Factors Contributing to Patient Satisfaction Among VA Medical Center and Non-VA Medical Center Hospitals.

INTRODUCTION: Veteran satisfaction of care within the Veterans Affairs is typically very high. Yet recommendation ratings of VA medical center (VA) hospitals as measured by Hospital Consumer Assessment of Healthcare Providers and Systems are generally lower than non-VA hospitals.Therefore, it was our objective to assess Veteran satisfaction and recommendation scores and then examine whether satisfaction correlates to recommendation. METHODS: We identified all acute care VAs as our primary analytic cohort. As a comparator group, we also included all acute care academic hospitals (non-VAs), as designated by the Centers for Medicare Services. Using data from Hospital Consumer Assessment of Healthcare Providers and Systems and Strategic Analytics for Improvement and Learning (SAIL) Value Model, we collated patient satisfaction scores, as well as markers of surgical safety from Hospital Compare. We then analyzed the correlation within VAs and non-VAs, primarily focusing the relationship between the "would you recommend Hospital Rating" and subdomains of the "Overall Hospital Rating," as well as a composite score of patient safety. RESULTS: A total of 133 VAs and 1116 non-VAs were identified. Among VAs, the "Would you Recommend" hospital rating was significantly and positively correlated with markers of patient satisfaction including care transitions (Pearson's r = 0.59, P = 0.03), Nursing communication (Pearson's R 0.79, P = 0.001), and percent of primary care provider wait times less than 30 min (Pearson's r = 0.25, P = 0.01). VA-recommended scores were negatively correlated with factors such as time to emergency department discharge, and the "leaving the emergency department before being evaluated." When looking at non-VAs, correlation directions were similar, albeit with stronger associations at almost every metric. While recommended scores correlated strongly to overall hospital ratings for both groups, VAs had no significant correlation between "would you recommend" and patient safety. However, there was a slight negative correlation between patient safety and "recommend" among non-VAs. CONCLUSIONS: Although satisfiers and dissatisfiers of care appear similar between VAs and non-VAs, "would you recommend" is a far weaker marker of patient perceptions of safety and quality. These seemingly empathetic markers such as "would you recommend" should be used with caution as they may not address the fundamental question being asked.

The interprofessional Veterans Affairs Quality Scholars program pre- and postdoctoral nurse fellow outcomes.

BACKGROUND: The Department of Veterans Affairs (VA) Quality Scholars (VAQS) program, an interprofessional fellowship that includes pre- and postdoctoral nurses, aims to inspire practice change leaders. Fellows participate in a national curriculum, lead improvement/research teams, and establish professional development plans with expert mentor guidance. PURPOSE: To describe the distinctive elements of the VAQS program, nurse fellow outcomes, and accomplishments of nurse alumni as leaders, researchers, and educators. METHODS: Data were reviewed and aggregated from past and current fellow surveys. FINDINGS: Nurse fellows completed research and improvement projects that benefitted both the VA and the local health systems. Scholarly outcomes include publications, conference presentations, grant submissions, teaching/leading quality improvement, and research initiatives. Graduates transition to positions as nurse scientists, academic faculty, and operational leaders. DISCUSSION: Fellows contribute to the strategic priorities of local and national VA and external health care organizations providing a pipeline of health system expert leaders, educators, and researchers. CONCLUSION: Doctoral nursing fellowship experiences build human capital for enhancing the science of improvement and implementation, interprofessional collaboration, and leadership.

Social determinants of mental health care systems: intensive community based Care in the Veterans Health Administration.

BACKGROUND: Since deinstitutionalization in the 1950s-1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health. Analysis of the place of community-based programs within a comprehensive health system such as the Veterans Health Administration (VHA) may illuminate the role of social forces in shaping contemporary public mental health systems. METHODS: National VHA administrative data were used to compare veterans who exclusively received outpatient clinic care to those receiving four types of specialized community-based services, addressing: 1) functional disabilities from severe mental illness (SMI), 2) justice system involvement, 3) homelessness, and 4) vocational rehabilitation. Bivariate comparisons and multinomial logistic regression analyses compared groups on demographics, diagnoses, service use, and psychiatric prescription fills. RESULTS: An hierarchical classification of 1,386,487 Veterans who received specialty mental health services from VHA in Fiscal Year 2012, showed 1,134,977 (81.8%) were seen exclusively in outpatient clinics; 27,931 (2.0%) received intensive SMI-related services; 42,985 (3.1%) criminal justice services; 160,273 (11.6%) specialized homelessness services; and 20,921 (1.5%) vocational services. Compared to those seen only in clinics, veterans in the four community treatment groups were more likely to be black, diagnosed with HIV and hepatitis, had more numerous substance use diagnoses and made far more extensive use of mental health outpatient and inpatient care. CONCLUSIONS: Almost one-fifth of VHA mental health patients receive community-based services prominently addressing major social determinants of health and multimorbid substance use disorders.

