<DOC>
[107 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:83022.wais]
S. Hrg. 107-778
OPTIONS TO NURSING HOME CARE--IS VA PREPARED?
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
APRIL 25, 2002
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
80-022 WASHINGTON : 2002
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001
COMMITTEE ON VETERANS' AFFAIRS
JOHN D. ROCKEFELLER IV, West Virginia, Chairman
BOB GRAHAM, Florida ARLEN SPECTER, Pennsylvania
JAMES M. JEFFORDS (I), Vermont STROM THURMOND, South Carolina
DANIEL K. AKAKA, Hawaii FRANK H. MURKOWSKI, Alaska
PAUL WELLSTONE, Minnesota BEN NIGHTHORSE CAMPBELL, Colorado
PATTY MURRAY, Washington LARRY E. CRAIG, Idaho
ZELL MILLER, Georgia TIM HUTCHINSON, Arkansas
E. BENJAMIN NELSON, Nebraska KAY BAILEY HUTCHISON, Texas
William E. Brew, Chief Counsel
William F. Tuerk, Minority Chief Counsel and Staff Director
(ii)
C O N T E N T S
----------
April 25, 2002
SENATORS
Page
Murray, Hon. Patty, U.S. Senator from Washington, prepared
statement...................................................... 73
Rockefeller, Hon. John D. IV, U.S. Senator from West Virginia,
prepared statement............................................. 4
Specter, Hon. Arlen, U.S. Senator from Pennsylvania, prepared
statement...................................................... 5
WITNESSES
Bascetta, Cynthia A., Director, Health Care, Veterans' Health and
Benefits Issues, United States General Accounting Office....... 6
Prepared statement........................................... 8
Dickerson, Gladys, R.N., Home-Based Primary Care Coordinator,
Dallas VA Medical Center....................................... 37
Prepared statement........................................... 38
Hemmings, Paula, R.N., Department of Veterans Affairs' Veterans
Integrated Service Network No. 2, Geriatrics and Extended Care
Line Manager, representing the Alzheimer's Association......... 42
Prepared statement........................................... 44
McClure, Thomas, LCSW, Coordinator, VA Medical Foster Home
Program, Little Rock VA Medical Center......................... 39
Prepared statement........................................... 40
Moye, Jennifer, Ph.D., Director of the Geriatric Mental Health/
UPBEAT, Brockton VA Medical Center, and Associate Professor of
Psychology, Department of Psychiatry, Harvard Medical School... 48
Prepared statement........................................... 50
Roswell, Robert H., M.D., Under Secretary for Health, Department
of Veterans Affairs............................................ 58
Prepared statement........................................... 59
Response to written questions submitted by Hon. Patty Murray
to Robert Roswell.......................................... 64
APPENDIX
Alzheimer's Association, prepared statement...................... 75
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado,
prepared statement............................................. 75
Davidson, Arlene, Vice President, Planning and Development,
Evercare, a Unitedhealth Group Affiliate, prepared statement... 80
Fischl, James R., Director, National Veterans Affairs and
Rehabilitation Commission, The American Legion, prepared
statement...................................................... 79
(iii)
OPTIONS TO NURSING HOME CARE--IS VA PREPARED?
----------
THURSDAY, APRIL 25, 2002
U.S. Senate,
Committee on Veterans Affairs,
Washington, DC.
The committee met, pursuant to notice, at 10:25 a.m., in
room SR-418, Russell Senate Office Building, Hon. John D.
Rockefeller IV, chairman of the committee, presiding.
Present: Senators Rockefeller, Graham, Wellstone, Specter,
and Hutchinson.
Chairman Rockefeller. The hearing will come to order, and I
will forego my opening statement for the moment and yield with
the permission of Senator Hutchinson to Senator Wellstone who
has another pressing engagement.
Senator Wellstone. Thank you so much for your graciousness,
and then I really guess that what I want to say today, and I am
going to try to be back for more of the committee hearing, Mr.
Chairman and Senator Hutchinson, is that I was excited when
this Millennium bill based in 1999 and would thank you for your
leadership.
I mean having had two parents with Parkinson's and kind of
going through this ourselves about what do you do. People get
elderly and struggle with these illnesses. How do you help them
stay at home, live at home in as near normal circumstances with
dignity, or if they need to go in a nursing home, how do we
make sure that we--or we need respite care and all the rest. I
thought that we in passing this legislation made a really
significant commitment, and I guess my message for the VA today
is you all have got to follow through. We are not doing this.
I mean we did not pass a law just for symbolic reasons. We
passed this law to make this happen, and it is not happening,
and either the VA is going to have to sort of reorder its
priorities and figure out how with its staff and its resources
it, in fact, lives up to this mandate or to this vision or to
this mission. You know it's noble.
Or if the VA needs more resources, then, you know, we need
to know how much more and why and what we need to do. I just
put it in the context of--I said to Secretary Principi, whom I
think is one the nicest, best people in government service,
when he came here, you are great and people love you in
Minnesota, but this budget is a straightjacket. And we got long
waits and people are not getting access to specialty care in
Minnesota now, and we are not having any more outreach
community clinics.
This is a horrible budget, and I am getting increasingly
impatient that the VA is not, in fact, making this piece of
legislation a reality in terms of actually providing help for a
lot of our veterans who are now senior citizens and need the
help.
So there is a big missing piece here somewhere and this
hearing therefore is extremely important. I thank you. I am
going to try to come back, too.
Chairman Rockefeller. Thank you, Senator Wellstone. I now
want to introduce Senator Hutchinson for the purpose of making
an introduction not on the first but on the second panel.
