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IIR 03-243 – HSR&D Study

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IIR 03-243
Substance Use Disorder Patients in VA Nursing Homes
Sonne Lemke PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: June 2004 - November 2007

BACKGROUND/RATIONALE:
Substance use disorders (SUDs) are among the most common mental health diagnoses in VA Nursing Home (VANH) patients; rates are likely to increase with the expected influx of aging Vietnam-era veterans. Some research suggests that patients with SUDs may present special clinical challenges because they exhibit high levels of psychiatric comorbidity and difficult behaviors.

OBJECTIVE(S):
Project aims were to identify (1) special health care problems and care burden that patients with SUDs pose for VANHs, (2) ways VANHs are responding to these patients, and (3) patient and program characteristics predictive of VANH SUD patients' health care utilization, costs, and outcomes.

METHODS:
We used secondary analyses of VA administrative databases and a survey of VANHs to address these objectives. We identified the population of patients admitted to VANHs in FY00 and tested whether patients with SUDs present more clinical problems, use more health care services, have higher costs, or have poorer outcomes compared with non-SUD patients. A survey assessing the clinical challenges posed by patients with SUDs and the responses of VANHs to them was administered to nurse managers in 50 VANH units with high SUD prevalence. For SUD patient admissions to the surveyed units, health service use was tracked; these data and the VANH survey were used to identify individual patient and program factors that predicted SUD patients' service use, costs, and outcomes.

FINDINGS/RESULTS:
Patients with SUDs were more likely than others to be younger, male, unmarried, and low income. Patients with SUDs had particular mental health and medical comorbidities, were more independent in daily living activities, and engaged in more disruptive behavior. These differences remained when comparisons adjusted for demographics (e.g., age). Overall, patients with SUDs had lower nursing home costs, lived longer following nursing home admission, and were more often discharged to the community from the VANH. These differences were not significant when comparisons adjusted for demographics, but compared with similar non-SUD patients, patients with SUDs had higher costs for inpatient care. In the surveyed VANH units, 23% of patients had a SUD. However, treatment of SUDs was generally not viewed as central to the unit mission. Lack of staff knowledge and skills, limited information about community and hospital resources, and limited in-service training were viewed as barriers to effective treatment of patients with SUDs. Lack of coordination between VANH and SUD treatment staff and difficulties obtaining SUD services for patients with special needs also were seen as significant problems. Among factors predicting SUD patients' service use, older age appeared to be a barrier to mental health or SUD treatment, separate from patients' functioning and comorbidities. At the facility level, patients with SUDs were more likely to receive mental health and discharge services in units with more SUD assessment procedures and alternatives for intervening with patients with SUDs or problem behaviors.

IMPACT:
These findings can help VA clinicians and administrators plan for providing high quality care to patients with SUDs in VANHs by clarifying these patients' needs, the resources they may require to address their medical and psychosocial needs, the options for effective program responses, and the challenges and barriers to care of patients with SUDs.

PUBLICATIONS:

Journal Articles

  1. Smith MW, Lemke S, Schaefer J. Substance use disorders and health care costs among veterans affairs nursing home residents. Medical care. 2011 Jun 1; 49(6):538-44.
  2. Lemke S, Schaefer JA. VA nursing home residents with substance use disorders: Mental health comorbidities, functioning, and problem behaviors. Aging & mental health. 2010 Jul 1; 14(5):593-602.
  3. Lemke SP, Schaefer JA. Recent changes in the prevalence of psychiatric disorders among VA nursing home residents. Psychiatric services (Washington, D.C.). 2010 Apr 1; 61(4):356-63.
Conference Presentations

  1. Schaefer JA, Lemke S. Substance use disorder patients in VA nursing homes: Care processes, treatment resources, and priorities for improving quality of care. Poster session presented at: Quality of Behavioral Healthcare: A Drive for Change Through Research Conference; 2010 Apr 1; Clearwater Beach, FL.
  2. Smith MW, Ananth L, Chow A, Lemke S, Schaefer JA. Costs of care for VA nursing home patients with substance use disorders. Paper presented at: VA HSR&D National Meeting; 2009 Feb 24; Baltimore, MD.
  3. Lemke S, Schaefer JA. The changing mental health profile of VA nursing home patients. Paper presented at: VA HSR&D National Meeting; 2009 Feb 11; Baltimore, MD.
  4. Schaefer JA, Cronkite RC, Turrubiartes P. Six-month Abstinence Among Inpatient/Residential Substance Use Disorder Patients: An Examination of Predictors Across the Continuum of Care. Poster session presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2008 Jul 22; Arlington, VA.
  5. Smith M, Ananth L, Chow A, Lemke S, Schaefer J. Substance Abuse in Nursing Homes: Implications for Cost of Care. Presented at: American Society of Health Economists Biennial Conference; 2008 Jun 22; Durham, NC.
  6. Smith MW, Lemke S, Schaefer J, Chow A, Ananth L. Nursing home patients with substance use disorders: Implications for cost of care. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC.
  7. Lemke S, Schaefer J, Fung KZ. Characterizing the clinical challenges of younger VA nursing home patients. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
  8. Lemke S, Schaefer J, Fung K. The undiagnosed substance use disorder patient in VA nursing homes. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD.


DRA: Substance Abuse and Addiction, Aging, Older Veterans' Health and Care
DRE: none
Keywords: Frail elderly, Long-term care
MeSH Terms: none