Trajectories and Transitions in Service Use Among Older Veterans at High Risk of Long-term Institutional Care.

BACKGROUND: We aimed to identify combinations of long-term services and supports (LTSS) Veterans use, describe transitions between groups, and identify factors influencing transition. METHODS: We explored LTSS across a continuum from home to institutional care. Analyses included 104,837 Veterans Health Administration (VHA) patients 66 years and older at high-risk of long-term institutional care (LTIC). We conduct latent class and latent transition analyses using VHA and Medicare data from fiscal years 2014 to 2017. We used logistic regression to identify variables associated with transition. RESULTS: We identified 5 latent classes: (1) No Services (11% of sample in 2015); (2) Medicare Services (31%), characterized by using LTSS only in Medicare; (3) VHA-Medicare Care Continuum (19%), including LTSS use in various settings across VHA and Medicare; (4) Personal Care Services (21%), characterized by high probabilities of using VHA homemaker/home health aide or self-directed care; and (5) Home-Centered Interdisciplinary Care (18%), characterized by a high probability of using home-based primary care. Veterans frequently stayed in the same class over the three years (30% to 46% in each class). Having a hip fracture, self-care impairment, or severe ambulatory limitation increased the odds of leaving No Services, and incontinence and dementia increased the odds of entering VHA-Medicare Care Continuum. Results were similar when restricted to Veterans who survived during all 3 years of the study period. CONCLUSIONS: Veterans at high risk of LTIC use a combination of services from across the care continuum and a mix of VHA and Medicare services. Service patterns are relatively stable for 3 years.

Sex differences in unmet needs between male and female older veterans.

Aging Veterans face complex needs across multiple domains. However, the needs of older female Veterans and the degree to which unmet needs differ by sex are unknown. We analyzed responses to the HERO CARE survey from 7,955 Veterans aged 55 years and older (weighted N = 490,148), 93.9% males and 6.1% females. We evaluated needs and unmet needs across the following domains: activities of daily living (ADLs), instrumental ADLs (IADLs), health management, and social. We calculated weighted estimates and compared sex differences using age-adjusted prevalence ratios. On average, female Veterans were younger, more were Non-Hispanic Black and unmarried. Females and males reported a similar prevalence of problems across all domains. However, compared to males, female Veterans had a lesser prevalence of missed appointments due to transportation (aPR 0.49; 95% CI: 0.26-0.92), housework unmet needs (aPR: 0.44; 95% CI: 0.20-0.97), and medication management unmet needs (aPR: 0.33; 95% CI: 0.11-0.95) but a higher prevalence of healthcare communication unmet needs (aPR: 2.40; 95% CI: 1.13-5.05) and monitoring health conditions unmet needs (aPR: 2.13, 95% CI: 1.08-4.20). Female Veterans' common experience of unmet needs in communicating with their healthcare teams could result in care that is less aligned with their preferences or needs. As the number of older female Veterans grows, these data and additional work to understand sex-specific unmet needs and ways to address them are essential to providing high-quality care for female Veterans.

Mental Health Treatment Among Nursing Home Residents With Alzheimer's Disease and Related Dementias.

OBJECTIVES: To examine the prevalence of mental health treatment among nursing home (NH) long-stay residents with Alzheimer's disease and related dementias (ADRD) and explore factors associated with utilization. DESIGN: Retrospective cohort study. Minimum Data Set data (April 2017-September 2018), Medicare Master Beneficiary Summary File, Part B Carrier file and Part D prescription file were used to identify mental illness and ADRD diagnoses, patient characteristics, and mental health treatment. SETTING AND PARTICIPANTS: All US Medicare- or Medicaid-certified NHs. Fee-for-service Medicare beneficiaries aged 65 and older who had a quarterly or annual Minimum Data Set assessment with ADRD and were enrolled in Medicare Parts B and D. Two cohorts: residents with both ADRD and psychiatric disorders; residents with ADRD only. METHODS: Primary outcomes: receipt of (1) any mental health treatment (medication or psychotherapy); (2) any psychotherapy in a calendar quarter. SECONDARY OUTCOMES: antipsychotics, antidepressants, hypnotics, antiepileptics, short-session ( ≤ 30 minutes), long-session ( ≥ 45 minutes), and family/group psychotherapy. Covariates included predisposing, enabling characteristics, and needs factors. Generalized Estimating Equation models of quarterly data, nested within patients, were estimated for each outcome among each cohort. RESULTS: Analyses included 1,913,945 resident-quarter observations from 503,077 unique NH long-stay residents. Overall, 68.5% of NH long-stay residents with ADRD have psychiatric disorders; of these, 85% received mental health treatment. African American or Hispanic residents were less likely to use antidepressants. African American residents or residents living in rural locations were less likely to receive long-session psychotherapy. Hispanic residents were more likely to receive long-session psychotherapy. Residents in minority groups were more likely to receive group/family psychotherapy. CONCLUSIONS AND IMPLICATIONS: Most of NH long-stay residents with ADRD had psychiatric disorders and most of them received treatment. Antidepressants or long-session psychotherapy were less likely to be provided to African American residents. Factors that determine the efficacy of mental health treatment and reasons for the racial disparities require further exploration.