Senator Hutchinson. Mr. Chairman, I thank you for your
willingness to allow me to do this, because our schedules are
so crazy up here, and I am afraid I will not be here when Tom
testifies, and I did want to take the opportunity to say a word
of welcome to one of my constituents who will be testifying on
the second panel, and, Mr. Chairman, I also want to thank you
for calling the hearing today. I think this is a very, very
important topic, and the GAO study is going to be, I think,
revealing, and this is a timely hearing, and I thank you for
doing that.
But it is my great privilege to welcome one of my
constituents, Tom McClure, from Hot Springs, AR. Tom has
dedicated his entire professional life to helping others,
particularly veterans. He has served in the VA for 27 years. In
January of 2000, he was appointed as the coordinator for the VA
Medical Care Foster Home Program in central Arkansas.
The Foster Home Program that Tom oversees is really, I
think, a model, and it is also very much a win-win for the
veterans and the Veterans Administration because the program
offers the veteran a loving, caring home to reside in at no
cost to the Veterans Administration.
The program maintains a comprehensive medical plan by a
multidisciplinary team of care providers and increases
customers' satisfaction for the VA. Initially it was just a
pilot program, but it was so successful that the Arkansas VA
continued to fund the Foster Home Program out of their own
operating funds.
So, Tom, we thank you for your work and the committee is
pleased to have you with us today. We look forward to your
testimony. Thank you, Mr. Chairman.
Chairman Rockefeller. Thank you, Senator Hutchinson, very
much. We appreciate your being here and making that
introduction. I think I can probably go ahead as chairman and
give my opening statement.
So I will. And it basically is what Paul was saying and
what Tim was saying. In my mind, it is about the eighth hearing
we have had on this subject, and the Millennium bill passed in
1999. I remember every single second of the conference
committee. I was surprised that the House went along with it to
the extent that they did, but they did.
It was the first time that long-term care coverage has
happened in public policy since Medicaid. It was an extremely
exciting concept that we could actually do some long-term care
on a non-institutional basis and absolutely nothing has
happened.
That was in 1999, so it was 1999, 2000, 2001, 2002. I call
this an embarrassment because ignoring the single-most
important demand for long-term care will only intensify. And so
we have hearings, and we ask why, and we get answers that are
not satisfactory--OMB rules and regulations, this and that.
But it always occurs to me that the Department of Veterans
Affairs is the second largest organization outside of the
Department of Defense in all of government, 220,000 people, led
by a very able administrator and health deputy, and it seems to
me that 220,000 people collectively would be able to find a way
to take a law that was passed over 3 years ago, which addresses
the primary concerns of veterans, and put it into practice, and
this particular senator is now past the point of impatience.
I am very angry about it. Therefore, this hearing is being
set up in a very different way. We are having people who are
making this work. We are having a GAO report, and then we are
having the VA as the last panel so that the head of the health
administration can hear and be told about what others before
him said, because there are people who out there on their own
are deciding to make this work.
When Secretary Principi, who as Paul indicated is a
wonderful person and really is, and is beloved by veterans and
by this chairman, when he was up for his confirmation, I said,
you know, I said the only question that is worth asking you
really, because I know you and you have been here before, is
are you willing to go face to face with the President of the
United States, much less OMB, on budget issues, and he said,
yes, I will.
And I think the answer is no, he has not. And that is very
clear or else it seems to me that this, the most important
issue of long-term care, the one thing other than death and
taxes that we all absolutely are going to face at some point,
either in the comfort of home, as is contemplated here, or in a
nursing home. For the first time in many years a government
action relating to long-term care has been enacted, and then VA
says, oh, by the way, we are hung up on rules and regulations.
I do not buy that. I do not care if it is President
Clinton. I do not care if it is President Bush. I do not care
who it is. It is inexcusable. It is absolutely inexcusable, and
so this hearing is for the purpose of either embarrassing or
humiliating the VA into doing something. It is therefore what I
would call a constructive hearing because its purpose is to get
something going which is already in law.
If there is a Federal law, we try to follow it. So I am
ready to hear about the lack of guidance from central offices
and OMB and regulations going back and forth, but they carry
no--they create not a ripple of interest on my part anymore. I
am only interested in a result, and I do not know, I am not
seeking to do retribution here, but I am getting very close to
it. I am getting very close to it because this is something
that was not only really important to me. I happened to
negotiate this personally, and as I say, it is the one thing
everybody needs.
I had a mother who died from Alzheimer's. That took 10
years. It was not pleasant. I am not poor, so we were able to
afford to give her what she needed, but she needed a whole lot.
And so do veterans and many are poor and they cannot do it on
their own. So we have a law which is being ignored and excuses
do not work anymore.
So we have people who are doing things. You know it is not
like this cannot be done, because that is why we are going to
have some witnesses from some VA places who are going ahead
with this on their own. I do not know if they are in violation
of VA rules or not, but to me they are heroes, and we are going
to hear from them.
There are more veterans today than ever seeking
alternatives to nursing homes--what is known as non-
institutional care. They want to remain in the community. They
want to remain in their home. My mother wanted to spend her
last period of time in her home listening to the music that she
loved, and I mean that is human nature. She was beyond the
point of knowing where she was at that point, but it was
incredibly important to those who cared about her. The
Department of Veterans Affairs cares about veterans, and they
have to show that through what they do.
So 35 percent of the veteran population is 65 years or
older. The law and the demand gave VA a very clear mandate for
action. It was not--this would be a nice thing for you to
consider. It is something you are going to do. Mandate is a
strong word, not beloved by the American people, but beloved by
people who pass laws and want to see them enacted.
So the VA has been excruciatingly slow. Today we are going
to try to get some answers about why this has happened and more
importantly what the VA is going to do to change their ways,
and I do not want to hear a lot about OMB because there are
people here who evidently are not worried about OMB and who are
doing things on their own.
