Veterans Health Administration Community Research Articles

Veteran suicide prevention learning collaborative: implementation strategy and processes

The majority of Veterans who died by suicide in 2021 had not recently used Veterans Health Administration (VA) services. A public health approach to Veteran suicide prevention has been prioritized as part of the VA National Strategy for Preventing Veteran Suicide. Aligned with this approach, VA’s Patient Safety Center of Inquiry—Suicide Prevention Collaborative piloted a Veteran suicide prevention learning collaborative with both clinical and non-clinical community agencies that serve Veterans. The VA COmmunity LeArning CollaboraTive (CO-ACT) uses a quality improvement framework and facilitative process to support community organizational implementation of evidence-based and best practice suicide prevention strategies to achieve this goal. This paper details the structure of CO-ACT and processes by which it is implemented. This includes the CO-ACT toolkit, an organizational self-assessment, a summary of recommendations, creation of a blueprint for change, selection of suicide prevention program components, and an action plan to guide organizations in implementing suicide prevention practices. CO-ACT pilot outcomes are reported in a previous publication.

Racial and Ethnic Differences in Health Care Experiences for Veterans Receiving VA Community Care from 2016 to 2021.

Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner. To examine differences in Veterans' experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021. Observational analyses of Veterans' ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors. Respondents to the 2016-2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey. Care ratings in nine domains. The sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from - 0.04 to - 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted. This study identified small but persistent racial and ethnic differences in Veterans' experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans' patient experience could advance equity in VA community care.

NURSE STAFFING AND VETERAN OUTCOMES IN THE VETERANS HEALTH ADMINISTRATION’S COMMUNITY LIVING CENTERS

Abstract Higher nurse staffing levels have been associated with better outcomes for patients in the acute care setting and for residents in the long-term care setting. There are several publications available linking nurse staffing to improved quality measures. Conversely, minimal research has occurred examining associations between nurse staffing and Veteran outcomes. The purpose of this research study was to assess for associations between nursing hours per patient day (NHPPD) and Veteran outcome measures in the Veterans Health Administration Community Living Centers. A retrospective data review was completed for NHPPD and quality measures for 134 Community Living Centers. Descriptive statistics were used to analyze the average total NHPPD for each of six Minimum Data Set, version 3.0, quality measures. Linear regression was utilized to assess for a linear association between average total NHPPD and the defined quality measures. This study found no linear association between average total NHPPD and the following Veteran outcome measures: improvement in function (p=0.15), ability to move independently worsened (p=0.13), catheter in bladder (p=0.48), and UTI (p=0.48). However, a statistically significant linear association was found between average total NHPPD and the following Veteran outcome measures: falls with major injury (p=0.02) and help with ADLs (p=0.01). As the average total NHPPD increased, the mean for falls with major injury and the mean for help with ADLs decreased. This study adds to the body of literature regarding the impact of nurse staffing on quality measures in the long-term care setting.

A comparison of end-of-life care quality for Veterans receiving hospice in VA nursing homes and community nursing homes.

While the Veterans Health Administration (VA) has long provided hospice care within VA community living centers (CLCs, i.e., VA nursing homes), an increasing number of Veterans are receiving hospice in VA-contracted community nursing homes (CNHs). However, little data exist about the quality of end-of-life (EOL) care provided in CNHs. The aim of this study was to compare family ratings of the quality of EOL care provided to Veterans receiving hospice in VA CLCs and VA-contracted CNHs. We conducted a retrospective analysis of national data from VA's electronic medical record and Bereaved Family Survey (BFS) for Veterans who received hospice in VA CLCs or VA-contracted CNHs between October 2021 and March 2022. The final sample included 1238 Veterans who died in either a CLC (n = 1012) or a CNH (n = 226) and whose next-of-kin completed the BFS. Our primary outcome was the BFS global rating of care received in the last 30 days of life. Secondary outcomes included BFS items related to symptom management, communication, emotional and spiritual support, and information about burial and survivor benefits. We compared unadjusted and adjusted proportions for all BFS outcomes between those who received hospice in CLCs and CNHs. The adjusted proportion of family members who gave the best possible rating (a score of 9 or 10 out of a possible 10) for the overall care received near EOL was more than 13 percentage points higher for Veterans who received hospice in VA CLCs compared to VA-contracted CNHs. Our findings also revealed quality gaps of even greater magnitude in specific EOL care-focused domains. Our findings document inadequacies in the quality of multiple aspects of EOL care provided to Veterans in CNH-based hospice and illuminate the urgent need for policy and practice interventions to improve this care.

