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J Am Geriatr Soc. 2017 Nov;65(11):2446-2451. doi: 10.1111/jgs.15053. Epub 2017 Aug 21.

Innovation in a Learning Health Care System: Veteran-Directed Home- and Community-Based Services.

Author information

Partnered Evidence-Based Policy Resource Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.
Geriatrics Research, Education, and Clinical Center, James J Peters Veterans Affairs Medical Center, Bronx, New York.
Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
Geriatrics and Extended Care Services, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia.
Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts.
Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island.
Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, Rhode Island.
Department of Medicine, Brown University, Warren Alpert Medical School, Providence, Rhode Island.
Center for Health Services Research in Primary Care, Health Services Research and Development Service, Durham, North Carolina.
Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina.
Durham Veterans Affairs Health Services Research and Development, Durham VA Medical Center, Durham, North Carolina.
Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts.
Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University, Cambridge, Massachusetts.


A path-breaking example of the interplay between geriatrics and learning healthcare systems is the Veterans Health Administration's (VHA's) planned roll-out of a program for providing participant-directed home- and community-based services to veterans with cognitive and functional limitations. We describe the design of a large-scale, stepped-wedge, cluster-randomized trial of the Veteran-Directed Home- and Community-Based Services (VD-HCBS) program. From March 2017 through December 2019, up to 77 Veterans Affairs Medical Centers will be randomized to times to begin offering VD-HCBS to veterans at risk of nursing home placement. Services will be provided to community-dwelling participants with support from Aging and Disability Network Agencies. The VHA Partnered Evidence-based Policy Resource Center (PEPReC) is coordinating the evaluation, which includes collaboration from operational stakeholders from the VHA and Administration for Community Living and interdisciplinary researchers from the Center of Innovation in Long-Term Services and Supports and the Center for Health Services Research in Primary Care. For older veterans with functional limitations who are eligible for VD-HCBS, we will evaluate health outcomes (hospitalizations, emergency department visits, nursing home admissions, days at home) and healthcare costs associated with VD-HCBS availability. Learning healthcare systems facilitate diffusion of innovation while enabling rigorous evaluation of effects on patient outcomes. The VHA's randomized rollout of VD-HCBS to veterans at risk of nursing home placement is an example of how to achieve these goals simultaneously. PEPReC's experience designing an evaluation with researchers and operations stakeholders may serve as a framework for others seeking to develop rapid, rigorous, large-scale evaluations of delivery system innovations targeted to older adults.


participant-directed care; randomized program evaluation; veterans

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