Original Study| Volume 22, ISSUE 8, P1658-1663.e6, August 2021

Derivation and Validation of a Predictive Algorithm for Long-Term Care Admission or Death



      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.”


      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.


      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.


      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.


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        • US Department of Veterans Affairs
        FY 2018 Budget Submission.
        (Available at:)
        Date accessed: August 15, 2020
        • Stearns C.
        H.R.2116—106th Congress (1999-2000): Veterans Millennium Health Care and Benefits Act.
        (Available at:)
        • US Department of Veterans Affairs
        Budget in brief.
        (Available at:)
        • Binette J.
        • Vasold K.
        2018 Home and Community Preferences: A national survey of adults age 18-plus.
        (Available at:)
        • Eiken S.
        • Sredl K.
        • Burwell B.
        • Amos A.
        Medicaid expenditures for long-term services and supports in FY 2016.
        (Available at:)
        • Thomas K.S.
        • Cote D.
        • Makineni R.
        • et al.
        Change in VA community living centers 2004–2011: Shifting long-term care to the community.
        J Aging Soc Policy. 2018; 30: 93-108
        • US Department of Housing and Urban Development
        Evidence matters: Measuring the costs and savings of aging in place.
        (Available at:)
        • Miller E.A.
        • Intrator O.
        • Gadbois E.
        • et al.
        VA staff perceptions of barriers and facilitators to home-and community-based placement post–hospital discharge.
        J Aging Soc Policy. 2019; 31: 1-29
        • Duan-Porter W.
        • Ullman K.
        • Rosebush C.
        • et al.
        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
        • US Department of Veterans Affairs
        Health services research and development: VA priorities and VHA strategic plans.
        (Available at:)
        • Dally S.
        • Wesgate S.
        • Phibbs C.
        • et al.
        Guidebook for Use of the GECDAC Core Files.
        US Department of Veterans Affairs, Washington, DC2018
        • Ruiz J.G.
        • Priyadarshni S.
        • Rahaman Z.
        • et al.
        Validation of an automatically generated screening score for frailty: The Care Assessment Need (CAN) score.
        BMC Geriatr. 2018; 18: 106
        • Rotenberg J.
        • Kinosian B.
        • Boling P.
        • Taler G.
        Home-based primary care: Beyond extension of the independence at home demonstration.
        J Am Geriatr Soc. 2018; 66: 812-817
        • Kinosian B.
        • Wieland D.
        • Gu X.
        • et al.
        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
      1. The Supreme Court of the United States. Olmstead v. L. C., 527 U.S. 581. 1999
        • Isakson J.S.
        2372—115th Congress (2017-2018): VA MISSION Act of 2018. US Congress website.
        (Available at:)
        • US Office of Accountability
        Medicaid home- and community-based services: Selected states’ program structures and challenges providing services.
        (Available at:)
        Date accessed: August 16, 2020
        • Medicare and Medicaid Programs
        Reform of Requirements for Long-Term Care Facilities. Final rule. Fed Regist 2016;81:68688-68872.
        (Available at:)
      2. Profile of veterans: 2016. Data from the American Community Survey. National Center for Veterans Analysis and Statistics, Department of Veterans Affairs.
        (Available at:)
        • Meffert B.N.
        • Morabito D.M.
        • Sawicki D.A.
        • et al.
        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
        • RAND Corporation
        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:)
        • Stiefel M.
        • Nolan K.
        A guide to measuring the triple aim: Population health, experience of care, and per capita cost.
        (Available at:)