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Does Care Consultation Affect Use of VHA Versus Non-VHA Care?
Robert O. Morgan, PhD; Shweta Pathak, PhD, MPH; David M. Bass, PhD; Katherine S. Judge, PhD; Nancy L. Wilson, MSW; Catherine McCarthy; Jung Hyun Kim, PhD, MPH; and Mark E. Kunik, MD, MPH

Does Care Consultation Affect Use of VHA Versus Non-VHA Care?

Robert O. Morgan, PhD; Shweta Pathak, PhD, MPH; David M. Bass, PhD; Katherine S. Judge, PhD; Nancy L. Wilson, MSW; Catherine McCarthy; Jung Hyun Kim, PhD, MPH; and Mark E. Kunik, MD, MPH
Uncoordinated multisystem use is problematic for Veterans Health Administration (VHA) patients with dementia. The Partners in Dementia Care intervention is successful in changing the pattern of VHA versus non-VHA use.

Our findings extend the existing literature on non-VHA and VHA use by veterans by demonstrating that the PDC intervention appeared to affect where veterans with dementia sought hospital care. Prebaseline, veterans with dementia were more likely to seek hospital care from non-VHA sites, regardless of patients’ proximities to VHA facilities. In contrast, by the 12-month interview, veterans receiving the PDC intervention who lived closer to a VHA medical center showed a preference for using VHA inpatient care. We did not see a similar change in site of ED care. In contrast to inpatient care, need for ED care may be more likely to result in the use of facilities that are nearby, regardless of VHA affiliation. Inpatient care may be more affected by physician and/or patient preference and thus more susceptible to influence by PDC.

The implications of our findings potentially extend beyond the VHA system. Accountable care organizations (ACOs) share some vulnerabilities of the VHA. In both, coordination of care is essential to delivery of high-quality services, yet patients often seek care “out-of-network.” PDC successfully includes health promotion and assistance for self-management, known to increase patient engagement and activation, which are important for the success of ACOs,31 and improved satisfaction with providers, which is important for retaining patients in care.21

In our models, we examined several factors that have previously been shown to be related to choice of VHA versus non-VHA care. Several of these factors were associated with use in our models as well. For inpatient admissions (Table 2), these included the number of ADLs and comorbidity burden, both positively related (ie, higher scores associated with a higher likelihood of utilization), and caregiver education. For ED use, these included patient age and having a spouse caregiver (positively related), caregiver age (negatively related), number of ADLs (positively related), and PDC region (North > South). However, we did not find some associations that we were expecting. This included VHA priority status. Priority status is partly dependent on service-related disability; consequently, it may have overlapped with other measures, such as the Charlson-Deyo Index or ADL scores, both of which were significant in the models. Unfortunately, we did not have measures of household income and possession of other insurance, both of which have been shown to be related to inpatient and ED use; thus, we could not include them in the models. Our proxy measure for Medicare enrollment was nonsignificant, although that may have been due to its age dependence and the significance of age in our models.


A major limitation of this study was the lack of randomization within site. There were significant site-related differences in use among PDC and UC participants prior to implementing the intervention. This suggests that some differences in use are driven by differences in patient comorbidity levels or in the service structure across the individual sites. We attempted to account for these site effects by using a within-patient DID approach, controlling for comorbidities, and estimating robust standard errors to account for natural clustering in the data.


Our findings suggest that the PDC intervention can affect the choice of VHA versus non-VHA care by veterans with dementia, with its impact differing in meaningful ways by type of care (inpatient vs ED) and distance from VHA medical centers. We were not able to address whether increasing use of the VHA for hospital admissions among veterans closest to VHA facilities was directly linked to better outcomes. Notably, the likelihood of non-VHA hospital services increased for veterans living further away. However, we have shown previously that participants in the PDC intervention group demonstrated significant improvements in psychosocial outcomes, as well as reduced overall inpatient and ED utilization among the subgroup of veterans with cognitive impairment and behavioral symptoms.26,32 As shown by our prior work, these positive outcomes appear to come without significantly increasing VHA costs over a 1-year follow-up period compared with UC.10 Future efforts should focus on testing implementations of PDC on a larger scale as a step toward demonstrating real-world impact and sustainability.

Author Affiliations: The University of Texas Health Science Center at Houston (UTHealth) School of Public Health (ROM), Houston, TX;  University of North Carolina at Chapel Hill, Eshelman School of Pharmacy (SP), Chapel Hill, NC; Benjamin Rose Institute on Aging (DMB, CM), Cleveland, OH; Department of Psychology, Cleveland State University (KSJ), Cleveland, OH; Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety (NLW, MEK), Houston, TX; Baylor College of Medicine (NLW, MEK), Houston, TX; The UTHealth School of Biomedical Informatics (JHK), Houston, TX; South Central Veterans Affairs Mental Illness Research, Education, and Clinical Center (MEK), Houston, TX.

Source of Funding: This work was supported by a grant from the Department of Veterans Affairs (VA), Health Services Research and Development (HSR&D) (HR 04-238-3), and grants from the Alzheimer’s Association (IIRG-08-89058) and the Robert Wood Johnson Foundation (#57816). This work was also supported in part by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness & Safety (CIN 13–413). The attitudes expressed here are those of the authors and do not necessarily reflect those of the VA/US government, Baylor College of Medicine, or The UTHealth School of Public Health.

