Transitional Care Outcomes in Veterans Receiving Post-Acute Care in a Skilled Nursing Facility

Background: As the veteran population ages, more veterans are receiving post-acute care in skilled nursing facilities (SNFs). However, the outcomes of these transitions across Veterans Affairs (VA) and non-VA settings are unclear.

Objective: To measure adverse outcomes in veterans transitioning from hospital to SNF in VA and non-VA hospitals and SNFs.

Design: Retrospective observational study using the 2012 to 2014 Residential History File, which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for veterans.

Setting: VA and non-VA hospitals and SNFs in four categories: non-VA SNFs, VA-contracted SNFs, VA Community Living Centers (CLCs), and State Veterans Homes.

Participants: Veterans, aged 65 years or older, who were acutely hospitalized and discharged to an SNF; one transition was randomly selected per patient.

Measurements: Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge.

Results: More than four in five veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7% in the 388 339 veterans included. Adverse outcomes were lowest in VA hospital-CLC transitions (7.5%; 95% confidence interval [CI] = 7.1%-7.8%) and highest in non-VA hospital to VA-contracted nursing home transitions (17.5%; 95% CI = 16.0%-18.9%) in unadjusted analysis. In multivariate analyses adjusted for patient and hospital characteristics, VA hospitals had lower adverse outcome rates than non-VA hospitals (odds ratio [OR] = 0.80; 95% CI = 0.74-0.86). In comparison to VA hospital-VA CLC transitions, non-VA hospital to VA-contracted nursing homes (OR = 2.51; 95% CI = 2.09-3.02) and non-VA hospital to CLC (OR = 2.25; 95% CI = 1.81-2.79) had the highest overall adverse outcome rates.

Conclusion: Most veteran hospital-SNF transitions occur outside the VA, although adverse transitional care outcomes are lowest inside the VA. These findings raise important questions about the VA's role as a provider and payer of post-acute care in SNFs. J Am Geriatr Soc 67:1820-1826, 2019.