Comparing Post-Acute Populations and Care in Veterans Affairs and Community Nursing Homes.

OBJECTIVE: The quality of care provided by the US Department of Veterans Affairs (VA) is increasingly being compared to community providers. The objective of this study was to compare the VA Community Living Centers (CLCs) to nursing homes in the community (NHs) in terms of characteristics of their post-acute populations and performance on 3 claims-based ("short-stay") quality measures. DESIGN: Observational, cross-sectional. SETTING AND PARTICIPANTS: CLC and NH residents admitted from hospitals during July 2015-June 2016. METHODS: CLC residents were compared with 3 NH populations: males, Veterans, and all NH residents. CLC and NH performance was compared on risk-adjusted claims-based measures: unplanned rehospitalizations and emergency department visits within 30 days of CLC or NH admission and successful discharge to the community within 100 days of NH admission. RESULTS: Veterans admitted from hospitals to CLCs (n = 23,839 Veterans/135 CLCs) were less physically impaired, less likely to have anxiety, congestive heart failure, hypertension, and dementia than Veterans (n = 241,177/14,818 NHs), males (n = 661,872/15,280 NHs), and all residents (n = 1,674,578/15,395 NHs) admitted to NHs from hospitals. Emergency department and successful discharge risk-adjusted rates of CLCs were statistically significantly better than those of NHs [mean (standard deviation): 8.3% (4.6%) and 67.7% (11.5%) in CLCs vs 11.9% (5.3%) and 57.0% (10.5%) in NHs, respectively]. CLCs had slightly worse rehospitalization rates [22.5% (6.2%) in CLCs vs 21.1% (5.9%) in NHs], but lower combined emergency department and rehospitalization rates [30.8% (0.8%) in CLCs vs 33.0% (0.7%) in NHs]. CONCLUSIONS AND IMPLICATIONS: CLCs and NHs serve different post-acute care populations. Using the same risk-adjusted NH quality metrics, CLCs provided better post-acute care than community NHs.

Honoring Veterans' Preferences: The Association Between Comfort Care Goals and Care Received at the End of Life.

CONTEXT: As part of its Life-Sustaining Treatment (LST) Decisions Initiative, the Veterans Health Administration (VA) in January 2017 began requiring electronic documentation of goals of care and preferences for Veterans with serious illness and at high risk for life-threatening events. OBJECTIVES: To evaluate whether goals of "to be comfortable" were associated with greater palliative care (PC) use and lesser acute care use. METHODS: We identified Veterans with VA inpatient or nursing home stays overlapping July 2018-January 2019, with LST templates documented by January 31, 2019, and who died by April 30, 2019 (N = 18,163). From template documentation, we identified a "to be comfortable" goal. Using VA and Medicare data, we determined PC use (consultations and hospice) and hospital, intensive care unit, and emergency department use 7 and 30 days before death. Multivariate logistic regression examined the associations of interest. RESULTS: Sixty-four percent of the 18,163 Veterans had comfort-care goals; 80% with comfort care goals received hospice and 57% PC consultations (versus 57% and 46%, respectively, for decedents without comfort-care goals). In adjusted analyses, comfort care documented on the LST template prior to death was associated with significantly lower odds of hospital, intensive care unit, and emergency department use near the end of life. In the last 30 days of life, Veterans with a comfort care goal had 44% lower odds (adjusted odds ratio 0.57; 95% CI: 0.51, 0.63) of being hospitalized. CONCLUSION: Findings support the VA's commitment to honoring of Veterans' preferences post introduction of its Life Sustaining Treatment Decisions Initiative.

Designing clinical practice feedback reports: three steps illustrated in Veterans Health Affairs long-term care facilities and programs.

BACKGROUND: User-centered design (UCD) methods are well-established techniques for creating useful artifacts, but few studies illustrate their application to clinical feedback reports. When used as an implementation strategy, the content of feedback reports depends on a foundational audit process involving performance measures and data, but these important relationships have not been adequately described. Better guidance on UCD methods for designing feedback reports is needed. Our objective is to describe the feedback report design method for refining the content of prototype reports. METHODS: We propose a three-step feedback report design method (refinement of measures, data, and display). The three steps follow dependencies such that refinement of measures can require changes to data, which in turn may require changes to the display. We believe this method can be used effectively with a broad range of UCD techniques. RESULTS: We illustrate the three-step method as used in implementation of goals of care conversations in long-term care settings in the U.S. Veterans Health Administration. Using iterative usability testing, feedback report content evolved over cycles of the three steps. Following the steps in the proposed method through 12 iterations with 13 participants, we improved the usability of the feedback reports. CONCLUSIONS: UCD methods can improve feedback report content through an iterative process. When designing feedback reports, refining measures, data, and display may enable report designers to improve the user centeredness of feedback reports.

Iraq and Afghanistan Veterans' Use of Veterans Health Administration and Purchased Care Before and After Veterans Choice Program Implementation.

BACKGROUND: The Veterans Choice Program (VCP), enacted by Congress after concerns surfaced about access, enables veterans to receive care outside Veterans Health Administration (VHA) facilities. Veterans who face long wait times, large driving distances, or particular hardships are eligible for VCP. Prior purchased care programs were comparatively limited in scope. OBJECTIVES: We sought to describe utilization of VHA-provided and purchased outpatient care by veterans eligible for VCP before and after VCP implementation. We focused on veterans recently eligible for VHA as they are of particular policy relevance and might have less established care patterns. RESEARCH DESIGN: We identified all Iraq and Afghanistan veterans who were eligible for VCP in 2015. We tabulated their use of VHA and purchased outpatient care for 3 years before (FY2012-2014) and 1 year after VCP implementation (FY2015). SUBJECTS: Our study population consisted of 214,449 Iraq and Afghanistan veterans who were eligible for VCP due to wait-time, distance, or hardship issues. RESULTS: In the first year of the program, 3821 (2%) of these Iraq and Afghanistan veterans used non-VHA services through VCP. Per capita VHA utilization tended to decline slightly after VCP implementation, but these changes varied by type of outpatient care. CONCLUSIONS: There was low uptake of VCP services in the first year of the program. Data from additional years are needed to better understand the impact of this policy.