Barriers to a Timely Discharge From Short-Term Care in VA Community Living Centers

Abstract

This study aimed to identify the barriers to a timely discharge from short-term care in Veterans Health Administration (VHA) Community Living Centers (CLCs). Ninety-nine interviews were conducted with CLC staff in leadership and direct-care positions in eight varied CLCs. Major themes identified through qualitative analysis as barriers to a timely discharge were a lack of patients’ financial resources, low social support, and reluctance of some veterans and staff to view a timely veteran discharge as their goal. Staff also perceived that barriers were much more difficult to overcome in regions where community-based long-term services and supports were limited or nonexistent. Because VHA has lagged behind Medicaid more generally in terms of investment in these types of services, additional strategies are warranted to achieve the important policy goal of deinstitutionalizing VHA care and returning veterans to their homes in the community.

Introduction

The Veterans Health Administration (VHA) provides health care to approximately 8.6 million veterans, of whom 45% are aged 65 and older (Shay, Hyduke, & Burris, 2013). While all veterans enrolled in VHA care are eligible to receive long-term care (LTC), veterans whose disability is deemed to be at least 70% service-related bear no costs for their care, while others are charged a co-pay. In 1999, passage of the Veterans Millennium Health Care and Benefits Act mandated increased access to community-based LTC for veterans and the development of alternative community-based options to better balance the proportion of LTC costs between institutional and noninstitutional care, so that veterans can better receive care where they reside, most often their homes. This mandate reflects similar policy pressures to “rebalance” Medicaid, the primary provider of LTC nationally (Wenzlow, Eiken, & Sredl, 2016). Efforts to rebalance Medicaid are aimed at reducing its “institutional bias” that often favors placing those needing services in institutions, such as nursing homes, over care provided in home- and community-based settings (Harrington et al., 1998; Smith et al., 2000, Center for Health Policy Research, paper 5, http://hsrc.himmelfarb.gwu.edu/sphhs_policy_chpr/5).

In response to the imperative of rebalancing LTC, the VHA Office of Geriatrics and Extended Care (GEC) took steps to shift the care focus of Veterans Affairs (VA) nursing homes, now called Community Living Centers (CLCs), away from long-term custodial care and toward short-term rehabilitative and skilled nursing care. However, GEC was concerned about the potential of post-acute care in the CLCs to substitute for continued hospital care as occurred in the non-VA sector in the wake of Medicare’s payment reforms of the 1990s in which patients were discharged “quicker and sicker” to avoid penalties (Burke et al., 2015). GEC was also concerned that post-acute care in CLCs could serve as yet another entry route into long-term custodial care.

To avoid premature discharges from hospitals, GEC issued a directive requiring CLCs to admit only those veterans who are medically and psychiatrically stable. Furthermore, the level of care and services required by the veteran must be assessed at admission using the Minimum Data Set Resident Assessment Instrument to determine whether the level of care and associated services needed are available at the CLC in question (Veterans Health Administration, 2005). To facilitate a timely discharge, GEC required CLCs to document each patient’s expected length of stay and discharge destination upon admission to CLCs and to initiate discharge planning at admission as well (Veterans Health Administration, 2005). GEC stressed the goal of discharging veterans from CLCs to their homes or other community-based settings as soon as treatment goals were met.

These changes in CLC discharge planning for short-term care were meant to increase the quality of CLC care as well as to promote a timely discharge. However, while there were indications that quality of care increased during the five years following implementation of this policy directive, the larger study, of which this qualitative research is part, found little change in average length of stay among patients admitted to CLCs for short-term care during the study period (2004–2011; Thomas et al., 2018). Similarly, two recent systematic reviews and meta-analyses of randomized controlled trials of nurse-led early discharge planning programs in the hospital setting demonstrated the programs’ effectiveness in reducing hospital readmission rates and all-cause mortality compared to controls, but they did not result in reduced length of stay (Fox et al., 2013; Zhu, Liu, Hu, & Wang, 2015).

