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Management Brief No. 156

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Management eBriefs
Issue 156July 2019

The report is a product of the VA/HSR Evidence Synthesis Program.

Evidence Review: Risk Factors and Interventions to Prevent or Delay Long-term Nursing Home Placement for Adults with Impairments

In fiscal year 2020, VA is projected to spend $9.8 billion on long-term care services for eligible Veterans. Recent legislation also has created and expanded VA programs to support informal caregivers (i.e., family or friends who provide unpaid care for Veterans with substantial impairments). In 2017, the VA Secretary launched the Choose Home Initiative to enhance VA policies and practices for supporting Veterans and their informal caregivers—and to improve collaboration with non-VA community groups — thereby helping Veterans with significant impairments remain in community settings, if they choose. To help VA policymakers understand the effects of VA-provided or VA-funded home and community-based services (HCBS), particularly in avoiding long-term nursing home placement (NHP), the VA Evidence Synthesis Program was asked to examine evidence on modifiable risk factors for long-term nursing home placement and interventions that aim to delay long-term NHP for community-dwelling adults with physical and/or cognitive impairments.

Investigators with VA's Evidence Synthesis Program in Minneapolis, MN searched for systematic reviews in multiple databases, including: MEDLINE, Sociological Abstracts, PsycINFO, CINAHL, Embase, Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, Agency for Healthcare Research and Quality Evidence-based Practice Center and VA ESP reports. They screened 7,014 unique citations for systematic reviews and reviewed the full text of 336 articles, identifying 67 eligible systematic reviews, which mainly addressed older adults and/or those with dementia. Articles were included if review authors clearly intended to examine long-term NHP as an outcome of interest. Investigators found no eligible reviews that addressed long-term NHP for individuals with PTSD and/or traumatic brain injury (TBI).

Summary of Review
Existing evidence on a wide range of risk factors and interventions for older adults demonstrated the complexity of contributors to long-term nursing home placement and the difficulty of preventing or delaying this outcome. There was a lack of evidence evaluating certain risk factors, particularly at the level of systems and environment. While evidence on case management, caregiver support, and preventive home visits showed no benefit overall for delaying or preventing long-term NHP across studies, a few high-intensity models of these interventions may delay long-term NHP. Although there are a variety of VA programs and services that seek to help Veterans with impairments, many do not involve similar levels of participant contact and dedicated coordination of care and services over years, compared with those interventions that delayed long-term NHP.

Additional key findings:

  • Frailty status and higher frailty scores were associated with higher risk for long-term NHP.
  • Functional impairments, including difficulty with activities of daily living, demonstrated the most consistent and substantial associations with higher risk for long-term NHP.
  • Caregiver distress and/or burden was associated with higher risk for long-term NHP.
  • For a variety of other interventions, such as physical activity, home-based primary care, and assistive technologies, very limited to no evidence was available for effects on long-term NHP.
  • Adult day clinics did not decrease long-term NHP but evidence for respite care (in a variety of settings) was inconclusive.

Policy Implications
As an integrated national healthcare system, VA may be better situated to ensure integration of services across settings to meet the entire range of needs for eligible Veterans with impairments. However, VA also purchases substantial amounts of care provided by non-VA community agencies and organizations. This is especially true for long-term care services, in which the majority of Veterans receiving VA-paid HCBS and nursing home care are served by non-VA providers. It seems unlikely that VA can change the landscape of local resources (and availability of new models of care), unless it strategically partners with organizations that determine the majority of financial incentives (and regulations) for long-term care service providers in the US.

Additionally, VA facilities differ in the number and types of long-term care programs and services that are provided and/or funded. Understanding what is available at a particular VA facility – and coordinating services across multiple VA programs at the same facility – remain key challenges for Veterans, their caregivers, and VA clinical staff. Therefore, case management for Veterans with impairments may offer substantial benefits, despite the lack of effectiveness in general, as suggested by review results. To impact long-term NHP, case management (and other similar interventions) should have relatively high-frequency longitudinal contacts with participants, be initiated early in the course of chronic conditions (e.g., dementia), and extend for at least several years.

More specific suggestions include:

  • Organize and streamline VA programs and services according to their key goals, which may include delaying long-term NHP or other important outcomes, such as caregiver support and wellbeing.
  • Compare VA programs that aim to prevent or delay long-term NHP with models of high-intensity interventions (i.e., case management, caregiver support, and/or home visits) that have some evidence for effects on long-term NHP – and consider that lower-intensity programs may have low likelihood of changing long-term NHP.
  • Combine implementation of improved assessment for physical and cognitive impairments and social resources with programs to provide dedicated, longitudinal care coordination over years, in order to change long-term NHP.
  • Evaluate programs (including alternative residential settings that provide a high level of care) for cost-effectiveness from improved patient and family-centered outcomes, rather than cost-savings (from avoidance of long-term NHP).
  • Leverage past VA experience with the implementation of complex programs that address both healthcare and social needs for vulnerable Veterans to develop new models of support.

Future Research
Investigators recommend the following targets for future research:

  • Longitudinal observational studies examining whether individuals with PTSD and/or TBI are at substantial risk of long-term NHP.
  • Longitudinal studies on the effect of factors such as attitudes and preferences for settings of care, and systems and environmental factors (e.g., local availability of HCBS), on long-term NHP.
  • Randomized evaluations of complex interventions that compare models of care which differ in only 1-2 key components or characteristics (e.g., similar types of services at home vs in clinic).
  • Randomized evaluations of interventions with longer follow-up (likely >2 years) and larger sample size, particularly if targeting individuals at lower overall risk of long-term NHP.
  • Consider strategies to optimize selection of intervention components and evaluation designs that explicitly consider implementation outcomes in future studies of complex interventions to address long-term NHP.

Duan-Porter W, Ullman K, Rosebush C, McKenzie L, Ensrud KE, Ratner E, Greer N, Shippee T, Gaugler J, and Wilt TJ. Risk Factors and Interventions to Prevent or Delay Long- Term Nursing Home Placement for Adults with Impairments. VA ESP Project #09-009; 2019.

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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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