Spotlight on Long Term Care

December 2018

Introduction

VA offers multiple long-term care (LTC) services to Veterans, including residential and nursing home settings, home- and community-based care, shared decision making, and advance care planning¹. VA's Office of Geriatrics and Extended Care (GEC) oversees VA's programs to provide both geriatric and LTC programs and services to Veterans². Investigators within HSR&D, particularly the Center of Innovation in Long-Term Services and Supports (LTSS COIN)³, conduct research into the delivery, effectiveness, and value of LTC services. Further, in accordance with the Mission Act and the Veteran Access Choice and Accountability Act before it, and due to the large number of Veterans expected to need LTC in upcoming years, HSR&D researchers continue to seek the best mix of clinical and community-based care for chronic and age-related LTC⁴. December’s Web Feature highlights several studies investigating attempts to improve Veteran experiences by bringing LTC out of traditional residential settings and into the community.

• Helping Invested Families Improve Veterans' Experiences (HI-FIVES)
• Implementing and Evaluating INTERACT in VA Community Living Centers
• Increasing Veterans' Use of Community-based LTC via timely Discharge from VA Community Living Centers
• Medical Foster Homes: A Safe, Cost Effective Substitute for Nursing Homes?

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Helping Invested Families Improve Veterans’ Experiences (HI-FIVES)

The 1999 Millennium Act, which expanded coverage of Long Term Care for Veterans, stipulated that Veterans receive care in the least restrictive setting possible - often their homes, yet half of informal VA caregivers report that they have not received necessary training. In this study, a control group of informal caregivers received support line, web site, and contact information, while an intervention group received the HI-FIVES informal caregiver training program, consisting of 3 tailored phone calls with a nurse, 4 group sessions, and 2 additional tailored calls. While final results are pending, preliminary findings were:

• HI-FIVES was associated with a clinically meaningful but not statistically significant18% increase in the rate of days at home for the patient/Veteran, translating to a mean difference of 2 days over a year.
• For caregiver experience of VA care, the mean difference between HI-FIVES and controls at 6 months was 0.53.
• For patient experience of VA care, the mean difference between HI-FIVES and controls at 12 months was 0.48.
• No significant differences were observed in health care system costs or in depression scale scores.

Implications:  Skills training advances caregiver and patient perceptions of VA care quality, and shows promise towards increasing the days a patient remains at home 12 months following the intervention. Skills training does not ameliorate caregiver depressive symptoms, thus other approaches are needed to clinically treat depression. HI-FIVES skills training results increase knowledge about how to improve caregivers’ and patients’experience of VA care.

This study resulted in the following publication(s):

Van Houtven CH, Oddone EZ, Hastings SN, et al., Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES): study design and methodology. Contemporary clinical trials. 2014 Jul 1; 38(2):260-9.

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Implementing and Evaluating INTERACT in VA Community Living Centers

Avoiding preventable hospitalizations for nursing home (NH) residents reduces hospitalization-associated complications including: distress, delirium; poly-pharmacy, falls; hospital-acquired infection (HAI); poor nutrition, loss of mobility, and pressure ulcers. INTERACT trains staff to identify Veterans' changes in condition earlier, communicate more effectively to clinicians, and evaluate and safely manage acute changes in the residence when feasible, thereby avoiding unnecessary hospitalizations. Based on the substantial reduction of hospitalizations among residents in NH’s using INTERACT, this study sought to implement and evaluate the QI program in 8 VA Community Living Centers (CLCs) pair matched with 8 control CLCs. Staff was trained for 6 months and monitored for 12 months. Findings were:

• The SBAR tool, a component of INTERACT designed to document changes in Veterans’ clinical condition, was used very differently across participating CLCs.
• Other aspects of the INTERACT interventions were also implemented inconsistently.
• The intervention CLC hospitalization rates declined slightly, but not statistically significantly, compared to rates in control CLCs.
• Only 12% of hospitalizations were found to be avoidable using the Agency for Healthcare Research and Quality (AHRQ) diagnosis based algorithm.
• Only 7% of cases were determined to have been avoidable based upon blinded clinician reviews.

Implications:  Based upon our analyses, rates of avoidable hospitalizations from CLC, whether using the AHRQ algorithm or clinicians' judgment, were much lower than anticipated and previously reported in the literature, suggesting that the relatively high rate of hospitalization from CLC may be warranted.

This study resulted in the following publication(s) to date (others are in process):

Mochel AL, Henry ND, Saliba D, et al., INTERACT in VA Community Living Centers (CLCs): Training and Implementation Strategies. Geriatric nursing (New York, N.Y.). 2018 Mar 1; 39(2):212-218.