Dr. Roswell, for whom I have enormous respect--his new job
is Under Secretary--needs to know and does, I am sure, the time
for action is immediate. So there are clinicians here who have
gone ahead. I am always gratified when you see people who work
in large organizations who go against the grain and do things
because they believe it. I want them to be applauded and
showcased here and for us to learn from them.
So I am not only no longer interested in dilatory tactics,
but I am going to find ways to get very difficult about this,
and I suspect that my good friend from Pennsylvania will join
me in that effort. I yield to him at this point.
[The prepared statement of Senator Rockefeller follows:]
Prepared Statement of Hon. John D. Rockefeller IV, U.S. Senator From
West Virginia
I called today's hearing to focus on VA's inaction in
making long-term care services available to veterans--
especially those who can and wish to reside in the community.
This inaction is a terrible failure, to be sure. Veterans need
these services, Congress was clear in demanding that they be
provided, and for a variety of reasons, VA has chosen to both
ignore the mandate and failed to meet veterans' needs.
There is another side to this story: despite a dearth of
guidance from Central Office, there are places on the VA
landscape where some truly wonderful things are happening to
keep veterans well cared for and in the setting of their
choice. Good programs must be fostered, but in the VA
environment, long-term care services are frequently starved.
Today, more and more veterans are seeking alternatives to
nursing homes. They want to remain in the community and, with
the right kind of support and care from VA, are able to do so--
even with chronic and debilitating conditions.
In 1999, Congress spoke clearly about the need for VA to
step up its long-term care effort, not because we had issues
about quality, but because of the high demand for care. The
numbers bear repeating: About 35 percent of the veteran
population is 65 years or older--it is the single largest
segment of today's veteran population--and many need long-term
care services. While the law and the demand gave VA a clear
mandate for action, VA has moved excruciatingly slow. Today we
will try to get some answers about why that has happened and,
more importantly, about what VA will do to correct the
situation. With Dr. Roswell new in his job as Under Secretary,
the time is ripe for action.
As I noted, there are VA clinicians who, in grappling with
the demand, have not waited but have found some innovative
solutions. I am always deeply gratified by the level of
dedication and innovation of VA employees, and I applaud those
who have moved forward.
While the focus of this hearing is on options to nursing
homes, I note the need for VA nursing home beds. For many
veterans, non-institutional options will not work, and because
of this Congress is on record stating that VA must have
sufficient nursing home capacity. I am concerned, however, that
the quest to maintain and fill nursing home beds not overshadow
the need for other options. I know that VA is concerned about
this as well, and is requesting some relief.
It is vital that VA's role as a model for long-term care be
recognized and rewarded, because we will have enormous problems
with demand for this care in the years ahead. The only entity
of any scope, size, or capacity that is dealing with how to
meet the needs of an older population--albeit at a slower pace
than I'd like--is VA. This role of VA must be highlighted and
supported. I am here to do just that.
Senator Specter. Thank you very much, Mr. Chairman. I would
ask unanimous consent that my written statement be included in
the record.
Chairman Rockefeller. Absolutely.
Senator Specter. I do not want to speak too long because I
am anxious to hear how nasty you are going to be. [Laughter.]
As I said to Senator Rockefeller on the floor a few minutes
ago, it is time to get tough about this. I will support strong
action by the chairman. We passed this legislation over a lot
of objections in the House and the Senate, and we meant it. We
want it to be carried out. And I commend you, Mr. Chairman, for
having convened this oversight hearing.
I regret being a little late arriving. We had a markup in
the Environment and Public Works Committee and Judiciary
Committee has scheduled an executive meeting later this
morning, so I may have to excuse myself. But I will stay as
long as I can, and I will review the record. I think this is a
very, very important session, and I have never seen you nasty,
so I am looking forward to that. [Laughter.]
[The prepared statement of Senator Specter follows:]
Prepared Statement of Hon. Arlen Specter, U.S. Senator From
Pennsylvania
Thank you, Mr. Chairman, for convening this hearing on the
important issue of long-term care for our Nation's veterans. I
know you and I both agree this is a critical service for
America's veterans, their families, and for the Nation as a
whole.
Mr. Chairman, in 1999, you and I worked together diligently
here in the Senate, and in Conference with the House of
Representatives, to ensure that our veterans would have
universal access to noninstitutional long-term care provided by
the Department of Veterans Affairs. At that time, our proposal
was met with great hostility by the some Members of the House.
However, we prevailed in our efforts to make these services
available to all of our aging veterans. Unfortunately, the VA
has failed to abide by the law.
As the testimony by our GAO witness will demonstrate, more
than two and one half years after the passage of the Veterans
Millennium Health Care and Benefits Act of 1999, VA is still
not providing access to these crucial services for all of our
veterans in need of this care.
Fortunately, the need for these services has not gone
unnoticed on the front lines of some VA hospitals throughout
the nation. As the testimony of the members of our second panel
show, innovation and compassion for our veteran patients is
alive and well in VA hospitals. Unique programs, such as foster
care for elderly veterans in Arkansas and vigorous case
management of dementia patients in New York is showing
Congress, and more importantly, the leadership of VA Central
Office, that if the resources are available to assist in the
creation of special programs, we can do wonders for thousands
of sick and elderly veterans.
Mr. Chairman, I sincerely expect that this hearing will
light a fire in VA Central Office at the highest levels,
including the Secretary's Office. VA must know that when
Congress passes a law, we expect--and we demand--that it be
carried out. Institutional and noninstitutional long-term care
services are vital for our aging veteran population. Congress
has said so in statute. Now VA must say so in action.
Thank you very much Mr. Chairman for holding this hearing.
