Kate Magid is a Health Science Specialist; Chelsea Manheim is a Research Social Worker; Leah Haverhals is a Health Research Scientist and Investigator; and Cari Levy is the Co-Director, all at the Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Denver-Seattle Center of Innovation in Aurora, Colorado. Kali Thomas is an Investigator at Center for Innovation in Long-Term Services and Supports at the Providence Veteran Affairs Medical Center; and an Associate Professor at the Department of Health Services, Policy & Practice, and Center for Gerontology and Health Care Research, School of Public Health, Brown University in Rhode Island. Debra Saliba is a Physician Scientist at the Geriatric Research Education and Clinical Center and HSR Center of Innovation at the VA Greater Los Angeles Healthcare System; a Director and Professor of Medicine at the University of California Los Angeles Borun Center; and a Senior Natural Scientist at RAND. Cari Levy is a Professor in the Division of Health Care Policy and Research, School of Medicine, University of Colorado, Aurora. Correspondence: Kate Magid (kate.magid@va.gov)
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Objective: The Veterans Health Administration (VHA) Medical Foster Home (MFH) program was created to give veterans a community-based alternative to institutional long-term care (LTC). This study describes demographic, clinical, and functional characteristics of veterans in MFHs.
Methods: Findings from in-home assessments of veterans in MFHs tied to 4 VHA medical centers for ≥ 90 days between April 2014 and December 2015 were collected. Trained nurses completed Minimum Data Set (MDS) 3.0 assessments for 92 veterans in MFHs. The assessment included demographic characteristics, cognition, behaviors, depression, pain, functional status, mobility, and morbidity.
Results: MFH veterans were primarily male (85%), aged > 65 years (83%), cognitively impaired (55%), and had a diagnosis of depression (52%). Overall, 22% had caregiver-reported aggressive behaviors and 45% self-reported pain. More than half used a wheelchair (56%). Of the 11 activities of daily living (ADLs) assessed, MFH residents were most likely to require assistance with bathing and least likely to require assistance with bed mobility and eating, although more than half required eating assistance.
Conclusions: Veterans residing in MFHs have a wide range of care needs, including some veterans with high needs for help with ADLs and others who are completely independent in performing ADLs. These results provide insights about which veterans are staying in MFH care. Future studies should explore how VHA care providers refer veterans to LTC settings.
New models are needed for delivering long-term care (LTC) that are home-based, cost-effective, and appropriate for older adults with a range of care needs.1,2 In fiscal year (FY) 2015, the US Department of Veterans Affairs (VA) spent $7.4 billion on LTC, accounting for 13% of total VA health care spending. Overall, 71% of LTC spending in FY 2015 was allocated to institutional care.3 Beyond cost, 95% of older adults prefer to remain in community rather than institutional LTC settings, such as nursing homes.4 The COVID-19 pandemic created additional concerns related to the spread of infectious disease, with > 37% of COVID-19 deaths in the United States occurring in nursing homes irrespective of facility quality.5,6
One community-based LTC alternative developed within the VA is the Medical Foster Home (MFH) program. The MFH program is an adult foster care program in which veterans who are unable to live independently receive round-the-clock care in the home of a community-based caregiver.7 MFH caregivers usually have previous experience caring for family, working in a nursing home, or working as a caregiver in another capacity. These caregivers are responsible for providing 24-hour supervision and support to residents in their MFH and can care for up to 3 adults. In the MFH program, VA home-based primary care (HBPC) teams composed of physicians, registered nurses, physical and occupational therapists, social workers, pharmacists, dieticians, and psychologists, provide primary care for MFH veterans and oversee care in the caregiver’s home.
The goal of the VA HBPC program is to improve veterans’ access to medical care and shift LTC services from institutional to noninstitutional settings by providing in-home care for those who are too sick or disabled to go to a clinic for care. On average, veterans pay the MFH caregiver $2,500 out-of-pocket per month for their care.8 In 2016, there were 992 veterans residing in MFHs across the country.9 Since MFH program implementation expanded nationwide in 2008, more than 4,000 veterans have resided in MFHs in 45 states and territories.10
The VA is required to pay for nursing home care for veterans who have a qualifying VA service-connected disability or who meet a specific threshold of disability.11 Currently, the VA is not authorized to pay for MFH care for veterans who meet the eligibility criteria for VA-paid nursing home care. Over the past decade, the VA has introduced and expanded several initiatives and programs to help veterans who require LTC remain in their homes and communities. These include but are not limited to the Veteran Directed Care program, the Choose Home Initiative, and the Caregiver Support Program.12-14 Additionally, attempts have been made to pass legislation to authorize the VA to pay for MFH for veterans’ care whose military benefits include coverage for nursing home care.15 This legislation and VA initiatives are clear signs that the VA is committed to supporting programs such as the MFH program. Given this commitment, demand for the MFH program will likely increase.
Therefore, VA practitioners need to better identify which veterans are currently in the MFH program. While veterans are expected to need nursing home level care to qualify for MFH enrollment, little has been published about the physical and mental health care needs of veterans currently receiving MFH care. One previous study compared the demographics, diagnostic characteristics, and care utilization of MFH veterans with that of veterans receiving LTC in VA community living centers (CLCs), and found that veterans in MFHs had similar levels of frailty and comorbidity and had a higher mean age when compared with veterans in CLCs.16
Our study assessed a sample of veterans living in MFHs and describes these veterans’ clinical and functional characteristics. We used the Minimum Data Set 3.0 (MDS) to complete the assessments to allow comparisons with other populations residing in long-term care.17,18 While MDS assessments are required for Medicare/Medicaid-certified nursing home residents and for residents in VA CLCs, this study was the first attempt to perform in-home MDS data assessments in MFHs. This collection of descriptive clinical data is an important first step in providing VA practitioners with information about the characteristics of veterans currently cared for in MFHs and policymakers with data to think critically about which veterans are willing to pay for the MFH program.
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