Variation in Low-Value Service Use Across Veterans Affairs Facilities.

It is unclear whether extensive variation in the use of low-value services exists even within a national integrated delivery system like the Veterans Health Administration (VA). To quantify variation in the use of low-value services across VA facilities and examine associations between facility characteristics and low-value service use. In this retrospective cross-sectional study of VA administrative data, we constructed facility-level rates of low-value service use as the mean count of 29 low-value services per 100 Veterans per year. Adjusted rates were calculated via ordinary least squares regression including covariates for Veteran sociodemographic and clinical characteristics. We quantified the association between adjusted facility-level rates and facility geographic/operational characteristics. 5,242,301 patients across 139 VA facilities. Use of 29 low-value services within six domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and surgery. The mean rate of low-value service use was 20.0 services per 100 patients per year (S.D. 6.1). Rates ranged from 13.9 at the 10th percentile to 27.6 at the 90th percentile (90th/10th percentile ratio 2.0, 95% CI 1.8‒2.3). With adjustment for patient covariates, variation across facilities narrowed (S.D. 5.2, 90th/10th percentile ratio 1.8, 95% CI 1.6‒1.9). Only one facility characteristic was positively associated with low-value service use percent of patients seeing non-VA clinicians via VA Community Care, p < 0.05); none was associated with total low-value service use after adjustment for other facility characteristics. There was extensive variation in low-value service use within categories of facility operational characteristics. Despite extensive variation in the use of low-value services across VA facilities, we observed substantial use of these services across facility operational characteristics and at facilities with lower rates of low-value service use. Thus, system-wide interventions to address low-value services may be more effective than interventions targeted to specific facilities or facility types.

Nurse Staffing and Veteran Outcomes in the Veterans Health Administration's Community Living Centers.

The demand for nursing care is rising in the long-term care setting. Nurse staffing is a crucial measure linked to health care quality measure outcomes. To assess for associations between nursing hours per patient day (NHPPD) and outcome measures in the Veterans Health Administration Community Living Centers. A retrospective data review of NHPPD and quality measures for 134 community living centers was conducted. Linear regression was used to assess for linear associations between average total NHPPD and 6 quality measures. A significant linear association was found between average total NHPPD and falls with major injury ( P = .02) and help with activities of daily living ( P = .01). No associations were found between nurse staffing and 4 other quality measures. This study adds to the body of literature regarding the impact of nurse staffing on quality measures.

Infections, Hospitalizations, and Deaths Among US Nursing Home Residents With vs Without a SARS-CoV-2 Vaccine Booster

