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Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, Providence, RI, USABrown University School of Public Health, Providence, RI, USA
Rocky Mountain Regional Veterans Affairs Medical Center, Denver-Seattle Center of Innovation, Aurora, CO, USADivision of Health Care Policy & Research, School of Medicine, University of Colorado, Aurora, CO, USA
Examine the decline in admission to community nursing homes among Veterans that occurred following the onset of the COVID-19 pandemic.
Design
Multimethods study using Department of Veterans Affairs (VA) purchasing records to examine trends in total admissions and semistructured interviews with staff connected to the VA community nursing home program to contextualize observed trends.
Setting and participants
All VA-paid admissions to community nursing homes (N = 56,720 admissions) and national data on nursing home admissions from LTCFocUS. Semistructured interviews were conducted with 9 VA staff from 4 VA medical centers working in the VA community nursing home program, including social workers, nurses, and program coordinators.
Results
Between April and December 2020, community nursing home admissions among Veterans were 35% lower compared with the same period in 2019. Nationally, total nursing home admissions decreased by 19.6%. VA community nursing home program staff described 3 themes that contributed to this decline: (1) fewer nursing home beds available, (2) lower admissions due to fear of Veterans being exposed to COVID-19 in nursing homes, and (3) leaving nursing homes in favor of living at home with home-based care.
Conclusions and Implications
The decline in nursing home admissions among Veterans raises questions about how replacing nursing home care in favor of home- and community-based care affects the health outcomes and well-being of Veterans and their caregivers.
As of July 2022, more than 150,000 residents of nursing homes and 2500 nursing home staff have died of SARS-CoV-2 (COVID-19) and one-third of all deaths in the United States occurred in a nursing home.
The high incidence of cases and mortality among residents and employees of nursing homes fundamentally altered care practices and raised concern that nursing homes were unprepared to manage outbreaks.
The Veterans Health Administration’s (VA’s) community nursing home program, which pays for long-term care in privately owned facilities, grew by 26% from 7771 per day in 2014 to 9808 in 2018.
Thus far, there is a lack of published studies examining how the COVID-19 pandemic has influenced the trend in Veterans’ use of community nursing homes and how it compares to national trends. We undertook a multimethods analysis to examine those questions.
Methods
Quantitative Methods
We used data from VA’s Corporate Data Warehouse. We defined Veterans’ community nursing home stays in community nursing homes between January 2019 and December 2021. The data do not include VA-operated community living centers, nor state-operated state Veterans homes. The admission was designated as from a hospital if the Veteran was discharged from a hospital within 1 day before being admitted into the nursing home. We considered hospital stays in VA medical centers and VA-paid stays in community hospitals. We obtained national data on beds, occupancy, and admissions in 2019-2020 from LTCFocUS.
LTCFocus Public Use Data sponsored by the National Institute on Aging (P01 AG027296) through a cooperative agreement with the Brown University School of Public Health.
All analyses were performed using SAS Enterprise Guide 7.1 (SAS Institute Inc). To examine the rate of total hospital admissions by month, we used VA Support Service Center Capital Assets (VSSC) data.
Qualitative Methods
As part of a larger study of VA-contracted community nursing home care, we interviewed VA staff about their experiences overseeing care for Veterans in community nursing homes during the COVID-19 pandemic. We conducted telephone interviews in September and October 2020 with social workers and nurses who participated in interviews in the larger study and who were affiliated with 4 VA Medical Centers. Of the 12 VA staff invited to participate in follow-up interviews about overseeing care during the COVID-19 pandemic, 9 agreed. Interviews were recorded and transcribed, and uploaded to ATLAS.ti software (version 8.4.19; Scientific Software Development GmbH). We used a team-based approach to content analysis to analyze data and identify themes. We collected qualitative and quantitative data concurrently, analyzed these data independently, and combined these data at the stage of interpretation of results.
This study was approved by the XXXX Review Boards, respectively, for the quantitative and qualitative aims.
