PURPOSE: To describe a pilot initiative sponsored by the Veterans Health Administration (VHA) to improve the health and community tenure of frail older veterans living in rural counties 50-100 miles from two host VHA medical centers. DESIGN AND METHODS: Veterans aged 75 and older who scored at risk of repeated hospital admission on the PRA-Plus telephone questionnaire were targeted and visited by evaluators who administered a comprehensive health questionnaire prior to being assessed at home by the Coordination and Advocacy for Rural Elders (CARE) program clinical teams. Guided by current state-of-the-art practices, the nurse-social worker teams performed in-home standardized assessments using the MDS-HC, developed patient-specific care plans, and mobilized family, community, and VHA resources to implement plans. RESULTS: On average, eight problems were identified for each patient, most commonly falls risk, social needs, pain, and needs related to IADL disability. As a result of initial assessment, two thirds of CARE participants received referral/linkage to formal services, more than half to medical providers. IMPLICATIONS: Through CARE, the VHA is learning more about the unmet needs of older rural veterans. Further development and evaluation should guide the VHA toward providing efficient, effective community-based services to all frail older veterans.
PURPOSE: To describe a pilot initiative sponsored by the Veterans Health Administration (VHA) to improve the health and community tenure of frail older veterans living in rural counties 50-100 miles from two host VHA medical centers. DESIGN AND METHODS: Veterans aged 75 and older who scored at risk of repeated hospital admission on the PRA-Plus telephone questionnaire were targeted and visited by evaluators who administered a comprehensive health questionnaire prior to being assessed at home by the Coordination and Advocacy for Rural Elders (CARE) program clinical teams. Guided by current state-of-the-art practices, the nurse-social worker teams performed in-home standardized assessments using the MDS-HC, developed patient-specific care plans, and mobilized family, community, and VHA resources to implement plans. RESULTS: On average, eight problems were identified for each patient, most commonly falls risk, social needs, pain, and needs related to IADL disability. As a result of initial assessment, two thirds of CARE participants received referral/linkage to formal services, more than half to medical providers. IMPLICATIONS: Through CARE, the VHA is learning more about the unmet needs of older rural veterans. Further development and evaluation should guide the VHA toward providing efficient, effective community-based services to all frail older veterans.