Preimplementation Evaluation of a Self-Directed Care Program in a Veterans Health Administration Regional Network: Protocol for a Mixed Methods Study.

BACKGROUND: The Veteran-Directed Care (VDC) program serves to assist veterans at risk of long-term institutional care to remain at home by providing funding to hire veteran-selected caregivers. VDC is operated through partnerships between Department of Veterans Affairs (VA) Medical Centers (VAMCs) and third-party Aging and Disability Network Agency providers. OBJECTIVE: We aim to identify facilitators, barriers, and adaptations in VDC implementation across 7 VAMCs in 1 region: Veterans Integrated Service Network (VISN) 8, which covers Florida, South Georgia, Puerto Rico, and the US Virgin Islands. We also attempted to understand leadership and stakeholder perspectives on VDC programs' reach and implementation and identify veterans served by VISN 8's VDC programs and describe their home- and community-based service use. Finally, we want to compare veterans served by VDC programs in VISN 8 to the veterans served in VDC programs across the VA. This information is intended to be used to identify strategies and propose recommendations to guide VDC program expansion in VISN 8. METHODS: The mixed methods study design encompasses electronically delivered surveys, semistructured interviews, and administrative data. It is guided by the Consolidated Framework for Implementation Research (CFIR version 2.0). Participants included the staff of VAMCs and partnering aging and disability network agencies across VISN 8, leadership at these VAMCs and VISN 8, veterans enrolled in VDC, and veterans who declined VDC enrollment and their caregivers. We interviewed selected VAMC site leaders in social work, Geriatrics and Extended Care, and the Caregiver Support Program. Each interviewee will be asked to complete a preinterview survey that includes information about their personal characteristics, experiences with the VDC program, and perceptions of program aspects according to the CFIR (version 2.0) framework. Participants will complete a semistructured interview that covers constructs relevant to the respondent and facilitators, barriers, and adaptations in VDC implementation at their site. RESULTS: We will calculate descriptive statistics including means, SDs, and percentages for survey responses. Facilitators, barriers, number of patients enrolled, and staffing will also be presented. Interviews will be analyzed using rapid qualitative techniques guided by CFIR domains and constructs. Findings from VISN 8 will be collated to identify strategies for VDC expansion. We will use administrative data to describe veterans served by the programs in VISN 8. CONCLUSIONS: The VA has prioritized VDC rollout nationwide and this study will inform these expansion efforts. The findings from this study will provide information about the experiences of the staff, leadership, veterans, and caregivers in the VDC program and identify program facilitators and barriers. These results may be used to improve program delivery, facilitate growth within VISN 8, and inform new program establishment at other sites nationwide as the VDC program expands. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57341.

What is the additive value of nutritional deficiency to VA-FI in the risk assessment for heart failure patients?