Results
Quantitative Results
In 2019, the VA admitted an average of 650 Veterans to community nursing homes each week for long-stay nursing home care paid for by VA (Figure 1). From the week of April 12, 2020, to December 26, 2020, there were an average of 441 Veteran admissions to community nursing homes per week (15,781 admissions total)—nearly a 35% decrease from the same calendar period in 2019 (95% CI, P < .001). Although admissions increased after April 2020, the admission rate for community nursing home care remained well below the 2019 average: in the calendar year 2021, an average of 526 Veterans per week (total, 27,352) were admitted to nursing homes, only 82% of the average in 2019 (P = .008).
Fig. 1VA-paid admissions to community nursing homes per week declined in March 2020 compared to the previous year. Each data point represents the week’s total count of VA-paid admissions to community nursing homes.
Figure 2 shows that the proportion of admissions to a community nursing home for long-stay care preceded by a hospital stay were only slightly higher in 2020 and 2021 than in 2019. The proportion of admission to a community nursing home preceded by a hospital stay was about 68% from April to December in 2019, compared with 70% in that calendar period in 2020 (Figure 2). According to reports from VSSC, overall hospital admissions were 42% lower in April 2020 compared with April 2019 (P < .01; data not shown).
Fig. 2Proportion of community nursing home admissions preceded by hospital stay. Each data point represents the proportion total community nursing home admissions in a calendar month that were preceded by a hospital stay.
Nationally, total nursing home admissions reported in LTCFocUS dropped in 2020 from 3.2 million (1.9 admissions per bed, per year) to 2.6 million (1.6 admissions per bed, per year)—a 19.6% decrease.
Qualitative Results
Three themes emerged relating to how the COVID-19 pandemic affected VA community nursing home program staff and Veteran admissions to nursing homes.
Theme 1: nursing home infection prevention and COVID-19 policies limited admissions
Participants described several challenges to admitting Veterans to community nursing homes, such as policies that required nursing homes to quarantine residents to reduce risk of infection. One community nursing home program coordinator shared how new community nursing home policies requiring private rooms for residents limited her ability to place Veterans: “Bed availability has been a challenge because facilities have their own requirements for things like quarantine . . . instead of having a two-bedroom, now you had to have a private room, so it really reduced facilities’ numbers of beds” (coordinator). Additionally, participants mentioned being unable to admit new Veterans to community nursing homes throughout the pandemic because of active outbreaks in facilities, resulting in a ban on new residents: “There was a point where almost all of them [nursing homes] were not accepting admissions because of COVID outbreaks, and we have several now who’ve had secondary outbreaks and so they are, put the admissions on hold” (social worker).
Theme 2: hesitancy and fear around nursing home care
Several participants reported that Veterans hesitated to go to nursing homes due to concerns about outbreaks, contributing to fewer admissions: “Our census had been really low, like half-mast for, for months . . . that’s how COVID is affecting [us] because people aren’t wanting to go to the nursing homes” (coordinator). Additionally, participants described how fear about potential COVID-19 outbreaks in nursing homes led Veterans and their family members to cancel nursing home care. One participant shared, “The Veteran or the family just don’t want to take the chance of the Veteran getting COVID inside of a nursing home, so sometimes they’ve cancelled their respite stay or they’ll just continue to do home hospice” (coordinator).
Theme 3: pandemic risk spurred veterans to leave nursing homes
Participants described Veterans requesting to move out of nursing homes due to perceived risks of an outbreak: “We have had some Veterans go home because of COVID-19, you know, where they just felt that their risk for exposure was higher in that setting and even though it’s gonna be a challenge to go” (coordinator). Most participants expressed concern that Veterans who opted to discharge home would not have adequate care and support. For example, one participant highlighted how concerns about COVID-19 resulted in a Veteran moving home and the Veteran’s family declining supportive services: “They even turned down things like home health and other kinds of services. They didn’t want anybody coming in the home out of concern for COVID. They’ve turned down adult day and other care” (coordinator). Conversely, one participant shared how fears about an outbreak resulted in the positive consequence of a low-care Veteran who no longer required nursing home level care moving home: “I think that [the pandemic] pushed him and his family. He’d been there [nursing home] quite some time. . . . He was ready to go home, and I think it was just hard to kind of get himself to do that, and then when this [the pandemic] happened, it made it an easier choice for him” (social worker).
