Background: Among patients with multiple chronic conditions, care coordination and integration remains one of the major challenges facing the U.S. health care system. A home-based, patient-centered primary care program has been offered through the Veterans Health Administration (VHA) since the 1970s for frail veterans who have difficulty accessing VHA clinics. The VHA Home Based Primary Care (VHA HBPC) aims to integrate primary care, rehabilitation, disease management, palliative care, and coordination of care for frail individuals with complex, chronic diseases within their homes. Early research suggested that VHA HBPC was associated with positive outcomes (e.g., reduced resource use and patient satisfaction). However, evidence regarding the effect of the VHA HBPC program on health services use (especially hospital and nursing home use), expenditures, and other patient outcomes remains limited. The present study is designed to fill this gap as the rise in the number of veterans with complex health care needs will likely increase in the coming decades. Objectives: The current study aimed to examine the impact of VHA HBPC on health services use, expenditures, and mortality among a cohort of new VHA HBPC enrollees identified in the national VHA data system. The specific aims of this study were: 1) to examine the effect of VHA HBPC on major health service use (hospital, nursing home, and outpatient care) paid for by the Veterans Administration; 2) to examine the effect of VHA HBPC on total health services expenditures; and 3) to examine whether VHA HBPC enrollees experienced similar mortality and survival as compared to a matched concurrent cohort. Methods: This study used a retrospective cohort design. A new VHA HBPC enrollee cohort (the treatment group) and a propensity matched comparison cohort (the comparison group) were identified from VHA claims in fiscal years (FY) 2009 and 2010 and were followed through FY 2012. Data on health service use, expenditures, and mortality/survival data were obtained via the VHA administrative datasets (i.e., Decision Support System, Purchased Care, and Vital Status Files). Propensity scores of being enrolled in the VHA HBPC were generated by a logistic regression model controlling for potential confounders. After 41,244 matched pairs were determined adequate through several diagnostic methods, means tests, relative risk analyses, and generalized linear models were used to estimate the effect of VHA HBPC on outcomes. Additionally, a Cox proportional hazards regression model was used to estimate the effect of VHA HBPC on survival. Subgroup analyses were conducted stratifying by age (85 and older), comorbidities (2 or more), and the receipt of palliative care. Based on the results of the original analyses, a series of sensitivity analyses were conducted that modified the described sample selection criteria and matching algorithm. Results: Analyses of the original cohort revealed that VHA HBPC patients had significantly higher risks of being admitted into a hospital (RR 1.53, 95% CI 1.51-1.56) or nursing home (RR 1.65, CI 1.50 - 1.81). The average total expenditures during the study period were significantly higher for the VHA HBPC group as compared to the control group ($85,808 vs. $44,833, respectively; p < .001). In terms of mortality and survival, VHA HBPC enrollees had higher mortality (RR 1.45, CI 1.43 - 1.47), and shorter survival (HR 1.89, CI 1.86 - 1.93) as compared to those in the comparison group. Subgroup analyses found that these relationships generally remained when stratified by age 85 or older or having two or more comorbidities. However, for those who received palliative care, VHA HBPC participants had significantly lower risk of VHA hospitalization overall (RR 0.84, CI 0.81 - 0.87) and immediately prior to death. Finally, exploratory post-hoc analysis suggested that VHA HBPC recipients were at higher risk of VHA hospitalization at 30 (RR 1.11, CI 1.06 - 1.16), 60 (RR 1.16, CI 1.11 - 1.20), and 90 days (RR 1.16, 1.12 - 1.21) prior to death relative to the comparison group. After selecting only those that had a baseline hospitalization and refining the matching algorithm to account for time to death and additional comorbidities, VHA HBPC participants who had been enrolled in the program for at least six months had lower risks for hospital (RR 0.89, CI 0.88 - 0.90) and nursing home admissions (RR 0.74, CI 0.67 - 0.81). However, total expenditures remained significantly higher among those in VHA HBPC relative to the comparison group ($89,761 vs. $85,371, respectively; p < .001). Discussion: This study found that without accounting for important covariates such as initial hospitalization, time to death, and a range of comorbidities, VHA HBPC was associated with higher health service use, higher expenditures, higher mortality, and shorter survival as compared to a similar group of patients not receiving VHA HBPC. After accounting for these factors, VHA HBPC was associated with a lower risk of nursing home use, and after six months, VHA HBPC was associated with lower risk of both nursing home and hospital use. These findings suggest that while VHA HBPC may improve quality of life and patient satisfaction through patient-centered integrated primary care, it may not generate cost savings for the healthcare system. Future research is needed to understand variation in program implementation and how this affects the impact of VHA HBPC on service use and cost.