Implementation of Legionella Prevention Policy in Health Care Facilities: The United States Veterans Health Administration Experience.

CONTEXT: The Veterans Health Administration requires implementation of Legionella prevention policy in potable water systems at Department of Veterans Affairs (VA) medical facilities across the United States and territories. PROGRAM: The Veterans Health Administration Central Office program offices with expertise in engineering and clinical aspects of Legionella prevention policy have provided joint, structured on-site assistance to VA medical facilities for consultation on policy implementation. Site visits included review of facility documentation and data, discussions with staff, touring of buildings, and development of recommendations. IMPLEMENTATION: Information obtained from on-site consultative assistance provided to VA medical facilities from December 2012 through January 2018 was reviewed to identify engineering and clinical challenges and lessons from implementation of Legionella prevention policy in VA health care buildings. Fifteen consultative site visits were conducted during this period regarding implementation of Legionella prevention and validation of effectiveness. EVALUATION: It was found that implementation of Legionella prevention policy in potable water systems was complex and practices varied for each building. Common implementation challenges included capability of applying engineering controls, water stagnation, and assessment of health care association of Legionella cases. Process challenges included routine verification of actions, methods for assessing environmental validation data, and documentation of requirements. It was found that consistent and data-driven implementation of policy is crucial for an effective program. DISCUSSION: Guidance and standards documents in the community for Legionella prevention in building water systems are often general in nature, but implementation requires specific decisions and routine assessments and modifications to optimize outcomes. This real-world review of challenges and lessons from a large health care system with a detailed primary Legionella prevention policy informs future development of guidance and policy, both within and external to VA, and can provide insight to other health care facilities planning to implement practices for water safety.

Treatment of Low Back Pain With Opioids and Nonpharmacologic Treatment Modalities for Army Veterans.

BACKGROUND: In the Veterans Health Administration (VHA) there is growing interest in the use of nonpharmacologic treatment (NPT) for low back pain (LBP) as pain intensity and interference do not decrease with opioid use. OBJECTIVES: To describe overall and facility-level variation in the extent to which specific NPT modalities are used in VHA for LBP, either alone or as adjuncts to opioid medications, and to understand associations between veterans' clinical and demographic characteristics and type of treatment. RESEARCH DESIGN: This retrospective cohort study examined use of opioids and 21 specific NPT modalities used by veterans. SUBJECTS: VHA-enrolled Iraq and Afghanistan veterans who utilized care in ("linked" to) 130 VHA facilities within 12 months after their separation from the Army between fiscal years 2008-2011, and who were diagnosed with LBP within 12 months after linkage (n=49,885). MEASURES: Measures included per patient: days' supply of opioids, number of visits for NPT modalities, and pain scores within one year after a LBP diagnosis. RESULTS: Thirty-four percent of veterans filled a prescription for opioids, 35% utilized at least 1 NPT modality, and 15% used both within the same year. Most patients with LBP receiving NPT, on average, had moderate pain (36%), followed by low pain (27%), severe pain (15%), and no pain (11%). Eleven percent had no pain scores recorded. CONCLUSIONS: About 65% of VHA patients with a LBP diagnosis did not receive NPT, and about 43% of NPT users also were prescribed an opioid. Understanding utilization patterns and their relationship with patient characteristics can guide pain management decisions and future study.

Implementation and Dissemination of a Department of Veterans Affairs Oral Care Initiative to Prevent Hospital-Acquired Pneumonia Among Nonventilated Patients.

