Changes in post-hospital care in skilled nursing facilities for Veterans: A cohort analysis
Abstract: BACKGROUND: Like the US population, the Veteran population is aging rapidly and has increasing current and future needs for skilled nursing facilities (SNF). OBJECTIVES: We examined trends in SNF use among Veterans after hospitalization before and after the 2018 MISSION Act and the onset of the COVID-19 pandemic. We assessed factors influencing SNF placement and outcomes across three SNF types. DESIGN: Retrospective cohort study of hospitalized Veterans with subsequent SNF stays from January 1, 2015, to December 31, 2022, using data from both VA and non-VA sources. PARTICIPANTS: Veterans aged 66 + with an acute hospitalization followed by SNF admission within 1 day were included. We excluded long-term nursing home residents, psychiatric discharges, and users of other institutional post-acute care. MAIN MEASURES: We analyzed trends in SNF use over time, examined factors affecting SNF type, and compared outcomes across three settings: VA-operated SNFs (Community Living Centers, CLCs), VA-paid non-VA SNFs (Contract Nursing Homes, CNHs), and Medicare-paid non-VA SNFs. KEY RESULTS: Among 1,405,701 qualifying hospital-to-SNF transitions, 90.0% were to Medicare-paid non-VA SNFs, 5.8% to CLCs, and 4.2% to CNHs. CNH use increased after mid-2019, while overall SNF use declined sharply with the start of COVID-19 and remained below pre-pandemic levels through 2020. The hospital type was the strongest predictor of SNF destination: VA hospitals sent Veterans to VA SNFs, while non-VA hospitals used non-VA SNFs. CLCs had the highest 30-day readmission rates (22.1%) but the lowest 30-day mortality (4.3%). CNHs had the longest median stays (29 days; IQR 14-63) and the highest rates of stays over 100 days (16.2%). CONCLUSIONS: Veteran SNF use shifted after the MISSION Act and COVID-19, with notable differences in utilization and outcomes by SNF type. These findings highlight the need to better understand how hospital and policy factors affect post-acute care access, quality, and cost for older Veterans.