Characterizing Guardianship in VA: a mixed methods pilot study

About This Grant

Background: Veterans who lack capacity to make their own decisions and do not have a surrogate decision- maker cannot consent to discharge from VA inpatient settings. In these cases, a professional guardian must be court appointed before the Veteran can be discharged from inpatient care to other settings. The guardianship process is complex and time- and resource-intensive. As a result, medically stable, unrepresented Veterans may spend unnecessary months, or even years, in inappropriate inpatient settings awaiting guardianship. These needless delays in discharge: (1) result in inappropriate use of inpatient beds and increased risks of hospital-acquired conditions, (2) conflict with a patient’s right to care in the least restrictive setting and (3) cost VA upwards of $200 Million dollars per year, a figure that is expected to rise as the VA population ages. However, VA does not systematically document or track guardianship processes or outcomes and has no national, standardized approach to guardianship. Research is needed to gauge the scope of the problem, understand the VA guardianship process, and identify ways to improve it. Significance to VA: The US Senate Special Committee on Aging recently called for increased scrutiny of guardianship laws and outcomes, citing the lack of data nationally. According to the VA Social Work Guardianship National Committee, VA lacks national policies and processes for incapacitated Veterans who require transition from inpatient care settings to lower levels of care. The recently updated VA Directive 1004.01 highlights VA’s commitment to provide care for Veterans in the least restrictive setting possible while supporting their right to autonomous, informed participation in their health care decisions. VA must invest in infrastructure to track guardianship in Veterans and support research to enable greater understanding and meaningful improvement of guardianship processes. Innovation and Impact: The proposed study is innovative because it generates new knowledge and creates a foundation for future research on guardianship in VA. Specifically, this work focuses on a unique and underserved population of Veterans who are particularly vulnerable and often excluded from research studies. This mixed methods study is the first of its kind in VA. Our ongoing partnership with the Office of Care Management and Social Work ensures that this work will be used to inform VA policy and practice. Specific Aims: (1) Create a test dataset made up of a national sample of Veterans who have undergone the guardianship process in VA inpatient settings that includes their sociodemographic and clinical factors. (2) Understand key shareholder perspectives of current VA guardianship processes, including workflows, challenges, best practices, and opportunities for improvement. Methodology: (Aim 1): Using retrospective observational methods and an extension of methods developed by our team, we will do searches of VA electronic health record notes and administrative data, followed by manual chart reviews, to create a nationally representative test dataset of Veterans who have guardians. For each case, we will also collect information about their guardianship, health care and demographics. (Aim 2): We will conduct semi-structured interviews with VA staff and leadership who are involved in guardianship policy or practice to understand current guardianship processes, challenges, and ways to improve them at the local VAMC and national levels. We will also conduct interviews with Veterans who have guardians and their guardians to understand their experiences of the process and opportunities for improvement. Path to Translation/ Implementation: We will use the test dataset created in Aim 1 in a future IIR to validate a natural language processing approach to systematically identify Veterans who have guardians. This will facilitate research examining guardianship in VA on a national scale. Findings from Aim 2 will inform future research to develop an intervention improve the guardianship process for future study and dissemination.