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Quality of Care for Veterans in Community Nursing Homes 1999-2002

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. Acknowledgements. Research team

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Quality of Care for Veterans in Community Nursing Homes 1999-2002

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  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

  9. Results

  10. Results

  11. 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 .

  12. 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.

  13. 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.

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