Community Nursing Home Program Oversight: Can the VA Meet Increased Demand for Community-Based Care?
Background: The US Department of Veterans Affairs (VA) Community Nursing Home (CNH) program provides in-person oversight monitoring the quality of care of veterans in VA-contracted community-based skilled nursing homes. The number of veterans receiving CNH care is projected to increase by 80% by 2037.
Methods: Retrospective observational data describing the distance between contracted facilities and VA medical centers (VAMCs) were linked to Centers for Medicare and Medicaid monthly Nursing Home Compare and Brown University Long Term Care: Facts on Care in the US data. Qualitative interviews with CNH-based staff and VA-based CNH program oversight team members were conducted using a semistructured interview guide. Quantitative and qualitative data were analyzed independently and integrated during the interpretation of results.
Results: The number of CNHs per VAMC ranged from 1 to 68 (mean, 18). One in 4 CNHs were > 70 miles from the associated VAMC; among CNHs with 2 to 5 veterans, 44% were located > 50 miles away. Four qualitative themes emerged regarding VA CNH oversight: (1) benefits of VA CNH team engagement/visits, including quality assurance and care coordination; (2) burden of VA CNH oversight due to geographic dispersion with too few or too many veterans at each to achieve efficiency; (3) oversight burdens and limited staffing restricted ability to add CNHs; and (4) remote access and interoperability of electronic health records and balancing the number of CNH veterans with staffing could facilitate successful oversight.
Conclusions: The success of the CNH program will depend on the exchange of information and matching available resources to veterans’ needs. At a time when strategies to ease the burden on NHs and VA CNH coordinators are needed, the VA needs to improve to properly scale the program.
METHODS
This study was a component of a larger research project examining VA-purchased CNH care; recruitment methods are available in previous publications describing this work.7 Participants provided written or verbal consent before video and phone interviews, respectively. This study was approved by the Colorado Multiple Institutional Review Board (Protocol #18-1186).
Video and phone interviews were conducted by 3 team members from October 2018 to March 2020 with CNH staff and VA CNH program oversight team members. Participant recruitment was paused from May to October 2020 as a result of the COVID-19 pandemic and ambiguity about VA NH care purchasing policies following the passage of the VA MISSION Act.5 We used semistructured interview guides (eAppendix 1 for VA staff and eAppendix 2 for NH staff, available online at doi:10.12788/fp.0421). Recorded and transcribed interviews ranged from 15 to 90 minutes.
Two members of the research team analyzed transcripts using both deductive and inductive content analysis.8 The interview guide informed an a priori codebook, and in vivo codes were included as they emerged. We jointly coded 6 transcripts to reach a consensus on coding approaches and analyzed the remaining transcripts independently with frequent meetings to develop themes with a qualitative methodologist. All qualitative data were analyzed using ATLAS.ti software.
This was a retrospective observational study of veterans who received VA-paid care in CNHs during the 2019 fiscal year (10/1/2018-9/30/2019) using data from the enrollment, inpatient and outpatient encounters, and other care paid for by the VA in the VA Corporate Data Warehouse. We linked Centers for Medicare and Medicaid monthly Nursing Home Compare reports and the Brown University Long Term Care: Facts on Care in the US (LTC FoCUS) annual files to identify facility addresses.9
Descriptive analyses of quantitative data were conducted in parallel with the qualitative findings.8 Distance from the contracting VAMC to CNH was calculated using the greater-circle formula to find the linear distance between geographic coordinates. Quantitative and qualitative data were collected concurrently, analyzed independently, and integrated into the interpretation of results.10
RESULTS
We conducted 36 interviews with VA and NH staff who were affiliated with 6 VAMCs and 17 CNHs. Four themes emerged concerning CNH oversight: (1) benefits of VA CNH team engagement/visits; (2) burden of VA CNH oversight; (3) burden of oversight limited the ability to contract with additional NHs; and (4) factors that ease the burden and facilitate successful oversight.
Benefits of Engagement/Visits
VA SWs and nurses visit each veteran every 30 to 45 days to review their health records, meet with them, and check in with NH staff. In addition, VA SWs and nurses coordinate each veteran’s care by working as liaisons between the VA and the NH to help NH staff problem solve veteran-related issues through care conferences. VA SWs and nurses act as extra advocates for veterans to make sure their needs are met. “This program definitely helps ensure that veterans are receiving higher quality care because if we see that they aren’t, then we do something about it,” a VA NH coordinator reported in an interview.