Implementation and dissemination of an oral care initiative enhanced the safety and well-being of Veterans at the Salem VA Medical Center by reducing the risk of non-ventilator-associated hospital-acquired pneumonia (NV-HAP). The incidence rate of non-ventilator-associated hospital-acquired pneumonia decreased from 105 cases to 8.3 cases per 1000 patient-days (by 92%) in the initial VA pilot, yielding an estimated cost avoidance of $2.84 million and 13 lives saved in 19 months postimplementation. The team was successful in translating this research into a meaningful quality improvement intervention in 8 VA hospitals (in North Carolina, Texas, and Virginia) that has promoted effective and consistent delivery of oral care across hospital service lines and systems, improved the health of Veterans, and driven down health care costs associated with this largely preventable illness. The steps needed for successful replication and dissemination of this nurse-led, evidence-based practice are summarized in this article.

Telemedicine broadening access to care for complex cases.

BACKGROUND: Surgical and nonsurgical specialists are highly centralized, making access to high-quality care difficult for many Americans. We explored the feasibility, benefits, preliminary outcomes, and patient satisfaction with a new type of health visit, in which a surgical oncologist used video telecommunication to manage and treat complex cancer diseases, including patients with severe comorbidities. MATERIALS AND METHODS: Patients visited local VA medical centers throughout Florida to engage in video telecommunication visits with a centralized surgical oncologist in Miami, who directed their oncology treatment. The average length of stay and rate of unplanned readmission were calculated within each organ. The total mileage saved was calculated by subtracting the distance between the patient's home address and the local VA from the distance between the patient's home address and the Miami VA. Travel costs were determined by the VA's reimbursement of $0.415/mile for health-related travel and reimbursement of $150.00 for an overnight hotel stay. A Likert scale with both positively and negatively keyed questions was used to assess patient satisfaction. RESULTS: In 24 mo, seven unplanned readmissions occurred among 195 operations. Patients experienced an 80.7% reduction in travel distance and saved a total of 213,007.58 miles by visiting their local VA instead of the Miami VA. Survey results indicate that 86% of patients believed that the telemedicine program made medical care more accessible. CONCLUSIONS: The Specialist-Directed Telemedicine Model can save patients substantial time and money by not traveling to centralized areas, while delivering greater continuity of care and patient satisfaction.

Does Co-Occurring Traumatic Brain Injury Affect VHA Outpatient Health Service Utilization and Associated Costs Among Veterans With Posttraumatic Stress Disorder? An Examination Based on VHA Administrative Data.

OBJECTIVE: To examine whether a traumatic brain injury (TBI) diagnosis was associated with increased outpatient service utilization and associated costs among Iraq and Afghanistan (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]/Operation New Dawn [OND]) War veterans with posttraumatic stress disorder (PTSD) who used Veterans Health Affairs (VHA) care in a 1-year period. SETTING: N/A. PARTICIPANTS: OEF/OIF/OND veterans with a diagnosis of PTSD and/or TBI who utilized VHA services during fiscal year 2012 (N = 164 644). DESIGN: Observational study using VHA administrative data. MAIN MEASURES: Outpatient VHA utilization (total and by category of care) and associated costs (total and by VA Health Economic Resource Center cost category). RESULTS: Veterans in the comorbid PTSD/TBI group had significantly more total outpatient appointment than veterans with PTSD but no TBI. This pattern held for all categories of care except orthopedics. The comorbid TBI/PTSD group ($5769) incurred greater median outpatient healthcare costs than the PTSD ($3168) or TBI-alone ($2815) group. CONCLUSIONS: Co-occurring TBI increases the already high level of healthcare utilization by veterans with PTSD, suggesting that OEF/OIF/OND veterans with comorbid PTSD/TBI have complex and wide-ranging healthcare needs.

Evaluating the Quality of Rural Intensive Case Management Services using Administrative Data: an Exploratory Study.

