Robert E Burke1,2, Anne Canamucio1, Thomas J Glorioso3, Anna E Barón3,4, Kira L Ryskina2. 1. Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania. 2. Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. 3. Center of Innovation for Veteran-Centered and Value-Driven Care, Denver VA Medical Center, Denver, Colorado. 4. Colorado School of Public Health, University of Colorado, Aurora, Colorado.
Abstract
BACKGROUND: As the veteran population ages, more veterans are receiving post-acute care in skilled nursing facilities (SNFs). However, the outcomes of these transitions across Veterans Affairs (VA) and non-VA settings are unclear. OBJECTIVE: To measure adverse outcomes in veterans transitioning from hospital to SNF in VA and non-VA hospitals and SNFs. DESIGN: Retrospective observational study using the 2012 to 2014 Residential History File, which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for veterans. SETTING: VA and non-VA hospitals and SNFs in four categories: non-VA SNFs, VA-contracted SNFs, VA Community Living Centers (CLCs), and State Veterans Homes. PARTICIPANTS: Veterans, aged 65 years or older, who were acutely hospitalized and discharged to an SNF; one transition was randomly selected per patient. MEASUREMENTS: Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS: More than four in five veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7% in the 388 339 veterans included. Adverse outcomes were lowest in VA hospital-CLC transitions (7.5%; 95% confidence interval [CI] = 7.1%-7.8%) and highest in non-VA hospital to VA-contracted nursing home transitions (17.5%; 95% CI = 16.0%-18.9%) in unadjusted analysis. In multivariate analyses adjusted for patient and hospital characteristics, VA hospitals had lower adverse outcome rates than non-VA hospitals (odds ratio [OR] = 0.80; 95% CI = 0.74-0.86). In comparison to VA hospital-VA CLC transitions, non-VA hospital to VA-contracted nursing homes (OR = 2.51; 95% CI = 2.09-3.02) and non-VA hospital to CLC (OR = 2.25; 95% CI = 1.81-2.79) had the highest overall adverse outcome rates. CONCLUSION: Most veteran hospital-SNF transitions occur outside the VA, although adverse transitional care outcomes are lowest inside the VA. These findings raise important questions about the VA's role as a provider and payer of post-acute care in SNFs. J Am Geriatr Soc 67:1820-1826, 2019.
BACKGROUND: As the veteran population ages, more veterans are receiving post-acute care in skilled nursing facilities (SNFs). However, the outcomes of these transitions across Veterans Affairs (VA) and non-VA settings are unclear. OBJECTIVE: To measure adverse outcomes in veterans transitioning from hospital to SNF in VA and non-VA hospitals and SNFs. DESIGN: Retrospective observational study using the 2012 to 2014 Residential History File, which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for veterans. SETTING: VA and non-VA hospitals and SNFs in four categories: non-VA SNFs, VA-contracted SNFs, VA Community Living Centers (CLCs), and State Veterans Homes. PARTICIPANTS: Veterans, aged 65 years or older, who were acutely hospitalized and discharged to an SNF; one transition was randomly selected per patient. MEASUREMENTS: Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS: More than four in five veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7% in the 388 339 veterans included. Adverse outcomes were lowest in VA hospital-CLC transitions (7.5%; 95% confidence interval [CI] = 7.1%-7.8%) and highest in non-VA hospital to VA-contracted nursing home transitions (17.5%; 95% CI = 16.0%-18.9%) in unadjusted analysis. In multivariate analyses adjusted for patient and hospital characteristics, VA hospitals had lower adverse outcome rates than non-VA hospitals (odds ratio [OR] = 0.80; 95% CI = 0.74-0.86). In comparison to VA hospital-VA CLC transitions, non-VA hospital to VA-contracted nursing homes (OR = 2.51; 95% CI = 2.09-3.02) and non-VA hospital to CLC (OR = 2.25; 95% CI = 1.81-2.79) had the highest overall adverse outcome rates. CONCLUSION: Most veteran hospital-SNF transitions occur outside the VA, although adverse transitional care outcomes are lowest inside the VA. These findings raise important questions about the VA's role as a provider and payer of post-acute care in SNFs. J Am Geriatr Soc 67:1820-1826, 2019.
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