A SARS-CoV-2 vaccine booster dose has been recommended for all nursing home residents. However, data on the effectiveness of an mRNA vaccine booster in preventing infection, hospitalization, and death in this vulnerable population are lacking. To evaluate the association between receipt of a SARS-CoV-2 mRNA vaccine booster and prevention of infection, hospitalization, or death among nursing home residents. This cohort study emulated sequentially nested target trials for vaccination using data from 2 large multistate US nursing home systems: Genesis HealthCare, a community nursing home operator (system 1) and Veterans Health Administration community living centers (VHA CLCs; system 2). The cohort included long-term (≥100 days) nursing home residents (10 949 residents from 202 community nursing homes and 4321 residents from 128 VHA CLCs) who completed a 2-dose series of an mRNA vaccine (either BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) and were eligible for a booster dose between September 22 and November 30, 2021. Residents were followed up until March 8, 2022. Receipt of a third mRNA vaccine dose, defined as a booster dose (boosted group), or nonreceipt of a booster dose (unboosted group) on an eligible target trial date. If participants in the unboosted group received a booster dose on a later target trial date, they were included in the booster group for that target trial; thus, participants could be included in both the boosted and unboosted groups. Test-confirmed SARS-CoV-2 infection, hospitalization, or death was followed up to 12 weeks after booster vaccination. The primary measure of estimated vaccine effectiveness was the ratio of cumulative incidences in the boosted group vs the unboosted group at week 12, adjusted with inverse probability weights for treatment and censoring. System 1 included 202 community nursing homes; among 8332 boosted residents (5325 [63.9%] female; 6685 [80.2%] White) vs 10 886 unboosted residents (6865 [63.1%] female; 8651 [79.5%] White), the median age was 78 (IQR, 68-87) years vs 78 (IQR, 68-86) years. System 2 included 128 VHA CLCs; among 3289 boosted residents (3157 [96.0%] male; 1950 [59.3%] White) vs 4317 unboosted residents (4151 [96.2%] male; 2434 [56.4%] White), the median age was 74 (IQR, 70-80) vs 74 (IQR, 69-80) years. Booster vaccination was associated with reductions in SARS-CoV-2 infections of 37.7% (95% CI, 25.4%-44.2%) in system 1 and 57.7% (95% CI, 43.5%-67.8%) in system 2. For hospitalization, reductions of 74.4% (95% CI, 44.6%-86.2%) in system 1 and 64.1% (95% CI, 41.3%-76.0%) in system 2 were observed. Estimated vaccine effectiveness for death associated with SARS-CoV-2 was 87.9% (95% CI, 75.9%-93.9%) in system 1; however, although a reduction in death was observed in system 2 (46.6%; 95% CI, -34.6% to 94.8%), this reduction was not statistically significant. A total of 45 SARS-CoV-2-associated deaths occurred in system 1 and 18 deaths occurred in system 2. For the combined end point of SARS-CoV-2-associated hospitalization or death, boosted residents in system 1 had an 80.3% (95% CI, 65.7%-88.5%) reduction, and boosted residents in system 2 had a 63.8% (95% CI, 41.4%-76.1%) reduction. In this study, during a period in which both the Delta and Omicron variants were circulating, SARS-CoV-2 booster vaccination was associated with significant reductions in SARS-CoV-2 infections, hospitalizations, and the combined end point of hospitalization or death among residents of 2 US nursing home systems. These findings suggest that administration of vaccine boosters to nursing home residents may have an important role in preventing COVID-19-associated morbidity and mortality.

Purchasing High-Quality Community Nursing Home Care: A Will to Work With VHA Diminished by Contracting Burdens.

The Veterans Health Administration (VHA) purchases community nursing home care; however, the administrative burden may lead nursing homes to avoid contracting with the VHA. This study aimed to describe how the VHA's purchasing policies impede or facilitate contracting with nursing homes. Semistructured interviews of key stakeholders in the VHA's community nursing home contracting process. We interviewed 15 VHA and 21 nursing home staff at 6 VHA medical centers and 17 nursing homes. VHA medical centers were selected from sites with the greatest magnitude of difference in quality rankings between VHA contracted and noncontracted nursing homes in the same market area. Qualitative content analysis of interviews. Five themes emerged: (1) VHA purchases nursing home care to fill gaps in geographic, specialty, and quality care needs; (2) business opportunities and the mission to care for Veterans motivate nursing homes to work with the VHA; (3) the VHA's reputation for unreliable or insufficient payment and inability of nursing homes to comply with federal wage standards serve as barriers to establishing contracts; (4)complexity of establishing a contract, ambiguity about new policies, and inadequate VHA staffing for the nursing home inspection team hinder the VHA's ability to establish contracts with nursing homes; and (5) nursing homes that have established corporate processes, nursing home administrators with prior experience working with the VHA, and relationships between VHA and nursing home staff serve as facilitators to establishing new nursing home contracts. Nursing homes will work with the VHA, but the process of executing VHA contracts is burdensome. Streamlining and standardizing the purchasing processes and ensuring timely payment may expand the number of nursing homes willing to contract with the VHA, thereby increasing choices for Veterans and becoming a model for other long-term care networks.

Veterans' Use of Telehealth for Veterans Health Administration Community Care Urgent Care During the Early COVID-19 Pandemic.