Assertive Community Treatment (ACT) for people with severe mental illness is an effective approach that is increasingly implemented in rural areas. Low-cost methods of evaluating fidelity to program models are needed to assure services are delivered as intended. In 2007, the Veterans Health Administration implemented an ACT-like Mental Health Intensive Case Management (ACT/ICM) program for SMI veterans in rural areas. This study demonstrates the use of administrative data, reflecting patient characteristics and intensity of service delivery, to characterize services delivered by these programs, to compare them to general mental health programs at the same VA medical centers, and to each other. A total of 298,509 veterans received mental health services at VA medical centers that also operated a rural ACT/ICM program in FY 2012. Altogether 854 (0.29%) received ACT/ICM services for 1 year or more (long term participants) and 259 (.09%) received them for less than 1 year (new entrants). Logistic regression showed ACT/ICM patients were distinguished by diagnoses of schizophrenia, bipolar disorder, and major depression; larger numbers of psychiatric or substance abuse visits; and use of 3 or more classes of psychotropic medication. The model had a high c statistic of 0.91. Propensity scores allowed clear identification of programs most and least conforming to the profile of a "typical" rural ACT/ICM program. Low cost administrative data can be used to identify programs successfully conforming to an empirically derived rural model of ACT/ICM. Further validation of this approach is needed.

The state of Veterans Affairs sleep medicine programs: 2012 inventory results.

PURPOSE: The Veterans Health Administration (VHA) represents one of the largest integrated health-care systems in the country. In 2012, the Veterans Affairs Sleep Network (VASN) sought to identify available sleep resources at VA medical centers (VAMCs) across the country through a national sleep inventory. METHODS: The sleep inventory was administered at the annual 2012 VA Sleep Practitioners meeting and by email to sleep contacts at each VAMC. National prosthetics contacts were used to identify personnel at VAMCs without established sleep programs. Follow-up emails and telephone calls were made through March 2013. RESULTS: One hundred eleven VA medical centers were included for analysis. Thirty-nine programs did not respond, and 10 were considered "satellites," referring all sleep services to a larger neighboring VAMC. Sleep programs were stratified based on extent of services offered (i.e., in-lab and home testing, sleep specialty clinics, cognitive behavioral therapy for insomnia (CBT-i)): 28 % were complex sleep programs (CSPs), 46 % were intermediate (ISPs), 9 % were standard (SSPs), and 17 % offered no formal sleep services. Overall, 138,175 clinic visits and 90,904 sleep testing encounters were provided in fiscal year 2011 by 112.1 physicians and clinical psychologists, 100.4 sleep technologists, and 115.3 respiratory therapists. More than half of all programs had home testing and CBT-i programs, and 26 % utilized sleep telehealth. CONCLUSIONS: The 2012 VA sleep inventory suggests considerable variability in sleep services within the VA. Demand for sleep services is high, with programs using home testing, sleep telehealth, and a growing number of mid-level providers to improve access to care.

Patient characteristics associated with the level of patient-reported care coordination among male patients with colorectal cancer in the Veterans Affairs health care system.

BACKGROUND: The current study was performed to determine whether patient characteristics, including race/ethnicity, were associated with patient-reported care coordination for patients with colorectal cancer (CRC) who were treated in the Veterans Affairs (VA) health care system, with the goal of better understanding potential goals of quality improvement efforts aimed at improving coordination. METHODS: The nationwide Cancer Care Assessment and Responsive Evaluation Studies survey involved VA patients with CRC who were diagnosed in 2008 (response rate, 67%). The survey included a 4-item scale of patient-reported frequency ("never," "sometimes," "usually," and "always") of care coordination activities (scale score range, 1-4). Among 913 patients with CRC who provided information regarding care coordination, demographics, and symptoms, multivariable logistic regression was used to examine odds of patients reporting optimal care coordination. RESULTS: VA patients with CRC were found to report high levels of care coordination (mean scale score, 3.50 [standard deviation, 0.61]). Approximately 85% of patients reported a high level of coordination, including the 43% reporting optimal/highest-level coordination. There was no difference observed in the odds of reporting optimal coordination by race/ethnicity. Patients with early-stage disease (odds ratio [OR], 0.60; 95% confidence interval [95% CI], 0.45-0.81), greater pain (OR, 0.97 for a 1-point increase in pain scale; 95% CI, 0.96-0.99), and greater levels of depression (OR, 0.97 for a 1-point increase in depression scale; 95% CI, 0.96-0.99) were less likely to report optimal coordination. CONCLUSIONS: Patients with CRC in the VA reported high levels of care coordination. Unlike what has been reported in settings outside the VA, there appears to be no racial/ethnic disparity in reported coordination. However, challenges remain in ensuring coordination of care for patients with less advanced disease and a high symptom burden. Cancer 2015;121:2207-2213. © 2015 American Cancer Society.