Author Disclosures: Dr Morgan presented a version of this work at the AcademyHealth meeting in June 2017. Dr Bass and Ms McCarthy are employed by Benjamin Rose Institute on Aging, which owns a care coordination program that is marketed as a product and is based, in part, on work discussed in this article. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ROM, DMB, KSJ, MEK); acquisition of data (DMB, KSJ, CM); analysis and interpretation of data (ROM, SP, DMB, JHK, MEK); drafting of the manuscript (ROM, SP, NLW, JHK, MEK); critical revision of the manuscript for important intellectual content (ROM, SP, NLW, MEK); statistical analysis (ROM, SP); provision of patients or study materials (DMB, CM); obtaining funding (DMB, KSJ, MEK); administrative, technical, or logistic support (KSJ, CM, JHK); supervision (ROM, KSJ); and supervision during trial (NLW).

Address Correspondence to: Robert O. Morgan, PhD, UTHealth School of Public Health, 1200 Pressler, E923, Houston, TX 77030. Email:

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2. Projections of the prevalence and incidence of dementias including Alzheimer’s disease for the total veteran, enrolled and patient populations, age 65 and older. Department of Veterans Affairs website. Published September 2013. Accessed March 7, 2017.

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12. Chodosh J, Colaiaco BA, Connor KI, et al. Dementia care management in an underserved community: the comparative effectiveness of two different approaches. J Aging Health. 2015;27(5):864-893. doi: 10.1177/0898264315569454.

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16. Bilimoria KY, Bentrem DJ, Tomlinson JS, et al. Quality of pancreatic cancer care at Veterans Administration compared with non–Veterans Administration hospitals. Am J Surg. 2007;194(5):588-593. doi: 10.1016/j.amjsurg.2007.07.012.

17. Glasgow RE, Jackson HH, Neumayer L, et al. Pancreatic resection in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1252-1260. doi: 10.1016/j.jamcollsurg.2007.03.015.

18. Selim AJ, Kazis LE, Qian S, et al. Differences in risk-adjusted mortality between Medicaid-eligible patients enrolled in Medicare Advantage plans and those enrolled in the Veterans Health Administration. J Ambul Care Manage. 2009;32(3):232-240. doi: 10.1097/JAC.0b013e3181ac9d49.

19. Zhu CW, Penrod JD, Ross JS, Dellenbaugh C, Sano M. Use of Medicare and Department of Veterans Affairs health care by veterans with dementia: a longitudinal analysis. J Am Geriatr Soc. 2009;57(10):1908-1914. doi: 10.1111/j.1532-5415.2009.02405.x.

20. Zhu CW, Livote EE, Ross JS, Penrod JD. A random effects multinomial logit analysis of using Medicare and VA healthcare among veterans with dementia. Home Health Care Serv Q. 2010;29(2):91-104. doi: 10.1080/01621424.2010.493771.

21. Steiger-Gallagher K, Bass DM, Judge KS, et al. Satisfaction with dementia care. Fed Pract. 2012;29(4):33-40.

22. Judge KS, Bass DM, Snow AL, et al. Partners in Dementia Care: a care coordination intervention for individuals with dementia and their family caregivers. Gerontologist. 2011;51(2):261-272. doi: 10.1093/geront/gnq097.

23. Jennings LA, Reuben DB, Evertson LC, et al. Unmet needs of caregivers of individuals referred to a dementia care program. J Am Geriatr Soc. 2015;63(2):282-289. doi: 10.1111/jgs.13251.

24. Black BS, Johnston D, Rabins PV, Morrison A, Lyketsos C, Samus QM. Unmet needs of community-residing persons with dementia and their informal caregivers: findings from the Maximizing Independence at Home study. J Am Geriatr Soc. 2013;61(12):2087-2095.

25. Understanding memory loss: what to do when you have trouble remembering. National Institute of Aging website. Published September 2010. Accessed March 7, 2017.

26. Bass DM, Judge KS, Snow AL, et al. A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months. Alzheimers Res Ther. 2014;6(1):9. doi: 10.1186/alzrt242.

27. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613-619. doi: 10.1016/0895-4356(92)90133-8.

28. Stroupe KT, Smith BM, Lee TA, et al. Effect of increased copayments on pharmacy use in the Department of Veterans Affairs. Med Care. 2007;45(11):1090-1097. doi: 10.1097/MLR.0b013e3180ca95be.

29. Bass DM, McClendon MJ, Deimling GT, Mukherjee S. The influence of a diagnosed mental impairment on family caregiver strain. J Gerontol. 1994;49(3):S146-S155.

30. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186.

31. Shortell SM, Sehgal NJ, Bibi S, et al. An early assessment of accountable care organizations’ efforts to engage patients and their families. Med Care Res Rev. 2015;72(5):580-604. doi: 10.1177/1077558715588874.

32. Bass DM, Judge KS, Snow AL, et al. Caregiver outcomes of Partners in Dementia Care: effect of a care coordination program for veterans with dementia and their family members and friends. J Am Geriatr Soc. 2013;61(8):1377-1386. doi: 10.1111/jgs.12362.
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