Finding a Final Home: A Needs and Gaps Analysis of the Referral Process into Long-Term Care for Aging Veterans with a Mental Health Diagnosis

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Introduction/Background: This study aimed to improve the referral process for Veterans with mental health who are seeking long-term care support through the VA with a needs and gaps analysis. Hackman and Oldham’s theoretical framework served as a lens to gain insight into stakeholders of the process and explore the need for stakeholders to know the whole process to yield the most effective outcome. Methods: Survey, 9 structured interviews, Mental Health admission data collection Results: More than 45% of all clinical staff at Manchester Veterans Affairs Medical Center reported not feeling confident or only slightly confident on their knowledge of the Long-Term Care Referral Process while 71% reported not feeling confident or slightly confident on their knowledge of the PASRR as part of the referral process. Data Collection from Geriatric programs found all four programs had 35% or more Veterans e nrolled with a Mental Health diagnosis. There were five central themes found from interviews in data analysis; a lack of knowledge of the referral process, an increase in aging mental health Veterans, needed resources, COVID Impact and a need for more training. Discussion: A discovered lack of knowledge of the whole referral process amongst stakeholders is negatively impacting nursing home placements with an inconsistency in completing the PASRR which supports existing literature on a need for a standardization of the PASRR and an Interdisciplinary approach. This study introduced an approach to standardize the PASRR implementation and improve the effectiveness of the LTC referral process through Oldham & Hackman’s theoretical framework. While this was applied to the LTC referral process this approach can be generalized to other areas working to breakdown the compartmentalization of workflows. Manchester is one VA of 171 facilities. This study was limited to VA stakeholders and future research would benefit from community stakeholder insight.

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Long-term care, Mental health, Veterans