STATEMENT OF
ROBERT H. ROSWELL, M.D.
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
ON
NON-INSTITUTIONAL LONG-TERM CARE
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
U. S. SENATE

April 25, 2002

Mr. Chairman and Members of the Committee:

Thank you for inviting me to discuss non-institutional alternatives to long-term care provided by the Department of Veterans Affairs (VA).

VA has a long history of providing high quality geriatric and extended care to chronically ill elderly veterans and is nationally recognized as a leader and innovator in the care of older persons. Today one of our greatest challenges is to find ways to meet the increasing demand for extended care services in the most appropriate settings and within available resources.

As you know, veterans prefer to receive care in their homes and communities when it is possible to do so. These programs are highly cost effective in comparison to institutional care and allow VA to provide care to a greater number of veterans than would be possible through increased reliance on institutional programs. However, our ability to expand these programs may be impacted by the interaction between competing requirements.

Since Public Law 106-117, the Veterans Millennium Health Care and Benefits Act, became effective in November 1999, VA has focused on implementation of the extended care provisions of that law. To date, the following provisions have been implemented:

• Mandatory nursing home care for veterans rated 70% service-connected and above and for any service-connected veteran who needs nursing home care for a service-connected disability;
• Three pilot programs evaluating different models of all-inclusive care for the elderly (VA as sole provider, at the Dayton VAMC; VA/community partnership, at the Denver VAMC; and VA as care coordinator, at the Columbia, SC, VAMC); and
• An assisted living pilot initiated in VISN 20 at all VA facilities in Alaska, Washington, Oregon, and Idaho.

VA anticipates publication of final regulations on the medical benefits package and co-payments for extended care next week. The regulations - to be effective 30 days from the date of publication - add three non-institutional extended care services, outpatient geriatric evaluation, adult day health care, and respite care, to VA's standard benefits package. Other important extended care services, e.g., home care, hospice/palliative care, and inpatient respite care, were already in VA's standard benefits package. Also last October the Veterans Health Administration ( VHA) issued a policy directive requiring provision of these non-institutional services. Access to these services is not currently uniform throughout the VA system, but work is ongoing to determine what barriers to access exist and to develop plans for addressing these barriers.

The requirement to maintain staffing and level of extended care services in VA facilities no lower than the 1998 level is being met for non-institutional care ( VA home-based primary care and VA adult day health care) but not for institutional care ( VA nursing home care and VA domiciliary). Plans are in place to be in full compliance by 2004. The Administration has recently proposed legislation to implement the President's FY 2003 Budget that would revise the requirement for maintaining levels of extended-care services to veterans.

As the VA health care system has redefined itself in the last six years as a "health care" system instead of a "hospital" system, VA's approach to extended care has further evolved from an institutionally-focused care model to one that includes a complete continuum of home and community-based extended care services in addition to nursing home care.

In its 1998 report, VA Long Term Care at the Crossroads, the Federal Advisory Committee on the Future of Long-Term Care in VA, made 20 recommendations and 4 related suggestions on the operation and future of VA long term care services. These recommendations served as the foundation for VHA's national strategy to re-vitalize and re-engineer long term care services. One of the major recommendations of the Committee was that VA should expand home and community-based care while retaining its three nursing home programs ( VA, contract community, and State home).

VA is making progress on that strategy. Between 1997 and 2001, VHA average daily census ( ADC) in home and community-based care increased from 11,500 to 16,150. VHA has a Budget Performance Measure calling for an ambitious 34 percent increase in the number of veterans receiving home and community-based care compared to FY 2001. We plan continued increases each year to achieve a level of 34,500 ADC in home and community-based programs in FY 2006. To achieve these goals, we will expand both the services VA provides directly and those we purchase from affiliates and community partners. We will meet most of the new need for long-term care through home health care, adult day health care, respite, and homemaker/home health aide services.

The piloting and evaluation of new models of care will be important. One example you have heard about today is VA's Advances in Home-Based Primary Care for End of Life in Advancing Dementia (AHEAD) quality improvement project, which was initiated in 2001 with 20 VA teams from 15 networks. AHEAD II is now underway to include a wider variety of primary care settings that serve community-dwelling veterans with dementia.

VA also must explore utilization of new technologies, such as telemedicine, to expand care of veterans in the home and other community settings. We have shown that by using interactive technology to coordinate care and monitor veterans in the home environment, we are able to significantly reduce hospitalizations, emergency room visits, and prescription drug requirements, while improving patient satisfaction with the care they receive. Use of technology not only reduces the need for institutional long-term care, but also provides veterans with a more rewarding quality of life and greater functional independence. For example, in FY 2000 VISN 8 developed an innovative alternative to institutional care known as the Community Care Coordination Service ( CCCS). CCCS provides care coordination of groups of clinically complex, high cost, chronically ill patients. With the use of technology, CCCS has improved their quality of life and their perceived functional status, thus allowing them to remain both independent and at home. A recent survey of these patients showed that 41 percent would be in a nursing home if not for enrollment in this program. An Odds Ratio Analysis has shown that these patients were 77.7 percent less likely to be admitted to a nursing home than a similar group that did not participate in the program. The innovative use of technology has also improved communication and clinical relationships with the State veterans domiciliary in Lake City, FL, and has increased access to assisted living facilities. A care coordinator has become the primary communication link between the domiciliary and the local VA medical center. This enhanced communication has reduced unscheduled clinic visits by veterans in the State home by 29 percent.

To the extent that we can do so within the existing programmatic resources, VA's plans for long-term care are as follows:

• achieve an integrated care management system that incorporates all of the patient's clinical care needs;
• provide more care in home and community-based settings as opposed to inpatient settings, when appropriate;
• achieve greater consistency in access to and quality of care provided in all settings;
• achieve greater consistency across the system in assessing patients for extended care and in managing care, including post institutional care;
• continue to emphasize VHA research and educational initiatives that will improve delivery of services and outcomes for VA's elderly veteran patients; and
• continue to develop new models of care for diseases and conditions that are prevalent among elderly veterans. You have heard testimony today about VISN 2's participation in one such initiative to find better ways of caring for veterans with severe dementia. To help find better ways of caring for these veterans, VHA is participating in a multi-site demonstration project on Alzheimer's disease and care management, which is co-sponsored by the Alzheimer's Association and the National Chronic Care Consortium (NCCC).

VA has made considerable progress toward organizing a geriatrics and LTC system that can respond to shifts in demand and to changes in local healthcare market characteristics, and provide seamless care. We have launched major national initiatives to improve end-of-life care and pain management for veteran patients. We are in the process of implementing an aggressive home- and community-based care strategy.

Mr. Chairman, this concludes my prepared remarks. For information purposes, I have included two attachments to my statement. The first addresses veteran demographics and population projections; the second discusses VA's geriatric and extended care programs. I will now be happy to address any questions that you and other members of the Committee might have.