Veteran-Directed Home and Community Based Services (VD-HCBS) is focused on preserving Veteran's independence and the VA Office of Geriatrics and Extended Care is planning an expansion of VD-HCBS to 90 additional VA Medical Centers over the next 3 years. This proposal seeks to evaluate the VD-HCBS expansion to capture comprehensive information on the impact of VD-HCBS on Veterans' and Caregivers' outcomes, as well as, to identify how the program was implemented.

In the next decade, there will be a doubling of older Veterans for whom the VA has a requirement to provide long-term care. At a cost of $110,000 per year for long-term care, Geriatrics and Extended Care (GEC) is seeking to preserve Veteran independence in the community. VD-HCBS is a person-centered consumer-directed program that provides Veterans the opportunity to self-direct their long-term services and supports (LTSS) and continue to live independently at home. GEC is planning to expand VD-HCBS to an additional 90 VAMCs over the next 3 years. This proposal will provide important outcomes and context to the VD-HCBS expansion. The specific aims of this proposal are: Aim 1: To describe the impact of VD-HCBS on Veterans' satisfaction, unmet need for services, quality of life and independence using mixed methods. Aim 1 will utilize operations data to describe the change in Veteran-reported satisfaction, unmet needs, and independence from enrollment in VD-HCBS to 3 and 12 months. Additionally, the investigators will conduct interviews with Veterans to capture their experiences with the program. Aim 2: To understand the effect of VD-HCBS on Caregivers' well-being. Aim 2 will compare Caregivers' financial strain, depressive symptoms, caregiving stress, and health status and positive caregiver experiences to a propensity matched population from existing VA data to determine the impact of the VD-HCBS program on Caregivers. Aim 3: To examine the implementation of the VD-HCBS program expansion. Aim 3 will utilize the Consolidated Framework for Implementation Research and Expert Recommendations for Implementing Change to interview coordinators, and other key informants, from VA and ADNA VD-HCBS pairs. The analysis will shed light on how contextual factors and implementation strategies relate to implementation and Veteran outcomes. VD-HCBS has tremendous opportunity to improve the fiscal outlook of GEC's LTSS while delivering the highest level of Veteran-centered care. In concert with the outcomes of VD-HCBS, this implementation evaluation will be critical to determining how the VA system, in partnership with community-based organizations, implements programs and illuminating important leverage points to facilitate implementation effectiveness. With the diverse team assembled and the comprehensive evaluation proposed, the investigators will produce evidence to inform VA program implementation and dissemination, a critical component of the VA's priorities to develop high-performing, highly-reliable, and consistent networks.

Inclusion Criteria:

• Veterans who are eligible and enrolled in VD-HCBS at the expansion VAMCs

Exclusion Criteria:

• Non-Veterans
• Those not eligible or enrolled in VD-HCBS
• Enrolled in VD-HCBS at a non-expansion VAMC

Veterans enrolled in VD-HCBS tend to be older with functional impairments which could precipitate facility based care placement

Veterans enrolled in the VD-HCBS program completed a life satisfaction survey on unmet needs, satisfaction and quality of life. Caregivers completed a well-being survey focusing on financial strain, depressive symptoms, caregiving stress, health status and positive caregiver experiences.

12 months

Unexpected events slowed expansion of VD-HCBS