The purpose of this study was to describe barriers to timely discharge in VA CLCs as perceived by CLC leadership and other staff. Understanding the dynamics of factors that impact length of stay for veterans admitted to CLCs for short-term rehabilitation and skilled nursing care is critical to efforts to reduce length of stay and to inform VA policy and may also provide valuable information to policy makers and providers in the non-VA post-acute care sector.

Methods

This study used qualitative methods, including 99 interviews with staff at eight VHA CLCs. The eight CLCs were selected for site visits based on their geographic location, size, and average length of stay for short-stay patients. Two CLCs from each of the four U.S. Census Regions (Northeast, Midwest, West, and South) participated. Average daily census for these CLCs ranged from 23 to 141 veterans and average length of stay in 2011 for short-stay patients ranged from 18.9 days to 31.3 days (see Table 1). Selected CLCs were first contacted by email and invited to participate in the study. Follow-up phone calls were made to CLC leadership to gauge their interest in participating and to answer questions about the study. For those CLCs willing to participate, a contact person was identified and a date for the site visit was scheduled. Before the site visit, an email was sent to CLC staff that explained the study and alerted them to the date of the site visit, which took place between September 2014 and May 2015.

Table 1.

Site-visited CLC characteristics.

Geographic Region	Number of Beds	Average Daily Census	Average Length of Stay for Short-Term Patients
Northeast	112	36.6	24.14
Northeast	40	22.5	19.63
Midwest	173	140.8	30.02
Midwest	96	30.6	31.31
South	124	96.4	25.62
South	110	81.9	22.42
West	30	25.3	21.12
West	34	24.9	18.86

Key leadership targeted for interviews were CLC directors, medical directors, and directors of nursing. Direct care staff interviewed included registered nurses, licensed practical nurses, case managers, nursing assistants, and therapists. At each of the CLCs, the designated contact person scheduled interviews with key leadership prior to the site visit. Nursing and therapy staff available at the time of the site visit were approached by researchers, who reviewed the purpose of the study and answered any remaining questions. All participants consented individually at the beginning of their interview.

Interviews were audio-recorded and transcribed for data analysis. A number of topics were covered in these interviews. Most relevant to the focus of this study were questions related to the discharge planning process and its impact. Specifically, members of the CLC leadership team were interviewed about CLC policies and procedures, especially with regard to discharge planning. They were also asked how discharge planning helps veterans and their views of barriers to a timely discharge. Direct care staff were asked similar questions, as well as additional questions regarding their perceptions of the importance of a timely discharge and how their specific role in the CLC facilitates veterans’ return to their homes. See Appendix A for example interview questions by respondent type.

Data analysis

Data analysis involved a rigorous process to code the transcripts and identify emerging patterns and themes across transcripts (Crabtree & Miller, 1999; Padgett, 2012). We began by developing a preliminary coding scheme based on the questions we asked in our interview guides; we then modified and refined the scheme in an iterative fashion to add codes and refine code definitions. Additional codes resulted when unanticipated material emerged from interviews (Weston et al., 2001). Therefore, the resulting coding scheme reflected both a priori areas of interest from the interview questions as well as unanticipated findings that emerged from the data.

To begin the coding, all research team members read all interviews for the first two sites multiple times and individually made notations to code the material. In subsequent and repeated group meetings, team members then refined the coding scheme and code definitions and came to consensus about the interpretation of the material, with team decisions recorded in an audit trail. After analysis of the interviews from the first two sites were completed and coding became more standardized with increased familiarity with the coding scheme, each of the remaining interviews was coded by subteams of two team members. Members of these subteams rotated and the entire team convened regularly to discuss and resolve discrepancies and confirm the final codes in the transcripts. This strategy increases reliability of coding. Throughout analysis, team members noted potential emerging themes, that is, patterns of ideas and concepts expressed across interviews. Once coding was completed, the entire team discussed the potential themes to determine how prevalent they were across the interviews and how various themes related to our research questions and to each other.