Discussion
We found a drastic decrease in use of community nursing home care for Veterans because of the COVID-19 pandemic that was consistent with, and possibly greater in magnitude, than the national trend. Furthermore, the decline persisted into 2021. Our findings are consistent with other studies reporting decreases in post-acute, skilled-nursing admissions during the same time period.
Understanding the reasons for the decline may inform the redesign of the VA’s long-term care provision. Shortages of qualified staffing in nursing homes, which have undoubtedly exacerbated the bed shortage, persist.
They key question that needs investigation in order to apply lessons from the shift in long-term care admissions during the COVID-19 pandemic is the effect of this change on Veterans’ and their caregivers’ well-being and health outcomes. The effects of changes in nursing home care in 2020 will be difficult, if not impossible, to disentangle from other aspects of the pandemic, including overloaded health care infrastructure, shutdowns of services, delays in non-emergent care, and of course COVID-19 itself.
The substantial change in nursing home admissions was not unique to the VA but it may represent a greater shift—that is, a 35% decline among Veterans compared to a 19% decline nationwide. What distinguishes the VA from Medicare or most private insurance is the comprehensive array of social work support, counseling, home-based primary care, and extensive telehealth options for primary care.
Early in the pandemic, some experts strongly advocated for replacing intensive post-acute care with care in the home, but only with adequate training, equipment, and infection control for caregivers.
The availability of alternative long-term services and home supports in VA may have allowed Veterans to opt out of nursing home care at a higher rate than the national average.
Anecdotally, VA programs that provide services in the home or in homelike settings, such as home-based primary care and medical foster homes, were swamped with demand and unable to expand rapidly enough to enroll all Veterans who would have been eligible.
Caregivers who are stepping up to provide increasingly complex care because Veterans are not admitted to nursing homes may need more training and support than is currently provided, and caregiver training offered by the VA may need to increase its outreach and awareness campaigns to be fully available to caregivers who need it.
The VA’s Office of Connected Care was able to support a rapid pivot of nearly all services in the early months of the pandemic, from specialty to social work, to expand telehealth capacity and utilization for specialty services and mental health.
However, most long-term services and supports, by their nature, are difficult to substitute or supplement with teletherapies.
Our analysis has limitations. Our data did not include admissions by Veterans to nursing homes paid for under their Medicare or private insurance benefits. We did not have a reliable indicator in purchased care data on whether a contract was for long-term or short-term, post-acute care, and the recency of the data did not allow us to distinguish Veterans who go to a nursing home under their VA benefit for a long-term care or post-acute rehabilitation. Publicly available national data from LTCFocUS were available by calendar year, and so the 2020 admission totals include some “pre-pandemic” months. The small number of interviews may not represent comprehensive data on the viewpoint of staff connected to the community nursing home program.
Conclusions and Implications
The decline in nursing home admissions among Veterans raises questions about how replacing nursing home care in favor of home- and community-based care affects the health outcomes and well-being of Veterans and their caregivers. We stand to learn much from this decline in nursing home admissions among Veterans. At least some of the changes may be here to stay, both in health system practices and in patient preferences.
LTCFocus Public Use Data sponsored by the National Institute on Aging (P01 AG027296) through a cooperative agreement with the Brown University School of Public Health.
Funding sources: This work was supported by the Bureau of Veterans Affairs, Veterans Health Administration, Office of Health Services Research and Development (IIR no. 17-231).
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