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Unintended consequences of the VHA Millennium Act on Veterans Requiring Nursing Home Care.

Intrator O. Unintended consequences of the VHA Millennium Act on Veterans Requiring Nursing Home Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.




Abstract:

Title: Unintended Consequences of the VHA Millennium Act on Veterans Requiring Nursing Home Care Authors: Marissa Meucci, Orna Intrator, Shubing Cai, Bruce Kinosian Research Objective: The Millennium Act of 1999 instated that the Veterans Administration (VA) must provide free nursing home (NH) care for all Veterans with 70% or greater service-connected disability (priority status P1a) who are in need of such services. These Veterans are considered "mandatory" for NH care. Any resources that remain for NH care after the mandatory Veterans have been considered can then be allocated at the discretion of individual VA Medical Centers (VAMCs) to provide care for non- mandatory Veterans (priority statuses P1b-P8). This has the potential to create disparities in access to NH care geographically, and among Veterans of different priority statuses. The objective of this study was to determine whether mandatory Veterans newly admitted to VA-paid NHs were less clinically impairment than Veterans of non-mandatory statuses, and to determine whether a larger proportion of P1a Veterans receive VA-paid NH care than non-mandatory Veterans, and whether these proportions vary geographically. Study Design: We combined data from the VA, Medicare Claims, and MDS assessments to determine the demographic and case-mix characteristics of Veterans newly admitted to any NH in 2009, their priority status, preferred Veterans Integrated Service Network (VISN), and type of NH care. Population Studied: Our analysis focused on the 180,721 VHA enrolled Veterans newly admitted to NHs in 2009, 27,560 of whom relied on VA resources to pay for their care. Principal Findings: When compared non-mandatory Veterans, P1a Veterans were more likely to be younger (53% vs. 40% < 65 years old), and married (49.0% vs. 36.0%), less likely to have moderate-severe cognitive impairment (18.1% vs. 20.6%), high physical impairment (10.5% vs. 11.9%), or to be in the Rehabilitation RUG class (20.6% vs. 21.4%), and had a lower average case-mix index (0.96 vs. 0.98). Nationally, 45.6% of mandatory Veterans relied on VA-paid NH care compared to 26.2% of P1b, 28.7% of P4, and 16.1% of Veterans of other priority statuses. The percentage of mandatory Veterans relying on VA-paid care varied geographically from 61.7% - 34.9% among VISNs. Conclusions: Mandatory Veterans have greater access to VA-paid NH care than non-mandatory Veterans, and they appear to access this care earlier (as indicated by their lower level of impairment at admission). Large geographic variability in the percentage of mandatory Veterans admitted to VA-paid NHs suggests that discretionary NH provision may rely additionally on circumstances other than priority status or need for nursing home care. Implications for Policy, Delivery, or Practice: There have been recurrent proposals to expand mandated VA-paid NH coverage to include Veterans who are 50-70% service-connected (P1b's). Our current analyses suggest that P1a Veterans access VA-paid NH care earlier. Before expanding this benefit to P1b Veterans it is important to examine whether this difference in impairment is due to the hasty admission of P1a Veterans who could otherwise be managed in the community, or whether non-mandatory Veterans are delaying needed NH care until it becomes available. Our results point to the need to clarify which Veterans truly require NH care and to examine the potential benefits of establishing guidelines based on Veterans' needs.





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