I look forward to receiving the testimony of the witnesses.
Chairman Rockefeller. So we are going to go right to our
first panel. And I would ask them to come to the table. They
are representatives of the General Accounting Office, and they
are going to report on VA's response to the long-term care
provisions of the Millennium Act. I welcome Cindy Bascetta, who
is the Director of Veterans' Health Care Issues at GAO. I am
comforted by that position, just knowing that it is there,
Cynthia, so I am already happy about you.
And also Jim Musselwhite, who is Assistant Director for
Health Care. Ms. Bascetta, why do you not go ahead? Now we have
a 5-minute rule.
Ms. Bascetta. Right.
Chairman Rockefeller. I am sure you have been warned about
that.
Ms. Bascetta. Absolutely.
Chairman Rockefeller. Nobody has ever disobeyed that.
[Laughter.]
Ms. Bascetta. And I do not intend to.
STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR, HEALTH CARE,
VETERANS' HEALTH AND BENEFITS ISSUES, UNITED STATES GENERAL
ACCOUNTING OFFICE, ACCOMPANIED BY JIM MUSSELWHITE, ASSISTANT
DIRECTOR, HEALTH CARE, GAO
Ms. Bascetta. Mr. Chairman, Senator Specter, thank you for
inviting me here today to discuss our work on VA's non-
institutional long-term care services. It is no surprise, as
you have pointed out, that demographic pressures will increase
the demand for long-term care. The number of veterans aged 85
and older, those most at risk of needing long-term care, is
expected to triple over the next decade. While not all of their
needs can be met in non-institutional settings, aging veterans
are likely to be no different from other elderly Americans in
preferring care that allows them to remain in their homes or in
other settings that are less restrictive than nursing homes.
As you know, although VA has been providing long-term care
including non-institutional care on a discretionary basis, the
Millennium Act requires adult day health care, geriatric
evaluation, and respite care for all eligible veterans.
Today, I would like to discuss our findings about VA's
efforts to expand these services and highlight our early work
on the availability of non-institutional services in general
across the VA system.
Mr. Chairman, as you have pointed out, more than 2 years
after enactment, VA has not completed its response to the
Millennium Act. VA has issued proposed regulations that would
make the three services available in non-institutional
settings, and we understand that final regulations will be
issued next week.
In the interim, however, I would like to point out that VA
did issue a policy directive in October 2001 requiring that all
eligible veterans have access to these services outside of
institutions. Nevertheless, none of the three are universally
available. In a survey we conducted of all 139 medical
facilities, 99 reported offering adult day health care, 74
offered non-institutional geriatric evaluation, and 29 offered
non-institutional respite care.
According to VA, central monitoring of medical facilities
to ensure that they provide non-institutional access to all
three services will begin soon.
Our survey also showed that the six other non-institutional
services offered by VA also vary in their availability from
network to network. Most commonly offered by more than 120
medical facilities are homemaker and home health aide services
as well as skilled home health care. In contrast, non-
institutional clinics for Alzheimer's and dementia care are
available at fewer facilities with only 32 reporting such care.
In addition, we found that several facilities reported
offering at least eight of the nine non-institutional long-term
care services, but some offered only one non-institutional
service or none at all. The results of our survey are similar
to the distribution of services noted almost 4 years ago by the
Advisory Committee on the Future of VA Long-Term Care. In its
report, called ``VA Long-Term Care at the Crossroads,'' the
committee stated that despite a continuum of offerings, VA
services were not universally available and access was often
restricted.
VA headquarter's officials agree today that non-
institutional services are not yet equally accessible across
the country. Despite this picture, VA has roughly doubled the
proportion of long-term care provided outside of institutions
over the past decade. Nonetheless, like Medicaid, the largest
payer of long-term care, VA costs for non-institutional care
remain dwarfed by its costs for nursing home and other
institutional care.
Over the next 10 years, the nation's health system as well
as VA will face significant aging of the population
particularly for those 85 years or older. Nearly 20 percent of
individuals in this group report a disability compared to about
5 percent between the ages of 65 and 84.
Like its non-VA counterparts, VA needs to prepare for these
demographic challenges. The task force and the Millennium Act
reflect the importance of providing a continuum of non-
institutional services more evenly throughout the country to
help meet this challenge.
Our ongoing review, conducted at your request, will assess
the reasons for the current unevenness in non-institutional
long-term care services across the networks. Providing more
universal access to non-institutional care could help VA meet
the growth in demand and at the same time offer veterans more
options from which to choose. This concludes my prepared
statement, and I would be happy to answer any questions.
[The prepared statement of Ms. Bascetta follows:]
Prepared Statement of Cynthia A. Bascetta, Director, Health Care,
Veterans' Health and Benefits Issues, United States General Accounting
Office
Mr. Chairman and Members of the Committee:
I am pleased to be here today to discuss noninstitutional long-term
care services offered by the Department of Veterans Affairs (VA). These
services, such as homemaker services and adult day health care, are
delivered to veterans in their own homes and other locations in the
community. VA will see increasing demand for long-term care in the
coming years as the veteran population ages. Of particular significance
is the expected tripling of the number of veterans age 85 and older--
the group most in need of long-term care. Although not all veterans'
care needs can be met in noninstitutional settings, veterans may prefer
such care because it allows them to remain in their homes or in other
settings that are less restrictive than institutions.
VA generally provided or paid for long-term care on a discretionary
basis until passage of the Veterans Millennium Health Care and Benefits
Act in November 1999.\1\ The Millennium Act required VA to offer
certain long-term care services to eligible veterans, including
services provided in noninstitutional settings. In particular, adult
day health care, geriatric evaluation, and respite care are to be made
available to eligible veterans.
