Abstract

Background: As the population ages, the concomitant rise in frailty and disability will increase the demand for long-term care. In no health system is this more prevalent than in the Veterans Health Administration (VHA) of the U.S. Department of Veterans Affairs (VA), the largest integrated in health care system in the United States. Currently, 47.3% of 8.5 million Veterans enrolled in the VHA are aged 65 years or older, a number that is expect to rise in the coming decades. Emphasis on expanding access to home and community-based services (HCBS) has been firmly integrated into VA policy. Only modest progress has been made rebalancing VA long-term care spending away from institutional to non-institutional supports, however. This study identifies factors VA staff perceived to promote or impede HCBS placement post-hospital discharge among Veterans cared for within the VHA.

Methods: Data for this study derived from semi-structured interviews. Participants were selected through a combination of purposive and snowball sampling. Twelve VAMCs were selected for this study to ensure variation in geographic region and catchment area (rural, urban) and to ensure variability in available NH options. Thirty-five interviews were conducted with 36 individuals between 5/18/12 and 12/6/12. Interviewees were selected based on which VA staff were most knowledgeable about each VAMC’s extended care referral and contracting processes, including 20 social workers, 12 nurses, and 4 geriatrics physician leaders. An open-ended coding process was employed to analyze the interview transcripts.

Results: VA staff reported that Veterans’ care needs and social and financial resources influence HCBS placement. They also reported prerequisites for successful placement, including housing, unpaid informal care, and non-VA services funded privately and by public programs such as Medicaid and the Older Americans Act. Lack of staffing and failure to offer the specific types of services needed limits referral to and use of HCBS. Budgetary imperatives influence the relative availability of HCBS across VA Medical Centers (VAMCs). Findings highlight patient-, provider-, and system-level constraints that impede successful placement at home and in the community of Veterans in need of long-term services and supports after hospitalization.

Conclusion: Patient-level constraints arise from Veterans’ care needs and resources, particularly with respect to housing and informal caregivers. Provider-level constraints stem from limitations in supply, especially with respect to potential contracting agencies and staff. System-level constraints derive both internally, from prevailing budgetary imperatives, and externally, from the availability of supplemental community programs. Notably, these constraints vary across VAMCs and over time, thereby suggesting the need to develop strategies to promote rebalancing that account for each VAMC’s unique circumstances. Consequently, further effort should be devoted both to developing and disseminating policies that enhance the likelihood of successful community placement and to determining how those policies might be modified and leveraged to achieve the most optimal outcomes possible in different contexts.