The study, published in the Journal of General Internal Medicine, was led by Robert E. Burke of the Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania, together with colleagues across the VA and several academic institutions. The team assembled a retrospective descriptive cohort covering January 1, 2015 through December 31, 2022, drawing on the VA Residential History File, an unusually rich data resource that stitches together hospitalizations and post-acute stays across VA-provided care, VA-paid community care, Medicare, and Medicaid. That integration matters because it allowed the researchers to see the full landscape of options each Veteran actually had, rather than just the slice of care visible to any single payer.

The sample included 926,860 hospitalizations followed by skilled nursing facility stays among 662,432 unique Veterans, all aged 66 or older and enrolled in the VA. To be included, a Veteran had to be discharged from an acute hospitalization directly into a nursing facility within one day, and the researchers excluded patients admitted from nursing homes, those who stayed more than 100 consecutive days (who were effectively long-term residents), and discharges from psychiatric units, long-term acute care hospitals, or inpatient rehabilitation facilities. The overwhelming majority of stays, 94.6 percent, occurred in non-VA facilities paid for by Medicare, while 5.4 percent occurred in VA Community Living Centers or VA-contracted nursing homes.

To measure quality, the team relied on the five-star rating systems used by both the Centers for Medicare and Medicaid Services and the VA itself, which composite together health inspections, staffing levels, and individual quality measures on a scale from one star, the worst, to five stars, the best. Crucially, the researchers matched each Veteran to the facilities whose zip code centroid fell within 16 miles of the Veteran’s own home zip code, a distance chosen because more than 80 percent of urban Veterans actually used a facility within that radius. The VA publishes its own star ratings for Community Living Centers through a methodology that closely mirrors the CMS approach and correlates strongly with patient outcomes, allowing a fair comparison across the two systems of care.

The headline numbers are sobering. Only 34.4 percent of Veterans attended the highest-rated facility available in their area, while 15.4 percent ended up in the worst-rated one. Nearly two-thirds, 64.5 percent, had at least one higher-quality option nearby than the one they actually used, and 43.7 percent had five or more such options. Just 54.9 percent received care in a facility rated four stars or better, even though 96.9 percent of Veterans had at least one four-star facility within 16 miles and, on average, had 16.4 such facilities to choose from. These patterns were remarkably stable across the eight-year study window, suggesting that neither the maturation of public reporting nor the disruption of the COVID-19 pandemic fundamentally changed how Veterans and their families navigate this decision.

The findings echo, almost eerily, an earlier analysis by the Medicare Payment Advisory Commission using 2015 data on the general Medicare population. MedPAC found that 84 percent of beneficiaries had at least one higher-quality facility within roughly 15 miles of home than the one they chose, and 47 percent had five or more. The new Veteran study’s figure of 43.7 percent with five or more better options is strikingly similar, implying that a decade of star ratings, comparison websites, and quality campaigns has barely moved the needle. Veterans were supposed to be a best-case scenario: unlike typical Medicare beneficiaries, they can often choose between a VA nursing home, a VA-contracted community facility, or any Medicare-certified home, an expanded menu of options that might reasonably be expected to translate into better choices.

It did not. Veterans who used VA-provided or VA-paid care actually had slightly more high-quality options nearby, an average of 18.8 facilities rated four stars or better, compared with 16.2 for those using Medicare-paid facilities, yet they were no more likely to attend the best one: 31.4 percent versus 34.6 percent. More troubling still were the disparities buried in the subgroup analyses. Only 24.6 percent of Black Veterans used the highest-quality facility available, compared with 35.6 percent of white Veterans, even though Black Veterans had more high-quality options nearby on average, 24.2 versus 15.3. Unmarried Veterans, Veterans with higher comorbidity burden, those with longer hospital stays, and Veterans hospitalized primarily for mental, behavioral, or neurodevelopmental disorders all used the best available facility at lower rates than the overall population, again despite having equal or greater access to high-quality options.

Rural Veterans tell a different and somewhat paradoxical story. Within 16 miles, they had only 3.9 high-quality facilities on average, compared with 20.3 for urban Veterans, yet 36.1 percent of them used the best option available, slightly more than the 33.9 percent of urban Veterans. When the researchers expanded the radius to 36 miles, a distance at which more than 80 percent of rural Veterans actually obtained care, rural Veterans’ options ballooned to 17.3 high-quality facilities, but the share using the best one dropped to 27.4 percent. The pattern hints that when choices are scarce, families and discharge planners may scrutinize them more carefully, while abundance may breed a kind of decisional inertia in which proximity, habit, or convenience wins out over quality.

Why do so many people bypass better care that is demonstrably within reach? The authors lay out a three-gate framework: the Veteran or family must select the facility, the payer must approve it, and the facility must have a bed and accept the patient. Each gate can fail. Decision-making at hospital discharge is rushed and poorly supported, and families frequently lean on whatever facility the hospital team mentions first. Insurance networks constrain choice, particularly for the growing share of older adults enrolled in Medicare Advantage plans, whose skilled nursing networks have been shown to skew toward slightly lower-quality facilities. And bed availability is tightening: national nursing home occupancy rebounded to 84 percent by 2024, and because staffing shortages limit the number of beds that can actually be staffed, functional capacity is even scarcer than raw bed counts suggest. Pay-for-performance pressures add another layer, incentivizing facilities to prefer lower-risk, more profitable patients.

The stakes are not abstract. Recent quasi-experimental studies, including analyses that exploit bed vacancies to isolate the effect of facility quality, confirm that attending a higher-rated nursing home genuinely improves outcomes, even for patients at high risk of complications. That makes the subgroup disparities especially worrisome, and it also points toward practical fixes. The authors note that clinicians can, contrary to a common misconception about anti-kickback and Stark laws, recommend specific high-quality facilities to families, and that many hospitalists remain unfamiliar with the Medicare Care Compare tool. Because high-quality facilities cluster in wealthier areas while low-quality ones cluster in lower-income neighborhoods, sometimes the right advice is simply to travel farther, balanced against the caregiving burden longer distances impose on families. For the VA, the next step may be mapping post-acute care markets to identify where its dual leverage as provider and payer could most effectively steer Veterans toward the best care that, in most cases, is already just down the road.

Subject of Research: Access to and choice of high-quality skilled nursing facility care among older Veterans after hospitalization

Article Title: Access to and Choice of High-Quality Skilled Nursing Facility Care for Veterans After Hospitalization: A Cohort Analysis

Article References: Burke, R. E., Cidav, T., Tjader, A., Roberts, C. B., Benson, J. A., Piazza, K. M., Song, H., Wang, G., & Rose, L. (2026). Access to and Choice of High-Quality Skilled Nursing Facility Care for Veterans After Hospitalization: A Cohort Analysis. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10823-7

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10823-7

Keywords: skilled nursing facility, Veterans, post-acute care, nursing home quality, star ratings, Medicare, VA Community Living Centers, hospital discharge, health disparities, rural health, geriatrics, care transitions