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					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
       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.
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.
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.
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.
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
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.
    Descriptive Data
                               Non VA per-diem   VA per-diem facility
                                 observations       observations
                                (N = 39,648)        (N = 27,295)
Structure Variables
Met CNA Standard                   24.0%               18.8%
Met RN standard                    18.8%               15.1%
Process Variables
Tube feeding                     5.42 ± 8.11        7.89 ± 10.04
New catheterization              1.55 ± 3.00         1.97 ± 3.53
Mobility restraints              8.46 ± 12.14       10.45 ± 14.61
Outcome Variables
Quality of care deficiencies     1.62 ± 1.90         1.92 ± 2.06
Quality of life deficiencies     0.67 ± 1.07         0.84 ± 1.17
Total deficiencies               5.52 ± 5.56         6.55 ± 6.01
Results
                         Met CNA standard1         Met RN standard1
                         All          VA per-      All          VA per-
                         Facilities   diem         Facilities   diem
                                      facilities                facilities
    Any veterans         0.83**       NA           0.87**       NA

    High vet ratio       NA           0.91         NA           0.91

    Medicaid             0.90**       0.92**       0.83**       0.82**

    Medicare             1.12**       1.12**       1.45**       1.45**

    Total beds           0.99         0.99*        0.99         1.01**

    For profit           0.43**       0.41**       0.62**       0.64**

    Member of System     0.57**       0.54**       0.89**       0.96

    Hospital based SNF   1.09*        1.10         4.31**       5.10**

    Acuity index         1.16**       1.13**       1.15**       1.10**
     Results
                 Tube feeding1                 New catheterization1         Mobility restraints1
                 All             VA per-diem   All            VA per-diem   All             VA per-diem
                 Facilities      facilities    Facilities     facilities    Facilities      facilities
Any veterans     +0.490**        NA            +0.070**       NA            -0.067          NA

High vet ratio   NA              +0.738**      NA             -0.026        NA              -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**       +0.014**      +1.069**        +0.071**

For profit       +0.180**        +0.240        -0.107**       -0.127*       -0.475**        -0.843**

Member of        +0.024**        +0.010        -0.155**       -0.197**      -1.239**        -1.559**
   System
Hospital         +1.127**        +1.458**      +0.284**       +0.470**      -2.136**        -2.331**
     based
     SNF
Acuity index     +1.743**        +1.983**      +0.177**       +0.228**      +0.932**        +1.145**
             Quality of care            Quality of life            Total deficiencies1        Actual harm citation1       New pressure sores1
                   deficiencies1              deficiencies1
             All          VA per-       All          VA per-       All          VA per-diem   All           VA per-       All          VA per-diem
             Facilities          diem   Facilities          diem   Facilities   facilities    Facilities           diem   Facilities   facilities
                          facilities                 facilities                                             facilities
Any          +0.134**     NA            +0.069**     NA            +0.447**     NA            1.06**        NA            +0.180**     NA
Veterans

High vet     NA           -0.039        NA           +0.075**      NA           +0.214*       NA            0.90*         NA           -0.198**
Ratio
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*      -0.433        0.59**        0.56**        -1.096**     -1.443**

Total beds   +0.003**     +0.003**      +0.001**     +0.001**      +0.009**     +0.008**      1.03**        1.00**        +0.022**     +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    +0.158**     +0.165**      +0.105**     +0.091**      +0.337**     +0.334**      1.11**        1.09*         +0.094**     +0.144**
System
Hospital     -0.279**     -0.328**      -0.073**     -0.077*       -0.334**     -0.468**      0.78**        0.79*         -0.530**     -0.606**
based SNF
Acuity       +0.059**     +0.089**      +0.004       +0.014**      +0.072**     +0.141**      1.05**        1.07**        +0.255**     0.360**
index
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 .
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.
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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