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2015 HSR&D/QUERI National Conference Abstract

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3169 — Sequence of Functional Decline among Veterans in VA Nursing Homes

Levy CR, Denver/Seattle COIN; Zargoush M, McGill University; Williams AE, Bay Pines VAMC; WIlliams AR, James A. Haley VAMC; Giang P, George Mason University; Wojtusiak J, George Mason University; Kheirbek RE, Washington DC VAMC; Alemi F, Washington DC VAMC;

Objectives:
This study provides benchmarks for the likelihood, number of days until, and most likely and other plausible sequences of functional decline and recovery.

Methods:
We analyzed Activities of Daily Living (ADLs) of 296,051 residents in Veteran Affairs nursing homes between 1/1/2000 and 9/10/2012. ADLs were extracted from standard Minimum Data Set assessments. Twenty-five combinations of ADL deficits described the experience of 84.3% of all residents. A network model was constructed to describe transitions among these 25 combinations of ADL deficits. The network was used to calculate the shortest, longest and maximum likelihood paths using backward induction methodology. In addition, longitudinal data were used to derive a Bayesian network that preserved the sequence of occurrence of 9 ADL deficits.

Results:
The majority of residents (57%) followed 4 different paths in loss of function. Overall, in the analyzed cohort, the most likely sequence of loss was bathing, grooming, walking, dressing, toileting, bowel continence, urinary continence, transferring and feeding. The other three paths differ in order of dressing/toileting and bowel/urinary continence. Residents' ADL impairments persisted without any change for an average of 164 days (SD = 62). Partial or complete recovery from a single impairment occurred in 57% of cases over an average of 119 days (SD = 41). Recovery rates declined as residents developed more than 4 ADL impairments.

Implications:
Residents follow multiple paths for recovery and loss of function. Benchmarks for these changes in function can be described in terms of days until and most likely next event.

Impacts:
Average time to recovery was greater than 100 days, much longer than typical rehabiliation programs are designed to provide active rehabilitative care. Rehabilitative care models can be guided by understanding the expected sequence of and time until functional loss and recovery.