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QUERI Partnered Evaluation Initiatives

QUERI Partnered Evaluation Initiatives involve primary funding from an operations partner in order to conduct specific evaluations of initiatives with potential high impact on VA national policy. In the following Q&A, Meg Kabat, LCSW-C, CCM, Acting National Director for VA's Caregiver Support Program (CSP), and Courtney Van Houtven, PhD, Principal Investigator for Caregiver Support (VA-CARES) Evaluation Initiative, discuss their partnership.

What are your goals for this Partnered Evaluation Initiative?

Kabat: VA's Caregiver Support Program (CSP) is an innovative, ground-breaking program that provides services and supports to family members and friends who take care of Veterans, allowing them to reach their highest level of functioning, while living at home, in their own communities. Family (or informal) caregiving is a national issue as our country ages, and this is true for the Veterans we serve in VA. Because it is so innovative, program outcomes are of great interest to key stakeholders, including Congress and Veteran Service Organizations, in addition to non-profit organizations like AARP, the Caregiver Action Network (CAN), the National Alliance for Caregiving (NAC), and other organizations that focus on caregiving. Therefore, it is important to answer questions that we are being asked consistently from our stakeholders. Is CSP working? Is VA impacting the health and well-being of caregivers and the Veterans they care for? The budget is large - nearly $450 million for FY15 - is there value in this Program?

Van Houtven: We are evaluating the short-term impacts of the Caregiver Support Program (CSP) on Veteran and caregivers using multiple and mixed-methods approach and rich data sources. We use VA medical records data to describe how The Comprehensive Program has affected Veteran healthcare utilization patterns. We also survey caregivers to describe how training, the stipend, and other benefits have affected the perceived financial and emotional strain of caregivers and their families. Using mixed methods, we ascertain the experiences of Comprehensive Program and General Program [see below] caregivers and gain important understanding of their perspectives on the helpfulness of the programs, challenges, and/or unmet needs. Finally, we complement data on services offered by detailing the full delivery costs of the CSP, including personnel, programming (e.g. stipend, insurance), and supporting costs.

[The Caregivers and Veterans Omnibus Health Services Act of 2010 allowed VA to provide an unprecedented level of services and supports to caregivers of Veterans through the development and implementation of two programs. The Program of Comprehensive Assistance for Family Caregivers provides services and supports to eligible family caregivers of eligible Veterans who were injured post 9/11, including a stipend paid directly to family caregivers, health insurance for family caregivers if not already eligible for other health insurance, and mental health services. The Program of General Caregiver Support Services provides support, training, and education to all caregivers of Veterans not eligible for the Comprehensive Assistance Program. For more information on either program, go to www.caregiver.va.gov.]

How did your collaboration come about?

Kabat: In May 2011, CSP had contracted with an outside vendor to provide some assistance in reporting outcomes. While the contractor met their deliverables, it was clear that there was much more data within VA systems and databases that had not been accessed in this initial analysis. CSP then became aware of the QUERI Partnered Evaluation Initiative and jumped at the opportunity to work within VA and with VA researchers who understand not only VA data systems, but also Veterans and their families.

Van Houtven: In 2013, a call for proposals was released by QUERI to evaluate the VA Caregiver Support Program. The focus on understanding Veteran utilization and financial strain matched my expertise as a health economist who had been working on research studies examining the impact of informal care on Veterans and non-Veterans for the past 12 years. With the help of several other Durham HSR&D COIN investigators, I submitted a proposal. We were then fortunate enough to receive funding for the VA-CARES Partnered Evaluation Initiative through the QUERI program and the CSP National Program Office, and began the CSP evaluation in June 2014.

What is the expected impact of your collaboration on this initiative?

Kabat: Our collaboration will allow us to respond to questions from stakeholders and also ensure that we are providing the best care in support of Veterans. The Blueprint for Excellence describes VA's role in providing support to the most vulnerable Veterans. Without question, Veterans who require the assistance of another individual - a caregiver - in order to live independently in the community are the most vulnerable. Without the assistance of their caregivers, these Veterans may be at risk for divorce or other family/relationship issues, homelessness, and even institutionalization. By demonstrating the impact of CSP, VA will be able to ensure this program continues in future years.

Van Houtven: Our collaboration will improve the final product. Partners provide valuable insight. They know who their audience will be, and because they face different pressures than we as researchers do, it is critical to understand their audience and the pressures they face so we can meet their needs.

Why should other QUERI programs and/or VA Offices consider collaborating?

Kabat: VA has such rich data resources, and yet Program Partners do not have the expertise to access the data in a meaningful way. Partnering with QUERI allows policy experts and data experts to retrieve and analyze data in a way that allows policy to expand and adapt to outcomes.

Van Houtven: Such collaborations take advantage of the symbiosis that comes from melding researchers and operations. Each have specific expertise, and it is a way to ensure that as researchers we are addressing real world questions - the answers to which will have a much higher likelihood of being used. By melding researchers and operations, we can capitalize upon each other's expertise. In a talk that a statistician on the team will present in October 2015 at the International Conference on Health Policy Statistics, Karen Stechuchak, MS, part of Durham HSR&D's Center for Health Services Research in Primary Care, perfectly sums up how we need each other to do this type of work: “Operations needs our research expertise to develop a study design that will address confounding as best as possible, and increase the chance that we are measuring the actual impact of the program on outcomes. Likewise, we researchers need operations' expertise. We need them to tell us what we can reasonably ask of program office data - and to inform us whether demographic descriptive statistics and comorbidity rates are on target from their experience." This context is critical.

What advice would you offer those who are considering partnered research?

Kabat: Developing a shared language is so important and an essential first step. Those of us who respond to policy and action items due to Congress, questions from VHA and/or VA Leadership, and many other stakeholders, work at a very different pace and in a very different environment than researchers. Developing a shared language helps in establishing a shared culture that allows for successful partnership.

Van Houtven: Working on a Partnered Evaluation Initiative (PEI) is a way to address topics that have a high level of interest to operations. For example, there is a higher level of political interest than a research project in our current case due to pressure from Congress to report findings on caregiving for Veterans. As researchers, we have to adapt to several differences between a PEI and a regular research grant. Our PEI is on a much larger scale than a regular HSR&D research project, with more than 20 team members and multiple statisticians. We also face a compressed time frame to complete the work: two years versus the typical four years for a grant. Finally, the product is different, with reports first and academic products second, an important consideration for researchers. It also is critical to communicate often and well in order to make sure we, the researchers, meet the expectations of our partners. Moreover, as researchers we have to find a common language for terminology. Researchers must be clear in the use of statistical terms, orientation to tables, and descriptions of findings so that partners can articulate methods and findings to their stakeholders. This is a challenge as well as a reward.