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Increasing Veterans' Use of Community-based LTC via timely Discharge from VA Community Living Centers

Prompted by the escalating costs of institutional care and the preferences of most Veterans who require these services to remain in the community, shortening length of stay (LOS) and increasing safe discharge from VA Community Living Centers (CLCs) is a top priority for VA Geriatrics and Extended Care (GEC). Researchers analyzed discharges from VA CLCs between 2004 and 2012, and conducted more than 100 semi-structured interviews with staff, residents, and families at 8 CLCs to determine Veteran, CLC, and market factors that influenced 30-day Successful Discharge (SD), defined as discharge to the community without hospitalization or other institutionalization in the 30 days following discharge.

Findings were:

• Veterans with longer LOS were more likely to have a successful discharge.
• Older Veterans were less likely to experience SD.
• Black Veterans had higher odds of SD than Caucasian Veterans.
• Veterans with diagnoses of chronic heart failure, chronic obstructive pulmonary disease, diabetes, and bowel incontinence were less likely to experience SD.
• Veterans admitted for rehabilitation stays were more likely, and those admitted for skilled nursing stays were less likely, to achieve SD than Veterans admitted to the CLC for other reasons.
• At the facility level, a higher average daily census was associated with higher rates of SD, but there was no relationship between SD and nurse staffing, nor between SD and average Veteran impairment level.
• Barriers to timely discharge included lack of financial and social support, while facilitators included early discharge planning, coordination with interdisciplinary teams, and family involvement in the discharge process.

Implications:  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 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.

This study resulted in the following publication(s):

Thomas KS, Cote D, Makineni R, et al., Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community. Journal of Aging & Social Policy. 2018 Mar 1; 30(2):93-108.

Tyler DA, Shield RR, Harrison J, et al., Barriers to a timely discharge from short-term care in VA Community Living Centers. Journal of Aging and Social Policy.  in press.

Harrison J, Tyler DA, Shield RR, et al., An unintended consequence of culture change in VA Community Living Centers. Journal of the American Medical Directors Association 2017, Apr 1; 18(4): 320-325.

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Medical Foster Homes: A Safe, Cost Effective Substitute for Nursing Homes?

Medical Foster Home (MFH) is a program for Veterans who meet nursing home (NH) level of care but instead receive care in the home of a foster family with the support of an interdisciplinary VA Home Based Primary Care (HBPC) team. Researchers sought to discover what leads Veterans to select or reject MFH’s over NH care, assess Veterans’ safety, and compare costs to traditional NH care. Qualitative data were gathered in a series of interviews with Veterans and program officials at three high-enrollment and three low-enrollment MFH’s. Data were analyzed for 212 MFH enrolled and 511 NH enrolled Veterans between 2008 and 2012.

Findings were:

• MFHs provide a safe alternative to nursing home placement by serving NH eligible Veterans in a home environment.  
• The decision to enroll requires an appropriate physical space in a desirable location, collaboration between Veterans, caregivers and medical teams, appropriate perceptions and expectations about MFH and, most importantly, an ability to afford the average out-of-pocket payment of $2,500 per month for MFH.
• Attributes which promoted access to MFH included a full time MFH coordinator at each medical center, pursuit of appropriate referrals, unmitigated HBPC engagement, and a match between Veteran, home, and caregiver.
• The overall rate of avoidable hospitalizations declined from 18.5 to 14.9 per 100 MFH enrollees, and the number of bed days declined by 39% in the first six months of MFH enrollment compared to the prior six months.
• Among the MFH enrolled Veterans compared to the NH enrolled Veterans, the reduction was at least $2645 per veteran per month

Implications:  VA expenditures for 2016 NH care were an estimated $970 million, nearly a three-fold increase over 10 years. These costs are expected to accelerate as the number of Priority 1a Veterans over the age of 65 years of age increases, from approximately 600,000 in 2016 to over 1 million by 2025. These data are being used in legislative efforts to lower costs (H.R. 294), by extending eligibility for MFH to Veterans currently eligible for NH care.

This study resulted in the following recent publication(s):

Levy C, Whitfield E. Medical Foster Homes: Can the adult foster care model substitute for nursing home care? J Am Geriatr Soc. Dec 2016; 64(12):2585-2592.

Gilman C, Haverhals L, Manheim C, Levy C. A qualitative exploration of veteran and family perspectives on medical foster homes. Home Health Care Services Quarterly. Dec 2017. 1-24.

Jones J, Haverhals LM, Manheim C, Levy C. Fostering Excellence: An Examination of High Enrollment VHA Medical Foster Home Programs. Home Health Care Management & Practice. 2017; 30(1): 16-22. 

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