Syftet var att undersöka hur sjuksköterskor, inom hemsjukvården, uppfattar sin egen kompetens och sitt behov av stöd i relation till sina arbetsuppgifter. Metoden är en enkätstudie. Enkäten förmedlades via e-post. Urvalet utgjordes av 131 sjuksköterskor inom hemsjukvården i en större stad i Mellansverige, varav 15 av sjuksköterskorna deltog i studien. Resultatet visar att den egenuppfattade kompetensen hos deltagarna var hög och majoriteten av de sjuksköterskor som medverkade känner sig trygga i att arbeta självständigt och att utföra sitt uppdrag som sjuksköterska inom hemsjukvården. Stödet från sjuksköterskekollegor anses som viktigt, dock önskas mer tid eller möjlighet att diskutera patienters vårdproblem. Att ha en bra arbetsrelation med sin läkare upplevs som mycket viktigt hos deltagarna. Majoriteten önskade ett mer omfattande samarbete med läkaren. Slutsatsen är att sjuksköterskorna inom studien uppfattade sin egen kompetens som bra och samtliga känner sig bekväma med att jobba självständigt. Att ha bra arbetsrelationer med kollegor och läkare är mycket viktigt för studiedeltagarna däremot anser några deltagare att de inte alltid kan räkna med sina sjuksköterskekollegor i svåra situationer. Majoriteten av sjuksköterskorna önskade ett mer omfattande samarbete med läkaren. Urvalet i studien var litet och bortfallet var stort, därför behövs en mer omfattande studie inom området. / Aim: The purpose of this study was to describe registered nurses (RNs) perceptions of their competence within the municipal elderly care and their need of support in relation to their job assignment. Method: A questionnaire survey. The questionnaire was delivered electronically as an email. The sample consist of 131 RNs within the municipal elderly care in a large city in the middle of Sweden. 15 of the RNs engaged in the study. Results: The RNs perceive their competence as high and the majority feel secure to perform their job assignment. The support from their nurse colleagues is considered important, however more time and opportunities to discuss care issues is desirable. A good labour relation with the physician is considered important among the respondents. The majority wishes a better physician-nurse teamwork. Conclusion: The RNs perceive their competence as good and the majority feel secure to perform their job assignment independent. A good labour relation with the colleagues and physician is considered important. However some RNs doesn’t believe that they can count on their colleagues in difficult situations. The majority of the RNs desires increased teamwork with the physician. Future interventions are needed with larger sample and a lesser falling off.

Introduction: Home visits have become increasingly uncommon although evidence suggests they improve healthcare quality and reduce overall expenditures. This thesis identifies the number and proportion of physician delivering home visits at patient’s end of life and describes characteristics of primary care physicians delivering end-of-life home visits and explores associations with delivery. Method: A retrospective cohort design using population-level health administrative data housed at ICES. Results: A total of 9,884 physicians were identified, of which 2,568 (25.7%) delivered at least one end-of-life home visit. Variables associated with increased odds of home visit delivery were older age, international training, capitation models of remuneration, and population size. Conclusions: This research demonstrates primary care physician’s characteristics and home visit practice patterns. This study aims to improve end-of-life primary care at a system and provider level by identifying factors associated with increased service provision. Increasing physician home services could greatly improve the dying experience of Canadians.