Special Issue: Linking VA and Non-VA Data to Address US Veteran Health Services Issues
Dual Use and Hospital Admissions among Veterans Enrolled in the VA's Homeless Patient Aligned Care Team
Amal N. Trivedi M.D., M.P.H.,
Lan Jiang M.S., Erin E. Johnson B.A.,
Julie C. Lima Ph.D.,
Michael Flores Ph.D., Thomas P. O'Toole M.D.,
Corresponding Author
Amal N. Trivedi M.D., M.P.H.
Providence VA Medical Center, Providence, RI
Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
Address correspondence to Amal N. Trivedi, M.D., M.P.H., Providence VA Medical Center (151), 830 Chalkstone Avenue, Providence, RI 02908 and also Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI; e-mail: [email protected]. Search for more papers by this authorErin E. Johnson B.A.
Providence VA Medical Center, Providence, RI
Search for more papers by this authorJulie C. Lima Ph.D.
Providence VA Medical Center, Providence, RI
Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
Search for more papers by this authorThomas P. O'Toole M.D.
Providence VA Medical Center, Providence, RI
Search for more papers by this authorAmal N. Trivedi M.D., M.P.H.,
Lan Jiang M.S., Erin E. Johnson B.A.,
Julie C. Lima Ph.D.,
Michael Flores Ph.D., Thomas P. O'Toole M.D.,
Corresponding Author
Amal N. Trivedi M.D., M.P.H.
Providence VA Medical Center, Providence, RI
Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
Address correspondence to Amal N. Trivedi, M.D., M.P.H., Providence VA Medical Center (151), 830 Chalkstone Avenue, Providence, RI 02908 and also Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI; e-mail: [email protected]. Search for more papers by this authorErin E. Johnson B.A.
Providence VA Medical Center, Providence, RI
Search for more papers by this authorJulie C. Lima Ph.D.
Providence VA Medical Center, Providence, RI
Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
Search for more papers by this authorThomas P. O'Toole M.D.
Providence VA Medical Center, Providence, RI
Search for more papers by this authorAbstract
Objective
To examine the association between reliance on VA outpatient care and hospital admissions among Medicare-eligible Veterans enrolled in the Homeless Patient Aligned Care Team (H-PACT).
Data Sources/Study Setting
Registry of H-PACT enrollees linked to VA and Medicare utilization data for 2013.
Study Design
After assigning Veterans to two groups according to whether they received >90 percent of outpatient care in VA (higher reliance) or <90 percent of outpatient care in VA (lower reliance), generalized linear models with inverse probability of treatment weights were used to estimate the association of reliance with Medicare and VA-financed hospital admissions.
Principal Findings
Compared with higher reliance Veterans, lower reliance Veterans had an equivalent number of annual VA hospitalizations (0.63 vs. 0.50; p = .14) but substantially greater Medicare hospitalizations (0.85 vs. 0.08; p < .001). Among Veterans in the highest tertile of outpatient visits, we observed statistically similar rates of VA hospital use but over 10-fold greater rates of Medicare-financed hospitalizations (1.31 for lower reliance vs. 0.15 for high reliance; p < .001).
Conclusions
Among Veterans receiving integrated care in VA's H-PACT, dual use of Medicare and VA outpatient care is strongly associated with acute hospitalizations financed by Medicare. Linking VA and non-VA data may identify a subset of homeless Veterans with fragmented outpatient care who are at increased risk of poor outcomes.
Supporting Information
| Filename | Description |
|---|---|
| hesr13034-sup-0001-AppendixSA1.pdfPDF document, 677.2 KB | Appendix SA1: Author Matrix. |
| hesr13034-sup-0002-AppendixSA2.docxWord document, 71 KB | Appendix SA2: Summary of Propensity Score Methods. |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
References
- Aldridge, R. W., A. Story, S. W. Hwang, M. Nordentoft, S. A. Luchenski, G. Hartwell, E. J. Tweed, D. Lewer, S. V. Katikireddi, and A. C. Hayward. 2017. “Morbidity and Mortality in Homeless Individuals, Prisoners, Sex Workers, and Individuals with Substance Use Disorders in High-income Countries: A Systematic Review and Meta-Analysis.” Lancet 391: 241–50.
- Austin, P. C. 2011. “An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies.” Multivariate Behavioral Research 46 (3): 399–424.
- Baggett, T. P., J. J. O'Connell, D. E. Singer, and N. A. Rigotti. 2010. “The Unmet Health Care Needs of Homeless Adults: A National Study.” American Journal of Public Health 100 (7): 1326–33.
- Baggett, T. P., S. W. Hwang, J. J. O'Connell, B. C. Porneala, E. J. Stringfellow, E. J. Orav, D. E. Singer, and N. A. Rigotti. 2013. “Mortality among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-year Period.” JAMA Internal Medicine 173 (3): 189–95.
- Brown, R. T., D. K. Kiely, M. Bharel, and S. L. Mitchell. 2012. “Geriatric Syndromes in Older Homeless Adults.” Journal of General Internal Medicine 27 (1): 16–22.