OBJECTIVES: To assess the impact of adding the Prognostic Nutritional Index (PNI) to the U.S. Veterans Health Administration frailty index (VA-FI) for the prediction of time-to-death and other clinical outcomes in Veterans hospitalized with Heart Failure. METHODS: A retrospective cohort study of veterans hospitalized for heart failure (HF) from October 2015 to October 2018. Veterans ≥50 years with albumin and lymphocyte counts, needed to calculate the PNI, in the year prior to hospitalization were included. We defined malnutrition as PNI ≤43.6, based on the Youden index. VA-FI was calculated from the year prior to the hospitalization and identified three groups: robust (≤0.1), prefrail (0.1-0.2), and frail (>0.2). Malnutrition was added to the VA-FI (VA-FI-Nutrition) as a 32nd deficit with the total number of deficits divided by 32. Frailty levels used the same cut-offs as the VA-FI. We compared categories based on VA-FI to those based on VA-FI-Nutrition and estimated the hazard ratio (HR) for post-discharge all-cause mortality over the study period as the primary outcome and other adverse events as secondary outcomes among patients with reduced or preserved ejection fraction in each VA-FI and VA-FI-Nutrition frailty groups. RESULTS: We identified 37,601 Veterans hospitalized for HF (mean age: 73.4 ± 10.3 years, BMI: 31.3 ± 7.4 kg/m2). In general, VA-FI-Nutrition reclassified 1959 (18.6%) Veterans to a higher frailty level. The VA-FI identified 1,880 (5%) as robust, 8,644 (23%) as prefrail, and 27,077 (72%) as frail. The VA-FI-Nutrition reclassified 382 (20.3%) from robust to prefrail and 1577 (18.2%) from prefrail to frail creating the modified-prefrail and modified-frail categories based on the VA-FI-Nutrition. We observed shorter time-to-death among Veterans reclassified to a higher frailty status vs. those who remained in their original group (Median of 2.8 years (IQR:0.5,6.8) in modified-prefrail vs. 6.3 (IQR:1.8,6.8) years in robust, and 2.2 (IQR:0.7,5.7) years in modified-frail vs. 3.9 (IQR:1.4,6.8) years in prefrail). The adjusted HR in the reclassified groups was also significantly higher in the VA-FI-Nutrition frailty categories with a 38% increase in overall all-cause mortality among modified-prefrail and a 50% increase among modified-frails. Similar trends of increasing adverse events were also observed among reclassified groups for other clinical outcomes. CONCLUSION: Adding PNI to VA-FI provides a more accurate and comprehensive assessment among Veterans hospitalized for HF. Clinicians should consider adding a specific nutrition algorithm to automated frailty tools to improve the validity of risk prediction in patients hospitalized with HF.

Increase in blood pressure precedes distress behavior in nursing home residents with dementia.

BACKGROUND: Distress behaviors in dementia (DBD) likely increase sympathetic nervous system activity. The aim of this study was to examine the associations among DBD, blood pressure (BP), and intensity of antihypertensive treatment, in nursing home (NH) residents with dementia. METHODS: We identified long-stay Veterans Affairs NH residents with dementia in 2019-20 electronic health data. Each individual with a BP reading and a DBD incident according to a structured behavior note on a calendar day (DBD group) was compared with an individual with a BP reading but without a DBD incident on that same day (comparison group). In each group we calculated daily mean BP from 14 days before to 7 days after the DBD incident day. We then calculated the change in BP between the DBD incident day and, as baseline, the 7-day average of BP 1 week prior, and tested for differences between DBD and comparison groups in a generalized estimating equations multivariate model. RESULTS: The DBD and comparison groups consisted of 707 and 2328 individuals, respectively. The DBD group was older (74 vs. 72 y), was more likely to have severe cognitive impairment (13% vs. 8%), and had worse physical function scores (15 vs. 13 on 28-point scale). In the DBD group, mean systolic BP on the DBD incident day was 1.6 mmHg higher than baseline (p < .001), a change that was not observed in the comparison group. After adjusting for covariates, residents in the DBD group, but not the comparison group, had increased likelihood of having systolic BP > = 160 mmHg on DBD incident days (OR 1.02; 95%CI 1.00-1.03). Systolic BP in the DBD group began to rise 7 days before the DBD incident day and this rise persisted 1 week after. There were no significant changes in mean number of antihypertensive medications over this time period in either group. CONCLUSIONS: NH residents with dementia have higher BP when they experience DBD, and BP rises 7 days before the DBD incident. Clinicians should be aware of these findings when deciding intensity of BP treatment.

Better performance for right-skewed data using an alternative gamma model.

BACKGROUND: The Maximum Likelihood Estimator (MLE) for parameters of the gamma distribution is commonly used to estimate models of right-skewed variables such as costs, hospital length of stay, and appointment wait times in Economics and Healthcare research. The common specification for this estimator assumes the variance is proportional to the square of the mean, which underlies estimation and specification tests. We present a specification in which the variance is directly proportional to the mean. METHODS: We used simulation experiments to investigate finite sample results, and we used United States Department of Veterans Affairs (VA) healthcare cost data as an empirical example comparing the fit and predictive ability of the models. RESULTS: Simulation showed the MLE based on a correctly specified alternative has less parameter bias, lower standard errors, and less skewness in distribution than a misspecified standard model. The application to VA healthcare cost data showed the alternative specification can have better R square, smaller root mean squared error, and smaller mean residuals within deciles of predicted values. CONCLUSIONS: The alternative gamma specification can be a useful alternative to the standard specification for estimating models of right-skewed continuous variables.