Medical and surgical readmissions in the Veterans Health Administration: what proportion are related to the index hospitalization?

BACKGROUND: Readmissions are an attractive quality measure because they offer a broad view of quality beyond the index hospitalization. However, the extent to which medical or surgical readmissions reflect quality of care is largely unknown, because of the complexity of factors related to readmission. Identifying those readmissions that are clinically related to the index hospitalization is an important first step in closing this knowledge gap. OBJECTIVES: The aims of this study were to examine unplanned readmissions in the Veterans Health Administration, identify clinically related versus unrelated unplanned readmissions, and compare the leading reasons for unplanned readmission between medical and surgical discharges. METHODS: We classified 2,069,804 Veterans Health Administration hospital discharges (Fiscal Years 2003-2007) into medical/surgical index discharges with/without readmissions per their diagnosis-related groups. Our outcome variable was "all-cause" 30-day unplanned readmission. We compared medical and surgical unplanned readmissions (n=217,767) on demographics, clinical characteristics, and readmission reasons using descriptive statistics. RESULTS: Among all unplanned readmissions, 41.5% were identified as clinically related. Not surprisingly, heart failure (10.2%) and chronic obstructive pulmonary disease (6.5%) were the top 2 reasons for clinically related readmissions among medical discharges; postoperative complications (ie, complications of surgical procedures and medical care or complications of devices) accounted for 70.5% of clinically related readmissions among surgical discharges. CONCLUSIONS: Although almost 42% of unplanned readmissions were identified as clinically related, the majority of unplanned readmissions were unrelated to the index hospitalization. Quality improvement interventions targeted at processes of care associated with the index hospitalization are likely to be most effective in reducing clinically related readmissions. It is less clear how to reduce nonclinically related readmissions; these may involve broader factors than inpatient care.

VA health service utilization for homeless and low-income Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles.

BACKGROUND: The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program-the VA's Housing First effort-is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing. OBJECTIVES: We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans. RESEARCH DESIGN: We performed a secondary database analysis of Veterans (n=62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status. RESULTS: HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group. CONCLUSIONS: Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.

Tribal Veterans Representative (TVR) training program: the effect of community outreach workers on American Indian and Alaska Native Veterans access to and utilization of the Veterans Health Administration.

American Indians and Alaska Natives serve at the highest rate of any US race or ethnic group, yet are the most underserved population of Veterans and do not take advantage of the Department of Veterans Affairs (VA) benefits and services. Barriers to seeking care include stigma, especially for mental health issues; distance to care; and lack of awareness of benefits and services they are entitled to receive. In response to this underutilization of the VA, an innovative program--the Tribal Veterans Representative (TVR) program--was developed within the VA to work with American Indians and Alaska Natives in rural and remote areas. The TVR goes through extensive training every year; is a volunteer, a Veteran and tribal community member who seeks out unenrolled Native Veterans, provides them with information on VA health care services and benefits, and assists them with enrollment paperwork. Being from the community they serve, these outreach workers are able to develop relationships and build rapport and trust with fellow Veterans. In place for over a decade in Montana, this program has enrolled a countless number of Veterans, benefiting not only the individual, but their family and the community as well. Also resulting from this program, are the implementation of Telemental Health Clinics treating Veterans with PTSD, a transportation program helping Veterans get to and from distant VA facilities, a Veteran Resource Center, and a Veteran Tribal Clinic. This program has successfully trained over 800 TVRs, expanded to other parts of the country and into remote areas of Alaska.

Contextual factors influencing the association between the Affordable Care Act's Medicaid expansion and Veteran VA-Medicaid dual enrollment.

