title: Improving access to noninstitutional long-term care for American Indian veterans.
abstract: Home-based primary care (HBPC) is an effective model of noninstitutional long-term care developed in the Department of Veterans Affairs (VA) to provide ongoing care to homebound persons. Significant rural populations of American Indians have limited access to services designed for frail older adults. Fourteen Veterans Affairs Medical Centers (VAMCs) initiated efforts to expand access to HBPC in concert with local tribes and Indian Health Service (IHS) facilities. This study characterizes the resulting emerging models of HBPC and co-management. Using an observational design, key respondent telephone interviews (n = 37) were conducted with stakeholders representing the 14 VAMCs to describe these HBPC programs, and HBPC models were evaluated in relation to VAMC organizational culture as revealed on the annual VA All Employee Survey. Twelve VAMCs independently developed HBPC expansion programs for American Indian veterans, and six different program models were implemented. Two models were unique to collaborations between VAMCs and tribes; in these collaborations, the tribes retained primary care responsibilities. VAMC used the other four models for delivery of care in remote rural areas to all veteran populations, American Indians and non-Indians alike. Strategies to improve access by reducing geographic barriers occur in all models. Comparing mean VAMC organizational culture ratings, as defined in the Competing Values Framework, revealed significant group differences for one of these six models. Findings from this study illustrate the flexibility of the HBPC program and opportunities for co-management and expansion of healthcare access for American Indians and non-Indians, particularly in rural areas.
authors: Veterans Affairs Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California; Division of Geriatric Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.
authors: Betty Jo Josea
authors: BJ
authors: Kramer
authors: Beth
authors: B
authors: Creekmur
authors: Sarah
authors: S
authors: Cote
authors: Debra
authors: D
authors: Saliba
mesh_terms: D006297:Health Services Accessibility / Q000639:trends*; D006699:Home Care Services / Q000639:trends; D006801:Humans; D007198:Indians, North American; D007407:Interviews as Topic; D008134:Long-Term Care / Q000639:trends*; D008962:Models, Theoretical; D019035:Rural Health Services / Q000600:supply & distribution; D014481:United States; D014728:Veterans
keywords: Department of Veterans Affairs; Indian Health Service; rural