VA offers multiple long-term care (LTC) services to Veterans, including residential and nursing home settings, home- and community-based care, shared decision making, and advance care planning1. VA's Office of Geriatrics and Extended Care (GEC) oversees VA's programs to provide both geriatric and LTC programs and services to Veterans2. Investigators within HSR&D, particularly the Center of Innovation in Long-Term Services and Supports (LTSS COIN)3, conduct research into the delivery, effectiveness, and value of LTC services. Further, in accordance with the Mission Act and the Veteran Access Choice and Accountability Act before it, and due to the large number of Veterans expected to need LTC in upcoming years, HSR&D researchers continue to seek the best mix of clinical and community-based care for chronic and age-related LTC4. December’s Web Feature highlights several studies investigating attempts to improve Veteran experiences by bringing LTC out of traditional residential settings and into the community.
(Photo © iStock/kali9)
The 1999 Millennium Act, which expanded coverage of Long Term Care for Veterans, stipulated that Veterans receive care in the least restrictive setting possible - often their homes, yet half of informal VA caregivers report that they have not received necessary training. In this study, a control group of informal caregivers received support line, web site, and contact information, while an intervention group received the HI-FIVES informal caregiver training program, consisting of 3 tailored phone calls with a nurse, 4 group sessions, and 2 additional tailored calls. While final results are pending, preliminary findings were:
Implications: Skills training advances caregiver and patient perceptions of VA care quality, and shows promise towards increasing the days a patient remains at home 12 months following the intervention. Skills training does not ameliorate caregiver depressive symptoms, thus other approaches are needed to clinically treat depression. HI-FIVES skills training results increase knowledge about how to improve caregivers’ and patients’experience of VA care.
This study resulted in the following publication(s):
Van Houtven CH, Oddone EZ, Hastings SN, et al., Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES): study design and methodology. Contemporary clinical trials. 2014 Jul 1; 38(2):260-9.
(Photo © iStock/subman)
Avoiding preventable hospitalizations for nursing home (NH) residents reduces hospitalization-associated complications including: distress, delirium; poly-pharmacy, falls; hospital-acquired infection (HAI); poor nutrition, loss of mobility, and pressure ulcers. INTERACT trains staff to identify Veterans' changes in condition earlier, communicate more effectively to clinicians, and evaluate and safely manage acute changes in the residence when feasible, thereby avoiding unnecessary hospitalizations. Based on the substantial reduction of hospitalizations among residents in NH’s using INTERACT, this study sought to implement and evaluate the QI program in 8 VA Community Living Centers (CLCs) pair matched with 8 control CLCs. Staff was trained for 6 months and monitored for 12 months. Findings were:
Implications: Based upon our analyses, rates of avoidable hospitalizations from CLC, whether using the AHRQ algorithm or clinicians' judgment, were much lower than anticipated and previously reported in the literature, suggesting that the relatively high rate of hospitalization from CLC may be warranted.
This study resulted in the following publication(s) to date (others are in process):
Mochel AL, Henry ND, Saliba D, et al., INTERACT in VA Community Living Centers (CLCs): Training and Implementation Strategies. Geriatric nursing (New York, N.Y.). 2018 Mar 1; 39(2):212-218.
(Photo © iStock/fstop123)
Prompted by the escalating costs of institutional care and the preferences of most Veterans who require these services to remain in the community, shortening length of stay (LOS) and increasing safe discharge from VA Community Living Centers (CLCs) is a top priority for VA Geriatrics and Extended Care (GEC). Researchers analyzed discharges from VA CLCs between 2004 and 2012, and conducted more than 100 semi-structured interviews with staff, residents, and families at 8 CLCs to determine Veteran, CLC, and market factors that influenced 30-day Successful Discharge (SD), defined as discharge to the community without hospitalization or other institutionalization in the 30 days following discharge.
Findings were:
Implications: GEC leadership may use the results of this study to help refine policies regarding the mission and operations of CLCs to align with GEC goals of rebalancing VA long-term care as well as Veterans' preferences. Further, CLC "best practice" administrative protocols regarding admission screening, early initiation of discharge planning, and maximizing safe transitions to the community identified during site visits will bring VA closer to the ideal of using the CLC as a bridge to a less restrictive care setting for Veterans that allows for maximum functioning and quality of life.
This study resulted in the following publication(s):
Thomas KS, Cote D, Makineni R, et al., Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community. Journal of Aging & Social Policy. 2018 Mar 1; 30(2):93-108.
Tyler DA, Shield RR, Harrison J, et al., Barriers to a timely discharge from short-term care in VA Community Living Centers. Journal of Aging and Social Policy. in press.
Harrison J, Tyler DA, Shield RR, et al., An unintended consequence of culture change in VA Community Living Centers. Journal of the American Medical Directors Association 2017, Apr 1; 18(4): 320-325.
(Photo © iStock/Dean Mitchell)
Medical Foster Home (MFH) is a program for Veterans who meet nursing home (NH) level of care but instead receive care in the home of a foster family with the support of an interdisciplinary VA Home Based Primary Care (HBPC) team. Researchers sought to discover what leads Veterans to select or reject MFH’s over NH care, assess Veterans’ safety, and compare costs to traditional NH care. Qualitative data were gathered in a series of interviews with Veterans and program officials at three high-enrollment and three low-enrollment MFH’s. Data were analyzed for 212 MFH enrolled and 511 NH enrolled Veterans between 2008 and 2012.
Findings were:
Implications: VA expenditures for 2016 NH care were an estimated $970 million, nearly a three-fold increase over 10 years. These costs are expected to accelerate as the number of Priority 1a Veterans over the age of 65 years of age increases, from approximately 600,000 in 2016 to over 1 million by 2025. These data are being used in legislative efforts to lower costs (H.R. 294), by extending eligibility for MFH to Veterans currently eligible for NH care.
This study resulted in the following recent publication(s):
Levy C, Whitfield E. Medical Foster Homes: Can the adult foster care model substitute for nursing home care? J Am Geriatr Soc. Dec 2016; 64(12):2585-2592.
Gilman C, Haverhals L, Manheim C, Levy C. A qualitative exploration of veteran and family perspectives on medical foster homes. Home Health Care Services Quarterly. Dec 2017. 1-24.
Jones J, Haverhals LM, Manheim C, Levy C. Fostering Excellence: An Examination of High Enrollment VHA Medical Foster Home Programs. Home Health Care Management & Practice. 2017; 30(1): 16-22.