VA Community Living Centers to Home

Up to 29% of Community Living Center (CLC; VA nursing homes) residents may not require
nursing home levels of care and could successfully reside in the community with appropriate
rehabilitative services. Many older adults prefer to remain in their homes, though living
independently in the community is not always possible or safe. According to the model of
person-environment fit (P-E fit), older adults are at risk for poor outcomes when the demands
and resources available in the living environment are not in balance with the individual's
everyday competence (the ability to solve problems associated with everyday life).
Community-dwelling older adults with low levels of everyday competence and little support are
at risk for nursing home transition. Conversely, older adults with higher levels of everyday
competence who live in more restrictive environments (e.g., nursing home) may experience
declines in functioning resulting from a lack of stimulation. Often, transitions into nursing
homes occur during a time of crisis (e.g., after acute hospital stay), leaving little
opportunity for appropriate consideration of the individual's current and future level of
everyday competence.

In VA, a major focus is to minimize the time spent in the CLCs by providing rehabilitation
services and transitioning Veterans back into the community. The mission for the CLC program
is to return the Veteran to his or her highest level of well-being, thus maximizing P-E fit.
Despite this, CLC staff and Veterans face many barriers to facilitating transitions to the
community (e.g., caregiving needs, housing, etc.). Currently no standardized process exists
to assure that treatment planning includes processes to maximize P-E fit (e.g., assessing
everyday competence, setting resident-directed goals around rehabilitation needs, and
developing care plans to transition the Veteran to the community whenever possible).

The investigators' team has developed an instrument to allow providers to assess everyday
competence for safe and independent living in the community. However, to ensure successful
transitions, assessing everyday competence without intervention is not sufficient. Once CLC
interdisciplinary team members have an understanding of the resident's everyday competence
and barriers to transition, goal-setting must occur, focused on rehabilitation goals and care
planning around transitioning to the community.

The objective of the proposed research is to develop an effective and feasible toolkit the
CLC interdisciplinary team can use to 1) assess the Veteran's everyday competence for safe
and independent living; 2) develop personally meaningful rehabilitation goals that facilitate
successful transition out of the CLC based on everyday competence; and 3) conduct structured
care planning to support resident goals around transitioning back into the community. With
the innovative consideration of everyday competence and goal-setting in this context,
Veterans will have optimal P-E fit upon returning to the community, thus ensuring a
successful transition outcome (i.e., not readmitted to the CLC within 90 days).

Inclusion Criteria:

- CLC residents will be included if they are able to demonstrate understanding of the
informed consent process through teach-back and to communicate verbally.

Exclusion Criteria:

- CLC residents will be excluded if they are too cognitively impaired or have serious
mental illness too severe to meaningfully participate in interviews (i.e., they are
not "transition-capable").

- No participants will be excluded based on gender, race, social class, or ethnicity.