MANAGEMENT BRIEF

Number 17 Overviews of Health Care Topics for VA Senior Managers October 2000

Long-Term Care Needs Increase as Veteran Population Ages

“The aging of America’s veteran population is a major challenge for its health care system.

VA is working to address the long-term care needs of all veterans, including the chronically ill.”

John G. Demakis, MD

Director, Health Services Research and Development Service

Why is long-term care becoming a critical issue

for veterans?

Approximately 9.3 million veterans are age 65 or older.1

It is estimated that in less than five years, the number of veterans who require long-term care on any given day will be

approximately 180,000.1

 A substantial number of these veterans have long-term health care needs, and the demand will

grow as the elderly veteran population increases. Long-term

care also encompasses chronically ill veterans who may have

multiple medical, psychological and/or social problems.

For example, veterans with spinal cord injuries, or those

who have chronic mental illness or terminal illness may also

require long-term care.

What are some important aspects of long-term care?

There are many aspects of long-term care that require comprehensive consideration and planning. Adult-day health care

services, medical services (e.g., primary care, preventive care,

and nursing home care), patient transportation, respite care,

hospice care, and coordination of these services are just some

of the issues that managers, health care providers, patients

and their families may need to consider when arranging longterm care.

What is VA doing to improve long-term health care?

On November 30, 1999, Congress enacted the Veterans

Millennium Healthcare and Benefits Act to address long-term

care issues within VA. Included in the Act are pilot programs

slated to begin in January 2001 related to long-term care and

to assisted living. The long-term care pilots must provide participating veterans with integrated, comprehensive services

including: medical services as needed, adult-day health care

services, transportation, home care services, and respite care.

The Assisted Living pilots will help assess the feasibility of

enabling eligible veterans to secure needed assisted living

services as an alternative to nursing home care. In addition,

the Expansion of Eligibility for Nursing Home Care Directive was issued in February 2000. This Directive implements

provisions of the Act and reiterates VA policy guidelines that

protect a patient's right to participate in the decision-making

process surrounding the provision of long-term care by VA.

VA HSR&D researchers will evaluate the pilot programs as

well as conduct an overall assessment of VA’s implementation process.

Besides these evaluations, there is a significant amount

of ongoing and planned HSR&D research on long-term

health care. Below are recent findings from a few HSR&D

studies that focus on important issues related to providing

optimal long-term care for veterans.

Effect of clinical practice guidelines on pressure ulcer

care in nursing homes

Pressure ulcers are a common medical problem associated

with considerable morbidity, particularly for patients with

long-term care needs such as those in nursing homes. Practice guidelines on the prevention of pressure ulcers have been

widely disseminated, and these guidelines have been successfully implemented in some VA nursing homes. An HSR&D

study sought to identify how these facilities accomplished

successful implementation so that pressure ulcer care may be

improved system-wide. Investigators studied 36 VA nursing

homes. Combining surveys with reviews of medical records

and administrative databases, they reviewed organizational

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VA HSR&D Management Brief Number 17, October 2000 Page 2 of 3

features such as culture, hospital policies, and employee control systems. Preliminary findings show that 79 percent of

nursing home staff are familiar with guidelines, and over

50 percent report adopting at least one guideline.

Further results of this ongoing study will help researchers

distinguish specific strategies that improve adherence to

guideline recommendations and whether adoption of these

guidelines prevents pressure ulcers. These findings may then

be applied to improve guideline adherence for other conditions common in nursing homes, such as urinary incontinence

and depression, thus improving health outcomes for veterans

in nursing home care. Better adherence to best practice guidelines, no matter the condition, enhances the quality of patient

care and improves outcomes.

Berlowitz DR, Bezerra HQ, Brandeis GH, Kader B,

Anderson JJ. Are we improving the quality of nursing home

care: the case of pressure ulcers. Journal of the American

Geriatrics Society. In press.

Berlowitz DR, Anderson JJ, Brandeis GH, Lehner LA,

Brand HK, Ash AS, and Moskowitz MA. Pressure ulcer

development in the VA: Characteristics of nursing homes

providing best care. American Journal of Medical Quality

1999;14(1):39-44.

HSR&D, study #CPG 97-012

Study examines long-term care utilization for men

and women veterans

VA has one of the most comprehensive long-term care

(LTC) programs in the United States. However, there was no

database that linked long-term programs or services together.

In order to identify existing LTC data, HSR&D investigators

compiled a three-volume Resource Guide: VA Long Term

Care Programs and Services (see next column for more information), with the help of an expert panel of 107 VA and nonVA clinicians, researchers, and policy makers. In gathering

and developing this data, an analysis of VA nursing homes

was conducted that focused on differences in use by female

and male veterans over time.

Results of this analysis showed that female veteran nursing

home patients tend to be older and poorer than male counterparts, and are half as likely to be married. It also suggests that

female patients have different resource utilization needs.

For example, in 1995, regarding Resource Utilization Group

(RUG) scores, the RUG category “reduced physical function”

was ranked first for female patients, while “clinically complex” (particular medical or skilled nursing problems, i.e.,

dehydration) was the most frequent RUG category for

males. Female patients differed in terms of length of stay:

13.6 percent of female nursing home patients had lengths

of stay equal to or exceeding five years versus 7.6 percent of

male patients.

It is projected that by 2030, nearly half of the veteran

population – one-third of our female veterans – will be 65

or older. A substantial number of these veterans will have

LTC needs, thus this kind of HSR&D research is essential

in providing data sources and documentation to the VA

community so that it may provide information about health

care use and outcomes by gender for an increasing elderly

veteran population.

Guihan M, Weaver FM, Cowper DC, Nydam T,

Miskevics S. Using Department of Veterans Affairs Administrative databases to examine long-term care utilization

for men and women veterans. Journal of Medical Systems

1999;23(3):201-218.