Results

Eight to sixteen interviews (depending on CLC size) were conducted at each CLC, for a total of 99 interviews. Two staff members in leadership positions were interviewed at each CLC with the remainder of interviews conducted with nurses, nursing assistants, therapists, and other direct care staff. Below we present five dominant themes regarding barriers to a timely discharge that were identified through our analysis (lack of financial resources, lack of social support, veteran reluctance to leave the CLC, staff reluctance to force a timely discharge when veterans preferred to stay, and inadequate community-based services in the veteran’s geographic area). In addition, we present three themes related to aspects of the discharge process perceived by staff to be facilitators of a timely discharge (discharge planning begins at admission, well-integrated interdisciplinary team, and family involvement in discharge planning).

Barriers to a timely discharge

Lack of financial resources was found to be a key barrier to timely discharge. For example, a nurse manager described the situation of veterans who have neither the finances nor the insurance to be transferred to a community nursing home:

That’s what plugs things up … time-wise it takes so long to get [Medicaid] applications and the funding source established and it would be really great if we had another place that they could go and get care in the meantime.

Those veterans lacking both finances and a place to live present particular challenges to a timely discharge to the community. One social worker described this situation:

But sometimes there’s situations where they have no funds whatsoever, they didn’t pay into social security, they didn’t have a job, they didn’t have a savings, and it’s like you’re trying to place them, and placement is very expensive. And sometimes they want to live independently, sometimes we do a lot of shelter placement. We go for services outside as well, like there’ll be different organizations that can help with placement. But when they have no money, it’s so difficult.

Lack of social support was also cited as a barrier to timely discharge. In some cases, families were no longer able or willing to care for patients at home, possibly due to the high level of care required, disruptive behavior associated with cognitive impairment, or their own work status or poor health. In cases where the veteran lived alone prior to hospitalization, families resisted discharge because they believed that the patient could not care for himself or herself. As this social worker stated:

Some of the biggest barriers I would say is maybe lack of family support. Maybe the family thought okay, well when the veteran gets rehab then he can come home, but maybe he can’t. Maybe his needs surpass what the family is able to do and then that becomes challenging because the families tend to want them to stay here [in the CLC].

A nurse manager stated this more bluntly saying, “Families is a big, big deal too. The patients or residents want to go home, but the families don’t want them home.”

There were also instances reported where veterans were reluctant to leave the CLC and even sabotaged their care in order to remain in the facility:

… another case comes to mind of a veteran who came in for respite and he’s always loved coming to the CLC and will think of any excuse not to go home, and we’ve seen patients even kind of sabotage their care in order to stay longer … and it just tells me that their home environment probably is so lonely and maybe just … it’s hard to know, but they do [resist discharge]. They love socializing with the other vets, and just all the things that we do here for them …

One nurse described her experience this way:

Like we have a couple now that have some care issues that they could go to a home health … but for whatever reason, when you talk to them about discharge, they have another issue come up, like “I have chest pain.” And so and then it requires another week or two of stay.

The issue of veterans not wanting to leave the CLC was sometimes complicated by the attitudes of some staff members who felt it was the veterans’ right to receive care in the CLC despite the VHA’s policy shift to a focus on short-term rehabilitation and timely discharge back to the community. As the associate director of one CLC stated:

I think it’s just here in [Location]. … The thought process for some of them is “you know, they’re veterans, if they want to be here it’s okay to be here and we just need to take care of them …”

A medical director at another CLC agreed and said:

I think we have a lot of kind, caring, compassionate folks over here that are providing care, that try to do what they can to help the veteran and sometimes it’s hard to say okay, well you gotta leave. And so I think those are some factors which lengthen our length of stay.

While the patient-level factors discussed above were key barriers in preventing a timely discharge from CLCs, even patients with adequate socioeconomic and social support resources were delayed if they resided in areas where community services were limited or nonexistent. Many VHA facilities’ catchment areas stretch for hundreds of miles and community services may vary based on the proximity of the patient’s home to the VHA medical center. As an administrative nurse reported:

Depending on where some of our veterans live. If they live in one of the communities that’s close to the VA that’s fine, but we get them from all over. I mean, those resources may not be available in their community.

