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.
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.
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.
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.
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.
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