---------------------------------------------------------------------------
\1\ Pub. L. No. 106-117, 113 Stat. 1545 (1999).
---------------------------------------------------------------------------
As part of our ongoing work addressing the availability of
noninstitutional long-term care in VA, you asked us to provide
information on (1) VA's efforts to expand noninstitutional long-term
care in response to the Millennium Act's requirements,\2\ and (2) the
noninstitutional long-term care services that VA's medical facilities
offer. My statement focuses on the information we provided in a letter
on VA's noninstitutional long-term care services,\3\ which is being
released today. That letter is based on data from a survey of all 139
VA medical facilities,\4\ interviews with officials in VA's Geriatrics
and Extended Care Strategic Healthcare Group, and interviews with VA
field officials responsible for long-term care services. To determine
which noninstitutional long-term care services to include in our
survey, we compiled a list of the services as identified by VA
officials and in VA documents. (Descriptions of these noninstitutional
services are provided in appendix I.)
---------------------------------------------------------------------------
\2\ Although nursing home care and domiciliary care are also
required by the act, we do not address these requirements.
\3\ VA Long-Term Care: Implementation of Certain Millennium Act
Provisions Is Incomplete, and Availability of Noninstitutional Services
Is Uneven (GAO-02-510R, March 29, 2002).
\4\ Although VA has 172 medical centers, in some instances 2 or
more medical centers have consolidated into health care systems.
Counting health care systems and individual medical centers that are
not part of a health care system as single facilities, VA has 139
facilities.
---------------------------------------------------------------------------
In summary, more than 2 years after the act's passage VA has not
completed its response to the act's requirement that eligible veterans
be offered adult day health care, geriatric evaluation, and respite
care. Although VA published proposed regulations that would make these
three services available in noninstitutional settings to eligible
veterans,\5\ the regulations had not been made final as of April 17,
2002. To be responsive to the act's requirements before its draft
regulations were made final, VA issued a policy directive requiring
that these three services be available in noninstitutional settings. VA
also offers other noninstitutional services. At the time of our review,
however, both the services required as a result of the act and VA's
other noninstitutional services were unevenly available across the VA
system.
---------------------------------------------------------------------------
\5\ 66 Fed. Reg. 50,594 (2001).
---------------------------------------------------------------------------
background
VA served about one-third of its fiscal year 2001 long-term care
workload, or average daily census, in noninstitutional settings (see
table 1). Noninstitutional care accounted for about 8 percent of VA's
long-term care costs during the same year.
Table 1: VA Long-Term Care Workload and Costs, by Care Setting, Fiscal
Year 2001
------------------------------------------------------------------------
Average daily
Long-term care setting census <SUP>a</SUP> Total cost
------------------------------------------------------------------------
Institutional <SUP>b</SUP>................... 45,033 $2,888,659,000
Noninstitutional.................. 23,205 239,939,000
-------------------------------------
Total......................... 68,238 $3,128,598,000
------------------------------------------------------------------------
Source: VA.
<SUP>a</SUP> The average daily census represents the total number of days of
inpatient care for institutional care and the total number of
outpatient encounters for noninstitutional care, each divided by the
number of days in the year. These figures may overstate the number of
veterans receiving noninstitutional services because some veterans may
receive more than one noninstitutional service on a particular day.
<SUP>b</SUP> Institutional long-term care includes care that VA provides or pays
for in nursing homes and other residential settings.
The proportion of VA's long-term care costs for noninstitutional
care has doubled over the past decade, as shown in figure 1. This has
occurred as part of a larger trend within VA toward reducing its heavy
reliance on inpatient care. Nevertheless, VA's costs for
noninstitutional long-term care remain small relative to its costs for
institutional long-term care.
Figure 1: VA Long-Term Care Costs, By Care Setting, Fiscal Year 1991-
Fiscal Year 2001
------------------------------------------------------------------------
1991 2002
------------------------------------------------------------------------
Noninstitutional long-term care....................... 4% 8%
Institutional long-term care.......................... 96% 92%
------------------------------------------------------------------------
Source: VA.
Medicaid--the nation's largest purchaser of long-term care--has
seen a similar increase in the proportion of its long-term care costs
for noninstitutional services. As in VA, the proportion of Medicaid's
long-term care costs for this purpose has doubled, from 13 percent in
1990 to 27 percent in 2000. However, similar to VA, the bulk of
Medicaid's long-term care costs are still for institutional care.
VA is one of several federal agencies attempting to emphasize
noninstitutional long-term care. Executive Order 13217,\6\ signed in
June 2001, directs six federal agencies to evaluate their policies,
programs, statutes, and regulations to determine whether any should be
revised or modified to improve the availability of noninstitutional
services for qualified individuals with disabilities.\7\ Although VA
was not among the agencies named in the order, VA joined the effort on
a voluntary basis and subsequently reported that it will evaluate its
noninstitutional long-term care services to determine whether any could
be expanded or modified to further promote noninstitutional services to
veterans with disabilities.
---------------------------------------------------------------------------
\6\ 66 Fed. Reg. 33,155 (June 18, 2001).
\7\ The agencies were the Departments of Education, Health and
Human Services, Housing and Urban Development, Justice, and Labor, and
the Social Security Administration.
---------------------------------------------------------------------------
VA will face increasing demand for long-term care as our nation's
veteran population ages. VA statistics show that, although the total
number of veterans will decline in the next 10 years, the number of
veterans age 85 and older will triple during that time. This will
significantly increase the need for VA's long-term care resources
because although a chronic physical or mental disability may occur at
any age, the older an individual becomes, the more likely it is that a
disability will develop or worsen. Indeed, while about 4.8 percent of
persons age 65-84 report a disability, the proportion nearly quadruples
to 18.1 percent among those 85 and older.\8\
---------------------------------------------------------------------------
\8\ These data represent individuals reporting a problem with two
or more of the following six activities of daily living: bathing,
dressing, eating, transferring between bed and chair, toileting, and
getting around inside the home. Data are from the Department of Health
and Human Services' 1994-95 National Health Interview Survey on
Disability.
