PERCEIVED BARRIERS AND FACILITATORS TO HOME AND COMMUNITY-BASED PLACEMENT IN THE VETERANS HEALTH ADMINISTRATION

摘要

The U.S. Department of Veterans Affairs (VA) administers the largest integrated health care system within the United States with more than 1,700 sites of care serving close to 8.8 million Veterans annually. The demand for VA funded long-term services and supports have risen concomitantly with the aging of the Veterans population. Because national VA policy has been to rebalance the provision of long-term care away from nursing homes and towards home- and community-based services (HCBS) options, lessons from the VA’s experience in promoting greater use of non-institutional services and supports may prove informative for other initiatives seeking to shift the locus of care internationally. The purpose of this study is to identify factors that promote or impede the diversion of long-term care recipients from institutional nursing home care to non-institutional HCBS during the long-term care referral process, a heretofore limited area of study. Data derives from analysis of thirty-five semi-structured interviews performed with key informants from 12 VA Medical Centers (VAMCs). Results indicate that care teams recommend whether or not to refer Veterans for an HCBS or nursing home consult. Veterans’ care needs and preferences and social and financial resources influence these recommendations; so too does the perspectives of care team members. Lack of staffing and failure to offer the specific types of services needed limits the use of HCBS. Distance and crime/safety concerns pose further barriers in rural and urban jurisdictions, respectively. Budgetary imperatives influence the relative availability of HCBS across VAMCs. Findings highlight the impact of provider-level practices and system-level constraints in impeding the successful diversion of long-term care recipients from nursing homes to alternative settings in the home and community.