STATEMENT OF GERALD M. CROSS, MD, FAAFP ACTING PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
HOUSE COMMITTEE ON APPROPRIATIONS
SUBCOMMITTEE ON MILITARY CONSTRUCTION, VETERANS AFFAIRS AND RELATED AGENCIES

March 20, 2007

Mr. Chairman and members of the Subcommittee, I am pleased to be here today to discuss the broad policy issues related to long-term care in the Department of Veterans Affairs ( VA) and the President's budget proposal to support that care in Fiscal Year ( FY) 2008. With me are Dr. James F. Burris, Chief Consultant, Geriatrics & Extended Care SHG, and Paul Kearns, VHA Chief Financial Officer. I would like to take this opportunity to give an overview of VA's long-term care services and programs.

Growing Need For Long-term Care

VA has testified previously that there is a great and growing need for long-term care services for elderly and disabled veterans. Between 2005 and 2012, the number of enrolled veterans aged 65 and older is projected to increase from 3.45 million to 3.92 million. The number of enrolled veterans aged 85 and older will increase from 337,000 to 741,000 during the same period, an increase of 120 percent. This latter group, those aged 85 and older, are the most vulnerable of the older veteran population and are especially likely to require not only long-term care services, but also other health care services along the continuum of care such as acute care and preventive care.

VA is addressing the mandates for nursing home care for service-connected veterans with a disability rated at seventy percent or greater and for selected home and community based care services for all enrolled veterans, as set by Congress in the Millennium Act, Public Law 106-117, and prioritize care for those veterans most in need of our services including:

• veterans returning from OEF/OIF service,
• veterans with service-connected disabilities,
• those with lower incomes, and
• veterans with special health care needs such as serious chronic mental illness and spinal cord injury and disease

Since many enrolled veterans are also eligible for long-term care through other public and private programs, including Medicare, Medicaid, State Veterans Homes, and private insurance, it is in the interest of both the government and veterans to coordinate the benefits of their various programs and work together toward the goal of providing compassionate, and high-quality care. The Veterans Health Administration staffs have extensive experience in coordinating services among agencies for the benefit of veterans, within statutory limitations and in accordance with desires of patients and their families. I want to emphasize that our efforts in long-term care case management are driven by the clinical needs of each patient, the patient's preferences, and the benefit options available to that patient. VA health care providers work closely with patients and family, on a case-by-case basis, to coordinate the veteran's various Federal and State benefits, and to maximize options for that veteran. Among those programs within VA that address coordinating veteran care needs are Social Work Service, Home Based Primary Care Program, community health nurse coordinators, and Care Coordination/Telehealth.

Community Nursing Home

VA's philosophy of care, in keeping with practice patterns in the private sector, is to provide patient-centered long-term care services in the least restrictive setting that is suitable for a veteran's medical condition and personal circumstances, and whenever possible, in home and community-based settings. This approach honors veterans' preferences at the end of life and helps to maintain relationships with the veteran's spouse, family, friends, and faith community. Nursing home care should be reserved for situations in which the veteran can no longer be safely maintained in the home and community. The current budget request will support continued expansion of veterans' access to VA's spectrum of non-institutional home and community based long-term care services while sustaining capacity in VA's own Nursing Home Care Units and the Community Nursing Home Program and continuing to support growth in capacity in the State Veterans Home Program. VA long-term care is composed of a dynamic array of services provided in residential, outpatient, and inpatient settings that can be deployed as needed to meet a veteran's changing health care needs over time. In addition to direct patient care services, VA supports important research and education related to the health care needs of elderly and disabled veterans through the work of its 21 Geriatric Research, Education, and Clinical Centers, or GRECCs.

Non-institutional Care Programs

VA's goal is to make non-institutional long-term care services available to every enrolled veteran who needs them and seeks them from VA. The spectrum of non-institutional home and community-based long-term care services supported by VA includes:

• Home Based Primary Care,
• Contract Skilled Home Care,
• Homemaker/Home Health Aide,
• Adult Day Health Care,
• Home Respite,
• Home Hospice,
• Spinal Cord Injury Home Care, and
• Care Coordination/Home Telehealth.

VA also provides quality oversight of care purchased by veterans in Community Residential Care and Medical Foster Home facilities through an annual review process and monthly or more frequent monitoring by VA staff.

The workload in the non-institutional care programs included in the Long-Term Care section of the budget proposal has grown from an average daily census of 19,810 in 1998 to 29,489 through the end of FY 2006. The budget proposal will support a further 19.1 percent expansion of workload in these programs in FY 2008 beyond the level projected to be achieved in FY 2007. More than 9 out of 10 VA Medical Centers now offer some or all of these services, substantially enhancing veterans' access to non-institutional long-term care services. VA continues to have a VISN performance measure to increase the average daily census of veterans receiving home and community-based care. Each VISN has been assigned targets for increase in their non-institutional long-term care workload. VA is expanding both the services it provides directly and those it purchases from providers in the community.

