Background / Rationale:
Prompted by the escalating costs of institutional care and the preferences of most Veterans who require these services to remain in the community, the landscape of VA long term care (LTC) is changing rapidly. Shortening length of stay (LOS) and increasing safe discharge to the community in VA Community Living Centers (CLCs) is a top priority for VA Geriatrics and Extended Care (GEC), both to accommodate the increasing number of Veterans who require post-acute care, and to facilitate timely return to the community with needed home and community-based services (HCBS).
The objectives of this project were to examine changes in VA CLCs over time (2004-2012), and to identify the veteran, facility, and HCBS market factors associated with Successful Discharge to the community, i.e., without readmission to CLC, admission to a community nursing homes, or rehospitalization.
Mullti-level regression analyses using data from a wide variety of VA and non-VA data sources identified Veteran, CLC and market factors that influenced Successful Discharge to the community, i.e., discharges that result in maximum possible time spent out of institutions. We also constructed county-level markets to determine availability of Medicare, Medicaid and VA home health services in Veteran county of residence (Veteran market) and in clusters of counties that contain 75% of Veterans served by a given CLC (CLC market). Rates of HCBS utilization (as a proxy for availability) were then used in multi-level analyses to determine influence of home health services on key study outcomes.
Quantitative data was complemented by 8 site visits to CLCs with varying characteristics and locations. Over 100 semi-structured qualitative interviews were conducted with key staff, selected residents and families to determine their awareness of and attitudes regarding the culture and mission of VA CLCs, particularly as they relate to timely discharge to the community with HCBS.
Findings / Results:
Change Over Time We found that the proportion of both non-hospice Short (< 90 days) and non-hospice Long Stays (>90 days) admitted to CLCs decreased over the study period (2004-2011), and the proportion of Hospice Stays increased. We also observed some variation in CLC LOS but little overall change, although there is significant variation among CLCs nationally. Modest increases in the proportion of Veterans discharged to the community (rather than to the hospital or a community nursing home) and, among those discharged to the community, who had a successful discharge (without rehospitalization or bounceback to the CLC), were observed for both Long Stay and Short Stay Veterans.
Multivariate Results Findings indicate wide variation in county rates of Medicaid, Medicare and VA home health service availability across Veteran and CLC markets. We used logistic regression analysis adjusting for clustering at the CLC level to identify predictors of Veterans' 30 day Successful Discharge to the Community. Veteran LOS was positively related to SD, while Veteran age was negatively related to SD, and Veterans of Black race had higher odds of SD than Veterans who were Caucasian. Veterans with diagnoses of chronic heart failure, chronic obstructive pulmonary disease, diabetes and bowel incontinence were less likely to have a SD than Veterans without these diagnoses. Finally, Veterans admitted for Rehabilitation stays were more likely, and those admitted for skilled Nursing stays were less likely than Veterans admitted to the CLC for other reasons. At the facility level, CLCs' Average Daily Census (ADC) was positively related to 30 day Successful Discharge (SD). Higher aide hours per bed day were inversely related to SD but RN and LPN staffing levels were not related to this outcome, nor was the CLC average impairment level of Veterans served . "Rich" Medicare HHA markets increased the odds of SD but rich Medicare OT/PT appear to be inversely related to SD. VA HHA and HBPC were not related to SD in our model.
Budget Impact Since change in LOS was relatively stable over the study period, we examined the impact of change in type of stay. A decrease of 179,809 short stay beddays and a decrease of 907,933 long stay beddays occurred between 2004-2011, while we observed an increase of 106,511 hospice beddays. Short stays are more expensive than either hospice or long stays, thus it is likely that substantial savings were associated with the expansion of hospice care in VA CLCs.
Site Visit Results Qualitative analysis of site visit interview data reveals a number of barriers to discharging Veterans from CLCs as soon as treatment goals are met. Key among these barriers are lack of financial resources, lack of social support to provide care in the community, Veteran disinclination to leave the CLC, and staff attitudes toward keeping Veterans in the CLC ("they deserve to be here"). Facilitators to timely discharge to the community were the initiation of discharge planning at Veteran admission to the CLC, a well-functioning interdisciplinary team, CLC relationships with community agencies, and family involvement in the discharge process.
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 the 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.
- Allen SM, Thomas K., Youssef R, Cutty M. Getting Stuck in VA's Community Living Centers. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
- Hartmann CW, Wewiorski N, Palmer JA, Hilgeman M, Halli A, Jacobs L, Parmelee P, Snow L. Quantifying Nursing Home Person-Centered Care: Development of a New Systematic Observation Tool of Resident and Staff Engagement and Relationship. Presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
- Pimentel C, Snow L, Palmer JA, Allen RS, Wewiorski NJ, Hopkins S, Hartmann CW. Facilitation As an Effective Implementation Strategy for Quality Improvement Efforts in Nursing Homes. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
- Allen SM, Cote DL, Wysoki A, Thomas K, Intrator O, Youssef R, Kinosian B, Phibbs CS, Mor V. A National Profile of Change in VA Community Living Centers 2004-2011. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
- Thomas K, Cote DL, Intrator O, Kinosian B, Mor V, Phibbs CS, Wysocki A, Makineni R, Youssef R, Allen SM. Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community. Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN.