Comprehensive Support for Family Caregivers of Post-9/11 Veterans Increases Veteran Utilization of Long-term Services and Supports: A Propensity Score Analysis

Study Aim/Purpose: This study examined trends in the use of VA-purchased long-term services and supports (LTSS) to determine whether there is an association between participation in the Veterans’ Administration (VA)’s Program of Comprehensive Assistance for Family Caregivers (PCAFC)1 and Veteran use of home and community based services (HCBS) and institutional LTSS. 

Summary of Methods: This study used a quasi-experimental pre/post retrospective cohort design, comparing veteran LTSS utilization at six month intervals for up to 24 months between 15,650 Veterans whose caregivers were ever enrolled in the PCAFC anytime from May 2011 to March 2014 (treatment group) and 8,339 Veterans whose caregivers applied to PCAFC during the same period but were never approved (comparison group). The authors used VA program data and electronic health records to measure changes in the following three key outcomes: (1) use of any VA-provided or VA-purchased HCBS or institutional care; (2) receipt of any VA-purchased HCBS (homemaker home health care services, skilled home health care, adult day health care, hospice or respite care services); and (3) receipt of any care in a VA skilled nursing facility, community nursing home, State Veterans Home, or medical foster care home. For data analysis, two 6-month intervals of service use data prior to the application were included as the “pre-baseline” period. 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 24 months total). To address possible confounding effects of the differences between the 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: Veterans whose family caregivers participated in PCAFC had significantly higher relative rates of LTSS use and HCBS use specifically than individuals in the comparison group following program application. The findings were inconclusive with regard to an effect of PCAFC on institutional LTSS use, since at some data collection points LTSS use was higher among the treatment group than the comparison group and at other time periods it was not .

Study Limitations (as cited by authors): The authors note that propensity scoring to weight the treatment and comparison groups did not address all unobserved confounding, including unobserved confounding related to PCAFC eligibility criteria. Other study limitations cited included the limit of 24-months of follow-up to measure impacts, lack of information about care recipients’ ADLs, IADLs or cognitive function, and the fact that the authors only had access to data on veterans’ LTSS use if it was provided or purchased by the VA health system. 

Authors’ Discussion/Conclusions: The authors stated that while more research is needed to understand their findings on fluctuating trends on institutional LTSS use, the fact that PCAFC increased the use of HCBS will have very important implications for the VA and how they can connect Veterans to high quality, lower cost HCBS. The authors recommend more research to understand: (1) the longer term impact of support for family caregivers on Veteran LTSS use and costs; (2) Veteran preferences for informal versus formal care and HCBS versus institutional LTSS; (3) the impact of supports for family caregivers on civilian populations that likely face a different set of health concerns and system supports; and (4) the positive and negative burden impacts of HCBS versus institutional LTSS and if they increase burden ways to restructure LTSS to better support family caregiver needs.