Background:Since the onset of the COVID-19 pandemic, telehealth has been an option for Veterans receiving urgent care through Veterans Health Administration Community Care (CC).Objective:We assessed use, arrangements, Veteran decision-making, and experiences with CC urgent care delivered via telehealth.Design:Convergent parallel mixed methods, combining multivariable regression analyses of claims data with semistructured Veteran interviews.Subjects:Veterans residing in the Western United States and Hawaii, with CC urgent care claims March 1 to September 30, 2020.Key Results:In comparison to having in-person only visits, having a telehealth-only visit was more likely for Veterans who were non-Hispanic Black, were urban-dwelling, lived further from the clinic used, had a COVID-related visit, and did not require an in-person procedure. Predictors of having both telehealth and in-person (compared with in-person only) visits were other (non-White, non-Black) non-Hispanic race/ethnicity, urban-dwelling status, living further from the clinic used, and having had a COVID-related visit. Care arrangements varied widely; telephone-only care was common. Veteran decisions about using telehealth were driven by limitations in in-person care availability and COVID-related concerns. Veterans receiving care via telehealth generally reported high satisfaction.Conclusions:CC urgent care via telehealth played an important role in providing Veterans with care access early in the COVID-19 pandemic. Use of telehealth differed by Veteran characteristics; lack of in-person care availability was a driver. Future work should assess for changes in telehealth use with pandemic progression, geographic differences, and impact on care quality, care coordination, outcomes, and costs to ensure Veterans’ optimal and equitable access to care.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

BackgroundEmpirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.MethodsPERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations.DiscussionThe PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

Use and Cost of Low-Value Health Services Delivered or Paid for by the Veterans Health Administration

Within the Veterans Health Administration (VA), the use and cost of low-value services delivered by VA facilities or increasingly by VA Community Care (VACC) programs have not been comprehensively quantified. To quantify veterans' overall use and cost of low-value services, including VA-delivered care and VA-purchased community care. This cross-sectional study assessed a national population of VA-enrolled veterans. Data on enrollment, sociodemographic characteristics, comorbidities, and health care services delivered by VA facilities or paid for by the VA through VACC programs were compiled for fiscal year 2018 from the VA Corporate Data Warehouse. Data analysis was conducted from April 2020 to January 2022. VA administrative data were applied using an established low-value service metric to quantify the use of 29 potentially low-value tests and procedures delivered in VA facilities and by VACC programs across 6 domains: cancer screening, diagnostic and preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and other procedures. Sensitive and specific criteria were used to determine the low-value service counts per 100 veterans overall, by domain, and by individual service; count and percentage of each low-value service delivered by each setting; and estimated cost of each service. Among 5.2 million enrolled veterans, the mean (SD) age was 62.5 (16.0) years, 91.7% were male, 68.0% were non-Hispanic White, and 32.3% received any service through VACC. By specific criteria, 19.6 low-value services per 100 veterans were delivered in VA facilities or by VACC programs, involving 13.6% of veterans at a total cost of $205.8 million. Overall, the most frequently delivered low-value service was prostate-specific antigen testing for men aged 75 years or older (5.9 per 100 veterans); this was also the service with the greatest proportion delivered by VA facilities (98.9%). The costliest low-value services were spinal injections for low back pain ($43.9 million; 21.4% of low-value care spending) and percutaneous coronary intervention for stable coronary disease ($36.8 million; 17.9% of spending). This cross-sectional study found that among veterans enrolled in the VA, more than 1 in 10 have received a low-value service from VA facilities or VACC programs, with approximately $200 million in associated costs. Such information on the use and costs of low-value services are essential to guide the VA's efforts to reduce delivery and spending on such care.

Evaluating the staffing methodology model in the veterans health administration's community living centers

PurposeProgram evaluation to describe nursing hours per patient day (NHPPD) within the Veterans Health Administration (VHA) and to evaluate Staffing Methodology in the VHA Community Living Centers (CLCs). MethodsTargeted and actual NHPPD were compiled retrospectively for each VHA CLC unit over a one-year timeframe for calendar year 2019. For descriptive analyses, actual NHPPD were averaged across months for each CLC unit. ResultsThe mean for actual hours as a percent of target was 121.6% (95% CI, 118.5 to 124.7%) indicating the units’ average hours across 2019 were 21.6% significantly higher than target. The actual NHPPD significantly differed across months (p<0.001) with the 2019 months of January and October having the highest NHPPD. ConclusionsVeteran safety is a VHA priority and appropriate nurse staffing is key to providing care that improves Veteran outcomes. Further exploration is needed on the impact of nurse staffing on Veteran outcomes, safety, and satisfaction.