---------------------------------------------------------------------------
As a result of this demographic pressure, concerns have been raised
for some time about VA's ability to meet the expected rise in demand
for long-term care services. In 1997 VA established a Federal Advisory
Committee on the Future of VA Long-Term Care composed of national
leaders in long-term care, and charged it with evaluating VA long-term
care services and developing a strategy for meeting future needs. In
its June 1998 report,\9\ the committee stated that VA long-term care
was unevenly funded and recommended that VA expand noninstitutional
long-term care services and emphasize these services, when clinically
appropriate, for veterans needing long-term care.
---------------------------------------------------------------------------
\9\ Department of Veterans Affairs, VA Long-Term Care At The
Crossroads: Report of the Federal Advisory Committee on the Future of
VA Long-Term Care (Washington, D.C.: June 1998).
---------------------------------------------------------------------------
va's response to the millennium act is not complete
The Millennium Act requires VA to provide adult day health care--
noninstitutional care in which health maintenance and rehabilitative
services are provided to frail elderly veterans in an outpatient day
setting. The act also requires that VA provide two additional services,
geriatric evaluation and respite care,\10\ but does not specify whether
these services must be provided in institutional or noninstitutional
settings.
---------------------------------------------------------------------------
\10\ Geriatric evaluation involves evaluation of veterans with
particular geriatric needs and is generally provided by VA through one
of two services, geriatric evaluation and management or geriatric
primary care. Respite care is a program in which brief periods of care
are provided to veterans in order to give veterans' regular caregivers
a period of respite.
---------------------------------------------------------------------------
More than 2 years after the act's passage, however, VA has not
completed its response to the act's requirement that all eligible
veterans be offered these three services. In October 2001, VA published
proposed regulations to add the three required services in
noninstitutional settings to its medical benefits package, the standard
health plan available to all veterans enrolled in VA's health care
system. As of April 17, 2002, final regulations had not been published,
although VA officials told us that VA sent draft final regulations to
the Office of Management and Budget for approval on March 14, 2002.
To be responsive to the act's requirements before its draft
regulations were finalized, however, VA issued a policy directive in
October 2001 requiring that its medical facilities ensure that veterans
have access to adult day health care, geriatric evaluation, and respite
care in noninstitutional settings. A VA headquarters official told us
that VA headquarters will soon begin monitoring medical facilities to
ensure that they provide access to these three services in
noninstitutional settings.
Both VA's directive and its proposed regulations specify that
geriatric evaluation and respite care be provided in noninstitutional
settings even though the act does not state whether they must be
provided in institutional or noninstitutional settings. (Adult day
health care is by definition a noninstitutional service.) VA officials
told us that VA chose to make clear its intent to have these services
provided in noninstitutional settings because they were already widely
offered in institutional settings. In fact, prior to the act VA was not
authorized to provide noninstitutional respite care--until then, VA
could provide respite care only in institutional settings. In contrast,
prior to the act VA provided both adult day health care and
noninstitutional geriatric evaluation; VA headquarters encouraged
facilities to offer these services and provided guidance for facilities
to use when doing so.
When VA issued its policy directive in October 2001, it was far
from its goal of universal access to these three noninstitutional
services, as shown in figure 2. Among the three services, adult day
health care was most widely available, followed by geriatric evaluation
and respite care. VA officials told us that noninstitutional respite
care is not widely offered because until the Millennium Act VA was not
authorized to provide respite care in noninstitutional settings.
figure 2: number of 139 va facilities offering certain long-term care
services required by the millennium act and available in
noninstitutional settings, fall 2001
<GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT>
Source: GAO survey of VA facilities; VA headquarters data.
Note: Responses to our survey were submitted in September and October
2001.
<SUP>a</SUP> ``Geriatric evaluation'' encompasses facilities reporting geriatric
evaluation and management services in our survey and additional
facilities reported by VA headquarters as offering geriatric primary
care.
availability of other noninstitutional services is also uneven
Uneven availability of noninstitutional services is not limited to
the three services that VA requires its facilities to offer in response
to the Millennium Act. Although at least nine different
noninstitutional long-term care services are provided or contracted for
by VA (including the three services that VA requires as a result of the
act), considerable unevenness exists in what services are offered by
individual facilities. For example, 123 VA facilities reported offering
skilled home health care,\11\ while about half as many facilities--63--
reported offering community residential care. Figure 3 shows the number
of VA's 139 facilities at which these nine noninstitutional long-term
care services are offered.
---------------------------------------------------------------------------
\11\ Skilled home health care consists of professional home health
care services, mostly nursing services, purchased by VA and delivered
by non-VA health care providers.
---------------------------------------------------------------------------
figure 3: number of 139 va facilities at which noninstitutional long-
term care services are offered, by service (fall 2001)
<GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT>
Source: GAO survey of VA facilities; VA headquarters data.
Note: Responses to our survey were submitted in September and October
2001.
<SUP>a</SUP> Includes facilities reporting geriatric evaluation and management
services in our survey and additional facilities reported by VA
headquarters as offering geriatric primary care.
Similar variation exists in the number of services offered by
individual facilities. For example, while several facilities reported
offering at least eight of the nine noninstitutional long-term care
services we identified, one facility reported offering only one
noninstitutional service, and two more facilities reported offering
none at all.
