DESCRIPTION (provided by applicant): The Millennium Act of 1999 precipitated change in the delivery of VA-covered long term care (LTC); specifically, to shift the locus of LTC from institutions to the community. Since that time, VA GEC has implemented innovative models of home-based care by providing home-based services that either delay or avoid institutionalization altogether (Edes, 2010). However, little i known about the status or consequences of the shift in emphasis of VA nursing homes from primarily long stay institutions to short (post-acute) stay Community Living Centers (CLCs) in which Veterans receive restorative and rehabilitative care in a home environment that discourages dependency and enables prompt return to the community when treatment goals are met. The overall goal of this project is to evaluate the impact of recent (2006) GEC initiative to reduce length of CLC stays, particularly for sort stay (post-acute) veterans, including Cultural Transformation of CLCs and mandates to enhance discharge planning, on changes in CLC length of stay (LOS) and rates of successful community discharge, i.e., without readmission to CLCs or non-VA nursing homes, and VA and non-VA costs. Informed by the HATCh (Holistic Approach to Transformational Change) model illustrating the interrelated individual, organizational and community components of Veteran- centered care, the project will use quantitative and qualitative methods to accomplish the following aims: Aim 1: a) Describe CLC LOS and rates of successful discharge to the community as they change over time (2004-2013) and vary by facilities, and examine the inter-relationship between LOS and successful discharge (discharge without readmission). b) In bivariate analyses, examine the relationship of CLC characteristics and the investment in VA and non-VA HCBS in the CLC market on the changes in CLC LOS and rates of successful discharge. Aim 2: Conduct an analysis of the impact of CLC characteristics and HCBS availability in the CLC market on the joint distribution of LOS and successful discharges, controlling for case-mix. Aim 3: Evaluate the impact of growth in VA and non-VA HCBS, and increase in therapy staff and staff skill mix, on length of CLC post-acute stays, and on rates of successful discharge of Veterans to the community for the years 2004-2013. Aim 4: Conduct a budget impact analysis of accelerating discharge from post acute care based on the findings from the previous aims. Aim 5: Conduct site visits to 8 CLCs with site selection informed by our quantitative analysis that will identify CLCs with varying lengths of stay and rates of successful discharge in order to explore other unmeasured factors likely to be related to CLC variation in these factors and that are best captured through qualitative data collection, e.g., institutional and staff attitudes and values, and protocols for admission, discharge planning, and transition assistance provided to Veterans at discharge. Results of this study will be used by GEC leadership to refine current policies regarding the mission and operations of CLCs nationally to ensure that they align with GEC goals. Further, dissemination of "best practice" administrative protocols regarding admission, discharge and transitions to the community will advance the transformation of VA CLCs' culture and mission closer to the ideal of using the CLC as a bridge to a less restrictive care setting that allows for Veterans' maximum autonomy, functioning and quality of life.

Shortening length of post acute stays in CLCs is a top priority for VA GEC, both to accommodate the increasing number of Veterans who require post acute care and to meet Veterans' preferences to remain in the community. However, the benefits of decreasing LOS may be offset if availability of home and community- based services (HCBS) is inadequate or if CLCs do not implement system change to facilitate access to HCBS consistent with the goal of accelerating discharge back to community settings. Possible consequences could include increased rates of CLC readmission, hospitalization, and/or emergency department use that may be more costly than the additional time spent in CLCs. Thus, it is important to understand whether there are tradeoffs in reducing LOS for post acute care. GEC leadership will use the results of this study to help refine policies regarding the mission and operations of CLCs to align with GEC goals, particularly in crafting incentives to promote the adoption of effective practices and structures.