OBJECTIVE: To evaluate changes in dual enrollment after Affordable Care Act Medicaid expansion by VA priority group, (e.g., service connection), sex, and type of state expansion. STUDY SETTING: Our cohort was all Veterans ages 18-64 enrolled in VA and eligible for benefits due to military service-connection or low income from 2011 to 2016; the unit of analysis was person-year. STUDY DESIGN: Difference-in-difference and event-study analysis. The outcome was dual VA-Medicaid enrollment for at least 1 month annually. Medicaid expansion, VA priority status, whether a state expanded by a Section 1115 waiver, and sex were independent variables. We controlled for race, ethnicity, age, disease burden, distance to VA facilities, state, and year. DATA EXTRACTION METHODS: We used data from the VA Corporate Data Warehouse (CDW) regarding age and VA Priority Group to select our cohort of VA-enrolled individuals. We then took the cohort and crossed checked it with Medicaid Analytic Extract (MAX) and T-MSIS Analytic Files (TAF) to determine Medicaid enrollment status. PRINCIPAL FINDINGS: Service-connected Veterans experienced lower dual-enrollment increases across all sex and state-waiver groups (3.44 percentage points (95% CI: 1.83, 5.05 pp) for women, 3.93 pp (2.98, 4.98) for men, 4.06 pp (2.85, 5.27) for non-waiver states, and 3.00 pp (1.58 to 4.41) for waiver states) than Veterans who enrolled in the VA due to low income (8.19 pp (5.43, 10.95) for women, 9.80 pp (7.06, 12.54) for men, 10.21 pp (7.17, 13.25) for non-waiver states, and 7.39 pp (5.28, 9.50) for waiver states). CONCLUSIONS: Medicaid expansion is associated with dual enrollment. Dual-enrollment changes are greatest in those enrolled in the VA due to low income, but do not differ by sex or expansion type. Results can help VA identify groups disproportionately likely to have potential care-coordination issues due to usage of multiple health care systems.

Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless.

OBJECTIVE: To evaluate universal suicide risk screening and evaluation processes among newly homeless Veterans. STUDY SETTING: Not applicable. STUDY DESIGN: Examination of Veterans Health Administration (VHA) using newly homeless patients' health record data in Calendar Year 2021. DATA COLLECTION: Not applicable. DATA SOURCE: Health record data. PRINCIPAL FINDINGS: Most patients received suicide risk screening and/or evaluation in the year prior to and/or following homeless identification (n = 49,505; 87.4%). Smaller percentages of patients were screened and/or evaluated in close proximity to identification (n = 7358; 16.0%), 1-30 days prior to identification (n = 12,840; 39.6%), or 1-30 days following identification (n = 14,263; 34.3%). Common settings for screening included primary care, emergency and urgent care, and mental health services. Of positive screens (i.e., potentially elevated risk for suicide), 72.6% had a Comprehensive Suicide Risk Evaluation (CSRE) completed in a timely manner (i.e., same day or within 24 h). Age, race, and sex were largely unrelated to screening and/or evaluation. CONCLUSIONS: Although many newly identified homeless patients were screened and/or evaluated for suicide risk, approximately 13% were not screened; and 27% of positive screens did not receive a timely CSRE. Continued efforts are warranted to facilitate suicide risk identification to ensure homeless patients have access to evidence-based interventions.

What We Know About Homeless Veterans With Other-than-honorable and Punitive Discharges: Data From the Grant and Per Diem (GPD) Program.

INTRODUCTION: The U.S. DVA Grant and Per Diem (GPD) program funds community agencies to provide housing and case management services to Veterans experiencing homelessness. GPD is one of the few VA programs that can enroll Veterans with Other-than-Honorable (OTH) military discharges. The characteristics of OTH Veterans and their outcomes in GPD are unknown. MATERIALS AND METHODS: We linked the Homeless Operations and Management Evaluation System database and VA Corporate Data Warehouse to identify Veterans with complete GPD enrollment and discharge data between 2018 and 2020. We categorized Veterans into three military discharge groups: Honorable, OTH, or Punitive. We evaluated key GPD process and outcomes measures: days enrolled in GPD, use of VA-funded emergency department care while in GPD, and whether a Veteran was successfully discharged from GPD, their housing status at program exit, employment status at program exit, and connection to mental health and substance abuse treatment at discharge. We conducted multivariable regressions to determine the adjusted association (controlling for demographics and comorbidities) between military discharge status and process and outcome measures. RESULTS: Among 21,646 Veterans in the GPD program, 20,517 (95%) were honorably discharged; 811 (4%) had an OTH discharge; and 318 (1%) had a Punitive discharge. There was no difference in GPD length of enrollment by discharge status. Compared to honorably discharged veterans, OTH and Punitive discharged Veterans were less likely to successfully exit GPD, more likely to be homeless and employed at program exit, and were less likely to have a VA-funded emergency department visit while in GPD and less likely to be connected to mental health care or substance use treatment at program exit. CONCLUSIONS: The GPD program serves hundreds of homeless Veterans with OTH and Punitive discharges every year, but they seem to be at greater risk for negative health and psychosocial outcomes and do not have the same access to VA services as other Veterans. These findings may inform policy considerations about expanding VA care and opportunities for community providers to serve Veterans with OTH and Punitive discharges.