In other instances, community services were reported to be limited in the entire region or even the entire state:

The social workers will try to link them in with community resources as much as possible. But the community resources are very limited, too, now and it seems like even five or six years ago … I find my job is harder to do as I’m managing these patients because the resources seem, both state and VA, seem to be less.

A medical director agreed:

The community lacks [services], especially for the geriatric population. … In-home support is … really lacking. Keeping people at home is not done well [here].

Facilitators of timely discharge

While the quantitative results of our larger study did not find significant reductions in length of stay in CLCs nationally (Thomas et al., 2018), some CLCs were more successful than others in discharging veterans in a timely fashion. Interview participants reported specific aspects of the discharge process that seemed to facilitate a timely discharge. For example, a number of respondents emphasized that discharge planning begins at admission. As one director of nursing outlined the approach:

So really planning from … day one: What is the plan for discharge and how do we then pull all the pieces together so we’re ready for discharge by that time frame.

In addition, staff reported that the discharge process functions most effectively when a well-integrated interdisciplinary team is involved from the beginning. As one social worker noted:

It’s the relationship with the team, the recommendations, the services that we have. The independent living evaluation is great! Or having the neuropsychologist available to do assessments and say, you know, they [the patient] just don’t realize their limitations. And being able to know that when you’re working on those kinds of discharges. So to me, I’m not going in blind, but I also have support from the team.

A case manager also noted the importance of a well-integrated team:

I’m really pleased with how our unit handles the discharge process, how our providers, how our interdisciplinary team listens to each other and gets input from each other to where our discharge process, I think, is really well built to where our veterans go home with every chance for success that we can provide them.

Many respondents noted the importance of family involvement in discharge planning. These participants noted how the inclusion of family members at discharge planning meetings contributed to a timely discharge. This involvement took two primary forms: having families agree with the plans for timely discharge by providing them with a discharge date and involving them in determining an appropriate discharge location. Once committed to the discharge, families may be more motivated to be present in the planning process. One social worker noted that discharges happened more smoothly and in a timely manner “when the family’s involved and the interdisciplinary team and everyone tends to agree that this is going to be the best discharge option for this patient…”

Staff members also emphasized the importance of education for family members related to the care the patient would need after discharge. One physical therapist described this process as, “And [family members] will practice if they need assistance with the transfer … or different equipment needs …”

Discussion

Our results show that CLC staff perceive that a number of barriers delay the goal of a timely discharge for some veterans. The barriers they reported were generally related to veteran socioeconomic and social support issues. CLC staff noted that they experienced difficulty discharging patients with very limited resources, little or no social support, and no home to which to return. They also described how some veterans do not want to leave the CLC and that some families resist taking veterans home. In some cases, our data suggest that staff attitudes may also be a barrier to timely discharge because some staff feel that veterans deserve CLC care and should be allowed to remain there as long as they wish. Finally, many point to inadequate home-and community-based services (HCBS) in the area of the CLC and/or the veterans’ homes.

Our findings regarding participants’ perceptions of personal barriers (socioeconomic and social support) to a timely discharge are consistent with several quantitative studies focused on discharge planning for long-term, mostly low-care, nursing home residents participating in Money Follows the Person and other nursing home transition programs (Arling, Abrahamson, Cooke, Kane, & Lewis, 2011; Leedahl et al., 2015; Lester, Irvin, & Lim, 2013; Meador et al., 2011). Similarly, research on the effect of dual eligibility (Medicare and Medicaid) versus Medicare-only status on the outcomes of patients entering skilled nursing facilities found dually eligible patients to be 12% more likely than Medicare-only patients to transition to long-stay status (Rahman, Tyler, Thomas, Grabowski, & Mor, 2015). Dually eligible patients are similar to veterans using VA services in that they are more likely than their non-veteran counterparts to live alone and have lower rates of home ownership, lower socioeconomic status, and poorer health status (Congressional Research Service [R44697], 2017). Thus, it is not surprising that we found socioeconomic issues to be related to timely discharge of VA patients.

