VA Community Living Centers to Home

Study Overview
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Brief Summary
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Older adults prefer to live as in the community as long as possible. Creating a standardized treatment planning process that includes assessments of everyday competence and goal-setting techniques to help Veterans move from VA nursing homes back to the community can improve functional health, well-being, and quality of life for older Veterans. Research has shown that 29% of nursing home residents might be able to live safely in the community instead. Currently, VA provides nursing home care to more than 13,000 Veterans across the country, which costs about $3.3 billion a year. It is expensive for VA to provide nursing home care to these inappropriate residents and they are using limited resources that could be given to another Veteran with more urgent needs. The Everyday Competence Assessment and Planning for Community Transitions (ECAP-CT) toolkit will help these Veterans to move back into the community with the services and supports they need based on their individual level of everyday competence.

Detailed Description
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Up to 29% of Community Living Center (CLC; VA nursing homes) residents may not require nursing home levels of care and could successfully reside in the community with appropriate rehabilitative services. Many older adults prefer to remain in their homes, though living independently in the community is not always possible or safe. According to the model of person-environment fit (P-E fit), older adults are at risk for poor outcomes when the demands and resources available in the living environment are not in balance with the individual's everyday competence (the ability to solve problems associated with everyday life). Community-dwelling older adults with low levels of everyday competence and little support are at risk for nursing home transition. Conversely, older adults with higher levels of everyday competence who live in more restrictive environments (e.g., nursing home) may experience declines in functioning resulting from a lack of stimulation. Often, transitions into nursing homes occur during a time of crisis (e.g., after acute hospital stay), leaving little opportunity for appropriate consideration of the individual's current and future level of everyday competence. In VA, a major focus is to minimize the time spent in the CLCs by providing rehabilitation services and transitioning Veterans back into the community. The mission for the CLC program is to return the Veteran to his or her highest level of well-being, thus maximizing P-E fit. Despite this, CLC staff and Veterans face many barriers to facilitating transitions to the community (e.g., caregiving needs, housing, etc.). Currently no standardized process exists to assure that treatment planning includes processes to maximize P-E fit (e.g., assessing everyday competence, setting resident-directed goals around rehabilitation needs, and developing care plans to transition the Veteran to the community whenever possible). The investigators' team has developed an instrument to allow providers to assess everyday competence for safe and independent living in the community. However, to ensure successful transitions, assessing everyday competence without intervention is not sufficient. Once CLC interdisciplinary team members have an understanding of the resident's everyday competence and barriers to transition, goal-setting must occur, focused on rehabilitation goals and care planning around transitioning to the community. The objective of the proposed research is to develop an effective and feasible toolkit the CLC interdisciplinary team can use to 1) assess the Veteran's everyday competence for safe and independent living; 2) develop personally meaningful rehabilitation goals that facilitate successful transition out of the CLC based on everyday competence; and 3) conduct structured care planning to support resident goals around transitioning back into the community. With the innovative consideration of everyday competence and goal-setting in this context, Veterans will have optimal P-E fit upon returning to the community, thus ensuring a successful transition outcome (i.e., not readmitted to the CLC within 90 days).

Official Title
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Improving Veteran Transitions From VA Community Living Centers to the Community

Conditions
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Aged, Frail Elderly

Intervention / Treatment
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* Other: Everyday Competence Assessment and Planning for Community Transitions


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: CLC residents will be included if they are able to demonstrate understanding of the informed consent process through teach-back and to communicate verbally. Exclusion Criteria: CLC residents will be excluded if they are too cognitively impaired or have serious mental illness too severe to meaningfully participate in interviews (i.e., they are not transition-capable). No participants will be excluded based on gender, race, social class, or ethnicity.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Study Group<br>Individuals who want to leave the CLC will be allowed to participate in the study, there will be no assignment to groups. Individuals who want to leave the CLC will undergo transition care planning using the investigators' standardized toolkit. The investigators will compare outcomes to administrative data from other similar VA nursing homes. | Other: Everyday Competence Assessment and Planning for Community Transitions<br>* The Everyday Competence Assessment and Planning for Community Transitions (ECAP-CT) toolkit will allow CLC interdisciplinary team members to 1) assess the Veteran's everyday competence for safe and independent living; 2) develop personally meaningful rehabilitation goals that facilitate successful transition out of the CLC based on everyday competence; and 3) conduct structured treatment planning to support resident goals around transitioning back into the community. By considering everyday competence and goal-setting in this context, Veterans will have optimal P-E fit upon returning to the community, ensuring a successful transition.<br>* Other names: ECAP - CT;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Transition Outcome | The primary outcome of interest for this pilot study will be transition outcome. Transitions will be successful if the resident leaves the CLC with a community destination and is not readmitted to the CLC within 90 days. For the purposes of this study, transitions to the community include any non-institutional environment that is more independent than the CLCs (e.g., single-family home, senior apartment, assisted living, medical foster home, etc.). For individuals who are unable to transition or who transition and are readmitted to the CLC within 90 days, these transitions will be unsuccessful. | 90 days post-discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Goal Attainment Scaling | An important outcome for participants at the intervention sites will be Goal Attainment Scaling64, which will allow us to identify if the resident was able to achieve the transition goals within the planned timeframe. | Baseline | 
| Multilevel Assessment Instrument - Environment Scale [MAI-ES] | Measures person-environment fit | Baseline and 90 days | 
| Multilevel Assessment Instrument - Environment Scale [MAI-ES] | Measures person-environment fit. Will be assessed at baseline and 90 days. | 90 days | 
| Multilevel Assessment Instrument - Environment Scale | Measures person-environment fit. | Baseline and 90 days post discharge | 
| Money Follows the Person - Quality of Life Scale | Measures quality of life for individuals moving from a nursing home to the community. | Baseline and 90 days post discharge | 
| Care Transitions Measure - 3 | Measures individual's preparation for transitioning out of a health care facility. | Baseline and 90 days post discharge | 
| Geriatric Depression Scale - Residential | Measure of depression for older adults residing in residential care facilities. | Baseline and 90 days post discharge | 
| Length of Stay in CLC | Length of stay in the clc | 30 days and 90 days post discharge | 
| Health Services Utilization | Identify health services (e.g., hospital admission, ER visit, etc.) utilization following transition from CLC. | 30 days and 90 days post discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Quality of Life, Nursing Homes, Housing for the Elderly, Homes for the Aged