{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,8]],"date-time":"2026-03-08T16:36:42Z","timestamp":1772987802867,"version":"3.50.1"},"reference-count":36,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2025,7,26]],"date-time":"2025-07-26T00:00:00Z","timestamp":1753488000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2025,7,26]],"date-time":"2025-07-26T00:00:00Z","timestamp":1753488000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Health Services Research"],"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To identify risk of long\u2010term institutionalization (LTI) among Veterans receiving care in the Veterans Health Administration (VA).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Setting and Design<\/jats:title>\n                    <jats:p>We developed the \u201cPredicted Long\u2010term Institutionalization\u201d (PLI) risk model for Veterans alive in the community at the end of fiscal\u2010year (FY) 2017 followed for LTI in nursing home (cumulative NH days allowing any acute care and up to 7\u2009days in community &gt;\u200990\u2009days) during FY2018\u2010FY2019.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data Sources and Analytic Sample<\/jats:title>\n                    <jats:p>PLI used demographics, diagnoses, prior hospital and nursing home (NH) use, and risk indices for death and frailty from VA and Medicare claims and Minimum Data Set data. Development of PLI used multiple iterations to maximize sensitivity, constrained by achieving a number needed to screen (\u2264\u20098), including age normalization to minimize algorithmic bias. We combined the elevated risk (ER) and common risk (CR) strata\u2010specific predictions from the logistic regression models to identify three tiers of PLI: low risk, moderate risk, and high risk. We describe Veterans' outcomes in FY2018\/2019 (LTI, death, hospitalization and VA cost) across the three PLI tiers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Principal Findings<\/jats:title>\n                    <jats:p>For identifying Veterans in LTI, compared to a baseline model that used only VA data as predictors (sensitivity 23%, specificity 98%), calibrating separate ER and CR strata increased sensitivity to 30%, the addition of Medicare data increased sensitivity to 33%, and age\u2010normalization with differential risk strata thresholds increased sensitivity to 41% (specificity 96.6%). The final PLI model (c\u2010statistic\u2009=\u20090.87) identified 3.5% of Veterans in PLI\u2010high risk (13% LTI rate), who accounted for 41% of new LTI, 22% of decedents, 19% of VA cost, and 11% of hospitalizations in FY2018\u20132019.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The PLI score identifies Veterans at high risk of LTI for further assessment and targeting of resources to support continued community residence.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/1475-6773.70016","type":"journal-article","created":{"date-parts":[[2025,7,26]],"date-time":"2025-07-26T12:23:40Z","timestamp":1753532620000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Predicting Risk of Long\u2010Term Institutionalization Among Community Dwelling Veterans Before the\n                    <scp>COVID<\/scp>\n                    \u201019 Pandemic"],"prefix":"10.1111","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2098-6340","authenticated-orcid":false,"given":"Bruce","family":"Kinosian","sequence":"first","affiliation":[{"name":"Geriatrics and Extended Care Data Analysis Center (GECDAC)  Bronx New York USA"},{"name":"Cpl Michael J Crescenz VA Medical Center  Philadelphia Pennsylvania USA"},{"name":"Leonard Davis Institute for Health Economics, University of Pennsylvania  Philadelphia Pennsylvania USA"},{"name":"Department of Medicine, Division of Geriatrics Perelman School of Medicine, University of Pennsylvania  Philadelphia Pennsylvania USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Susan","family":"Schmitt","sequence":"additional","affiliation":[{"name":"Geriatrics and Extended Care Data Analysis Center (GECDAC)  Bronx New York USA"},{"name":"VA Palo Alto Health Care System  Palo Alto California USA"},{"name":"Department of Pediatrics Stanford University  Palo Alto California USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matthew","family":"Augustine","sequence":"additional","affiliation":[{"name":"Geriatrics and Extended Care Data Analysis Center (GECDAC)  Bronx New York USA"},{"name":"James J Peters VAMC  Bronx New York USA"},{"name":"Department of Geriatrics &amp; Palliative Care Icahn School of Medicine at Mount Sinai  New York New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Scotte","family":"Hartronft","sequence":"additional","affiliation":[{"name":"Department of Veterans Affairs Geriatrics and Extended Care  Washington DC USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rajesh","family":"Makineni","sequence":"additional","affiliation":[{"name":"Geriatrics and Extended Care Data Analysis Center (GECDAC)  Bronx New York USA"},{"name":"Department of Public Health Sciences University of Rochester  Rochester New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kimberly","family":"Judon","sequence":"additional","affiliation":[{"name":"Geriatrics and Extended Care Data Analysis Center (GECDAC)  