Background: Each year, approximately 3,900 and 14,100 Veterans reside in VA community living centers (CLCs) and VA per diem contracted community nursing homes (CNHs) for post-stroke care, respectively. A growing body of evidence shows that when effective rehabilitation interventions are continued post-stroke, they can speed patient recovery processes and minimize patient functional disabilities and deficits. Although VA has funded studies examining the structure, process and outcomes of rehabilitation services received by Veterans in CLCs and/or CNHs, these studies have focused on CLCs alone or on CLCs and CNHs within a single state. To better understand the quality of care received by Veteran residents of different types of nursing facilities, further research is needed on the adjusted quality outcomes and geographical variations among Veterans with the same medical condition who reside in CLCs or CNHs. Objectives: The goals of this study are to examine institutional long-term rehabilitation care and to assess the quality and geographical variations of rehabilitation services received by VA stroke residents in CLCs versus VA stroke residents in CNHs. The three specific aims are: (1) to compare the differences in nursing home and VA stroke resident characteristics between CLCs and CNHs nationally and by Veterans Integrated Service Network (VISN);(2) to examine the differences in rehabilitation care, restorative care, and mood-behavioral disorder care received by the residents between CLCs and CNHs nationally and by VISN;and (3) to evaluate the differences of VA stroke residents in physical function, cognitive function, depression status, 12-month mortality and stroke rehospitalization between CLCs and CNHs nationally and by VISN. The long-term objectives are to systematically examine multiple-source long-term rehabilitation care;determine geographical variations in rehabilitation care;examine the comparative costs of rehabilitation care;and develop an integrated long-term rehabilitation care and outcome database for VA stroke patients. Methods: This retrospective study includes all VA residents who were diagnosed with stroke and newly admitted to CLCs or CNHs from January 1, 2006 to December 31, 2009, regardless of their race/ethnicity, gender, and age. CLC and CNH Minimum Data Sets (MDS) will be linked with different VA datasets to define residents'stroke diagnoses and obtain the data needed for the study. For Objective 1, descriptive statistics will be obtained on all variables and comparisons of facility and resident characteristics will be conducted between CLCs and CNHs nationally and by VISN. For Objective 2, Poisson regression or two-part model of health services utilization will be used to analyze rehabilitation and restorative services;cumulative logit model will be applied to assess the ordered response of mood-behavioral disorder care. For Objective 3, we will assess the differences between CLCs and CNHs in the ADL function, cognitive function and depression change from admission to 3-, 6- and 9-month and combine the evidence to assess the overall difference using meta-analysis method. Logistic regression for mortality and Poisson regression for the number of stroke rehospitalizations will be fitted. Objective 2 and 3 analyses will be case-mix risk-adjusted;national and VISN comparisons will be made between the residents in CLCs and CNHs. Significance: Quality and geographical variations in services for Veterans are of the highest importance since stroke is prevalent among VA patients. CLCs and CNHs are two major sources of long-term care for Veterans, and VA continues to expand its long-term programs to meet the increasing needs of Veterans with chronic disabilities. The study addresses two of HSR&D's funding priority categories: long-term care and healthcare access. Findings from the study are important for VA policy makers, clinicians, and Veterans, and will enable them make future decisions regarding the appropriate placement of Veterans in rehabilitation facilities for post- stroke care. The study will provide evidence-based information about the quality and geographical variations in post-stroke, institutional long-term rehabilitatio care among Veteran residents in CLCs and CNHs.
Stroke is prevalent among VA health care enrollees. Effective post-stroke rehabilitation care can speed patient recovery processes and minimize patient functional disabilities. VA community living centers (CLCs) and VA per diem contracted community nursing homes (CNHs) are two major sources of institutional long-term care for VA stroke patients. However, there has been no study systematically examining rehabilitation care received by VA stoke patients in these two types of facilities. The primary purpose of this study is to examine the quality and geographical variations of rehabilitation services received by VA stroke residents in CLCs versus VA stroke residents in CNHs. The study addresses two of HSR&D's funding priority categories: long-term care and healthcare access. The study will provide a better understanding about the quality of care received by Veteran residents of different types of nursing homes. Our findings will help VA policy makers and clinicians make future decisions regarding the appropriate placement of Veterans for institutional long-term rehabilitation care.