These results are similar to the distribution of services noted by
the 1998 Advisory Committee on the Future of VA Long-Term Care, which
stated that VA long-term care--institutional as well as
noninstitutional--was not available universally and that access to
long-term care was often restricted. Similarly, a VA headquarters
official we spoke with noted that VA's noninstitutional long-term care
services are not equally accessible across the country.
concluding observations
As the veteran population ages, VA will face increasing demand for
long-term care services. Providing more even access to noninstitutional
long-term care services across VA facilities, including those services
now required as a result of the Veterans Millennium Health Care and
Benefits Act, could help VA meet this demand while at the same time
offering veterans more options from which to choose.
* * * * *
Mr. Chairman, this concludes my prepared statement. I will be happy
to answer any questions you or the other committee members may have.
contacts and acknowledgments
For more information regarding this testimony, please contact me or
James Musselwhite. Joe Buschy and Steve Gaty also made key
contributions to this statement.
appendix i: noninstitutional long-term care services offered by va
<bullet> Adult day health care: health maintenance and
rehabilitative services provided to frail elderly veterans in an
outpatient day setting.
<bullet> Alzheimer's/dementia care: specialized outpatient services
such as behavioral and medical management provided to veterans with
Alzheimer's disease or related dementias.
<bullet> Community residential care: a service in which veterans
who do not require hospital or nursing home care--but who (because of
medical or psychosocial health conditions) are unable to live
independently--live in VA-approved community residential care
facilities; VA pays administrative costs only.
<bullet> Geriatric evaluation: evaluation of veterans with
particular geriatric needs, generally provided by VA through one of two
services: (1) geriatric evaluation and management (GEM), in which
interdisciplinary health care teams of geriatric specialists evaluate
and manage frail elderly veterans, and (2) geriatric primary care, in
which outpatient primary care, including medical and nursing services,
preventive health care services, health education, and specialty
referral, is provided to geriatric veterans.
<bullet> Home-based primary care: primary medical care provided in
the home by VA physicians, nurses, and other VA healthcare
professionals to severely disabled, chronically ill veterans whose
conditions make them unsuitable for management in outpatient clinics.
<bullet> Homemaker/home health aide: home health aide and homemaker
services, such as grooming, housekeeping, and meal preparation
services.
<bullet> Home respite care: home-based services provided to
veterans on a short-term basis to give veterans' caregivers a period of
relief or respite.
<bullet> Hospice care: home-based palliative and supportive
services for veterans in the last phases of incurable disease so that
they may live as fully and as comfortably as possible.
<bullet> Skilled home health care: medical services provided to
veterans at home by non-VA health care providers.
______
United States General Accounting Office,
Washington, DC,
March 29, 2002.
Hon. John D. Rockefeller IV,
Chairman, Committee on Veterans' Affairs,
U.S. Senate.
Hon. Lane Evans,
Ranking Democratic Member,
Committee on Veterans' Affairs,
House of Representatives
Subject: VA Long-Term Care: Implementation of Certain Millennium Act
Provisions Is Incomplete, and Availability of Noninstitutional Services
Is Uneven [GAO-02-510R VA Long-Term Care Services]
The Department of Veterans Affairs (VA) spent about $3.1 billion on
long-term care in fiscal year 2001, an amount that is likely to
increase in the coming years as the veteran population ages. VA
provides or pays for long-term care in institutional settings such as
nursing homes and through noninstitutional care in veterans' own homes
and other locations in the community. VA generally provided or
contracted for long-term care on a discretionary basis until passage of
the Veterans Millennium Health Care and Benefits Act in November
1999.\1\ The Millennium Act required VA to offer certain long-term care
services to eligible veterans, including care in noninstitutional
settings. As part of our ongoing work addressing the availability of
noninstitutional long-term care in VA, you asked us to provide the
information we have obtained to date on (1) VA's efforts to expand
noninstitutional long-term care in response to the act's requirements
and (2) the noninstitutional long-term care services that VA's medical
facilities offer. As agreed with your offices, we are also providing
data on the number of institutional services offered by VA's
facilities, and their utilization, to place the noninstitutional
services in perspective.
---------------------------------------------------------------------------
\1\ Pub. L. No. 106-117, 113 Stat. 1545 (1999).
---------------------------------------------------------------------------
In summary, more than 2 years after the act's passage VA has not
completely implemented its response to the act's requirement that all
eligible veterans be offered adult day health care, respite care, and
geriatric evaluation. Although VA published draft regulations that
would make these three services available in noninstitutional settings
to eligible veterans, the regulations had not been made final as of
March 19, 2002. To be responsive to the act's requirements before its
draft regulations were finalized, VA issued a policy directive
requiring that these three services be available in noninstitutional
settings. At the time of our review, however, access to these services
was far from universal in VA. More generally, the availability of all
VA noninstitutional long-term care services, including the newly
required services, is uneven across the VA system. In commenting on a
draft of this letter, VA officials generally agreed with our
assessment.
To determine the status of VA's efforts to expand noninstitutional
long-term care in response to the Millennium Act's requirements, we
interviewed officials in VA's Geriatrics and Extended Care Strategic
Healthcare Group and evaluated directives, regulations, and other
guidance that had been prepared in response to the act. To determine
which long-term care services are offered by each of VA's 139
facilities,\2\ we compiled a list of the services as identified by VA
officials and in VA documents. We subsequently used a survey instrument
to collect data on the types of services offered at each of VA's 139
facilities and the utilization of these services. In constructing this
survey, we consulted with VA headquarters officials and pretested it
with VA field staff to ensure that it would be clear to the
respondents. We received responses for all 139 VA facilities. However,
we did not conduct site visits or otherwise attempt to verify any of
the data provided to us in the surveys. Our work was conducted from
September 2001 through March 2002 in accordance with generally accepted
government auditing standards.
