# Optimizing Outcomes in Home-Based Primary Care

> **NIH VA IK2** · PORTLAND VA MEDICAL CENTER · 2020 · —

## Abstract

Objective: This proposal is for a CDA-2 mentored training program that will transition Samuel Edwards, MD,
MPH into an independent VA health services researcher who has special expertise in the design, function and
evaluation of care models for medically and socially complex Veterans. The overarching objective of the
research plan is explore what features of VA Home Based Primary Care (HBPC) drive its success in reducing
hospitalizations for ambulatory care sensitive conditions, and use these insights to develop an intervention to
promote best practices in HBPC.
Research Plan: Dr. Edwards will conduct three studies using mixed methods. The research approach will
draw upon the literature on patient complexity, core features of primary care, and the chronic care model. The
Specific Aims of the proposed research are to: 1) Characterize patterns of enrollment and care delivery within
HBPC, and determine clinical and systems correlates of preventable hospitalizations, 2) Assess HBPC
providers perceptions of appropriate patient selection and care delivery patterns, core functions of HBPC, and
barriers and facilitators to HBPC performance, and 3) Develop and test a pilot intervention to promote best
practices in HBPC.
Methods: Aims 1 and 2 will consist of an explanatory sequential mixed methods study exploring HBPC patient
selection, care delivery patterns, core functions of HBPC. Aim 1, is a quantitative study consisting of four
secondary analyses of national VHA data to (1) determine predictors of enrollment in HBPC, (2) define clinical
subgroups of HBPC patients, (3) describe care delivery patterns within HBPC, and (4) determine association of
patient subgroups and care delivery patterns with ambulatory care sensitive hospitalizations. Aim 2 is a two
phase qualitative study. In the first phase, we will perform an in depth study of our local HBPC program using
interviews, focus groups and structured observation. Second, we will perform interviews with program directors
at other HBPC programs to gain a broader understanding of differences between sites. In both phases we will
explore perceptions of the patient selection process, appropriate care delivery patterns, and the importance of
core HBPC functions focusing on 5 proposed domains: 1) strong provider-patient relationships, 2) medication
management 3) addressing social determinants of health, 4) integration of palliative care, and 5) coordination
of care. We also plan to explore provider perspectives on barriers and facilitators on HBPC performance.
Finally, Aim 3 will be the development of a pilot intervention to promote best practices in HBPC learned from
Aims 1 and 2, which will be tested locally in a trial. We will perform a formative evaluation concurrently focused
on acceptability and feasibility, with a preliminary look at efficacy. The expected outcome will be preliminary
data to support a multicenter trial of a refined intervention to be tested at multiple HBPC sites.
Career Plan: Dr. Edwa...

## Key facts

- **NIH application ID:** 9841733
- **Project number:** 5IK2HX002282-02
- **Recipient organization:** PORTLAND VA MEDICAL CENTER
- **Principal Investigator:** Samuel T Edwards
- **Activity code:** IK2 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2020
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2018-07-01 → 2023-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9841733

## Citation

> US National Institutes of Health, RePORTER application 9841733, Optimizing Outcomes in Home-Based Primary Care (5IK2HX002282-02). Retrieved via AI Analytics 2026-05-22 from https://api.ai-analytics.org/grant/nih/9841733. Licensed CC0.

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