June 2022

In This Issue: HSR&D Research on Community Care
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Improving Post-Acute Care Value for Veterans

Feature Article

Takeaway: This study will develop two tools (one for use at the bedside, and one for use nationally) to help optimize the choice of a skilled nursing facility to maximize value for Veterans who need rehabilitation after being discharged from the hospital.

More than 200,000 Veterans are discharged from the hospital to skilled nursing facilities (SNFs) annually, but more than 1 in 4 are readmitted to the hospital – and less than half have returned to the community by 100 days after hospital discharge. Although the intent of SNF care is to allow recuperation and rehabilitation, Veterans who do not successfully recover are commonly placed in institutional long-term care at significant cost to themselves and to VA, which spends more than $7 billion annually on institutional care. Veterans receive care in SNFs inside and outside VA, with different rates of success in returning them to the community. However, it is unclear how to identify “high-value” SNFs (those that deliver the best community discharge rates at lowest cost) for Veterans. The three most common post-acute care settings where Veterans receive SNF care are community living centers (CNHs), and non-VA SNFs.

This ongoing study (October 2021 – September 2025) seeks to identify “high-value” SNFs across VA and non-VA facilities – and to understand how much “matching” a Veteran with specific needs to specific SNFs improves value. Investigators will then use what they have learned to build models for how VA can create the highest-value SNF network possible. Specific aims include:

• Comparing outcomes (successful discharge to the community) and costs (federal dollars) across the population of Veterans discharged from a VA hospital to the three most common post-acute care settings where Veterans receive SNF care.
• Evaluating the effect of matching individual subpopulations of Veterans (e.g., by risk for adverse outcome) to SNF type (CLCs, CNHs, or non-VA SNFs) and SNF star rating on outcomes and costs.
• Comparing the effects of consolidating SNF referrals to the SNF type with best outcomes and lowest costs – or matching individual Veteran characteristics to different SNFs on Veteran outcomes, overall costs of care, and SNF capacity.

Methods

To establish the study’s goals, investigators are using advanced statistical techniques, such as instrumental variable and machine learning methods, as well as a unique dataset – the 2015-19 Residential History File (RHF), which links VA, fee-basis, Medicare, and Medicaid data into longitudinal episodes of care for individual Veterans and is provided by the Geriatrics and Extended Care Data Analysis Center (GECDAC). Investigators are also conducting a review of published tools to improve post-acute care choice – and are interviewing key stakeholders to ensure the tools are user-centered.

Findings

None to report at this time.

Anticipated Impact

Study results will be disseminated to VA Community Care leadership, as well as VISN and VA facility leadership through two tools that can be used at the bedside to optimize SNF choice – and at a leadership level to help shape the SNF network to maximize value. These represent novel contributions, as currently there are no published studies describing the outcomes of Veterans in post-acute care, identifying characteristics of high-performing facilities, nor establishing how matching patient to post-acute care provider characteristics affects outcomes.

Principal Investigator:  Robert Burke, MD, MS, is part of HSR&D’s Center for Health Equity, Research and Promotion (CHERP).

Publications

None to report at this time.

View study abstract