HSR&D Home » Research » IIR 02-228 – HSR&D Study
Assessing Practice Variation in Long Term Care Referrals
Susan C. Hedrick, PhD
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Funding Period: April 2004 - September 2006
Long-term care (LTC) is the range of nursing home and home and community-based services (HCBS) such as home care and adult day health care that support individuals needing chronic care. In FY2005, 92% of the $2.9 billion VA LTC was spent on nursing home care. VA has made a commitment to address this imbalance by increasing the availability of HCBS.
The study objective was to obtain information about VA LTC referrals that could be used to develop interventions that may increase the likelihood of HCBS referrals.
Quantitative: The study capitalizes on the nationwide implementation of a new uniform referral form, the Geriatrics and Extended Care Referral Form (GEC). We used GEC information and administrative records to describe the number and characteristics of patients referred to LTC in four sites in VISN 20: Seattle, American Lake, and Walla Walla, WA, and Boise ID. We obtained data on 2421 patients referred for LTC during the 10-30 month GEC implementation study period. We used logistic regression at the two largest sites to identify patient characteristics that could predict referrals to nursing homes vs. HCBS.
Qualitative: We conducted 14 focus groups with clinicians making and receiving LTC referrals and administrators at five VAMCs. We conducted 47 semi-structured interviews with veterans receiving a recent LTC referral and informal caregivers. Focus group discussions and interviews were recorded and transcribed, entered in Atlas.ti software, and content analysis used to identify common themes.
Quantitative: 57.5% of the 2421 patients were referred to nursing homes, ranging from 11 to 100 percent across sites. Significant predictors of nursing home referral at either the Seattle or American Lake sites in multivariate logistic regression analyses on the 1205 patients with complete data included: service-connected 50% or greater, less support from informal caregivers, greater dependence in basic Activities of Daily Living, not receiving help in the home from RN in past 30 days or scheduled RN home visit, a goal of behavioral stabilization or skilled nursing care, and need for frequent RN observation. The significant variables in the models varied across Medical Centers, indicating further variation in practice patterns. The areas under the Receiver Operating Curve were 0.82 and 0.78 for American Lake and Seattle, respectively, indicating good and moderate predictive power for these models.
Qualitative: Themes identified through focus groups with managers and clinicians and interviews with patients and caregivers indicate that: (1) Physicians are reported as influential in the LTC referral process, yet often lacking in information about HCBS; (2) Patients frequently reported preferring to be cared for at home and informal caregivers often agreed, but do not have sufficient information and few make concrete plans; (3) system barriers to HCBS referrals include: (a) insufficient funds for HCBS, (b) variability in HCBS availability across Medical Centers, and (c) insufficient time and resources to arrange for HCBS.
The study results could be used to develop interventions designed to decrease barriers to HCBS referrals and make best use of VA's finite resources to meet the needs of the rapidly growing number of veterans in need of LTC.
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DRA: Aging, Older Veterans' Health and Care, Health Systems
Keywords: Caregivers – not professionals, Frail elderly, Long-term care
MeSH Terms: none