Trends in Veteran hospitalizations and associated readmissions and emergency department visits during the MISSION Act era.

OBJECTIVE: To examine changes in hospitalization trends and healthcare utilization among Veterans following Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act implementation. DATA SOURCES AND STUDY SETTING: VA Corporate Data Warehouse and Centers for Medicare and Medicaid Services datasets. STUDY DESIGN: Retrospective cohort study to compare 7- and 30-day rates for unplanned readmission and emergency department visits following index hospital stays based on payor type (VHA facility stay, VA-funded stay in community facility [CC], or Medicare-funded community stay [CMS]). Segmented regression models were used to compare payors and estimate changes in outcome levels and slopes following MISSION Act implementation. DATA COLLECTION/EXTRACTION METHODS: Veterans with active VA primary care utilization and ≥1 acute hospitalization between January 1, 2016 and December 31, 2021. PRINCIPAL FINDINGS: Monthly index stays increased for all payors until MISSION Act implementation, when VHA and CMS admissions declined while CC admissions accelerated and overtook VHA admissions. In December 2021, CC admissions accounted for 54% of index admissions, up from 25% in January 2016. From adjusted models, just prior to implementation (May 2019), Veterans with CC admissions had 47% greater risk of 7-day readmission (risk ratio [RR]: 1.47, 95% confidence interval [CI]: 1.43, 1.51) and 20% greater risk of 30-day readmission (RR: 1.20, 95% CI: 1.19, 1.22) compared with those with VHA admissions; both effects persisted post-implementation. Pre-implementation CC admissions were also associated with higher 7- and 30-day ED visits, but both risks were substantially lower by study termination (RR: 0.90, 95% CI: 0.88, 0.91) and (RR: 0.89, 95% CI: 0.87, 0.90), respectively. CONCLUSIONS: MISSION Act implementation was associated with substantial shifts in treatment site and federal payor for Veteran hospitalizations. Post-implementation readmission risk was estimated to be higher for those with CC and CMS index admissions, while post-implementation risk of ED utilization following CC admissions was estimated to be lower compared with VHA index admissions. Reasons for this divergence require further investigation.

Examining the impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration: the case of readmissions.

BACKGROUND: By focusing primarily on outcomes in the inpatient setting one may overlook serious adverse events that may occur after discharge (eg, readmissions, mortality) as well as opportunities for improving outpatient care. OBJECTIVE: Our overall objective was to examine whether experiencing an Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) event in an index medical or surgical hospitalization increased the likelihood of readmission. METHODS: We applied the Agency for Healthcare Research and Quality PSI software (version 4.1.a) to 2003-2007 Veterans Health Administration inpatient discharge data to generate risk-adjusted PSI rates for 9 individual PSIs and 4 aggregate PSI measures: any PSI event and composite PSIs reflecting "Technical Care," "Continuity of Care," and both surgical and medical care (Mixed). We estimated separate logistic regression models to predict the likelihood of 30-day readmission for individual PSIs, any PSI event, and the 3 composites, adjusting for age, sex, comorbidities, and the occurrence of other PSI(s). RESULTS: The odds of readmission were 23% higher for index hospitalizations with any PSI event compared with those with no event [confidence interval (CI), 1.19-1.26], and ranged from 22% higher for Iatrogenic Pneumothorax (CI, 1.03-1.45) to 61% higher for Postoperative Wound Dehiscence (CI, 1.27-2.05). For the composites, the odds of readmission ranged from 15% higher for the Technical Care composite (CI, 1.08-1.22) to 37% higher for the Continuity of Care composite (CI, 1.26-1.50). CONCLUSIONS: Our results suggest that interventions that focus on minimizing preventable inpatient safety events as well as improving coordination of care between and across settings may decrease the likelihood of readmission.