Care Coordination Initiative/Home Telehealth

VA expects to meet a substantial part of the growing need for long-term care through such innovative services as Care Coordination/Home Telehealth. Care Coordination in VA involves the use of health informatics; telehealth and disease management technologies to enhance and extend existing care; and case management activities. VA's national Care Coordination initiative commenced in 2003 and is supported by a national program office. Care Coordination enables appropriately selected veteran patients with chronic conditions such as diabetes and congestive heart failure to remain in their own homes, and it defers or obviates the need for long-term institutional care. Care Coordination services are linked not only with services for the elderly such as Home Based Primary Care, but also with other services including Mental Health Intensive Case Management and General Primary and Ambulatory Care. Care Coordination/Home Telehealth enables delivery of VA health care to veterans living remotely from VA medical facilities, including those in rural areas.

Nursing Home Care

Inevitably, some veterans will be unable to continue to live safely in the community and will require nursing home care. VA will continue to provide nursing home care for all veterans for whom such care is mandated by statute, who need such care and seek it from VA. In addition, VA will continue to provide post-acute care for veterans who have suffered an accident or illness such as a broken hip or stroke, who require a period of recovery and rehabilitation before returning to the community. VA will also continue to provide nursing home care for veterans with special needs, including those with spinal cord injury or disease, ventilator dependence, and serious chronic mental illness. VA expects to sustain existing capacity in its own Nursing Home Care Units and in the Community Nursing Home Program and to support continued expansion of capacity in the State Veterans Home Program. Transforming the culture of care in nursing homes from the traditional medical model to a more home-like, patient-centered model is an important initiative in all of our nursing home programs.

State Veterans Homes

The State Veterans Home Program provides care to veterans under eligibility criteria determined by the individual states. There are State Veterans Homes in operation or under construction in all 50 states and Puerto Rico. VA supports construction and renovation of State Veterans Homes through the State Home Construction Grant Program, which provides matching funds to assist states in purchasing, constructing, and renovating properties to serve as nursing homes, domiciliaries, and adult day health care centers. Projects are funded in priority order until available funds for each fiscal year are exhausted, with highest priority given to renovation projects needed to correct life safety deficiencies and for construction of new capacity in geographic areas of need.

The second component of the State Veterans Home is the Grant and Per Diem Program. VA pays a per diem to assist the states in providing care for eligible veteran residents.

The third component of the State Veterans Home program is VA's oversight function. VA has developed a system of on-site inspections to assure quality of care in State Veterans Homes, including the identification of life safety issues.

The total FY 2008 budget request for long-term care is $4.6 billion, of which 90 percent will support institutional services and 10 percent non-institutional home and community-based care. This request will provide the resources necessary for VA to strengthen our position as a leader in providing high-quality services for a growing population of elderly and disabled veterans, as well as those veterans returning from service in OEF/ OIF, veterans with service-connected disabilities, those with lower incomes, and veterans with special health care needs.

As you know, the population of veterans who are enrolled for health care in the VA are, on average, older, poorer, and sicker than the general population. VA is already seeing the kinds of demographic changes that are projected for the nation as a whole in coming decades. Recently, VA has also begun to care for younger veterans who have sustained polytraumatic injuries during their service in Operation Enduring Freedom and Operation Iraqi Freedom ( OEF/ OIF). While the number of seriously disabled OEF/ OIF veterans is relatively small, compared to the total number of veterans requiring extended care services, the complexity of care they require is high and their personal and social needs differ from those of older veterans. VA is moving to adapt its long-term care services to meet the needs of all veterans.

Many returning veterans are presenting with multiple and severe disabilities including speech, hearing and visual impairment as well as loss of limbs and brain injuries, and behavioral issues due to the stress of combat. In addition, they have families, including children who want to be actively involved in their care. Unlike other cohorts of veterans in long-term care, this cohort thrives on independence, is physically strong, and is part of a generation socialized differently than their older counterparts. These generational differences pose unique challenges in the institutional and long-term care environment.

VA is taking measures to first recognize the generational differences of this population and incorporate them into the care routines. For example, in VA nursing homes, transforming the culture of care to make the living space more home friendly is important, as is having an "internet café", computer games, or age appropriate music and videos available for nursing home residents. Allowing for family, especially children to visit, and perhaps even stay over when needed is another example of accommodating generational differences. Personalizing care routines such as bathing and dining times and offering food items that are palatable to younger persons are examples of the changes that are occurring in long-term care.

Conclusion

VA takes great pride in our accomplishments, and looks forward to working with the members of this Subcommittee to continue the Department's tradition of providing timely, high-quality health care to those who have helped defend and preserve freedom around the world.

Mr. Chairman, this completes my statement. I will be happy to address any questions that you and other members of the Subcommittee may have.