Home Modifications for Rural Veterans With Disabilities
Background : Appropriate home modifications (HMs) can make the home environment accessible and relatively safe by reducing the risk of falls. Of special concern are individuals living alone, living in rural communities, and/or living in substandard housing. The Home Improvements and Structural Alterations (HISA) is a Veterans Health Administration (VHA) benefit program providing HMs for veterans with disabilities.
Methods: The objective of this study was to detail the profile of rural veteran (RV) HISA users and report on national HISA utilization patterns. We compare use at US Department of Veterans Affairs (VA) medical centers of varying complexity levels, and in VA regions. An examination of the relationship between travel time/distance and HISA utilization is also provided. This retrospective database study uses GeoSpatial analyses and 3 VA sources: The National Prosthetics Patient Database, the VHA Medical Inpatient Dataset, and the VHA Outpatient Dataset.
Results: From 2015 through 2018, 10,810 RVs used HISA with a mean age of 70.9 years. A majority of participants were White (79.5%), married (74.3%), and male (96.5%) veterans. They traveled a mean of 79.8 miles for 94.5 minutes to reach a facility where they received a HISA prescription. Nearly 75% of HISA users were able to receive a HISA prescription from their nearest facility, while about one-quarter traveled to a facility farther away, of which 43% travelled between 100 and 200 miles to obtain the HISA benefit. The top categories of diagnoses were musculoskeletal (19.1%), neurologic (12.5%), and cardiovascular (5.4%). There were about 11,166 HM prescriptions afforded to rural HISA users during the period, including bathroom (82.4%), doorway (4.9%), and railing (3.6%) modifications.
Conclusions: This study documents the national demographics and clinical characteristics of rural HISA users, data that may be useful to policy makers, HM service providers and advocate as well as HISA administrators in predicting future use and users.
Travel-Related Variables
HISA beneficiaries face significant travel-related challenges. Just 3.6% of RHUs could access a facility within 40 miles of their home and 43.2% traveled 100 to 200 miles from their home to access a HM prescription. Further exploration is warranted to understand how travel patterns impact access to or the uptake of HISA.
RVs already have problems with accessing care because of long travel time.14,15 The choice or necessity to travel to a farther facility for HISA prescription is problematic for RVs, especially when transportation is often reported in the literature as a barrier to resources for people living in rural communities.15-17 When patients have travel barriers, they wait longer to obtain medical services and often wait for their conditions to worsen before seeking services.15,18 Once HM is completed, telerehabilitation is an effective delivery method used for delivering health care services to people in remote places.18,19 Considering that HISA use has the potential to improve quality of life, afford comfort, facilitate the accomplishment of activities of daily living for RVs, it is important that future studies examine how existing telehealth technologies can be used to improve HISA access.
Future Directions
County-level analyses is warranted in future studies exploring potential variables associated with HISA use; for example, county-level rates of primary care physicians and other HCPs. Future research should explore how long distance travel impacts the HISA application process and HM implementation. Further research also should focus on the HISA application structure and process to identify causes of delays. The HISA application process takes a mean 6 months to complete, yet the duration of hospital stays is 1 to 3 weeks, thus it is impossible to connect HISA to hospital discharge, which was the original intent of the program. Future research can examine how telehealth services can expedite HISA obtainment and coordination of the application process. Future research also may study the possible causes of the wide variations in HM prescriptions per facility. It is also important that educational programs provide information on the array of HM items that veterans can obtain.
Conclusions
In our previous study of the HISA cohort (2011-2017), we documented that an increase in utilization of the HISA program was warranted based on the low national budgetary appropriation and identification of significant low participation by vulnerable subpopulations, including veterans residing in rural areas or having returned from recent conflicts.7 The present study documents national utilization patterns, demographic profiles, and clinical characteristics of RHUs from FY 2015 through FY 2018, data that may be useful to policy makers and HISA administrators in predicting future use and users. It is important to note that the data and information presented in this article identify trends. The work in no way establishes a gold standard or any targeted goal of utilization. Future research could focus on conceptualizing or theorizing what steps are necessary to set such a gold standard of utilization rate and steps toward achievement.
Acknowledgments
This research was supported by grant 15521 from the US Department of Veterans Affairs, Office of Rural Health . Furthermore, the research was supported in part by grant K12 HD055929 from the National Institutes of Health.