Financial Performance is Associated With PPE Shortages in Chain-Affiliated Nursing Homes During the COVID-19 Pandemic: A Longitudinal Study.

Many nursing homes operated at thin profit margins prior to the COVID-19 pandemic. This study examines the role of nursing homes' financial performance and chain affiliation in shortages of personal protection equipment (PPE) during the first year of the COVID-19 pandemic. We constructed a longitudinal file of 79 868 nursing home-week observations from 10 872 unique facilities. We found that a positive profit margin was associated with a 21.0% lower probability of reporting PPE shortages in chain-affiliated nursing homes, but not in non-chain nursing homes. Having adequate financial resources may help nursing homes address future emergencies, especially those affiliated with a multi-facility chain.

Measuring the unmet needs of American military Veterans and their caregivers: Survey protocol of the HERO CARE survey.

BACKGROUND: Empowering Veterans to age in place is a Department of Veterans Affairs priority. Family or unpaid caregivers play an important role in supporting Veterans to achieve this goal. Effectively meeting the needs of Veterans and caregivers requires identifying unmet needs and relevant gaps in resources to address those needs. METHODS: Using a modified Socio-Ecological Model, we developed a prospective longitudinal panel design survey. We randomly selected 20,000 community-dwelling Veterans enrolled in the Veterans Health Administration (VHA), across five VHA sites. We oversampled Veterans with a higher predicted 2-year long-term institutional care (LTIC) risk. Veterans were mailed a packet containing a Veteran survey and a caregiver survey, to be answered by their caregiver if they had one. The Veteran survey assessed the following health-related domains: physical, mental, social determinants of health, and caregiver assistance. Caregivers completed questions regarding their demographic factors, caregiving activities, impact of caregiving, use of VA and non-VA services, and caregiver support resources. Follow-up surveys will be repeated twice at 12-month intervals for the same respondents. This article describes the HERO CARE survey protocol, content, and response rates. RESULTS: We received responses from 8,056 Veterans and 3,579 caregivers between July 2021 and January 2022, with 95.6% being received via mail. Veteran respondents were mostly males (96.5%), over 65 years of age (94.9%), married (55.0%), Non-Hispanic White (75.2%), and residing in urban areas (80.7%). CONCLUSIONS: This longitudinal survey is unique in its comprehensive assessment of domains relevant to older Veterans stratified by LTIC risk and their caregivers, focusing on social determinants, caregiver support, and the use of caregiver support resources. Survey data will be linked to Centers for Medicare & Medicaid Services and VA data. The results of this study will inform better planning of non-institutional care services and policy for Veterans and their caregivers.

Effects of a Rehabilitation-at-Home Program Compared to Post-acute Skilled Nursing Facility Care on Safety, Readmission, and Community Dwelling Status: A Matched Cohort Analysis.

OBJECTIVES: To evaluate the effectiveness and safety of Rehabilitation-at-Home (RaH), which provides high-frequency, multidisciplinary post-acute rehabilitative services in patients' homes. DESIGN: Comparative effectiveness analysis. SETTING AND PARTICIPANTS: Medicare Fee-For-Service patients who received RaH in a Center for Medicare and Medicaid Innovation Center Demonstration during 2016-2017 (N=173) or who received Medicare Skilled Nursing Facility (SNF) care in 2016-2017 within the same geographic service area with similar inclusion and exclusion criteria (N=5535). METHODS: We propensity-matched RaH participants to a cohort of SNF patients using clinical and demographic characteristics with exact match on surgical and non-surgical hospitalizations. Outcomes included hospitalization within 30 days of post-acute admission, death within 30 days of post-acute discharge, length of stay, falls, use of antipsychotic medication, and discharge to community. RESULTS: The majority of RaH participants were older than or equal to 85 years (57.8%) and non-Hispanic white (72.2%) with mean hospital length of stay of 8.1 (SD 7.6) days. In propensity-matched analyses, 10.1% (95% CI: 0.5%, 19.8) and 4.2% (95% CI: 0.1%, 8.5%) fewer RaH participants experienced hospital readmission and death, respectively. RaH participants had, on average, 2.8 fewer days (95% CI 1.4, 4.3) of post-acute care; 11.4% (95% CI: 5.2%, 17.7%) fewer RaH participants experienced fall; and 25.8% (95% CI: 17.8%, 33.9%) more were discharged to the community. Use of antipsychotic medications was no different. CONCLUSIONS AND IMPLICATIONS: RaH is a promising alternative to delivering SNF-level post-acute RaH. The program seems to be safe, readmissions are lower, and transition back to the community is improved.