- Burgess, J. F., and D. A. DeFiore. 1994. “The Effect of Distance to VA facilities on the Choice and Level of Utilization of VA Outpatient Services.” Social Science and Medicine 39 (1): 95–104.
- Burgess Jr, J. F., M. L. Maciejewski, C. L. Bryson, M. Chapko, J. C. Fortney, M. Perkins, N. D. Sharp, and C.-F. Liu. 2010. “Importance of Health Sector Context for Evaluating Utilization Patterns across Sectors.” Health Economics 20 (2): 239–51.
- Cooper, A., L. Jiang, J. Yoon, M. E. Charlton, I. B. Wilson, V. Mor, K. W. Kizer, and A. N. Trivedi. 2015. “Dual System Use and Intermediate Health Outcomes among Veterans Enrolled in Medicare Advantage Plans.” Health Services Research 50 (6): 1868–90.
- Doran, K. M., K. T. Ragins, A. L. Iacomacci, A. Cunningham, K. J. Jubanyik, and G. Y. Jenq. 2013. “The Revolving Hospital Door: Hospital Readmissions among Patients Who Are Homeless.” Medical Care 51 (9): 767–73.
- Fihn, S. D., J. Francis, C. Clancy, C. Nielson, K. Nelson, J. Rumsfeld, T. Cullen, J. Bates, and G. L. Graham. 2014. “Insights from Advanced Analytics at the Veterans Health Administration.” Health Affairs (Millwood) 33 (7): 1203–11.
- Garibaldi, B., A. Conde-Martel, and T. P. O'Toole. 2005. “Self-reported Comorbidities, Perceived Needs, and Sources of Usual Care for Older and Younger Homeless Adults.” Health Services Research 20 (8): 726–30.
- Garrido, M. M., A. S. Kelley, J. Paris, K. Roza, D. E. Meier, R. S. Morrison, and M. D. Aldridge. 2014. “Methods for Constructing and Assessing Propensity Scores.” Health Services Research 49 (5): 1701–20.
- Gelberg, L., L. S. Linn, and S. A. Mayer-Oakes. 1990a. “Differences in Health Status Between Older and Younger Homeless Adults.” Journal of the American Geriatrics Society 38 (11): 1220–9.
- Gelberg, L., L. S. Linn, R. P. Usatine, and M. H. Smith. 1990b. “Health, Homelessness, and Poverty: A Study of Clinic Users.” Archives of Internal Medicine 150: 2325–30.
- Gelberg, L., T. C. Gallagher, R. M. Andersen, and P. Koegel. 1997. “Competing Priorities as a Barrier to Medical Care among Homeless Adults in Los Angeles.” American Journal of Public Health 87 (2): 217–20.
- Hastings, S. N., V. A. Smith, M. Weinberger, K. E. Schmader, M. K. Olsen, and E. Z. Oddone. 2011. “Emergency Department Visits in Veterans Affairs Medical Facilities.” American Journal of Managed Care 17 (6 Spec No.): e215–23.
- Hester, E. J., D. J. Cook, and L. J. Robbins. 2005. “The VA and Medicare HMOs—Complementary or Redundant?” New England Journal of Medicine 353 (12): 1302–3.
- Hibbs, J., L. Benner, L. Klugman, R. Spencer, I. Macchia, A. K. Mellinger, and D. Fife. 1994. “Mortality in a Cohort of Homeless Adults in Philadelphia.” New England Journal of Medicine 331: 304–9.
- Hwang, S. 2001. “Homelessness and Health.” Canadian Medical Association Journal 164: 229–33.
- Hwang, S., E. J. Orav, J. J. O'Connell, J. M. Lebow, and T. A. Brennan. 1997. “Causes of Death in Homeless Adults in Boston.” Annals of Internal Medicine 126: 625–8.
- Hynes, D. M., K. Koelling, K. Stroupe, N. Arnold, K. Mallin, M. W. Sohn, F. M. Weaver, L. Manheim, and L. Kok. 2007. “Veterans’ Access To and Use of Medicare and Veterans Affairs Health Care.” Medical Care 45 (3): 214–23.
- Jia, H., Y. Zheng, D. M. Reker, D. C. Cowper, S. S. Wu, W. B. Vogel, G. C. Young, and P. W. Duncan. 2007. “Multiple System Utilization and Mortality for Veterans with Stroke.” Stroke 38 (2): 355–60.
- Kizer, K. W. 2012. “Veterans and the Affordable Care Act.” Journal of the American Medical Association 307 (8): 789–90.
- Kushel, M. B., E. Vittinghoff, and J. S. Haas. 2001. “Factors Associated with the Health Care Utilization of Homeless Persons.” Journal of the American Medical Association 285 (2): 200–6.
- Kushel, M. B., S. Perry, D. Bangsberg, R. Clark, and A. R. Moss. 2002. “Emergency Department Use among the Homeless and Marginally Housed: Results from a Community-based Study.” American Journal of Public Health 92 (5): 778–84.
