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

The COVID-19 pandemic had a profound impact on U.S. nursing homes, with more than 150,000 residents and 2,500 staff deaths by July 2022 and roughly one-third of all U.S. COVID-19 deaths occurring in nursing homes. These events raised serious concerns about infection control and preparedness in these settings. The VA’s community nursing home program, which funds long-term care in privately owned facilities, had been growing prior to the pandemic, yet there was little published evidence on how COVID-19 affected Veterans’ use of community nursing homes or how VA trends compared to national patterns. This study aimed to quantify changes in VA-paid admissions to community nursing homes during the pandemic and to contextualize these trends through qualitative insights from VA staff involved in community nursing home placements.

Design: Multimethods study integrating quantitative analyses of VA administrative data with qualitative interviews. Quantitative methods: The study used the VA Corporate Data Warehouse to identify all VA-paid admissions to community nursing homes (excluding VA-operated Community Living Centers and state Veterans homes) from January 2019 through December 2021. Admissions were classified as hospital-preceded if a Veteran was discharged from a hospital within 1 day prior to nursing home admission, considering both VA medical centers and VA-paid community hospital stays. National data on beds, occupancy, and admissions for 2019–2020 were obtained from LTCFocUS. Monthly hospital admission rates were examined using VA Support Service Center Capital Assets (VSSC) data. Analyses were conducted in SAS Enterprise Guide 7.1. Qualitative methods: Telephone semistructured interviews were conducted in September–October 2020 with 9 VA staff (social workers, nurses, program coordinators) from 4 VA medical centers involved in the community nursing home program. Interviews were recorded, transcribed, and analyzed using ATLAS.ti (v8.4.19). A team-based content analysis approach identified themes. Quantitative and qualitative data were collected concurrently, analyzed independently, and integrated at the interpretation stage. Approvals: The Providence VA Medical Center IRB and the Colorado Multiple Institutional Review Board (COMIRB; protocol 18-1186) approved the study.

• VA-paid admissions to community nursing homes declined markedly after the onset of COVID-19: from April 12 to December 26, 2020, average admissions were 441 per week (15,781 total), nearly a 35% decrease compared with the same period in 2019 (average 650 per week; P < .001). - In calendar year 2021, admissions averaged 526 per week (27,352 total), about 82% of the 2019 average (P = .008), indicating a persistent decline. - The share of community nursing home admissions preceded by a hospital stay changed only slightly: approximately 68% (Apr–Dec 2019) versus 70% (Apr–Dec 2020). - VA-reported overall hospital admissions were 42% lower in April 2020 compared with April 2019 (P < .01). - Nationally, total nursing home admissions (LTCFocUS) fell from 3.2 million in 2019 (1.9 admissions per bed/year) to 2.6 million in 2020 (1.6 admissions per bed/year), a 19.6% decrease. - Qualitative themes explaining the VA decline: (1) fewer available beds due to infection prevention policies (eg, quarantine, private-room requirements) and admission holds during outbreaks; (2) hesitancy and fear among Veterans and families about COVID-19 exposure in nursing homes; (3) movement out of nursing homes and preference for home-based care, sometimes with limited acceptance of in-home services due to infection concerns.

The study demonstrates a substantial decline in Veterans’ community nursing home admissions during COVID-19, exceeding the national decline, and persisting into 2021. These findings suggest the pandemic disrupted both supply (fewer available beds, staffing shortages, admission holds during outbreaks) and demand (Veteran and family reluctance due to infection concerns). The VA’s broad array of home- and community-based services, social work support, and telehealth may have facilitated a greater shift away from facility-based care relative to national trends. While these shifts may align with preferences to age at home, they also likely increased caregiving intensity and burden and may have strained the capacity of home-based programs to accommodate demand. Understanding the health and well-being outcomes for Veterans and caregivers under this shift is critical, though attribution is complicated by concurrent pandemic-related system stresses (service shutdowns, delays in care, and COVID-19 itself). The results inform considerations for redesigning VA long-term care provision, including investment in home-based supports, caregiver training, and infection control capacity in both community and facility settings.

VA-paid admissions to community nursing homes decreased sharply during the COVID-19 pandemic and remained below pre-pandemic levels into 2021. This decline appears larger than the national average and was driven by reduced bed availability due to infection control measures, fear of COVID-19 exposure, and a shift toward home-based care. The findings underscore the need to assess the impact of replacing nursing home care with home- and community-based services on Veterans’ and caregivers’ outcomes. Future work should evaluate the adequacy of home-based program capacity, caregiver supports and training, and the sustainability of these shifts in care preferences and practices.

• VA data did not include Veterans’ nursing home admissions financed by Medicare or private insurance, potentially underestimating total facility use. - The purchased care data lacked a reliable indicator distinguishing long-term custodial care from short-term post-acute rehabilitation under VA benefits. - The recency and structure of data limited differentiation between long-term and post-acute care episodes. - National LTCFocUS data were annual, so 2020 totals include pre-pandemic months. - The qualitative sample was small (9 staff at 4 VA medical centers) and may not represent all perspectives within the VA community nursing home program.