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.
Limitations
Limitations include the unique relationship between VA and CNH staff overseeing the quality of care provided to veterans in CNHs, which is not replicated in other models of care. Data collection was interrupted following the passage of the MISSION Act in 2018 until guidance on changes to practice resulting from the law were clarified in 2020. Interviews were also interrupted at the onset of the COVID-19 pandemic.
Conclusions
The current quality of the CNH care oversight structure will require adaptation as demand for CNH care increases. While the VA CNH program is one of the longest-standing programs collaborating with non-VA community care partners, it is now only one of many following the MISSION Act. The success of this and other programs will depend on matching available CNH resources to the complex medical and psychological needs of veterans. At a time when strategies to ease the burden on NHs and VA CNH coordinators are desperately needed, Veterans Health Information Exchange capabilities need to improve. Evidence is needed to guide the scaling of the program to meet the needs of the rapidly expanding veteran population who are eligible for CNH care.
Acknowledgments
The authors acknowledge Amy Mochel of the Providence Veterans Affairs Medical Center for project management support of this project.
