The business case for family caregiver skills training: Results from a multi-site trial in the Veterans Health Care System

Introduction

In the U.S., nearly 10% of adults provide unpaid caregiving, often for an aging family member.¹This need is expected to increase as the population ages while the direct care workforce remains limited.² Many family caregivers require training to provide better care and balance caregiving.³ Training can reduce caregiver burden and strain;⁴ however, it is not widely available⁵ and little is known about the costs of operating a caregiver training program. To encourage caregiver training, Medicare authorized billing and reimbursement for caregiver training beginning in 2024. Budget impact analyses (BIA) can inform the business case by estimating program delivery and implementation cost for health systems seeking to initiate caregiver training programs.⁶

The U.S. Department of Veterans Affairs (VA) provides comprehensive services for family caregivers. From 2018-2020 the VA tested and implemented the iHI-FIVES caregiver group skills training (implementation of Helping Invested Families Improve Veteran Experiences Study), which has demonstrated improvement in caregiver and Veteran experiences with care.^7,8 Extrapolating program costs outside of VA can inform non-VA health system implementation of caregiver training programs.⁹

This study conducted a BIA¹⁰ with data from an 8-site, stepped-wedge cluster randomized trial^8,11,12 to assess the resources needed to implement and deliver caregiver skills training in and out of the VA. This was a national study with all regions but the Northeast represented (site characteristics presented in Supplemental Table 1).

Methods

We applied best practices for BIA and a site-level micro-costing approach including: describing variation in resources, staffing models, and associated costs at implementing sites (Supplemental Table 2). Model assumptions and source data for the base case and one-way sensitivity analyses (e.g., staff hours, class size) are presented in Supplemental Table 3. In the non-VA scenario analyses, wages for delivery staff including registered nurses (RN) and social workers (SW) were based on national distributions of wages from the Bureau for Labor statistics. See Supplement.

Our estimation of labor hours included both one-time program startup activities and ongoing program delivery activities. Startup activities included time spent planning, training staff, securing space, and preparing content. Thus, the one-time delivery expenses may recur when there is staff turnover. Ongoing activities included caregiver recruitment and content delivery. Fixed costs such as overhead, rent, utilities, information technology, and expenses incurred prior to the implementation trial were considered sunk costs because they would not be impacted by the decision to implement iHI-FIVES; therefore, we did not include these costs in the BIA.¹³

Results

Sites used a variety of staffing models impacting iHI-FIVES delivery cost (Supplemental Table 2). The most common delivery role was SW with at least 2 SW at each site, followed by RNs at 3 sites. Overall, 38% of staff hours were spent delivering content, 32% recruitment, and 30% follow-up activities including documentation in the EHR.

The variation in hourly wages across roles, labor hours, and class size contributed to the substantial variation in total delivery costs. The number of staff delivering the training ranged from 2 to 3. Excluding one-time labor resources, the total hours of staff labor for each training round ranged from 17 to 41 (mean, 29 hours). During the trial, the reported number of caregivers trained per round (4 classes), or class size, for each site varied from 3 to 13 (mean, 8). Ongoing labor costs associated with delivering one training round varied from $882 to $3174 (mean, $1756). Across the 8 training programs, the average cost to the VA per caregiver trained was $294, higher than expected due to small class sizes at some sites.

Assuming class size of 8 and 29 staff hours per round, (Figure 1), the VA projected delivery cost was $166 and $180 per caregiver trained in the SW and RN delivery models, respectively. Class size had the largest impact on cost per caregiver, ranging from $114 and $123 (12 caregivers) to $274 and $296 (5 caregivers) in the SW and RN delivery models. Staff hours ranged from 17 to 41, resulting in costs from $99 ($107) to $236 ($255) per caregiver trained in the SW (RN) delivery models. Estimated costs were lower in the non-VA scenarios due to lower average wages for SW nationally ($133 per caregiver in the base case). Estimated costs were similar in the non-VA scenarios for RN delivery.

Figure 1.

One-way sensitivity analyses assessing variation in resources needed to deliver iHI-FIVES in VA and non-VA US settings

Panel A: Social worker delivery model

Panel B: Registered nurse delivery model

Abbreviations: iHI-FIVES, implementation of Helping Invested Families Improve Veteran Experiences Study; VA, U.S. Department of Veterans Affairs; CG, caregiver; $, U.S. Dollar.

Discussion

These findings support the feasibility and sustainability of expanding similar caregiver skills trainings in VA and non-VA settings and are relevant for programs with similar staffing models and delivery time. In this trial, iHI-FIVES was delivered in 4 sessions; however, nearly two-thirds of labor costs were incurred before and after delivery, presenting an opportunity to reduce costs through more efficient recruitment processes and follow-up mechanisms (e.g., EHR documentation). Expanding class sizes to 10 can reduce costs per caregiver, though the impact on training efficacy is unknown. Sites used various staffing models, demonstrating that non-VA providers can adapt delivery to fit their workforce and context. For example, health systems may reduce expenses by including social workers or lay health workers for program delivery; although non-health professionals may have limited ability to generate revenue and bill for reimbursement.

Insurer reimbursement for caregiving training could make these programs financially sustainable outside VA settings. In 2024, CMS introduced new fee-for-service billing codes for caregiver training in individual or group settings.⁹ Additionally, CMS launched the Guiding an Improved Dementia Experience model¹⁴, providing payments for caregiver training and supplemental payments for respite care. With only 8 sites, this trial was not powered to evaluate the relationship between site-level program costs and population outcomes. The relationship between program costs and outcomes must be a component of future studies to inform implementation decisions.

Increasing caregiver training programs is valuable; however, even minimal health insurance cost-sharing can reduce access for those who need it most.¹⁵ We evaluate costs from the VA perspective, where Veterans and caregivers do not face high out-of-pocket costs.¹⁶ Outside the VA, Medicare beneficiaries with care needs and caregivers do face these costs, potentially exacerbating health disparities. Integration and documentation of all caregivers in need of training is needed to support the systematic implementation of programs. Policies like the RAISE Family Caregivers Act³ encourage health systems to identify and provide necessary skills to family caregivers of hospitalized patients; yet, few health systems include a caregiver field in their EHR.¹² As the need for caregiver training increases, health systems may leverage new reimbursement mechanisms to support the financial feasibility of delivering evidence-based caregiver training programs.