1. Quality of Care for Veterans in Community Nursing Homes 1999- 2002 Christopher E. Johnson, Ph.D. Associate Professor Department of Health Policy and Management Texas A&M University System Health Science Center

2. Acknowledgements Research team Robert Weech-Maldonado, Ph.D. - University of Florida Huanguang Jia, Ph.D – VA’s Rehabilitation Outcomes Research Center Dean Reker, Ph.D. – Kansas University & VA Robert Buchanan, Ph.D. – Mississippi State University Alexandre Laberge – VA’s Rehabilitation Outcomes Research Center Disclaimer - The research reported here was supported by Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (project no. IIR 02-284). The views expressed in this presentation are those of the authors and do not necessarily represent the views of Department of Veterans Affairs.

3. Background VA’s Community Nursing Home Program Veterans Healthcare Administration (VHA) divided into 21 Veterans Integrated Services Networks ( VISN). Each VISN has a budget to provide long-term care in nursing homes outside of the VHA system. 2004 General Accounting Office Report Critical of VA oversight of the Community Nursing Home Program Cited lack of data available at the national level about the quality of care for veterans in community facilities.

4. Research Questions This is exploratory facility level research using the Structure-Process-Outcomes model to examine quality. We posed the following hypotheses: H(1): The presence of veterans on per-diem will result in increased structure-related quality. H(2): The presence of veterans on per-diem will result in increased process-related quality. H(3): The presence of veterans on per-diem will result in increased outcome-related quality.

5. Data CMS Minimum Data Set used to identify per- diem veterans in nursing homes. This information was merged with CMS OSCAR data for 1999 – 2002. Presence of any per-diem veterans in a facility was the main variable of interest A sub-analysis was done to examine, in those facilities that had per-diem veterans, high ratio facilities versus those with lower ratios of per- diem veterans. Controlled for Medicaid, Medicare, size, for profit, system membership, hospital-based, acuity, VISN, and year.

6. Dependent Variables Structure Met the CMS/Abt recommended standards for RNs (0.75 hours per resident day) and/or CNAs (2.8 hours per resident day). Process Tubefed residents New indwelling catheterizations Use of mobility restraints Outcomes Quality of care, quality of life, and total deficiencies cited against the nursing home. Actual harm citations (G or higher) New pressure sores

7. Methods Concerns about state-level variation with licensure survey data. Used hierarchical linear models to account for this state-level effect. Used Stata 9.0’s GLLAMM (for dichotomous variables) and xtmixed (for continuous variables) functions.

8. Descriptive Data Non VA per-diem observations (N = 39,648) VA per-diem facility observations (N = 27,295) Structure Variables Met CNA Standard24.0%18.8% Met RN standard18.8%15.1% Process Variables Tube feeding5.42 ± 8.117.89 ± 10.04 New catheterization1.55 ± 3.001.97 ± 3.53 Mobility restraints8.46 ± 12.1410.45 ± 14.61 Outcome Variables Quality of care deficiencies1.62 ± 1.901.92 ± 2.06 Quality of life deficiencies0.67 ± 1.070.84 ± 1.17 Total deficiencies5.52 ± 5.566.55 ± 6.01

9. Results Met CNA standard 1 Met RN standard 1 All Facilities VA per- diem facilities All Facilities VA per- diem facilities Any veterans0.83**NA0.87**NA High vet ratioNA0.91NA0.91 Medicaid0.90**0.92**0.83**0.82** Medicare1.12** 1.45** Total beds0.990.99*0.991.01** For profit0.43**0.41**0.62**0.64** Member of System0.57**0.54**0.89**0.96 Hospital based SNF1.09*1.104.31**5.10** Acuity index1.16**1.13**1.15**1.10**

10. Results Tube feeding 1 New catheterization 1 Mobility restraints 1 All Facilities VA per-diem facilities All Facilities VA per-diem facilities All Facilities VA per-diem facilities Any veterans+0.490**NA+0.070**NA-0.067NA High vet ratioNA+0.738**NA-0.026NA-1.07** Medicaid+6.705**+7.538**+0.503**+0.270*+1.775**+1.315** Medicare+3.003**+3.614**-0.718**-1.159**-4.587**-5.452** Total beds+0.059**+0.062**+0.014** +1.069**+0.071** For profit+0.180**+0.240-0.107**-0.127*-0.475**-0.843** Member of System +0.024**+0.010-0.155**-0.197**-1.239**-1.559** Hospital based SNF +1.127**+1.458**+0.284**+0.470**-2.136**-2.331** Acuity index+1.743**+1.983**+0.177**+0.228**+0.932**+1.145**

11. Quality of care deficiencies 1 Quality of life deficiencies 1 Total deficiencies 1 Actual harm citation 1 New pressure sores 1 All Facilities VA per- diem facilities All Facilities VA per- diem facilities All Facilities VA per-diem facilities All Facilities VA per- diem facilities All Facilities VA per-diem facilities Any Veterans +0.134**NA+0.069**NA+0.447**NA1.06**NA+0.180**NA High vet Ratio NA-0.039NA+0.075**NA+0.214*NA0.90*NA-0.198** Medicaid+0.512**+0.606**+0.504**+0.612**+2.157**+2.346**1.42**1.47**+0.368**+0.245 Medicare-0.151*-0.063+0.013+0.030-0.420*-0.4330.59**0.56**-1.096**-1.443** Total beds+0.003** +0.001** +0.009**+0.008**1.03**1.00**+0.022** For profit+0.264**+0.265**+0.181**+0.170**+0.974**+0.957**1.13**1.15**-0.195**-0.372** Member of System +0.158**+0.165**+0.105**+0.091**+0.337**+0.334**1.11**1.09*+0.094**+0.144** Hospital based SNF -0.279**-0.328**-0.073**-0.077*-0.334**-0.468**0.78**0.79*-0.530**-0.606** Acuity index +0.059**+0.089**+0.004+0.014**+0.072**+0.141**1.05**1.07**+0.255**0.360**

12. Results No support for our initial hypotheses. Per-diem veteran community facilities had significantly worse multi-dimensional quality related outcomes across the board when compared to facilities that do not serve veterans. Mobility restraints was the only dependent variable where per-diem veteran presence was not significant. However, nursing homes that served higher proportions of per-diem veterans were generally higher quality than those that served lower ratios of veterans.

13. Discussion These results raise questions about the quality of care for veterans within the community nursing home program. VA should consider a more national data collection and monitoring effort about the care provided within this setting. Specific types of community nursing homes are more likely to be involved with the Community Nursing Home Program.

14. Conclusion Limitations CMS MDS and OSCAR data known issues. Future research Need more detailed analyses of the community nursing home selection process in the VA. Additional projects should look at specific risk- adjusted outcomes for veterans in this setting. Ultimately, a comparison between the quality and costs for veterans within community nursing homes versus those in the VA setting needs to be undertaken.