Dedicated to the Mission: Strategies US Department of Veterans Affairs Home-Based Primary Care Teams Apply to Keep Veterans at Home

Leah M. Haverhals
Chelsea Manheim
Carrie Gilman
Jurgis Karuza
Tobie Olsan
Samuel T. Edwards
Cari R. Levy
Suzanne M. Gillespie
Peer-Reviewed Article
January 2019



Fostering a culture of caring for veterans takes interdisciplinary teams that work to build comprehensive, trusting, and reliable relationships through open and frequent communication and ongoing education.


The Department of Veterans Affairs established its Home Based Primary Care (HBPC) program in 1972 to provide long-term, comprehensive, home-based care for frail, chronically ill, and disabled veterans who require complex care coordination for medical, social, and behavioral conditions. In the VA HBPC program, the interdisciplinary care team (IDT) may include a primary care provider, nurse case manager, social worker, dietician, pharmacist, rehabilitation therapist, mental health provider, and program support assistant. This qualitative study of the VA’s program explores strategies for effective HBPC IDTs.


Drawing from the VA’s experiences, characteristics of successful IDTs include: (1) supporting both formal and informal communication within and between IDTs and veterans and their caregivers, (2) strengthening long-term, reliable, and trustworthy connections between IDT members and veterans and their caregivers, (3) providing continuous education for IDT members and veterans and their caregivers, and (4) emphasizing collaboration within and outside the HBPC IDT in order to provide comprehensive care to veterans with complex care needs with the shared goal of keeping them at home. These components allowed IDT members to foster tight-knit care teams that are empowered to go above and beyond to provide effective in-home care.


HBPC programs can promote these four characteristics to support IDT members in developing effective teams and providing high-quality comprehensive care. 

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