COVID-19 Impacts on Mental Health Care in Veterans Health Administration Community Living Centers

COVID-19 forced VHA Community Living Centers (CLC) to adjust how mental health (MH) care is provided. Beginning March 2020, admissions and staff entering CLC space were restricted in response to the pandemic. Some care shifted from in-person to virtual. Veterans were more isolated due to visitor restrictions and cancellation of communal activities. Pre-COVID, CLC teams cared for an already complex population – 80% of residents had a MH diagnosis (24% with serious mental illness). Changing resident composition and increased isolation may intensify challenges in providing MH care. Using VHA administrative data, we assess the impact of the changing CLC environment during the pandemic by comparing monthly average rates of MH diagnoses and provision of MH care and as-needed psychotropics to CLC residents pre-COVID (Oct 2019 – Feb 2020) to the COVID period (Mar 2020 – Feb 2021). CLCs experienced a 26% decline in the monthly resident census. However, the monthly percentage of residents with a serious mental illness increased 13%. Pre-COVID, virtual MH encounters were received by 2% of residents; 35% received an in-person MH encounter. During COVID, 8% received a virtual MH encounter and 33% received in-person. As-needed antipsychotics remained unchanged, while as-needed benzodiazepine prescriptions decreased 15%. Despite increased MH concerns, CLC teams did not appear to respond with increased pharmacological interventions. Rather, teams seem to have maintained clinical service connection for those with MH concerns. Documenting successful approaches for addressing MH needs during this challenging time will be instructive for future care during times of crisis.

Impact of an interdisciplinary intervention for distress behaviors in dementia on psychotropic drug use in Veterans Health Administration Community Living Centers: STAR-VA impact on psychotropic drug utilization

STAR-VA is an interdisciplinary behavioral approach for managing distress behaviors in residents with dementia, implemented at Veterans Health Administration nursing homes. This study evaluated the impact of STAR-VA implementation on psychotropic drug use. The study design is a retrospective, quasi-experimental cohort analysis of residents enrolled as STAR-VA training cases compared with eligible residents at untrained sites to evaluate treatment effects on psychotropic medication use. We matched 229 STAR-VA cases with 1,163 comparisons. STAR-VA cases experienced an average reduction of 0.92 “as-needed” doses per month (95% confidence interval [CI] -1.82, -0.02) compared with controls. No significant effect on non-STAR-VA cases in trained facilities was detected. STAR-VA programs are an important option for reducing potentially inappropriate psychotropic use.

Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice.

Background:The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers.Objectives:The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider.Research Design:This was a retrospective, observational over fiscal years (FY) 2015–2018.Subjects:Veterans receiving primary care services paid for by the VA.Measures:Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year.Results:There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care.Conclusion:As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans’ use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans’ health care needs are met.

Comparing VA and Community-Based Care: Trends in Sleep Studies Following the Veterans Choice Act.

To address concerns about access to care, the Veterans Access, Choice, and Accountability Act of 2014 was enacted to make care available in the community when Veterans Health Administration (VA) care was unavailable or not timely. This paper examined VA referrals for diagnostic sleep studies from federal fiscal year (FY) 2015-2018. Sleep studies completed between FY2015 and 2018 for Veterans tested within VA facilities (VAF) or referred to VA community care (VACC) providers were identified using VA administrative data files. Sleep studies were divided into laboratory and home studies. The number of sleep studies conducted increased over time; the proportion of home studies increased in VAF (32 to 47%). Veterans were more likely to be referred for a sleep study to VACC if they lived in a rural or highly rural area (ORs = 1.47 and 1.55, respectively), and had public or public and private insurance (ORs = 2.01 and 1.35), and were less likely to be referred to VACC if they were age 65+ (OR = 0.72) and were in the highest utilization risk based on Nosos score (OR = 0.78). Regression analysis of sleep study type revealed that lab studies were much more likely for VACC referrals (OR = 3.16), for persons living in rural areas (OR = 1.21), with higher comorbidity scores (OR = 1.28) and for ages 44-54, 55 to 64, and 65+ (ORs = 1.12, 1.28, 1.45, respectively) compared to younger Veterans. Veterans with some or full VA copayments (ORs = 0.91 and 0.86, respectively), and overweight Veterans (OR = 0.94) were less likely to have lab studies. The number of sleep studies performed on Veterans increased from 2015 to 2018. Access to sleep studies improved through a combination of providing care through the Veteran Choice Program, predominantly used by rural Veterans, and increased use of home sleep studies by VA.

