# Improving Quality of End-of-Life Care for Veterans Receiving Hospice in Community Nursing Homes

> **NIH VA I01** · VA BOSTON HEALTH CARE SYSTEM · 2024 · —

## Abstract

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-pe...

## Key facts

- **NIH application ID:** 10748575
- **Project number:** 1I01HX003744-01A1
- **Recipient organization:** VA BOSTON HEALTH CARE SYSTEM
- **Principal Investigator:** Ann Kutney Lee
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2024
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2024-03-01 → 2028-02-29

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10748575

## Citation

> US National Institutes of Health, RePORTER application 10748575, Improving Quality of End-of-Life Care for Veterans Receiving Hospice in Community Nursing Homes (1I01HX003744-01A1). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10748575. Licensed CC0.

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