Background Every day, more than 600 hospitalized Veterans face a time-pressured, complex, high-stakes choice regarding post-acute care (PAC) supports following hospitalization. While nearly all efforts to improve PAC choice have focused on which provider to use, the type of PAC services selected can have life-altering implications in terms of patient outcomes, finances, and caregiver burden. For the majority of older Veterans, the main choices are to go to a skilled nursing facility (SNF) or go home, with or without home health care (HH). In preliminary work, we found that Veterans are infrequently included in post-acute care decision-making and are not informed about tradeoffs between PAC settings. Significance/Impact This research program will provide critical knowledge to Veterans, clinicians, and policy makers about Veterans' outcomes across PAC settings, while also piloting a tool to support high-quality decision-making by better aligning Veterans priorities with services. Innovation This theoretically driven mixed methods approach will draw from decision science, use large datasets, and incorporate user-centered design to reveal new insights into what matters most to Veterans discharged to PAC, and how best to align care with their values and goals. Veterans' priorities and goals for PAC are unknown, and our approach will establish important patient-centered outcomes for the VA to consider in achieving patient-centered PAC. I will use these findings to develop a new PAC decision support tool that is feasible and acceptable to patients, caregivers, and clinicians. Specific Aims My specific aims include: 1) Identify attributes of PAC that matter most to a diverse sample of older Veterans and caregivers when making decisions about post-discharge supports. 2) Determine differences in 100-day outcomes for older hospitalized Veterans who receive PAC via SNF vs. HH. 3) Develop and pilot a decision tool to elicit hospitalized Veterans' priorities for PAC, so they may be shared with the healthcare team. Methodology To better inform PAC decisions and evidence-based practice, in Aim 1 I will first use a mixed-methods approach informed by decision-science to identify what matters most to Veterans and caregivers when deciding between care types. In Aim 2, I will compare patient-centered outcomes between PAC settings to identify important trade-offs in SNF vs. HH. I will use advanced statistical techniques and a unique dataset (the 2012-16 Residential History File) to accomplish this aim. Last, in Aim 3 with methods from user centered design, I will rigorously identify what matters most to Veterans when making PAC decisions and pilot a decision tool. Next Steps/Implementation This research program will help better out understand the tradeoffs in outcomes between post-acute care services, while piloting a tool to support decision-making.

This program of research using a mixed methods approach will reveal new insights into what matters most to Veterans discharged to post-acute care, and how best to align care with their values and goals. With the aging Veteran population and rising costs of care, the VA will need robust evaluation of Veteran priorities and outcomes across post-acute care settings to inform policy decisions. Choice of post-acute care type may be one of the highest-points to influence value and improve Veteran-relevant outcomes– given if individuals are unable to recover, they frequently go on to long-term care at an extraordinary expense to themselves and the VA. However, Veterans values and priorities for post-acute care are unknown, and our approach will establish important patient-centered outcomes for the VA to consider in achieving high-value post-acute care.