1155 — Trajectories and Transitions in Service Use among Older Veterans at High Risk of Long-Term Institutionalization

Lead/Presenter: Erin Bouldin,  COIN - Salt Lake City
All Authors: Bouldin ED (Elizabeth Dole Center of Excellence for Veteran and Caregiver Research; IDEAS Center, VA Salt Lake City Health Care System; University of Utah;), Brintz BJ (Elizabeth Dole Center of Excellence for Veteran and Caregiver Research; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System; University of Utah) Hansen J (Elizabeth Dole Center of Excellence for Veteran and Caregiver Research; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System; University of Utah) Rupper R (Elizabeth Dole Center of Excellence for Veteran and Caregiver Research; GRECC, VA Salt Lake City Health Care System; University of Utah) Brenner R (GRECC, VA Salt Lake City Health Care System; University of Utah) Intrator O (Canandaigua Veteran Affairs Medical Center, University of Rochester) Kinosian B (Geriatrics and Extended Care Data Analysis Center, Philadelphia Veterans Affairs Medical Center, University of Pennsylvania) Viny M (Elizabeth Dole Center of Excellence for Veteran and Caregiver Research; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System; University of Utah) Dang S (Elizabeth Dole Center of Excellence for Veteran and Caregiver Research; GRECC, Miami VA, University of Miami Miller School of Medicine) Pugh MJ (Elizabeth Dole Center of Excellence for Veteran and Caregiver Research; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System; University of Utah) Elizabeth Dole Center of Excellence for Veteran and Caregiver Research Team

Objectives:
We aimed to identify groups of Veterans aged 65 years and older based on the types of long-term support services (LTSS) they used, describe transitions between groups, and identify factors influencing transition.

Methods:
We explored LTSS across the care continuum from clinic to home-based and institutional care. We used combined VHA and Medicare data. Analyses included 104,837 Veterans who were 65 years and older between fiscal years 2014–2017 and were at high risk for long-term institutionalization (LTI), based on a machine learning model to forecast the 2-year risk of LTI, using demographic, health conditions, and service use information from the Geriatrics and Extended Care Data Analysis Center (GECDAC). We used latent class analysis (LCA) to identify groups and latent transition analyses (LTA) to assess group membership changes over a three-year period. LCA models assign people to the class with the highest probability and estimate the probability of using a specific LTSS given membership in a latent class. LTA models estimate the probability of moving between latent classes over time, including the odds of transition for covariates included in the model.

Results:
We identified five latent classes (groups): 1) No Services, a composite of non-LTSS users and decedents; 2) Medicare Services, characterized by the use of LTSS only in Medicare; 3) VHA-Medicare Care Continuum, which included LTSS use in various categories and in both VHA and Medicare; 4) Personal Care Services, characterized by high probabilities of using VHA homemaker/home health aide or Veteran-Directed Care and 5) Home-Centered Interdisciplinary Care, characterized by the use of mostly home-based LTSS, like Home-Based Primary Care along with personal care. Probabilities for facility-based care were relatively high in both Medicare Services and VHA-Medicare Care Continuum and lower in Personal Care Services and Home-Centered Interdisciplinary Care. White Veterans were more likely to be in the Medicare Services group than in other groups while Black Veterans were more likely to be in a group other than Medicare Services. Based on the LTA, Veterans frequently stayed in the same class over the three years (30-46% in each class) or moved into the No Services class (40-47%). Having a hip fracture, self-care impairment, or severe ambulatory limitation increased the odds of moving out of No Services, and incontinence and dementia increased the odds of moving into the VHA-Medicare Care Continuum.

Implications:
This Veteran cohort at high risk of LTI was best characterized by five classes of LTSS use. Veterans with substantial health conditions and impairments used a combination of services from across the care continuum and a mix of VHA and Medicare services to manage their health.

Impacts:
Understanding LTSS service use combinations and factors impacting changes in these patterns can inform service delivery, program development, and future resource allocation to better meet aging Veterans’ needs. Our results suggest Veterans receiving personal care and interdisciplinary services in-home may have less facility-based care. These finding also underscore the imperative to focus efforts on building better conduits for information exchange and coordination of care between VHA and Medicare sites across the care continuum.