Participants had concerns related to the VA MISSION Act and the possibility of more VA-paid NHs for rehabilitation or short-term care. Participants underscored the necessity for additional staff to account for the increased oversight burden or a reduction in oversight requirements. One SW felt that increasing the number of CNHs would increase the required oversight and the need for collaboration with NH staff, which would limit her ability to establish close and trusting working relationships with NH staff. Participants also described the challenges of meeting their current oversight requirements, which limited extra visits for acute issues and care conferences. This was attributed to a lack of adequate staffing in the VA CNH program, given the time-intensive nature of VA oversight requirements.
Easing Burden & Facilitating Oversight
Participants noted how obtaining remote access to veterans’ EHRs allowed them to conduct chart reviews before oversight visits. This permitted more time for interaction with veterans and CNH staff as well as coordinating care. While providing access to the VA EHR would not change the chart review component of VA oversight, some participants felt it might improve care coordination between VA and NH staff during monthly visits.
Participants felt they were able to build strong working relationships with facilities with more veterans due to frequent communication and collaboration. VA participants also noted that CNHs with larger veteran censuses were more likely to respond to VA concerns about care to maintain the business relationship and contract. To optimize strong working relationships and decrease the challenges of having too many veterans at a facility, some VA participants suggested that CNH programs create a local policy to recommend the number of veterans placed in a CNH.
Discussion
Participants interviewed for this study echoed findings from previous work that identified the importance of developing trusted working relationships with CNHs to care for veterans.11,12 However, interorganizational care coordination, a shortage of health care professionals, and resource demands associated with caring for veterans reported in other community care settings were also noted in our findings.12,13
Building upon prior recommendations related to community care of veterans, our analysis identified key areas that could improve CNH program oversight efficiency, including: (1) improving the interoperability of EHRs to facilitate coordination of care and oversight; (2) addressing inefficiencies associated with traveling to geographically dispersed CNHs; and (3) “right-sizing” the number of veterans residing in each CNH.
The interoperability of EHRs has been cited by multiple studies of VA community care programs as critical to reducing inefficiencies and allowing more in-person time with veterans and staff in care coordination, especially at rural locations.11-15 The Veterans Health Information Exchange Program is designed to optimize data sharing as veterans are increasingly referred to non-VA care through the MISSION Act. This program is organized around patient engagement, clinician adoption, partner engagement, and technological capabilities.16
Unfortunately, significant barriers exist for the VA CNH program within each of these information exchange domains. For example, patient engagement requires veteran consent for consumer-initiated exchange of medical information, which is not practical due to the high prevalence of cognitive impairment in NHs. Similarly, VA consent requirements prohibit EHR download and sharing with non-VA facilities like CNHs, limiting use. eHealth Exchange partnerships allow organizations caring for veterans to connect with the VA via networks that provide a common trust agreement and technical compliance testing. Unfortunately, in 2017, only 257 NHs in which veterans received care nationally were eHealth Exchange partners, which indicates that while NHs could partner in this information exchange, very few did.16
Finally, while the exchange is possible, it is not practical; most CNHs lack the staff that would be required to support data transfer on their technology platform into the appropriate translational gateways. Although remote access to EHRs in CNHs improved during the pandemic, the Veterans Health Information Exchange Program is not designed to facilitate interoperability of VA and CNH records and remains a significant barrier for this and many other VA community care programs.
The dispersal of veterans across CNHs that are > 50 miles from the nearest VAMC represents an additional area to improve program efficiency and meet growing demands for rural care. While recent field guidance to CNH oversight teams reduces the frequency of visits by VA CNH teams, the burden of driving to each facility is not likely to decrease as CNHs increasingly offer rehabilitation as a part of Veteran Care Agreements.17 Visits performed by telehealth or by trained local VA staff may represent alternatives.15
Finally, interview participants described the ideal range of the number of veterans in each CNH necessary to optimize efficiencies. Veterans who rely more heavily upon VA care tend to have more medical and mental health comorbidities than average Medicare beneficiaries.18,19 This was reflected in participants’ recommendation to have enough veterans to benefit from economies of scale but to also identify a limit when efficiencies are lost. Given that most CNHs cared for 8 to 15 veterans, facilities seem to have identified how best to match the resources available with veterans’ care needs. Based on these observations, new care networks that will be established because of the MISSION Act may benefit from establishing evidence-based policies that support flexibility in oversight frequency and either allow for remote oversight or consolidate the number of CNHs to improve efficiencies in care provision and oversight.20
