Background: The Covid-19 pandemic disrupted the ambulatory health care of Veterans with chronic conditions, including those with the highest need for VA care. Significance/Impact: This research will study the critical role of the VA healthcare system for delivering chronic disease management during the pandemic, including office, video, and telephone care, and assess clinical outcomes of older Veterans at the highest risk for hospitalizations for chronic disease exacerbations and acute fall injuries. In addition, we will explore how VA Geriatric Extended Care Home and Community- Based Services (HCBS) mitigated Covid-19 related healthcare disruptions. Innovation: This research will implement the newest analytic tools for studying health outcomes of older Veterans, approaches to measure access to VA HCBS programs, and identify those at highest risk of disrupted and delayed chronic disease care. Specific Aims: Using state-of-the-art methods, we will address the following Aims: Aim 1A: Examine the effect of disrupted ambulatory care visits on chronic condition management (CCM) for older Veterans. We will identify changes over time (“disruption”) in ambulatory care, including the volume of face-to-face and virtual visits, video and telephone calls, that are provided by outpatient primary and specialty care outpatient clinics. We will study ~ 1 million older (age ≥65) Veterans with at least 1 of 3 chronic medical and geriatric conditions: hypertension, congestive heart failure (CHF), or falls/mobility impairment during the Covid-19 crisis (2020-21). Management of chronic conditions will be measured by medication adherence, intensity, lab monitoring, and physical therapy services. Vulnerability to service disruption will be defined using the established method in VA patients and two other methods developed specifically for geriatric patient populations, the Predicted Long-term Institutionalization (PLI) measure. Next, in Aim 1B, we will test whether facilities who were able to maintain better access to HBCS mitigated the effect of disrupted ambulatory care on performance of chronic condition care management. This critical Aim will focus on 5 HBCS programs: Home-Based Primary Care, Personal Care Services (homemaker and home health aides, respite care), Veteran Directed Care, Adult Day Care, and Skilled Home Care (e.g., physical and occupational therapy, nursing, social work) Aim 2: Examine the effect of chronic condition management disruption on hospitalizations for ACSCs and acute fall injuries. We will determine whether older Veterans with less disrupted care during the initial and second Covid-19 surges also had a lower risk of hospitalization for chronic ACSC-related hospitalizations related to CHF and hypertension or for a fall-related injury. This Aim will result in a better understanding of how to predict hospitalization for ACSCs among older Veterans according to vulnerability. Methodology: This is a longitudinal study of older Veterans in the national VA healthcare system, using VA healthcare data merged with Medicare and Medicaid long-term care data, and pharmacy files from the VA and Medicare. We will use risk scores and data sources in partnership with the GEC Data Analysis Center. Next Steps: We will identify the chronic condition management services that should be prioritized for older Veterans and a potential roadmap for how the future VA ambulatory care and GEC healthcare systems can partner to provide better chronic condition management and attain better health outcomes for older Veterans.

The Covid-19 pandemic disrupted the health care of older Veterans with chronic conditions. This research will study the critical role of the VA healthcare system for delivering chronic disease management during the pandemic, including office, video, and telephone care, and assess clinical outcomes of older Veterans at risk for hospitalizations for chronic disease exacerbations and acute fall injuries. In addition, we will explore how certain VA Geriatric Extended Care Home and Community-Based Services (HCBS) mitigated Covid-19 related healthcare disruptions. The research will assess: (1) types of chronic condition care that were disrupted for Veterans with hypertension, congestive heart failure, and falls/mobility impairment (2) whether VA medical centers with better access to HCBS helped to mitigate the effect on chronic condition care, particularly among vulnerable frail Veterans, and (3) which types of chronic condition care were essential for protecting older Veterans from being hospitalized during the pandemic.