HSR&D, study #SDR 93-113

Resource Guide: VA Long Term Care Programs and

Services: This three volume Resource Guide is available

through HSR&D’s VA Information Resource Center

(VIReC) website located at http://www.virec.research.

med.va.gov/DATABASES/LTCRGUID/EXPAGE.HTM.

The Guide is intended for use by clinicians, policy makers,

and researchers. Volume I of the guide provides an overall

description of the LTC service or program, existing databases and how they may be accessed; issues of data quality

and areas in which the databases are incomplete; and a description of efforts to compile information on a particular

program or service. Volume II is a compendium of database file names, content statements, and value labels (when

available) for all databases identified in Volume I; and Volume III contains a listing of relevant Health Services Research projects on VA LTC services, including abstracts

and bibliographies when available.

Study seeks to determine the impact of dementia on

veterans’ families

Within VA, the number of veterans with dementia has

greatly increased over the last few decades and is now

approximately 600,000. Equal or higher numbers of veterans are estimated to have mild to moderate dementia. The

goal of this HSR&D research is to determine the impact

of dementia on veterans’ families in terms of informal

caregiving costs and quality of life. Further, the direct

non-medical costs (i.e., caregiving), indirect morbidity

costs (i.e., lost productivity), and quality of life related to

caregiving will be examined on a national level in relation

to the amount and types of service that are being utilized,

including institutionalization. Approximately 2,300 primary informal caregivers of veterans diagnosed with

Alzheimer’s disease or vascular dementia were surveyed at

baseline and are being followed over four years.
The MANAGEMENT BRIEF is produced by the Management

Decision and Research Center, a program within VA’s Office

of Research & Development, Health Services Research &

Development Service. The purpose of the MANAGEMENT BRIEF

is to provide VA senior management with a concise and

timely overview of a specific health care topic that includes

topic definition, benefits, VA research activities, and resources for further information.

For more information about this issue of MANAGEMENT

BRIEF, or to send comments, contact: Geraldine McGlynn,

Manager, Information Dissemination Program, MDRC

(152-M), VA Boston Health Care System, 150 S. Huntington

Avenue, Boston, MA 02130. Phone: 617-278-4433.

Fax: 617-278-4438.

Visit the Research and Development web page at

http://www.va.gov/resdev or the Intranet site at

http://vaww.va.gov/resdev, or utilize the MDRC

Fax-on-Demand system at (617) 278-4492 to see

additional HSR&D publications and reports.

An estimated $4 billion per year could be saved in the US

if institutionalization from dementing illnesses is

delayed by one month. Therefore, VA stands to benefit greatly

from an increase in the precision by which community care is

monitored. More important than the potential financial benefit, veterans with dementia who receive appropriately targeted interventions may be able to remain at home longer in

environments that promote maximum independence for both

caregivers and patients.

Ongoing HSR&D study #NRI 95-218;

Principal Investigator, Elizabeth Clipp, RN, PhD

Study shows decline in functional status is quality

indicator for long-term care

Measuring quality is essential for assessing improvements

in care, and because VA has a large proportion of long-term

care residents, assessment of the quality of care in long-term

care facilities is critical. Comparing resident outcomes across

long-term care facilities has become the ‘quintessential’

method of quality assessment. A decline in functional status,

as measured by an individual’s loss of independence in activities of daily living (ADLs, i.e., eating, morbidity), is considered to be one of the most meaningful outcomes for quality

assessment in long-term care. Although some decline in functional status is expected among long-term care patients, especially those with chronic illness, rehabilitative services and

other types of special care should maintain or improve physical functioning.

This HSR&D study examined 15,409 individuals residing

in 77 VA long-term care facilities to determine whether different definitions of decline in functional status affect judgments

about quality of care. ADL variables were used to generate

measures of functional status, and then differences between

resident’s baseline and semi-annual assessments were evaluated. Study results revealed that the percentage of residents

seen as declining in functional status varied with the measure

used. Thus, based upon the definition of outcome applied, a

decline in functional status from 7.7 percent to 31.5 percent

was reported. Improving the standard of measuring quality

accurately depends upon the development of standardized

indicators of functional status outcome. In addition, HSR&D

researchers are currently working on another project to

develop a risk-adjusted model for predicting a decline in

functional status that will compare facility-level rates of

decline in functional status and continuously measure functional change.

Accurate information about the quality of care provided

by facilities is necessary for informed decision-making,

thus the need for standardized measures that show both where

VA HSR&D Management Brief Number 17, October 2000 Page 3 of 3

improvements have taken place and where they are needed

is critical.

Rosen A, Berlowitz DR, Anderson JJ, Ash AS, Kazis LE,

Moskowitz MA.. Functional status outcomes for assessment

of quality in long-term care. International Journal for

Quality in Health Care 1999;11(1):37-46.

HSR&D, study #IIR 96-065

References:

1. Veterans Millennium Healthcare and Benefits Act

(Pubic Law 106-117) Veterans Health Administration

Long-Term Care Task Force Briefing Paper.

Internal report, April 26, 2000.

Please take a moment and tell us how you feel about

Management Brief by using our new Instant Feedback

Site for VA Health Services Research Publications on the

web at http://www.va.gov/resdev/prt/idp/. Your comments

and suggestions will guide us in our efforts to provide you

with important HSR&D information in future issues.

Correction: Please note a correction to the sixteenth

issue of Management Brief on Women Veterans’ Health.

On page two of this issue under the brief titled “Risky

health behaviors and poorer health status may predict postsurgery morbidity and mortality,” the last word in the second paragraph should read “morbidity” not “mortality.”