In addition to barriers to a timely discharge, many staff members stressed the elements of the discharge planning process that could facilitate a timely discharge, including a well-functioning interdisciplinary team, engaging families in the process, and the initiation of discharge planning at admission. Ironically, as discussed earlier, quantitative findings from our larger study indicate no change in overall CLC length of stay for short-stay patients over the study period, suggesting that early discharge planning did not systematically change the timing of discharge (Thomas et al., 2018; Zhu et al., 2015). However, it is likely that an improved discharge process is at least partly responsible for improvements observed over the study period in other patient outcomes, including an increase in the proportion of patients discharged to the community, a reduction in hospital admissions, readmissions to the CLC, and placement in non-VA nursing homes in the 30 days post-CLC discharge (Thomas et al., 2018). Therefore, enthusiasm for the success of the discharge process overall may have influenced staff perceptions of its effectiveness in promoting a timely discharge.

Our findings that staff are sometimes reluctant to “rush” discharge even though treatment goals are met are not entirely surprising because, while the directive to CLCs provided a framework for timely discharge through admission and discharge criteria (Veterans Health Administration, 2005), it did not specify procedures to follow when patients were reluctant to leave or had no family or home to return to. Furthermore, GEC’s ultimate goal to reduce CLC length of stay as part of an overall shift from long-stay custodial care to short-stay rehabilitative and skilled nursing care was not well articulated.

In contrast, a highly visible GEC effort to implement the principles of culture change in all aspects of the CLC environment and processes of care occurred during this same time period (Veterans Health Administration, 2008). The overarching principle of culture change is veteran-centered care, in which “personal preferences are honored and a sense of family or community exists” (Veterans Health Administration, 2008). It is likely that, in some cases, the culture of veteran preference as well as respect for veterans’ service to the nation may have superseded timely discharge as a priority (Harrison et al., 2017). In fact, the visible and attitudinal artifacts of culture change permeated the majority of CLCs we visited. The name change of these facilities from VA Nursing Home Care Units to Community Living Centers (CLCs) perfectly captures the institutional culture, typically defined as a system of shared assumptions, values, and beliefs that governs how people behave in organizations, that is highly likely to have influenced our respondents’ attitudes.

For VHA policy makers, the most important barrier to timely discharge that we and others (Arling et al., 2011) have identified is the need for better and more HCBS. While VHA has made strides in recent years in terms of the availability of noninstitutional supports and services, they lag behind efforts in the United States more generally. In 2015, about 29% of VHA LTC spending was on HCBS (Congressional Research Service [R44697], 2017). This is compared to approximately 55% of 2015 Medicaid spending on LTC nationally for HCBS (Eiken, Sredl, Burwell, & Woodward, 2017). To ensure veterans a timely discharge from VA CLCs, the VHA needs to provide primarily short-term rehabilitative care in their CLCs by continuing to invest in both traditional and novel approaches to HCBS that will allow patients to return to the community and be successful there. Also, the development and dissemination of community-based care models for veterans who are difficult to place is essential. Recently developed alternative models of care that VHA is in the process of disseminating nationally include Medical Foster Homes for frail elderly (Levy & Whitfield 2016), in which veterans with cognitive impairment are placed with caregivers who treat them as family members, and Veteran Directed HCBS, for veterans with a high level of care needs who are at risk for nursing home placement (see https://www.va.gov/GERIATRICS/Guide/LongTermCare/Home_and_Community_Based_Services.asp). Veteran-directed HCBS is a partnership between the U.S. Administration for Community Living and VHA and allows veterans the autonomy to select those services that will best meet his or her needs in the least restrictive setting while maintaining quality care (Thomas & Allen, 2016). Furthermore, veterans are allowed to hire friends and family members, thus allowing some caregivers to forgo or reduce hours of other paid employment to meet their loved one’s needs.

