Predicting Risk of Long-Term Institutionalization Among Community Dwelling Veterans Before the COVID-19 Pandemic.

Objective: To identify risk of long-term institutionalization (LTI) among Veterans receiving care in the Veterans Health Administration (VA).

Study Setting And Design: We developed the "Predicted Long-term Institutionalization" (PLI) risk model for Veterans alive in the community at the end of fiscal-year (FY) 2017 followed for LTI in nursing home (cumulative NH days allowing any acute care and up to 7 days in community > 90 days) during FY2018-FY2019.

Data Sources And Analytic Sample: PLI used demographics, diagnoses, prior hospital and nursing home (NH) use, and risk indices for death and frailty from VA and Medicare claims and Minimum Data Set data.

The Epidemiology of the Long-Term Care Needs and Unmet Needs of Older Veterans in the United States.

Veterans differ in sociodemographic composition and experience higher frequencies of disability than non-Veterans of the same age. Yet the epidemiology of the long-term care needs of Veterans, specifically activities of daily living (ADLs) and instrumental activities of daily living (IADLs), remains an important gap in the literature. The objectives of this study were to (1) characterize Veterans across levels of hierarchy of ADL and IADL support needs; (2) compare Veterans across the degree of need for help, from those who can still "self-manage" to those with an "unmet need"; and (3) identify the types and prevalence of ADL and IADL need combination patterns.

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.

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.

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.

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).

Opioid administration trends among long-stay community living centers residents with dementia.

Background: Pain assessment and management of Veterans with Alzheimer's disease and Related Dementia (ADRD) living in Community Living Centers (CLCs) is challenging. Safe and effective use of opioids in the treatment of pain is of great concern to patients and providers promulgating national policies and guidelines.

Methods: This study examined long-stay CLC Veterans with ADRD identified in three regulatory periods (period 1: 10/2012-6/2013, n = 3347; period 2: 1/2014-11/2015, n = 4426; period 3: 1/2017-9/2018, n = 4444; Total N = 12,217).

Decomposing Differences in Risk-Adjusted Rates of Emergency Department Visits Between Micropolitan and Urban Nursing Homes.

Objectives: Nursing homes (NHs) in micropolitan areas are reported to have different facility and market factors than urban NHs, but how these factors contribute to differences in emergency department (ED) visits remains unknown. This study examined and quantified sources of micropolitan-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED (PAED) visits of long-stay residents.

Design: The 2011-2013 national Medicare claims and NH Minimum Data Set (MDS) 3.

Changing landscape of nursing homes serving residents with dementia and mental illnesses.

Objective: Nursing homes (NHs) are serving an increasing proportion of residents with cognitive issues (e.g., dementia) and mental health conditions.

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.

Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis.

Background: Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents.

Objectives: To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents.

Research Design: We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.

Nursing Home and Market Factors and Risk-Adjusted Hospitalization Rates Among Urban, Micropolitan, and Rural Nursing Homes.

Objectives: Hospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3).

Design: The longitudinal associations of NH and market factors and hospitalization rates were modeled separately on urban, micropolitan, and rural NHs using generalized estimating equation models and a fully interacted model of all NH and market characteristics with micropolitan and rural indicators to test significance of differences compared with urban NHs.

Shortages of Staff in Nursing Homes During the COVID-19 Pandemic: What are the Driving Factors?

Objectives: During the Coronavirus Disease 2019 (COVID-19) pandemic, US nursing homes (NHs) have been under pressure to maintain staff levels with limited access to personal protection equipment (PPE). This study examines the prevalence and factors associated with shortages of NH staff during the COVID-19 pandemic.

Design: We obtained self-reported information on staff shortages, resident and staff exposure to COVID-19, and PPE availability from a survey conducted by the Centers for Medicare and Medicaid Services in May 2020.

Continuity of care and health care cost among community-dwelling older adult veterans living with dementia.

Objectives: To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia.

Data Sources: Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015.

Study Design: FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale.

Medicaid Nursing Home Policies and Risk-Adjusted Rates of Emergency Department Visits: Does Rural Location Matter?

Objectives: Medicaid nursing home (NH) reimbursement rates and bed-hold policies have been shown to be associated with hospitalization of urban NH residents, but their relationships with emergency department (ED) visits, especially in rural NHs, remain unknown. This study explores the relationships of Medicaid NH policies with three NH quarterly risk-adjusted rates of ED use for long-stay residents and evaluates whether the associations differed by NHs' geographical locations.

Design: Longitudinal study of Medicaid policies and NH risk-adjusted rates over 3 quarters (2011 Q3, 2012 Q3, and 2013 Q3), using Generalized Estimating Equation (GEE) models.

Construction and Validation of Risk-adjusted Rates of Emergency Department Visits for Long-stay Nursing Home Residents.

Background: Long-stay nursing home (NH) residents are at high risk of having emergency department (ED) visits, but current knowledge regarding risk-adjusted ED rates is limited.

Objectives: To construct and validate 3 quarterly risk-adjusted rates of long-stay residents' ED use: any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED).

Research Design: The authors calculated quarterly NH risk-adjusted ED rates from 2011 Q2 to 2013 Q3 national Medicare claims and Minimum Data Set data.

Hypertension Treatment in US Long-Term Nursing Home Residents With and Without Dementia.

Objectives: To describe patterns of antihypertensive medication treatment in hypertensive nursing home (NH) residents with and without dementia and determine the association between antihypertensive treatment and outcomes important to individuals with dementia.

Design: Observational cohort study.

Setting: All US NHs.

Antihypertensive Drug Deintensification and Recurrent Falls in Long-Term Care.

Objective: To examine the relationship between antihypertensive drug deintensification and recurrent falls in long-term care.

Data Sources/settings: Department of Veterans Affairs (VA) inpatient, outpatient, and purchased care data, Minimum Data Set assessments from VA nursing homes (NHs), and Medicare claims from fiscal years 2010 - 2015.

Study Design: We identified NH residents with evidence of overaggressive antihypertensive treatment, defined as systolic blood pressure (SBP) 80-120 and an index fall.

Attributable Cost of Dementia: Demonstrating Pitfalls of Ignoring Multiple Health Care System Utilization.

Objectives: To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data.

Data Sources: VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013.

Study Design: Analyses were conducted with VHA data alone and with combined VHA and Medicare data.

Increasing Veterans' Hospice Use: The Veterans Health Administration's Focus On Improving End-Of-Life Care.

In 2009 the Department of Veterans Affairs (VA) began a major, four-year investment in improving the quality of end-of-life care. The Comprehensive End of Life Care Initiative increased the numbers of VA medical center inpatient hospice units and palliative care staff members as well as the amount of palliative care training, quality monitoring, and community outreach. We divided male veterans ages sixty-six and older into categories based on their use of the VA and Medicare and examined whether the increases in their rates of hospice use in the last year of life differed from the concurrent increase among similar nonveterans enrolled in Medicare.