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Objective: To assess whether a team collaboration strategy (CONNECT) improves implementation outcomes of a family caregiver skills training program (iHI‐FIVES). Data Sources and Study Setting: iHI‐FIVES was delivered to caregivers at eight Veterans Affairs (VA) medical centers. Data sources were electronic health records, staff surveys, and interviews. Study Design: In a stepped wedge cluster randomized trial, sites were randomized to a 6‐month time interval start date for iHI‐FIVES launch. Sites were then randomized 1:1 to either (i) CONNECT, a team collaboration training strategy plus Replicating Effective Programs (REP), brief technical support training for staff, or (ii) REP only (non‐CONNECT arm). Implementation outcomes included reach (proportion of eligible caregivers enrolled) and fidelity (proportion of expected trainings delivered). Staff interviews and surveys assessed team function including communication, implementation experience, and their relation to CONNECT and iHI‐FIVES implementation outcomes. Data Collection/Extraction Methods: The sample for assessing implementation outcomes included 571 Veterans referred to VA home‐ and community‐based services and their family caregivers eligible for iHI‐FIVES. Prior to iHI‐FIVES launch, staff completed 65 surveys and 62 interviews. After the start of iHI‐FIVES, staff completed 52 surveys and 38 interviews. Mixed methods evaluated reach and fidelity by arm. Principal Findings: Fidelity was high overall with 88% of expected iHI‐FIVES trainings delivered, and higher among REP only (non‐CONNECT) compared with CONNECT sites (95% vs. 80%). Reach was 18% (average proportion of reach across eight sites) and higher among non‐CONNECT compared with CONNECT sites (22% vs. 14%). Qualitative interviews revealed strong leadership support at high‐reach sites. CONNECT did not influence self‐reported team function. Conclusions: A team collaboration strategy (CONNECT), added to REP, required more resources to implement iHI‐FIVES than REP only and did not substantially enhance reach or fidelity. Leadership support was a key condition of implementation success and may be an important factor for improving iHI‐FIVES reach with national expansion. [ABSTRACT FROM AUTHOR]

Objective: To assess the effects of an evidence‐based family caregiver training program (implementation of Helping Invested Families Improve Veteran Experiences Study [iHI‐FIVES]) in the Veterans Affairs healthcare system on Veteran days not at home and family caregiver well‐being. Data Sources and Study Setting: Participants included Veterans referred to home‐ and community‐based services with an identified caregiver across 8 medical centers and confirmed family caregivers of eligible Veterans. Study Design: In a stepped wedge cluster randomized trial, sites were randomized to a 6‐month time interval for starting iHI‐FIVES and received standardized implementation support. The primary outcome, number of Veteran "days not at home," and secondary outcomes, changes over 3 months in measures of caregiver well‐being, were compared between pre‐ and post‐iHI‐FIVES intervals using generalized linear models including covariates. Data Collection/Extraction Methods: Patient data were extracted from the electronic health record. Caregiver data were collected from 2 telephone‐based surveys. Principal Findings: Overall, n = 898 eligible Veterans were identified across pre‐iHI‐FIVES (n = 327) and post‐iHI‐FIVES intervals (n = 571). Just under one fifth (17%) of Veterans in post‐iHI‐FIVES intervals had a caregiver enroll in iHI‐FIVES. Veteran and caregiver demographics in pre‐iHI‐FIVES intervals were similar to those in post‐iHI‐FIVES intervals. In adjusted models, the estimated rate of days not at home over 6‐months was 42% lower (rate ratio = 0.58 [95% confidence interval: 0.31–1.09; p = 0.09]) post‐iHI‐FIVES compared with pre‐iHI‐FIVES. The estimated mean days not at home over a 6‐month period was 13.0 days pre‐iHI‐FIVES and 7.5 post‐iHI‐FIVES. There were no differences between pre‐ and post‐iHI‐FIVES in change over 3 months in caregiver well‐being measures. Conclusions: Reducing days not at home is consistent with effectiveness because more time at home increases quality of life. In this study, after adjusting for Veteran characteristics, we did not find evidence that implementation of a caregiver training program yielded a reduction in Veteran's days not at home. [ABSTRACT FROM AUTHOR]

