Changes in Post-hospital Care in Skilled Nursing Facilities for Veterans: A Cohort Analysis

Like the US population, the Veteran population is aging rapidly and has increasing current and future needs for skilled nursing facilities (SNF).

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.

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.

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.

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.

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%).

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.