It is possible that at least some part of staff members’ perception that HCBS were limited or nonexistent is due to incomplete knowledge of their presence, particularly when veterans live at a distance from the CLC. Staff education, particularly for discharge planners, regarding the availability of various types of HCBS in the entire Veterans Affairs Medical Center (VAMC) service area is essential and should occur on a regular basis to stay abreast of expansions of existing resources and the development of new HCBS models, including those sponsored by VHA. Research has also identified the importance of physicians’ role and inexperience in the HCBS referral process, suggesting the need for inclusion of physicians as well as nursing staff in any training programs (Reder, Hedrick, Guihan, & Miller, 2009).

Limited use of VA HCBS options may also be attributed to service caps, eligibility restrictions, and other administrative barriers, not the least of which was that the type and scope of available HCBS services at the time of this study were at the budgetary discretion of each VAMC. Thus access to HCBS was uneven across VAMCs nationally and, consequently, across their associated CLCs (Miller, Intrator, Gadbois, Gidmark, & Rudolph, 2019). In an effort to ensure that GEC HCBS options were equally available across VAMCs nationally, VHA Directive 1140.11 was issued (Veterans Health Administration, 2016). This directive describes the full range of GEC HCBS offered and emphasizes that these services are part of the VA Medical Benefits Package and are available to all enrolled veterans for whom the care is needed as alternatives to nursing home care.

In addition, VHA has added performance measures for CLCs as part of their SAIL initiative (see https://www.va.gov/QUALITYOFCARE/measure-up/Strategic_Analytics_for_Improvement_and_Learning_SAIL.asp). At the time of this writing, release of some of these measures is imminent, and VHA also plans to adopt claims-based performance measures for nursing homes delivering post-acute care developed by Medicare, including a measure that captures both the timeliness of discharge (within 100 days) and the absence of adverse events (hospitalization, readmission to nursing home, death) within 30 days post-discharge. This measure is called Successful Discharge (see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/New-Measures-Technical-Specifications-DRAFT-04-05-16-.pdf).

Our study contributes new findings on the importance of institutional culture in influencing CLC staff attitudes toward promoting a timely discharge. VA’s attention to veteran preferences appears to facilitate staff members’ reluctance to pursue discharge when veterans are disinclined to leave (Harrison et al., 2017). In addition, a lack of investment in HCBS by VHA may be creating an institutional bias that is reflected in the attitudes of staff and even patients. However, our study cannot answer the question of whether these attitudes result in less use of HCBS or whether the unavailability of HCBS leads to these attitudes.

Limitations

It should be noted that our study has some limitations. Although we spoke to a larger number of informants than is typical for qualitative research, our results are not generalizable to all nursing homes and possibly not even to all VHA CLCs. Although we sampled from the four major geographic areas of our country and selected CLCs that varied in size and average length of stay, the eight participating CLCs would not be expected to be representative of all VA CLCs. Also, as we heard from respondents in several CLCs in our study: “If you have seen one CLC, you have seen one CLC.” In addition, we did not interview veterans or their families and can only report the perceptions of CLC staff. Additional research should be used to further explore our findings, particularly qualitative research that includes veterans and their family members to provide a more complete picture of the barriers to a timely discharge than we report here.

This qualitative research was planned as part of a larger policy study to determine CLC progress in transitioning from primarily long-stay care to short-stay care with timely discharge to the community with needed HCBS. Our study, in particular, focused on reasons that timely discharge was often difficult to achieve. As such, we focused on interviews with CLC leadership and a wide range of staff members. We did not, however, interview veterans cared for in the CLC, and therefore our findings are lacking veterans’ voices. Our results may have been richer had veterans offered their opinions on why leaving the CLC was difficult, even when treatment goals were met.

Finally, there are factors that may impede a timely discharge to a greater extent in VA CLCs than in non-VA CLCs. The VHA patient population is known to be sicker and poorer than other patient populations, including veterans who do not use VA services (Agha, Lofgren, VanRuiswyk, & Layde, 2000) and this may help explain some of our findings regarding the link between socioeconomic factors and lack of timely discharge. VHA CLCs are also governed by restrictions and regulations that do not affect other nursing homes, such as requirements for a safe discharge. This means that patients cannot be discharged if necessary home modifications, such as wheelchair ramps, have not been installed, for example. Also, nursing home stays for patients outside VHA are often limited by their insurance coverage and longer stays may require out-of-pocket payments. This is not the case for patients in VHA whose care needs are at least 70% service-related; the VHA pays for their stay regardless of the length of stay even if the patient no longer needs a nursing home level of care.