Addressing Behavioral Symptoms of Dementia Through STAR-VA Implementation: Do Outcomes Vary by Behavior Type?

The STAR-VA program in Veterans Health Administration Community Living Centers (CLCs, nursing home settings) trains teams to implement a psychosocial intervention with residents with behavioral symptoms of dementia (BSD). Across 71 CLCs, 302 residents selected as training cases had target behaviors categorized into one of 5 types: physically aggressive (PA), physically nonaggressive, verbally aggressive, verbally nonaggressive, and behavior deficit (BD). Across all groups, there were significant declines in team-rated behavior frequency (36%) and severity (44%), agitation (10%), distress behaviors (42%), depression (17%), and anxiety (20%). The magnitude of changes varied across behavior category. For example, those with a PA target behavior experienced a greater percentage decline in agitation and distress behavior scores, and those with a BD target behavior experienced a greater percentage decline in depressive and anxiety symptoms. STAR-VA, a multicomponent intervention, is generally effective across various types of behavioral symptoms associated with dementia.

CHALLENGES AND STRATEGIES FOR SUSTAINING A NEW DEMENTIA BEHAVIORAL CARE APPROACH IN NURSING HOMES

The STAR-VA training program in Veterans Health Administration Community Living Centers (CLCs) has been helping interdisciplinary care teams understand and manage dementia-related behaviors in the nursing home setting, with promising clinical outcomes. However, sustaining a new care approach in a health care system poses multiple challenges. This presentation will discuss facilitators and barriers to STAR-VA sustainability based on CLC team and nurse leader feedback. Findings are informing development of a new site coaching program and a sustainability toolkit. Feedback to date suggests that critical STAR-VA implementation and sustainability strategies include: regularly scheduled team meetings to discuss behavioral assessment and care plans; ongoing staff training (e.g., new staff orientation); communicating care plans across shifts and in the health record; multiple nurse/shift champions; impromptu huddles; acknowledging staff successes; leadership engagement. The coaching program engages teams in setting and tracking site sustainability goals. Lessons learned will be discussed.

The Relationship between Costs andQuality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data.

To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data. One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool. We used a generalized estimating equationmodel with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days. With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs. The relationship between cost and quality depends on facility size and current level of performance.

Implementing a cornerstone of culture change: Consistent staff assignment in VHA community living centers.

In 2011, the Veterans Health Administration (VHA) began implementing consistent staff assignment in its nursing homes (called Community Living Centers or CLCs). Consistent assignment, a cornerstone of culture change, minimizes the number of staff who provide a resident's care. The present research assessed the level and stability of consistent assignment in units within VHA CLCs and identified unit characteristics related to implementation of this staff assignment model. Schedulers in 185 of 335 organizational units that make up VHA CLCs completed a Staffing Practices Survey. For the month prior to the survey, 53% of CLC units had full implementation of consistent assignment. Tracked back over time, 37% of CLC units had stable high consistent assignment, 29% had stable low consistent assignment, and 34% were variable. Units with stable high consistent assignment were most likely to use care teams with stable membership and to obtain staff input for care assignments. Schedulers in these units reported more positive experiences with consistent staff assignment and better unit functioning in terms of staff absences, complaints about workload fairness, and resolution of scheduling problems. Units with stable low and variable consistent assignment were similar in most of these respects; however, units with variable consistent assignment made greater use of stable care teams and were less likely to change assignments at a staff member's request. Overall, consistent assignment implementation was not related to unit size, nursing hours per resident day, or specialty focus. Findings can help guide consistent staff assignment implementation in VHA and community nursing homes. (PsycINFO Database Record