Fall-related Injuries and Opioid Administration Among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers.

OBJECTIVES: Opioid use is associated with fall-related injuries (FRI) among older adults, especially those with dementia. We examined FRI following changes in national opioid safety initiatives over 3 regulatory periods [preinitiatives baseline (period 1): October 2012 to June 2013; post-Veteran Affairs (VA) opioid safety initiative (period 2): January 2014 to November 2015; post-VA and CDC opioid prescribing guidelines (period 3): March 2017 to September 2018] among Department of VA Community Living Center (CLC) long-stay residents with dementia. DATA: VA provided and purchased care records, Medicare claims, CLC Minimum Data Set (MDS) assessments. VA bar-code medication administration data, VA outpatient prescription refill data, and Medicare Part D data were used to capture medication from inpatient, outpatient, and Medicare sources. SETTINGS AND PARTICIPANTS: A total of 12,229 long-stay CLC residents with dementia between October 2012 and September 2018. METHODS: We applied Veteran-regulatory period level (1) generalized linear model to examine the unadjusted and adjusted trends of FRI, and (2) difference-in-difference model with propensity score weighting to examine the relationship between opioid safety initiatives and FRI in 3 regulatory periods. We applied propensity score weighting to enable the cohorts in periods 2 and 3 had similar indications for opioid administration as in period 1. RESULTS: FRI prevalence per month among CLC residents with Alzheimer disease and related dementias decreased from 3.1% in period 1 to 1.6% and 1.2% in periods 2 and 3, and the adjusted probability of FRI was 17% and 40% lower in periods 2 and 3 compared with period 1. The any, incident, and continued opioid administration were significantly associated with higher FRI, whereas the differences in FRI probabilities between opioid and nonopioid users had no significant changes over the 3 regulatory periods. CONCLUSIONS: FRI was reduced among CLC residents with Alzheimer disease and related dementias receiving care in VA CLCs over the 3 regulatory periods, but the FRI reduction was not significantly associated with opioid safety initiatives. Other interventions that potentially targeted falls are likely to have helped reduce these fall events. Future studies could examine whether opioid use reduction ultimately benefitted nursing home residents by focusing on other possible outcomes or whether such reduction only resulted in more untreated pain.

Clinical use of photobiomodulation for the prevention and treatment of oral mucositis: the real-life experience of MASCC/ISOO members.

AIM: To assess clinical use and patient outcome of photobiomodulation (PBM) for oral mucositis (OM) prevention and treatment among specialized practitioners. METHODS: A poll was emailed to the members of the Mucositis Study Group of MASCC/ISOO. The PBM parameters used by the respondents were analyzed using exploratory statistical methods to identify combinations of PBM parameters (patterns) that characterize the variance in the protocols (principal component analysis). RESULTS: Responses were received from 101 MSG members, with 78 providing analyzable data. Most of the responders were dental practitioners or oral medicine specialists. PBM was used by 59% of the responders for OM or targeted therapy stomatitis. Technical parameters varied widely. Most responders used wavelengths ∼650 nm intra-orally. The spot-size and distance from the tissue were the main factors driving the variation. All PBM users noted that PBM relieved pain, either immediately or a delayed effect. High likelihood of pain relief (measured as responder's report of pain relief in 67-100% of patients) was reported by 22% and 19% of PBM users for immediate pain relief and delayed pain relief, respectively. The most common reported barriers to using PBM were financial considerations, time constraints, lack of training or experience and concern about the potential for malignant transformation or increased risk of cancer recurrence. CONCLUSIONS: The use of PBM for OM prevention or treatment is in early phases of adoption in practices, facing some obstacles to implement it. A wide variation in technical parameters was found. Nonetheless, responses indicate that PBM provided pain relief.

Developing a Machine Learning Risk-adjustment Method for Hospitalizations and Emergency Department Visits of Nursing Home Residents With Dementia.

