Examining Self-Directed Care for the Rural Veteran Population

Rural Veterans face more barriers to health care than those living in urban areas. In addition to having reduced access to health care facilities, providers, and medical transportation services, rural Veterans are more likely to experience lower quality care and greater communication barriers due to less advanced information technology.

The challenges are even greater for those receiving home- and community-based long-term supports and services. Understanding the relative benefits of self-directed services compared to other paid home- and community-based personal care services in rural areas is of particular interest to Veterans Health Administration (VHA) as nearly three million Veterans aged 65 years and older live in rural areas.

An example of a self-directed program, the Veteran Directed Care (VDC) program helps isolated, aging Veterans and their caregivers develop a spending plan and hire people of their choosing (including family members or neighbors) or purchase equipment or home modifications to ensure the Veteran can live independently at home. Home-based workers or paid family members provide assistance with daily activities (e.g., eating, grooming, getting dressed).

New Evidence:
In January 2022, evaluators from the Partnered Evidence-based Policy Resource Center (PEPReC) published a paper titled “Fewer Potentially Avoidable Health Care Events in Rural Veterans with Self-Directed Care versus Other Personal Care Services” in the Journal of the American Geriatrics Society. The objective was to understand whether rural and urban Veterans used less VHA-paid community or in-house nursing home, acute, or emergency department (ED) care following enrollment in VDC, compared to recipients of other VHA-paid personal care services.

This retrospective observational study included over 37,000 Veterans receiving VHA-paid home- and community-based long-term care services in fiscal year 2017. Using VHA administrative data on health status and health care use, evaluators compared the differences in outcomes from pre- to post-enrollment in the VDC program and other VHA-paid personal care services programs for Veterans living in rural and urban areas. The baseline period was 12 months prior to service initiation and the outcome period was 12 months after service initiation.

They used logistic regression models stratified by location (rural/urban) to estimate the relationships between VDC receipt and utilization of VHA-paid community or in-house hospital, nursing home, and ED services. Sensitivity analyses also matched Veterans on several covariates (e.g., age, dementia, comorbidities, etc.).

The authors found that both rural and urban VDC recipients had fewer VHA-paid community and in-house nursing home admissions, compared to recipients of other VHA-paid personal care services. Rural VDC enrollees had fewer VHA-paid community and in-house acute care admissions and VHA-paid community and in-house ED visits, unlike urban VDC enrollees who had no significant changes in admissions or ED visits before and after service initiation.

In terms of demographics, VDC recipients were younger, had a higher VHA priority status (significant health issues and/or disabilities; high financial need), and were more likely to have sustained a spinal cord injury compared to recipients of other VHA-paid personal care services programs.


This study had a few limitations. For example, the data did not include non-VHA paid (e.g., paid for out of pocket or by private insurance) long-term care services and evaluators did not compare administrative costs between the VDC program and other VHA-paid personal care services programs. The study was also unable to determine the degree to which improved health outcomes were due to the VDC program or the presence of a strong family caregiver.

This study suggests that the VDC program is an appropriate and beneficial care option for Veterans with multiple chronic conditions and/or cognitive impairment and may be particularly beneficial for Veterans living in rural areas. It also has the potential to reduce use of VHA-paid community and in-house health care more than other VHA-paid personal care services. Future studies should continue to explore the degree to which non-VHA paid care and nursing home admissions change among VDC recipients.

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