Discharge Disposition in Veterans With Heart Failure: Impact of Dementia and Severe Mental Illness.

Abstract

Objectives: Post-acute heart failure (HF) care presents significant management challenges, particularly among veterans with cognitive and behavioral impairments due to Alzheimer's disease and related dementias (AD/ADRD) or severe mental illness (SMI). We hypothesized that comorbid AD/ADRD and SMI would reduce the likelihood of discharge home following HF hospitalization. In addition, we explored how AD/ADRD and SMI influence discharge to Veterans Affairs (VA) Community Living Centers (CLCs) compared with Medicare Skilled Nursing Facilities (SNFs).

Design: Retrospective cohort study spanning January 1, 2011, to September 30, 2019.

Setting and participants: Veterans hospitalized with acute HF at VA hospitals (n = 291,117).

Methods: We examined VA administrative data from HF hospitalizations to assess how AD/ADRD and SMI impact post-hospital discharge location. Using diagnostic codes from the prior year, we stratified participants by the presence of AD/ADRD and/or SMI, then employed logistic regression models to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for discharge location, adjusted for demographics, comorbidities, and health care utilization.

Results: Participants were predominantly older (mean age: 78.1 ± 11.1 years), male (97.5%), and self-identified as White (72.7%). Those with AD/ADRD alone (n = 16,212) or SMI alone (n = 33,194) outnumbered those with both conditions (n = 3612). Compared with neither condition, the presence of AD/ADRD alone (adjusted OR [aOR], 0.523; 95% CI, 0.505-0.542), SMI alone (aOR, 0.869; 95% CI, 0.843-0.896), and both conditions (aOR, 0.505; 95% CI, 0.47-0.542) all reduced likelihood of discharge home. Participants with AD/ADRD and SMI were more likely to be discharged to a CLC than an SNF (aOR, 1.225; 95% CI, 1.064-1.411).

Conclusions and implications: Our findings indicate that AD/ADRD and SMI are major barriers to discharge home for patients with HF, suggesting a need for enhanced supervision during health care transitions. This study calls for further research into how discharge location affects short- and long-term clinical outcomes in patients with cognitive and behavioral impairment.