Does the Veterans Health Administration Purchase High-Quality Home Health Care?

Kennedy KA, DeVone F, Cornell PY, Gozalo P, Thomas KS, Gravenstein S, Magid KH, Mroz T, Jones CD. Does the Veterans Health Administration Purchase High-Quality Home Health Care? Journal of The American Medical Directors Association. 2025 May 21; 105684, DOI: 10.1016/j.jamda.2025.105684.

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Abstract:

OBJECTIVES: Veterans are frequently referred for skilled home health care (HHC) after hospital discharge. We examined access to high-quality VA-contracted home health agencies (HHAs) for Veterans following a VA medical center (VAMC) hospitalization and by rural or urban residence. DESIGN: Retrospective observational study. SETTING AND PARTICIPANTS: We used national VA data from April 2015 to September 2019 and included all Veterans discharged from a VAMC hospitalization who received skilled HHC paid for by VA. METHODS: We assigned every eligible discharge a choice set of VA-contracted HHAs serving the Veteran's county and a choice set of all HHAs serving the Veteran's county. We calculated a quality ratio (QR): the percentage of high-quality VA-contracted (4- or 5-star) HHAs relative to all high-quality HHAs serving the county reported in Home Health Compare. We then aggregated the QR by VAMC. High QRs (average QR and 95% CI > 1) indicate VA contracts with higher-quality HHAs, relative to all HHAs serving the county. Neutral QRs (positive or negative average QR and 95% CI includes 1) indicate no difference in quality. Low QRs (average QR and 95% CI < 1) indicate a lower-quality network. We examined bootstrapped QRs by VAMCs, including the subset serving mostly rural Veterans. RESULTS: We identified 60,406 VA-paid HHC episodes for 42,010 Veterans discharged from 113 VAMCs. Although 61.1% of VAMCs had high QRs, only 27.3% of the 33 VAMCs serving rural Veterans had high QRs. Rural-residing Veterans had lower proportions of high QRs than urban Veterans (46.3% vs 64.0%) and nearly double the proportion of neutral QRs (31.5% vs 16.2%), but similar proportions of low QRs (22.2% vs 19.1%). CONCLUSIONS AND IMPLICATIONS: Overall, VA-contracted HHAs were of higher quality compared to available HHAs serving Veterans' counties. Although VAMCs serving mostly rural Veterans provided less access to higher-quality HHAs, this effect was driven by lower access to multiple HHAs in rural counties, not by differentially contracting with lower-quality HHAs.