BACKGROUND: Long-stay nursing home (NH) residents with Alzheimer disease and related dementias (ADRD) are at high risk of hospital transfers. Machine learning might improve risk-adjustment methods for NHs. OBJECTIVES: The objective of this study was to develop and compare NH risk-adjusted rates of hospitalizations and emergency department (ED) visits among long-stay residents with ADRD using Extreme Gradient Boosting (XGBoost) and logistic regression. RESEARCH DESIGN: Secondary analysis of national Medicare claims and NH assessment data in 2012 Q3. Data were equally split into the training and test sets. Both XGBoost and logistic regression predicted any hospitalization and ED visit using 58 predictors. NH-level risk-adjusted rates from XGBoost and logistic regression were constructed and compared. Multivariate regressions examined NH and market factors associated with rates of hospitalization and ED visits. SUBJECTS: Long-stay Medicare residents with ADRD (N=413,557) from 14,057 NHs. RESULTS: A total of 8.1% and 8.9% residents experienced any hospitalization and ED visit in a quarter, respectively. XGBoost slightly outperformed logistic regression in area under the curve (0.88 vs. 0.86 for hospitalization; 0.85 vs. 0.83 for ED visit). NH-level risk-adjusted rates from XGBoost were slightly lower than logistic regression (hospitalization=8.3% and 8.4%; ED=8.9% and 9.0%, respectively), but were highly correlated. Facility and market factors associated with the XGBoost and logistic regression-adjusted hospitalization and ED rates were similar. NHs serving more residents with ADRD and having a higher registered nurse-to-total nursing staff ratio had lower rates. CONCLUSIONS: XGBoost and logistic regression provide comparable estimates of risk-adjusted hospitalization and ED rates.

Comparison of Claims-Based Frailty Indices in U.S. Veterans 65 and Older for Prediction of Long-Term Institutionalization and Mortality.

BACKGROUND: Frailty is increasingly recognized as a useful measure of vulnerability in older adults. Multiple claims-based frailty indices (CFIs) can readily identify individuals with frailty, but whether 1 CFI improves prediction over another is unknown. We sought to assess the ability of 5 distinct CFIs to predict long-term institutionalization (LTI) and mortality in older Veterans. METHODS: Retrospective study conducted in U.S. Veterans ≥65 years without prior LTI or hospice use in 2014. Five CFIs were compared: Kim, Orkaby (Veteran Affairs Frailty Index [VAFI]), Segal, Figueroa, and the JEN-FI, grounded in different theories of frailty: Rockwood cumulative deficit (Kim and VAFI), Fried physical phenotype (Segal), or expert opinion (Figueroa and JFI). The prevalence of frailty according to each CFI was compared. CFI performance for the coprimary outcomes of any LTI or mortality from 2015 to 2017 was examined. Because Segal and Kim include age, sex, or prior utilization, these variables were added to regression models to compare all 5 CFIs. Logistic regression was used to calculate model discrimination and calibration for both outcomes. RESULTS: A total of 3 million Veterans were included (mean age 75, 98% male participants, 80% White, and 9% Black). Frailty was identified for between 6.8% and 25.7% of the cohort with 2.6% identified as frail by all 5 CFIs. There was no meaningful difference between CFIs in the area under the receiver operating characteristic curve for LTI (0.78-0.80) or mortality (0.77-0.79). CONCLUSIONS: Based on different frailty constructs, and identifying different subsets of the population, all 5 CFIs similarly predicted LTI or death, suggesting each could be used for prediction or analytics.

Peer-to-Patient-Aligned Care Team (Peer-to-PACT; P2P), a Peer-Led Home Visit Intervention Program for Targeting and Improving Long-term Care Services and Support for Veterans With High Needs and High Risk: Protocol for a Mixed Methods Feasibility Study.

BACKGROUND: Keeping older veterans with high needs and high risk (HNHR) who are at risk of long-term institutional care safely in their homes for as long as possible is a Department of Veterans Affairs priority. Older veterans with HNHR face disproportionate barriers and disparities to engaging in their care, including accessing care and services. Veterans with HNHR often have poor ability to maintain health owing to complicated unmet health and social needs. The use of peer support specialists (peers) is a promising approach to improving patient engagement and addressing unmet needs. The Peer-to-Patient-Aligned Care Team (Peer-to-PACT; P2P) intervention is a multicomponential home visit intervention designed to support older veterans with HNHR to age in place. Participants receive a peer-led home visit to identify unmet needs and home safety risks aligned with the age-friendly health system model; care coordination, health care system navigation, and linking to needed services and resources in collaboration with their PACT; and patient empowerment and coaching using Department of Veterans Affairs whole health principles. OBJECTIVE: The primary aim of this study is to evaluate the preliminary effect of the P2P intervention on patient health care engagement. The second aim is to identify the number and types of needs and unmet needs as well as needs addressed using the P2P needs identification tool. The third aim is to evaluate the feasibility and acceptability of the P2P intervention delivered over 6 months. METHODS: We will use a quantitative-qualitative convergent mixed methods approach to evaluate the P2P intervention outcomes. For our primary outcome, we will conduct an independent, 2-tailed, 2-sample t test to compare the means of the 6-month pre-post differences in the number of outpatient PACT encounters between the intervention and matched comparison groups. Qualitative data analysis will follow a structured rapid approach using deductive coding as well as the Consolidated Framework for Implementation Research. RESULTS: Study enrollment began in July 2020 and was completed in March 2022. Our sample size consists of 114 veterans: 38 (33.3%) P2P intervention participants and 76 (66.7%) matched comparison group participants. Study findings are expected to be published in late 2023. CONCLUSIONS: Peers may help bridge the gap between PACT providers and veterans with HNHR by evaluating veterans' needs outside of the clinic, summarizing identified unmet needs, and developing team-based solutions in partnership with the PACT. The home visit component of the intervention provides eyes in the home and may be a promising and innovative tool to improve patient engagement. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46156.

