Background: The Department of Veterans Affairs (VA) has long recognized the importance of having a rich complement of home and community-based resources for the Veteran population. For Veterans experiencing disability-related impairments, home- and community-based services (HCBS) facilitate aging in place and alleviate family caregivers' burden. However, even in the enriched VA context, HCBS are underutilized. Our objective was to understand unmet needs and barriers to accessing HCBS from the perspectives of Veterans' family caregivers.

Methods: This multi-method study recruited family caregivers of Veterans seen within a major VA Health Care System. Eligible caregivers provided care for at least 8 h/week in the prior 6 months, to a Veteran with 1+ impairments in instrumental activities of daily living. Recruitment was conducted via flyers, physician referrals, registries, and chart reviews. Participants completed 1-h semi-structured interviews to assess unmet psychosocial needs and barriers to accessing VA and non-VA HCBS. Interviews were analyzed using a thematic analysis approach.

Results: A total of 23 caregivers (62.9 + 13.5 years; 74% women; 52.2% White; 26.1% Black; 95.2% pre-9/11) provided 8.4 ± 6.3 h of daily care. Most had provided care for more than 1 year; nine had cared for their Veteran for 5+ years. The following themes were identified: (1) need for clear, accurate, timely information about HCBS; (2) lack of time, amplified by COVID-19 restrictions; (3) need for respite to manage their own health and other caregiving responsibilities; and (4) perceived difference in care needs that can strain caregivers' relationship with the care recipient.

Conclusions: In addition to known barriers including lack of timely knowledge, service delays, and caregiver stress, Veteran-caregiver disagreements emerged as a novel barrier to using HCBS. A multi-pronged approach that addresses these barriers may increase timely access to HCBS.