Purpose of the Study: This paper is a report of a study of the Assistance, Support, and Self-health Initiated through Skill Training (ASSIST) randomized control trial. The aim of this paper is to understand whether participating in ASSIST significantly changed the out-of-pocket (OOP) costs for family caregivers of Alzheimer's disease (AD) or Parkinson's disease (PD) patients. Design and Methods: Secondary analysis of randomized control trial data, calculating average treatment effects of the intervention on OOP costs. Enrollment in the ASSIST trial occurred between 2002 and 2007 at 2 sites: Durham, North Carolina, and Birmingham, Alabama. We profile OOP costs for caregivers who participated in the ASSIST study and use 2-part expenditure models to examine the average treatment effect of the intervention on caregiver OOP expenditures. Results: ASSIST-trained AD and PD caregivers reported monthly OOP expenditures that averaged $500-$600. The intervention increased the likelihood of caregivers spending any money OOP by 26 percentage points over usual care, but the intervention did not significantly increase overall OOP costs. Implications: The ASSIST intervention was effective and inexpensive to the caregiver in direct monetary outlays; thus, there are minimal unintended consequences of the trial on caregiver financial well-being.

Purpose: The Veterans Affairs or VA health care system is in the process of significantly expanding home health care (HOC) nationwide. We describe VA HHC use in 2003 for all VA HHC users from 2002; we examine whether VA utilization across a broad spectrum of services differed for a sample of VA HHC users and their propensity-score-matched controls. We also consider crossover between the VA and Medicare. Design and Methods: This is a retrospective study using propensity score and stratified analysis to control for selection bias on observable characteristics. We examined the full cohort of 2002 VA HHC users (n = 24,169) and a 2:1 sample of age- and race-based nonusers (n = 53,356). Utilization measures included VA and Medicare outpatient, inpatient, nursing home, and hospice use, as well as VA home-based primary care, respite care, and adult day health care. Results: VA HHC users had a higher absolute probability of outpatient use by around 3%, of inpatient use by 12%, and nursing home use by 6% than their propensity-score-matched controls. Implications: Veterans who used HHC services had a higher rate of VA service use in the subsequent year than controls did, even after we adjusted for differences in observed health status, eligibility advantages, and supplemental insurance status. High utilization for VA home health users spilled over into high Medicare utilization.

OBJECTIVES: The Department of Veterans Affairs (VA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) is a clinical program providing training, a monthly stipend, and other services to caregivers of qualifying post-9/11 veterans with service-related injuries. Veteran-caregiver discharge from the program occurs when veteran recovery is achieved, participation is no longer in the veteran's best interest, or caregiving ceases. Public scrutiny about potentially inappropriate discharges resulted in a nationwide freeze on all discharges. PCAFC expanded to pre-9/11 veterans in October 2020; thus, lessons learned can continue to inform the expanded program. We pursued 3 objectives: (1) describe the discharge rate, reasons for discharge, and veteran and caregiver characteristics by discharge status; (2) identify factors associated with discharge from PCAFC nationally; and (3) characterize network variation in discharge predictors. STUDY DESIGN: Retrospective observational study using VA administrative data from fiscal year (FY) 2011 to FY 2017. METHODS: Using multivariable Cox proportional hazards regression, we examined factors associated with PCAFC discharge among veterans and caregivers enrolled in PCAFC during FY 2011 to FY 2016. RESULTS: A total of 40.5% of all participants were discharged. Nonspouse caregivers and those applying in later years had the highest rates of discharge; spouse caregivers and those applying in earlier years had the lowest rates of discharge. In 4 of 18 networks, caregivers of Black veterans faced higher rates of discharge compared with caregivers of White veterans, and in 1 network, they faced lower rates of discharge. Substantial variability in rates of discharge was also observed across Veterans Integrated Service Networks. CONCLUSIONS: Training on clinically appropriate discharge criteria could improve practice and increase equity. [ABSTRACT FROM AUTHOR]