Decline in Veterans' Admissions to Nursing Homes during COVID-19: Fewer Beds, More Fear, and Finding Alternative Care Settings

The COVID-19 pandemic significantly impacted nursing homes, resulting in high mortality rates among residents and staff. Prior to the pandemic, the Department of Veterans Affairs (VA) community nursing home program experienced a substantial increase in utilization. However, there was a lack of research on how the pandemic affected Veterans' use of these facilities. This multimethods study addresses this gap by analyzing VA purchasing records to identify trends in Veteran admissions to community nursing homes and conducting semi-structured interviews with VA staff to understand the contextual factors influencing these trends. The study's objective is to quantify the change in Veteran nursing home admissions during the pandemic and explore the qualitative reasons behind this shift. The findings are crucial for understanding the implications of shifting long-term care provision for Veterans and informing future strategies for long-term care delivery within the VA system. The high mortality and morbidity rates observed in nursing homes during the initial phase of the pandemic prompted concerns about the safety and preparedness of these facilities. This prompted a closer look into the implications of these changes in terms of Veterans' health and well-being, especially regarding the implications of reducing admissions to nursing homes and instead opting for home-based care.

Existing literature highlights the significant increase in Veteran utilization of the VA's community nursing home program before the pandemic. However, published research examining the pandemic's influence on Veteran use of community nursing homes and its comparison to national trends was lacking. Studies focusing on the broader impact of the pandemic on post-acute and skilled-nursing admissions have shown decreases during the same period. The study also references reports on nursing home staffing shortages, which likely exacerbated bed shortages. Experts have advocated for shifting towards home-based care, but only with adequate support and training for caregivers. Existing data demonstrates increased caregiver burden during the pandemic.

This study employed a multimethod approach. Quantitative data were obtained from the VA's Corporate Data Warehouse, encompassing all VA-paid admissions to community nursing homes between January 2019 and December 2021. National data on nursing home admissions, beds, and occupancy were sourced from LTCFocUS. Statistical analyses were conducted using SAS Enterprise Guide 7.1. Qualitative data were gathered through semi-structured telephone interviews conducted in September and October 2020 with nine VA staff members (social workers, nurses, and program coordinators) from four VA medical centers involved in the VA community nursing home program. Interviews were recorded, transcribed, and analyzed using ATLAS.ti software. Content analysis was utilized to identify emerging themes. Quantitative and qualitative data were analyzed independently and then integrated during the interpretation stage. The study received ethical approval from the Providence VA Medical Center Review Board and the Colorado Multiple Institutional Review Board.

The quantitative analysis revealed a significant 35% decrease in weekly VA-paid admissions to community nursing homes between April and December 2020 compared to the same period in 2019. While admissions increased after April 2020, they remained substantially below the 2019 average. In 2021, weekly admissions were only 82% of the 2019 average. The proportion of admissions preceded by a hospital stay remained relatively consistent across 2019, 2020, and 2021. Nationally, total nursing home admissions decreased by 19.6% in 2020. Qualitative data analysis yielded three major themes: (1) Nursing home infection prevention policies and COVID-19 outbreaks limited admissions due to requirements for private rooms and temporary bans on new residents. (2) Veteran and family hesitancy and fear of COVID-19 exposure in nursing homes contributed to a substantial decrease in admissions, often leading to cancellations of planned admissions or opting for home hospice instead. (3) The pandemic risk prompted some Veterans already residing in nursing homes to seek discharge, often returning home with limited support from family or external care services. In some cases this resulted in the Veteran receiving a lower level of care. Although some found this a positive outcome, many expressed concern about the lack of adequate care for Veterans returning home.

The study's findings highlight a substantial decrease in Veteran admissions to community nursing homes during the COVID-19 pandemic, exceeding the national decline in nursing home admissions. The decline persisted into 2021. The three themes emerging from the qualitative data provide valuable insight into the factors driving this decrease. The availability of alternative long-term services and home-based support within the VA system may have enabled a higher rate of opting out of nursing home care compared to the national average. However, increased demand on home-based services and potential gaps in caregiver training and support are concerning and need further investigation to determine the long term implications of this shift.

The significant decline in Veteran nursing home admissions during the COVID-19 pandemic warrants further research to assess its impact on Veterans' and their caregivers' health outcomes and well-being. This shift in care patterns raises important questions about the long-term sustainability and effectiveness of home- and community-based care alternatives and the level of training and support needed for caregivers. Future studies should focus on the long-term health implications of this shift and on how the VA can best support both Veterans and their caregivers.

The study's limitations include the exclusion of Veteran admissions to nursing homes paid for through Medicare or private insurance. The data did not reliably distinguish between long-term and short-term post-acute care, and the recency of the data limited the ability to precisely differentiate reasons for admission. National data from LTCFocUS were available only by calendar year, potentially incorporating pre-pandemic months into the 2020 data. The relatively small sample size of interviews might not fully represent the views of all staff involved in the community nursing home program.