Comprehensive Support for Family Caregivers: Impact on Veteran Health Care Utilization and Costs

Study Aim/Purpose: This study examines the early impact of a Veterans Administration program called the Program of Comprehensive Assistance for Family Caregivers (PCAFC).1 

Summary of Methods: This study used a quasi-experimental pre/post retrospective cohort design, comparing veteran health care utilization and costs at six month intervals for up to 36 months between two groups: (1) 15,650 Veterans whose caregivers were ever enrolled in the PCAFC anytime from May 2011 to March 2014 (even if they discontinued enrollment for any reason during the 36 months study period); and (2) 8,330 Veterans whose caregivers applied to PCAFC during the same period but were never approved. The three categories of outcomes measured were: (1) acute care use (including use of emergency department care and inpatient hospitalization for any reason); (2) VA outpatient care use (number of VA outpatient visits, receipt of any VA primary care visit, receipt of any VA specialty care visit, and receipt of any VA mental health care visit); and (3) total health care costs for VA and VA purchased care for the Veteran (including inpatient care, extended care, outpatient care—including emergency department and home-based primary care, and pharmacy costs). Data for the outcome analysis were obtained from the VA electronic health records and related VA accounting systems that maintain health care utilization data. For data analysis, baseline for the treatment group was the date of submission of the first approved application to the PCAFC; comparison group baseline was the date of the first submitted application. The post-outcomes were measures at 6-month intervals (up to 36 months) based on the application date to PCAFC. To address possible confounding effects of the differences between the PCAFC and non-PCAFC participating groups, the authors applied inverse probability of treatment weights constructed using propensity scores, based on the predicted probability of ever being enrolled in PCAFC. 

Summary of Results: Both groups had similar emergency department use and in-patient hospitalizations, but PCAFC enrollment was associated with increased use of VA outpatient care throughout the study period for all outpatient measures examined: total outpatient visits, receipt of any VA primary care, receipt of any VA specialty care, and receipt of any VA mental health care. In addition, estimated total health care costs for PCAFC Veterans were $1,500 to $3,400 higher per 6-month interval than for the control group. Total VA costs fell over time for both groups, but they remained significantly higher for Veterans whose caregivers has enrolled in PCAFC. 

Study Limitations (as cited by authors): The authors note that although the two groups had relative balance in utilization of health care at study baseline, it is possible that there are some other residual differences (that could not be accounted for with the propensity scoring) between the treatment and control groups which impacted outpatient care use and VA health care costs of the treatment group. A second potential limitation acknowledged by the authors is that the availability of outcome data for the 6-month and 1-year intervals post-application were available for nearly all of the study sample, but the outcome data were less available beyond that time period. Thus, the analysis is truly informative only regarding the short-term impacts of the program. 

Authors’ Discussion/Conclusions: Authors suggest that the study findings of increased outpatient care use and VA health costs indicate that PCAFC may have increased Veterans’ short term access to care due to the training and support offered to caregivers, the PCAFC stipend that may have enabled caregivers to make and accompany their care recipients to appointments, the access to health care insurance for caregivers that was provided by PCAFC may allow them to address their own health care needs and thus make it easier for them to help the Veteran access his or her care; and the quarterly home assessment visits required by the program. With regard to future research, the authors conclude that the rigorous methods used in this study, including carefully constructing the best available comparison and using techniques to minimize selection bias, are useful to guide future evaluation efforts of PCAFC and other LTSS programs.