- LaCoursiere Zucchero, T., S. McDannold, and D. K. McInnes. 2016. ““Walking in a Maze”: Community Providers’ Difficulties Coordinating Health Care for Homeless Patients.” BMC Health Services Research 16: 480.
- Liu, C. F., M. Chapko, C. L. Bryson, J. F. Burgess, J. C. Fortney, M. Perkins, N. D. Sharp, and M. L. Maciejewski. 2010. “Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient Clinics.” Health Services Research 45 (5 Pt 1): 1268–86.
- O'Toole, T. P., J. L. Gibbon, B. H. Hanusa, and M. J. Fine. 1999. “Utilization of Health Care Services among Subgroups of Urban Homeless and Housed Poor.” Journal of Health, Politics, Policy and Law 24 (1): 91–114.
- O'Toole, T. P., A. Conde-Martel, J. L. Gibbon, B. H. Hanusa, and M. J. Fine. 2003. “Health Care of Homeless Veterans.” Journal of General Internal Medicine 18 (11): 929–33.
- O'Toole, T. P., E. E. Johnson, S. Redihan, B. H. Hanusa, and M. J. Fine. 2015. “Needing Primary Care but Not Getting It: The Role of Trust, Stigma and Organizational Obstacles Reported by Homeless Veterans.” Journal of Health Care for the Poor and Underserved 26 (3): 1019–31.
- O'Toole, T. P., E. E. Johnson, R. Aiello, and L. Pape. 2016. “Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: The Veterans Health Administration's ‘Homeless Patient Aligned Care Team’ Program.” Preventing Chronic Disease 31 (13): E44.
- Petersen, L. A., M. M. Byrne, C. N. Daw, J. Hasche, B. Reis, and K. Pietz. 2010. “Relationship Between Clinical Conditions and Use of Veterans Affairs Health Care among Medicare-enrolled Veterans.” Health Services Research 45 (3): 762–91.
- Pizer, S. D., and J. A. Gardner. 2011. “Is Fragmented Financing Bad for Your Health?” Inquiry 48 (2): 109–22.
- Thorpe, J. M., C. T. Thorpe, W. F. Gellad, C. B. Good, J. T. Hanlon, M. K. Mor, J. R. Pleis, L. J. Schleiden, and C. H. Van Houtven. 2017. “Dual Health Care System Use and High-Risk Prescribing in Patients with Dementia: A National Cohort Study.” Annals of Internal Medicine 166 (3): 157–63.
- Trivedi, A. N., R. C. Grebla, L. Jiang, J. Yoon, V. Mor, and K. W. Kizer. 2012. “Duplicate Federal Payments for Dual Enrollees in the Veterans Affairs Health Care System and Medicare.” Journal of the American Medical Association 308 (1): 67–72.
- Trivedi, A. N., I. B. Wilson, M. Charlton, and K. W. Kizer. 2016. “Agreement Between HEDIS Performance Assessments in the VA and Medicare Advantage: Is Quality in the Eye of the Beholder?” Inquiry 53: 1–3.
- US Department of Housing and Urban Development. 2016. The 2016 Annual Homeless Assessment Report (AHAR) to Congress: Part 1, Point-in-Time Estimates of Homelessness. Washington, DC: US Department of Housing and Urban Development.
- US Department of Veterans Affairs. 2011. “ System of Records Notice 97VA10P1: Consolidated Data Information System-VA”. 76 FR 25409.
- US Department of Veterans Affairs. 2014. “ 172VA10P2: VHA Corporate Data Warehouse – VA”. 79 FR 4377.
- US Department of Veterans Affairs. 2016. “ Enrollment Priority Groups” [accessed on February 19, 2018]. Available at https://www.va.gov/TRIBALGOVERNMENT/docs/IB10-441_enrollment_priority_groups_fact_sheet_24_jan_17.pdf.
- VA Information Resource Center. 2015. Record and Person Counts in the VA/CMS Medicare Data, CY 1997–2013. Hines, IL: U.S. Dept. of Veterans Affairs, Health Services Research and Development Service, VA Information Resource Center.
- Veterans Health Administration. 2014. “ Blueprint for Excellence” [accessed on November 21, 2017]. Available at https://www.va.gov/HEALTH/docs/VHA_Blueprint_for_Excellence.pdf.
- Wolinsky, F. D., H. An, L. Liu, T. R. Miller, G. E. Rosenthal. 2007. “Exploring the Association of Dual Use of the VHA and Medicare with Mortality: Separating the Contributions of Inpatient and Outpatient Services.” BMC Health Services Research 7: 70.
- Wolinsky, F. D., T. R. Miller, H. An, P. R. Brezinski, T. E. Vaughn, and G. E. Rosenthal. 2006. “Dual Use of Medicare and the Veterans Health Administration: Are There Adverse Health Outcomes?” BMC Health Services Research 6: 131.
- Yoon, J., M. E. Vanneman, S. K. Dally, A. N. Trivedi, and C. S. Phibbs. 2017. “Use of Veterans Affairs and Medicaid Services for Dually Enrolled Veterans.” Health Services Research 53: 1539–61.
