Gaps and Opportunities to Improve Post-Acute Care Decision-Making for Older Veterans: Insights From Veterans Affairs National Leaders

Abstract

Objective: To understand how national leaders within the US Veterans Administration (VA)-a large, integrated single-payer/provider system-conceptualize post-acute care decision-making.

Design: Semistructured interviews.

Setting and participants: Interviews (n = 18) with national VA leaders responsible for post-acute care transitions and long-term outcomes of patients using post-acute care.

Methods: Thematic analysis describing gaps and opportunities around post-acute care decision-making.

Results: VA leaders described post-acute care not as a short-term discharge decision, but a pivotal moment that could shape whether veterans successfully age in place. Ideally, post-acute decisions would be driven by veterans' goals and informed by a full range of care options, including noninstitutional supports. In practice, however, leaders noted that decisions were often made without adequate information, poorly aligned with veterans' values, and constrained by eligibility complexity, uneven local resources, and inconsistent terminology. Participants identified key barriers to supporting veteran-centered decision-making, including lack of tools, staffing constraints, and limited provider knowledge. Finally, leaders emphasized the need for systems to track outcomes that matter to veterans (eg, satisfaction, quality of life, goal alignment) to improve transparency and enable a learning health care system.

Conclusions and implications: In contrast with short-term discharge planning, VA operational leaders viewed post-acute care decisions through a longitudinal lens as a critical opportunity to help veterans to age in place. Realizing this vision will require tools and processes that inform veterans and caregivers about care options, align services with their goals, and track meaningful outcomes across settings. Addressing system-level barriers, including fragmented infrastructure, eligibility complexity, and limited clinician support, is also essential. These findings identify key levers to redesign care, guide implementation strategies, and develop evidence-based guidelines for veteran-centered post-acute transitions for older adults. Insights may also inform other integrated health systems seeking to align post-acute transitions with long-term patient goals.

Keywords: Post-acute care; decision-making; skilled nursing facility; veterans.