# Optimizing the value of community care for Veterans with advanced kidney disease

> **NIH VA I01** · VA PUGET SOUND HEALTHCARE SYSTEM · 2024 · —

## Abstract

Background: The Veterans Health Administration has a long history of providing maintenance dialysis
treatment for Veterans with end-stage renal disease (ESRD) in the community under the VA Fee Basis
program. Starting Fiscal Year 2015, access to specialized nephrology care in the community became available
to the much larger population of Veterans with advanced kidney disease not yet on dialysis under the Veterans
Choice Program (VCP) and is expected to continue under a consolidated Community Care program. Like their
counterparts on dialysis, Veterans with advanced kidney disease not on dialysis are a high-cost high-needs
population for whom access to care, continuity of care and coordination of care are all vitally important in
optimizing quality and outcomes. All three metrics are important in building strong relationships between
patients and providers, and supporting the kind of iterative cycle of evaluation and re-evaluation and care
coordination needed to properly care for these patients
Objective: We will use mixed methods to study the impact of the VA’s evolving community care policy on
outcomes and costs for Veterans with advanced kidney disease and identify opportunities for program
improvement. Because many of the outcomes and care processes relevant to this population are sensitive to
continuity and coordination of care, we hypothesize that receipt of VA-financed nephrology care in the
community will negatively impact a range of clinical outcomes and care processes relevant to this population
and will be more costly than nephrology care provided within the VA. We anticipate that for some groups, the
potential harms of care fragmentation and discontinuity may be outweighed by the benefits of more timely
receipt of needed care in the community. Because some VA medical centers may be more effective in
coordinating care with community providers to mitigate the effects of care fragmentation, we hypothesize that
there will be heterogeneity in the effect of VA-financed community care within the population and across VA
medical centers that could be informative in improving the process of community referral for this population.
Methods: We will use national VA administrative and clinical data to track the impact of VA-financed
community care on clinical outcomes, care processes and costs to the VA system among Veterans with
advanced kidney disease using an instrumental variable approach (Aim 1). To identify opportunities for
improving the value of community referral for this population, we will elicit the perspectives and experiences of
Veterans with advanced kidney disease eligible for, or receiving VA-financed community care and their VA and
community care providers (Aim 2).
Impact: This proposal will directly address three VA HSR&D priority areas (Health Care Systems Change,
Healthcare Access and Patient-centered Care, Care Management, and Health Promotion). The work proposed
here is extraordinarily timely and policy-relevant given that the...

## Key facts

- **NIH application ID:** 10754896
- **Project number:** 5I01HX002682-04
- **Recipient organization:** VA PUGET SOUND HEALTHCARE SYSTEM
- **Principal Investigator:** ANN M. O'HARE
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2024
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2019-12-01 → 2024-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10754896

## Citation

> US National Institutes of Health, RePORTER application 10754896, Optimizing the value of community care for Veterans with advanced kidney disease (5I01HX002682-04). Retrieved via AI Analytics 2026-05-25 from https://api.ai-analytics.org/grant/nih/10754896. Licensed CC0.

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