing long wait time and false record-keeping. Ultimately, it led to resignations and mistrust in the department.
Separately, VA’s home care arm has faced financial challenges.
”It’s an expensive program, and it was only because it was able to demonstrate that its expense was still less expensive than the alternative that it really started becoming appreciated for the value it had,” Ritchie, who spent decades working at VA, said. “I think that’s true of home-based medical care programs across the board.”
By increasing its home- and community-based programs and offerings, studies show VA has reduced hospitalizations and actually cut total health care costs not only for VA, but for Medicare as a whole.
“It really is a true federal cost savings that transcends VA,” Edes said, noting that the programs are favored by veterans in addition to saving money.
The VA’s home-based primary care program was associated with a 25% reduction in combined VA and Medicare hospitalizations, 36% reduction in combined hospital days, and nearly 12% net reduction in combined VA and Medicare total costs after accounting for the cost of providing the care, according to “Better Access, Quality, and Cost for Clinically Complex Veterans with Home-Based Primary Care,” a 2014 study Edes co-authored.
Now, Medicare is testing the home-based primary care approach through the Independence at Home demonstration. If the model is widely adopted, Medicare savings could approach $4.8 billion per year, according to Edes’ 2014 findings.
And VA’s services could have an even greater impact, Edes says.
“In the context of the unsustainable rise in healthcare costs, VA geriatrics and extended care services are integral to the solution,” he said. “We are increasing access, improving quality for veterans and lowering total cost. We’re achieving those goals by adding innovative services, not restricting services.”
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