Conclusion

VHA policy has shifted its CLC focus from long-term custodial care to short-term rehabilitation with a goal of shifting from institutional care to HCBS. However, research has shown that this change in emphasis did not result in reduced length of stay in CLCs (Thomas et al., 2018). Our study sought to determine the barriers to timely discharge from CLCs and found the key barriers, as perceived by CLC staff, to be a lack of financial resources and social support on the part of veterans as well as a reluctance on the part of veterans and some staff to work toward discharge. Reported facilitators of timely discharge were early initiation of discharge planning, involvement of an interdisciplinary team in the discharge planning process, and the inclusion of family members in discharge planning. However, staff also reported that even with these elements in place, timely discharge was difficult or impossible in communities and regions where HCBS were limited or not available. Because VHA has lagged behind Medicaid more generally in terms of investment in these types of services, additional strategies are warranted to achieve the important policy goal of deinstitutionalizing VHA care and returning veterans to their homes in the community.

Appendix A. Example Interview Questions by Respondent Type

CLC leadership (e.g., CLC directors, director of nursing, medical director)	•What does your facility do to help veterans reach care goals and transition home? •How does your facility’s discharge planning routine particularly help transition veterans to the community? •What barriers do you think interfere with discharge to the community? •What suggestions do you have to improve discharge planning? •Does your staff have contacts/relationships with outside agencies or organizations that help the veteran after returning home? •What have you learned that you think would benefit other CLCs in increasing the effectiveness of discharge planning? •Have any recent changes to the way care is provided here been helpful in rehabilitating veterans and allowing them to return to the community?
Social worker or discharge planner	•In what specific ways do you think your facility enables veterans to transition home? What do you do specifically to help veterans return home? •What elements of discharge planning work particularly well in transitioning veterans to the community? What barriers do you think interfere with discharge to the community? •What suggestions do you have to improve discharge planning? •Does your staff have contacts/relationships with outside agencies or organizations that help the veteran after returning home? •What have you learned that you think would benefit other CLCs in increasing the effectiveness of discharge planning? •When in the course of a veteran’s stay do you begin discharge planning? •What do you think works well in the discharge planning that you do? •Please describe how you may work with other staff, departments, or agencies regarding discharge plans. •What specific hurdles does the veteran typically face after discharge? What makes for successful discharge home? •Do you attempt to help link veterans to services prior to his/her discharge? •What improvements, if any, would you like to see instituted to aid in the discharge and transition process? •Have any recent changes to how care is provided or discharge planning is done been helpful in rehabilitating veterans and allowing them to return to the community?
Therapists	•What is your role in helping veterans return to the community? •Please describe how you rehabilitate the veteran to return home. •What community resources are used to help with the veterans’ continued rehabilitative needs after discharge? •Which individuals, agencies, and services in the community are you currently working with? •What sense do you have about how well these agencies and individuals are doing with helping the veterans return home? •What information do you have from veterans, their families, and the referring agencies/individuals about how rehabilitation is going post-discharge? •What aspects of rehabilitation may help the veteran return to the community sooner? •Have any recent changes to how care is provided here been helpful in rehabilitating veterans and allowing them to return to the community? •Do you think veterans should be discharged to the community as soon as possible? •How well do the CLC staff members work together to aid the veteran’s rehabilitation?
Frontline staff (e.g., nurses and nursing assistants)	•Tell me about getting veterans back to the community. How quickly does that happen? What affects how quickly a veteran gets back into the community from here? •What do you do specifically to help veterans return home? •Do you feel it is important to get veterans back to the community quickly? •What do you see as problems facing veterans in returning home? •Do you have suggestions that would help this transition to home? •Have any recent changes to the way care is provided here been helpful in rehabilitating veterans and allowing them to return to the community?