Bronx New York USA"},{"name":"James J Peters VAMC  Bronx New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gregory","family":"Krautner","sequence":"additional","affiliation":[{"name":"Department of Veterans Affairs Geriatrics and Extended Care  Washington DC USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cheryl","family":"Schmitz","sequence":"additional","affiliation":[{"name":"Department of Veterans Affairs Geriatrics and Extended Care  Washington DC USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mary K.","family":"Goldstein","sequence":"additional","affiliation":[{"name":"Department of Veterans Affairs Geriatrics and Extended Care  Washington DC USA"},{"name":"Department of Health Policy Stanford University  Palo Alto California USA"},{"name":"VA Health Systems Research Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System  Palo Alto California USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4353-3507","authenticated-orcid":false,"given":"Ciaran S.","family":"Phibbs","sequence":"additional","affiliation":[{"name":"Geriatrics and Extended Care Data Analysis Center (GECDAC)  Bronx New York USA"},{"name":"VA Palo Alto Health Care System  Palo Alto California USA"},{"name":"Department of Pediatrics Stanford University  Palo Alto California USA"},{"name":"Department of Health Policy Stanford University  Palo Alto California USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Orna","family":"Intrator","sequence":"additional","affiliation":[{"name":"Geriatrics and Extended Care Data Analysis Center (GECDAC)  Bronx New York USA"},{"name":"James J Peters VAMC  Bronx New York USA"},{"name":"Department of Geriatrics &amp; Palliative Care Icahn School of Medicine at Mount Sinai  New York New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2025,7,26]]},"reference":[{"key":"e_1_2_10_2_1","unstructured":"US Government Accountability Office \u201cVeterans' use of long\u2010term care is increasing and VA faces challenges in meeting the demand (Report to Congressional Committees GAO\u201020\u2010284).\u201d(2020)https:\/\/www.gao.gov\/assets\/gao\u201020\u2010284.pdf."},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamda.2021.03.034"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.28.1.262"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2011.1237"},{"key":"e_1_2_10_6_1","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.15968"},{"key":"e_1_2_10_7_1","volume-title":"How the VA Plans to Keep Up With an Aging Veteran Population","author":"Campos R.","year":"2022"},{"issue":"12","key":"e_1_2_10_8_1","first-page":"e535","article-title":"Predicting Nursing Home Placement Among Home\u2010 and Community\u2010Based Services Program Participants","volume":"20","author":"Greiner M. 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M.Hearn et\u00a0al. \u201c(In)equity in Risk Prediction: Examining and Mitigating Racial Bias in the Veterans Affairs Care Assessment Needs (CAN) Risk Model.\u201dhttps:\/\/www.hsrd.research.va.gov\/meetings\/2023\/abstract\u2010display.cfm?AbsNum=1004."},{"key":"e_1_2_10_25_1","doi-asserted-by":"publisher","DOI":"10.1023\/A:1010933404324"},{"key":"e_1_2_10_26_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.317.7154.307"},{"key":"e_1_2_10_27_1","doi-asserted-by":"publisher","DOI":"10.1023\/A:1009752403260"},{"key":"e_1_2_10_28_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.g7594"},{"key":"e_1_2_10_29_1","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.18704"},{"key":"e_1_2_10_30_1","doi-asserted-by":"publisher","DOI":"10.1111\/1475\u20106773.14337"},{"key":"e_1_2_10_31_1","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.17174"},{"key":"e_1_2_10_32_1","doi-asserted-by":"publisher","DOI":"10.1111\/1475\u20106773.13687"},{"key":"e_1_2_10_33_1","doi-asserted-by":"publisher","DOI":"10.1111\/1475\u20106773.12454"},{"key":"e_1_2_10_34_1","doi-asserted-by":"publisher","DOI":"10.1111\/1475-6773.13048"},{"key":"e_1_2_10_35_1","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2024.00302"},{"key":"e_1_2_10_36_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamda.2021.09.001"},{"key":"e_1_2_10_37_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamda.2022.12.021"}],"container-title":["Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1475-6773.70016","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/1475-6773.70016","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1475-6773.70016","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,8]],"date-time":"2026-03-08T11:07:21Z","timestamp":1772968041000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/1475-6773.70016"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,26]]},"references-count":36,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,2]]}},"alternative-id":["10.1111\/1475-6773.70016"],"URL":"https:\/\/doi.org\/10.1111\/1475-6773.70016","archive":["Portico"],"relation":{},"ISSN":["0017-9124","1475-6773"],"issn-type":[{"value":"0017-9124","type":"print"},{"value":"1475-6773","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,26]]},"assertion":[{"value":"2025-01-09","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-07-10","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-07-26","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70016"}}