Trends in Risk-Adjusted Initiation and Reduction of Opioid Use among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers.

OBJECTIVE: Proper initiation and reduction of opioids is important in providing effective and safe pain relief to Veterans with dementia, including in Community Living Centers (CLCs). We examined the trends in aggregated monthly risk-adjusted opioid administration days and dosage over 3 opioid safety regulatory periods: pre-Opioid Safety Initiative period (October 1, 2012-June 30, 2013; period 1), pre-CDC Clinical Practice Guideline period (January 1, 2014-November 30, 2015, period 2) and post-Veterans Affairs Clinical Practice Guideline period (March 1, 2017-September 30, 2018; period 3). DESIGN: A retrospective study between October 1, 2012, and September 30, 2018. SETTINGS AND PARTICIPANTS: 4995 long-stay CLC residents with dementia who had incident (incident cohort, n = 2609) or continued (continued opioid cohort, n = 2386) opioid administration in CLCs. METHODS: CLC Minimum Data Set (MDS) assessments data and bar-code medication administration data were used. Opioid initiation was examined for incident opioid cohort and reduction was examined using continued opioid cohort. We first computed aggregated monthly risk-adjusted opioid administration days, opioid with benzodiazepine administration days and opioid dosage, and then examined risk-adjusted incident and continued opioid administration trends over the regulatory periods controlling for facility-level characteristics. RESULTS: Among the incident opioid cohort, compared to period 1, there were 1.9 and 2.1 fewer risk-adjusted opioid administration days per month in periods 2 and 3, respectively; 1.5 fewer risk-adjusted days per month with opioid and benzodiazepine administration in both periods 2 and 3; and 2.2 and 3.7 morphine milligrams equivalent per day (MMED) lower risk-adjusted dosage in periods 2 and 3, respectively. Among the continued opioid cohort, compared to period 1, there were 1.6 and 2.9 fewer risk-adjusted days with opioid and benzodiazepine administration days per month in periods 2 and 3, respectively, and 5.3 MMED lower risk-adjusted dosage per month in period 3. CONCLUSIONS AND IMPLICATIONS: CLC providers initiated and reduced opioid administration in fewer days and at lower dosage among Veterans with dementia across the regulatory periods. The result was likely due to systemic efforts from health care professionals, CLC administrators, and policy makers or VA central office, aiming to reduce opioid misuse and improve quality of care in nursing home residents with dementia. What is still unknown is whether pain was well controlled or nonpharmacologic treatments were utilized.

Developing a Parsimonious Frailty Index for Older, Multimorbid Adults With Heart Failure Using Machine Learning.

Frailty is associated with adverse outcomes in heart failure (HF). A parsimonious frailty index (FI) that predicts outcomes of older, multimorbid patients with HF could be a useful resource for clinicians. A retrospective study of veterans hospitalized from October 2015 to October 2018 with HF, aged ≥50 years, and discharged home developed a 10-item parsimonious FI using machine learning from diagnostic codes, laboratory results, vital signs, and ejection fraction (EF) from outpatient encounters. An unsupervised clustering technique identified 5 FI strata: severely frail, moderately frail, mildly frail, prefrail, and robust. We report hazard ratios (HRs) of mortality, adjusting for age, gender, race, and EF and odds ratios (ORs) for 30-day and 1-year emergency department visits and all-cause hospitalizations after discharge. We identified 37,431 veterans (age, 73 ± 10 years; co-morbidity index, 5 ± 3; 43.5% with EF ≤40%). All frailty groups had a higher mortality than the robust group: severely frail (HR 2.63, 95% confidence interval [CI] 2.42 to 2.86), moderately frail (HR 2.04, 95% CI 1.87 to 2.22), mildly frail (HR 1.60, 95% CI 1.47 to 1.74), and prefrail (HR 1.18, 95% CI: 1.07 to 1.29). The associations between frailty and mortality remained unchanged in the stratified analysis by age or EF. The combined (severely, moderately, and mildly) frail group had higher odds of 30-day emergency visits (OR 1.62, 95% CI 1.43 to 1.83), all-cause readmission (OR, 1.75, 95% CI 1.52 to 2.02), 1-year emergency visits (OR 1.70, 95% CI 1.53 to 1.89), rehospitalization (OR 2.18, 95% CI 1.97 to 2.41) than the robust group. In conclusion, a 10-item FI is associated with postdischarge outcomes among patients discharged home after a hospitalization for HF. A parsimonious FI may aid clinical prediction at the point of care.

