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Principal Investigator: Ann Kutney Lee
Organization: VA BOSTON HEALTH CARE SYSTEM
Fiscal Year: 2024
Funding agency: Veterans Affairs
Background: With the aging of the Veteran population, the demand for end-of-life (EOL) care,
including hospice services, is increasing. VA commits to ensuring that Veterans have access to
high-quality hospice in their setting of choice. In addition to home hospice services, VA offers to
provide hospice care within VA Community Living Centers (CLCs; i.e., VA nursing homes) or in
VA-contracted community nursing homes (CNHs). Until recently, little was known about the
quality of EOL care provided to Veterans receiving CNH-based hospice care. Our preliminary
work found that an alarmingly low percentage (58%) of family members of Veterans receiving
hospice in CNHs gave an “excellent” rating of the overall care received in the last 30 days of life
(compared to 83% of families of Veterans who received hospice in CLCs). We have also
observed significant variation across CNHs in quality of EOL care ratings.
Significance: CNHs are playing an increasingly critical role in VA’s commitment to ensuring
Veterans’ access to hospice care. A comprehensive understanding of the structures and
processes that underlie variation in quality of EOL care provided to Veterans receiving CNH-
based hospice is needed to illuminate levers for intervention to improve quality. Our study aligns
with HSR&D’s priority areas related to Community Care and Long-Term Care and Aging and
VA’s Strategic Plan that includes a key focus on “Aging, Frail, and End-of-Life Veterans.”
Innovation and Impact: Our application of positive deviance and machine learning methods to
identify factors underlying the quality of CNH-based hospice care are innovative contributions to
the field of EOL care research. Our findings have high potential for impact to guide VA
contracting decisions and the delivery of CNH-based hospice care to Veterans.
Specific Aims: 1) Examine the associations between CNH and hospice agency structural
characteristics, EOL care processes and bereaved family ratings of overall EOL care quality for
Veterans receiving hospice in CNHs; 2) Identify high- and low-performing CNHs based on the
BFS overall rating for Veterans who receive hospice; and determine the structures and EOL
care processes that are associated with high and low performance; 3) Explore bereaved family
member perceptions of the quality of EOL care for Veterans who received hospice in high- and
low-performing CNHs; and 4) Understand the delivery of CNH-based hospice care for Veterans
in high- and low-performing CNHs from the staff perspective.
Methodology: The project will employ a sequential explanatory mixed methods design. The
quantitative phase will use multi-level logistic regression models to understand the structural
characteristics and EOL care processes associated with BFS overall ratings (Aim 1) and a
machine learning approach to identify and study high- and low-performing CNHs based on BFS
ratings (Aim 2). The qualitative phase will deepen our understanding of the delivery of hospice
care in high- and low-performing CNHs using existing BFS data collected from bereaved family
members (Aim 3) and interviews with clinical staff and administrators (Aim 4).
Next Steps/Implementation: Findings will be used to refine VA’s CNH Dashboard that is used
to guide contracting decisions by incorporating EOL-focused measures. The study will also
create a Roadmap for Improving CNH-Based Hospice Care, including a Compendium of Best
Practices, that will inform quality improvement efforts and the development of a future
intervention study.
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