Abstract
Objectives
Older veterans prefer to remain in their homes and communities as long as possible.
Although targeted delivery of home- and community-based services for veterans might
delay long-term care placement, often, access to these services is inconsistently
organized or delayed. To aid in early recognition of veterans at high risk for long-term
care placement or death, we developed and validated a predictive algorithm, “Choose
Home.”
Design
A retrospective observational cohort analysis was used.
Setting and Participants
Two cohorts of Veterans Health Administration (VHA; a large integrated health care
system) users were assembled: Derivation (4.6 million) and Confirmation (4.7 million).
The Derivation Cohort included Veterans Administration users from fiscal year 2013;
the Confirmation Cohort included Veterans Administration users from fiscal year 2014.
Methods
A total of 148 predictor variables, including demographics, comorbidities, and utilizations
were selected using logistic regression to predict placement in a long-term care facility
for >90 days or death within 2 years.
Results
Veterans were predominantly male [92.8% (Derivation), 92.5% (Confirmation)] and older
[61.7±15.5 (Derivation), 61.5±15.6 years (Confirmation)], with a high prevalence of
comorbid conditions. Between the Derivation and Confirmation Cohorts, the areas under
the receiver operating characteristic curves were found to be 0.80 [95% confidence
interval (CI) 0.799, 0.802] and 0.80 (95% CI 0.800, 0.802), respectively, indicating
good discrimination for determining at-risk veterans.
Conclusions and Implications
We created a predictive algorithm that identifies veterans at highest risk for long-term
institutionalization or death. This algorithm provides clinicians with information
that can proactively inform clinical decision making and care coordination. This study
provides the groundwork for future investigations on how home- and community-based
services can target older adults at highest risk to extend time in their communities.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- FY 2018 Budget Submission.(Available at:)https://www.va.gov/budget/products.aspDate accessed: August 15, 2020
- H.R.2116—106th Congress (1999-2000): Veterans Millennium Health Care and Benefits Act.(Available at:)https://www.congress.gov/bill/106th-congress/house-bill/2116Date accessed: August 15, 2020
- Budget in brief.(Available at:)https://www.va.gov/budget/docs/summary/fy2021VAbudgetInBrief.pdfDate accessed: January 15, 2021
- 2018 Home and Community Preferences: A national survey of adults age 18-plus.(Available at:)https://www.aarp.org/research/topics/community/info-2018/2018-home-community-preference.htmlDate accessed: August 16, 2020
- Medicaid expenditures for long-term services and supports in FY 2016.(Available at:)http://www.advancingstates.org/sites/nasuad/files/ltssexpenditures2016.pdfDate accessed: August 16, 2020
- Change in VA community living centers 2004–2011: Shifting long-term care to the community.J Aging Soc Policy. 2018; 30: 93-108
- Evidence matters: Measuring the costs and savings of aging in place.(Available at:)https://www.huduser.gov/portal/periodicals/em/fall13/highlight2.htmlDate accessed: January 6, 2021
- VA staff perceptions of barriers and facilitators to home-and community-based placement post–hospital discharge.J Aging Soc Policy. 2019; 31: 1-29
- Interventions to prevent or delay long-term nursing home placement for adults with impairments—A systematic review of reviews.J Gen Int Med. 2020; 35: 2118-2129
- Health services research and development: VA priorities and VHA strategic plans.(Available at:)https://www.hsrd.research.va.gov/about/strategic_plan.cfmDate accessed: June 29, 2020
- Guidebook for Use of the GECDAC Core Files.US Department of Veterans Affairs, Washington, DC2018
- Validation of an automatically generated screening score for frailty: The Care Assessment Need (CAN) score.BMC Geriatr. 2018; 18: 106
- Home-based primary care: Beyond extension of the independence at home demonstration.J Am Geriatr Soc. 2018; 66: 812-817
- Validation of the JEN frailty index in the National Long-Term Care Survey community population: Identifying functionally impaired older adults from claims data.BMC Health Serv Res. 2018; 18: 908
- The Supreme Court of the United States. Olmstead v. L. C., 527 U.S. 581. 1999
- 2372—115th Congress (2017-2018): VA MISSION Act of 2018. US Congress website.(Available at:)https://www.congress.gov/bill/115th-congress/senate-bill/2372Date accessed: August 15, 2020
- Medicaid home- and community-based services: Selected states’ program structures and challenges providing services.(Available at:)https://www.gao.gov/products/GAO-18-628Date accessed: August 16, 2020
- Reform of Requirements for Long-Term Care Facilities. Final rule. Fed Regist 2016;81:68688-68872.(Available at:)https://www.govinfo.gov/content/pkg/FR-2016-10-04/pdf/2016-23503.pdfDate accessed: August 15, 2019
- Profile of veterans: 2016. Data from the American Community Survey. National Center for Veterans Analysis and Statistics, Department of Veterans Affairs.(Available at:)https://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Veterans_2016.pdfDate accessed: August 16, 2020
- US Veterans who do and do not utilize Veterans Affairs health care services: Demographic, military, medical, and psychosocial characteristics.Prim Care Companion CNS Disord. 2019; 21: 18m02350
- Current and future demographics of the Veteran population. In: Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs (pp. 31-56). 2015.(Available at:)http://www.jstor.org/stable/10.7249/j.ctt19w735m.12Date accessed: August 16, 2020
- A guide to measuring the triple aim: Population health, experience of care, and per capita cost.(Available at:)http://www.ihi.org/resources/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspxDate accessed: January 6, 2021
Article info
Publication history
Published online: May 10, 2021
Footnotes
C.M. and C.W.H. are co–first authors.
J.L.R., S.G., C.M., K.M., T.P.O., and C.W.H. are employees of the United States Department of Veterans Affairs.
The authors retained full independence in the conduct and communication of this research. The statements and opinions expressed are those of the authors and do not represent the official policy or procedures of the United States Government or the Department of Veterans Affairs.
Identification
Copyright
Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.