Hospital In Home: Evaluating Need and Readiness for Implementation (HENRI) in the Department of Veterans Affairs: protocol for a mixed-methods evaluation and participatory implementation planning study.

BACKGROUND AND OBJECTIVES: The Department of Veterans Affairs (VA) Hospital-In-Home (HIH) program delivers patient-centered, acute-level hospital care at home. Compared to inpatient care, HIH has demonstrated improved patient safety, effectiveness, and patient and caregiver satisfaction. The VA Office of Geriatrics & Extended Care (GEC) has supported the development of 12 HIH program sites nationally, yet adoption in VA remains modest, and questions remain regarding optimal implementation practices to extend reach and adaptability of this innovation. Guided by theoretical and procedural implementation science frameworks, this study aims to systematically gather evidence from the 12 HIH programs and to develop a participatory approach to engage stakeholders, assess readiness, and develop/adapt implementation strategies and evaluation metrics. RESEARCH DESIGN AND METHODS: We propose a multi-phase concurrent triangulation design comprising of (1) qualitative interviews with key informants and document review, (2) quantitative evaluation of effectiveness outcomes, and (3) mixed-methods synthesis and adaptation of a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM)-guided conceptual framework. RESULTS: The prospective phase will involve a participatory process of identifying stakeholders (leadership, HIH staff, veterans, and caregivers), engaging in planning meetings informed by implementation mapping, and developing implementation logic models and blueprints. The process will be assessed using a mixed-methods approach through participant observation and document review. DISCUSSION AND IMPLICATION: This study will support the continued spread of HIH programs, generate a catalog of HIH implementation evidence, and create implementation tools and infrastructure for future HIH development. The multi-phase nature of informing prospective planning with retrospective analysis is consistent with the Learning Health System framework.

Hospitals serving nursing home residents disproportionately penalized under hospital readmissions reduction program.

BACKGROUND: Risk factors common to nursing home (NH) residents are potentially not fully captured by the Hospital Readmissions Reduction Program (HRRP). The unique challenges faced by hospitals that disproportionately serve NH residents who are at greater risk of readmissions have not been studied. METHODS: Using 100% Medicare Provider Analysis and Review File and the Minimum Data Set from 2010-2013, we constructed a measure of hospital share of NH-originating hospitalizations (NOHs). We defined hospital share of NOHs as the proportion of inpatient stays by patients aged 65 or older who were directly admitted from NHs. To evaluate the impact of the share of NOHs on readmission penalties, we categorized hospitals into quartiles according to their share of NOHs and estimated the differences in the adjusted penalties across hospital quartiles after accounting for hospital characteristics, market characteristics and state fixed effects. We repeated the analyses for the penalties incurred in each year between 2015 and 2019. RESULTS: Hospitals varied substantially in the share of NOHs (median [interquartile range], 11.3% [8.2%-15.1%]), with limited variation over time. In 2015, hospitals in the highest quartile of NOH received on average 0.58% Medicare payment reduction compared to 0.44% reduction among those in the lowest quartile (32.9% higher penalties, p < 0.001). The increase in penalties continued to grow in 2017 and 2018 when the HRRP expanded to include additional target conditions (47.3% and 66.7%, respectively, p < 0.001 for both). Although the effect diminished in 2019 following the additional adjustment for hospital's dual-eligible share, hospitals in the highest quartile of NOH still incurred 43.0% (p < 0.001) higher penalties than those in the lowest quartile. CONCLUSIONS: Hospitals varied considerably in their share of NOHs. Hospitals having a higher share of NOHs were disproportionately penalized for excess readmissions, even under the revised policy that adjusts for the share of dual-eligible admissions.