---------------------------------------------------------------------------
\2\ Although VA has 172 medical centers, in some instances two or
more medical centers have consolidated into health care systems.
Counting health care systems and individual medical centers that are
not part of a health care system as single facilities, VA has 139
facilities.
---------------------------------------------------------------------------
background
VA served about one-third of its fiscal year 2001 long-term care
workload, or average daily census, in noninstitutional settings (see
table 1). Noninstitutional care accounted for about 8 percent of VA's
long-term care costs during the same year.
Table 1: VA Long-Term Care Workload and Costs, by Care Setting, Fiscal
Year 2001
------------------------------------------------------------------------
Average daily
Long-term care setting census <SUP>a</SUP> Total cost
------------------------------------------------------------------------
Institutional <SUP>b</SUP>................... 45,033 $2,888,659,000
Noninstitutional.................. 23,205 239,939,000
-------------------------------------
Total......................... 68,238 $3,128,598,000
------------------------------------------------------------------------
Source: VA.
<SUP>a</SUP> The average daily census represents the total number of days of
inpatient care for institutional care and the total number of
outpatient encounters for noninstitutional care, each divided by the
number of days in the year. These figures may overstate the number of
veterans receiving noninstitutional services because some veterans may
receive more than one noninstitutional service on a particular day.
<SUP>b</SUP> Institutional long-term care includes care that VA provides or pays
for in nursing homes and other residential settings.
VA is not alone among federal agencies in spending a relatively
small percentage of its long-term care dollars in noninstitutional
settings. Noninstitutional care also accounts for a relatively small
percentage of long-term care expenditures under Medicaid, the nation's
largest purchaser of long-term care. In 2000, for example, about 27
percent of Medicaid's long-term care spending was devoted to
noninstitutional care.
va's response to the millennium act is not fully implemented
The Millennium Act requires VA to provide adult day health care--
health maintenance and rehabilitative services provided to frail
elderly veterans in an outpatient day setting. The act also requires
that VA provide two additional services--geriatric evaluation
(evaluation of veterans with particular geriatric needs, generally
provided by VA through one of two services, geriatric evaluation and
management or geriatric primary care) and respite care (brief periods
of care provided to veterans in order to give veterans' regular
caregivers a period of respite)--but does not specify whether these
services must be provided in institutional or noninstitutional
settings.\3\ (Descriptions of these and other VA long-term care
services are provided in enclosure I.) The Millennium Act's long-term
care provisions were written partly in response to the 1998 report of
the Federal Advisory Committee on the Future of VA Long-Term Care.\4\
The committee's report stated that VA long-term care was ``marginalized
and unevenly funded'' and recommended that noninstitutional long-term
care become the preferred option, when clinically appropriate, for
veterans needing long-term care.
---------------------------------------------------------------------------
\3\ Although nursing home care and domiciliary care are also
required by the act, we do not address these requirements.
\4\ Department of Veterans Affairs, VA Long-Term Care At The
Crossroads: Report of the Federal Advisory Committee on the Future of
VA Long-Term Care (Washington, D.C.: June 1998).
---------------------------------------------------------------------------
More than 2 years after the act's passage, however, VA has not
completely implemented its response to the act's requirement that all
eligible veterans be offered adult day health care, respite care, and
geriatric evaluation. In October 2001, VA published draft regulations
to add the three required services in noninstitutional settings to its
medical benefits package, the standard health plan available to all
veterans enrolled in VA's health care system. As of March 19, 2002,
final regulations had not been published, although VA officials told us
that VA sent the regulations to the Office of Management and Budget for
approval on March 14, 2002.
To be responsive to the act's requirements before its draft
regulations were finalized, however, VA issued a policy directive in
October 2001 requiring medical facilities to ensure that veterans have
access to adult day health care, respite care, and geriatric
evaluations in noninstitutional settings. VA's directive--as well as
its draft regulations--specifies that respite care and geriatric
evaluation be provided in noninstitutional settings even though the act
does not state whether these two services must be provided in
institutional or noninstitutional settings. (Adult day health care is
by definition a noninstitutional service.) VA officials told us that VA
made this decision because respite care and geriatric evaluation were
already widely offered in institutional settings. A VA headquarters
official told us that VA headquarters will soon begin monitoring field
facilities to ensure that they provide access to these three services
in noninstitutional settings.
When VA issued its policy directive in October 2001, it was far
from its goal of universal access to these three noninstitutional
services, as shown in figure 1. Among the three services, respite care
was most widely available, although at most facilities this care was
still offered only in institutional settings. According to VA
officials, noninstitutional respite care is not widely offered because
until the Millennium Act VA was not authorized to provide respite care
in noninstitutional settings. Second to respite care in availability
was adult day health care, followed by geriatric evaluation.
figure 1: number of 139 va facilities offering certain long-term care
services required by the millennium act and available in
noninstitutional settings, during september and october 2001
<GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT>
Source: GAO survey of VA facilities; VA headquarters data.
<SUP>a</SUP> Includes facilities reporting geriatric evaluation and management
services in our survey and additional facilities reported by VA
headquarters as offering geriatric primary care.
availability of other noninstitutional services is uneven
Uneven availability of noninstitutional services is not limited to
the three services that VA requires its facilities to offer in response
to the Millennium Act. Although at least nine different
noninstitutional long-term care services are provided or paid for by VA
(including the three services that VA requires as a result of the act),
considerable unevenness exists in the number of these services offered
by individual facilities and their utilization. For example, 123 VA
facilities reported offering skilled home health care,\5\ while about
half as many facilities--63--reported offering community residential
care. These results are similar to the distribution of services noted
by the 1998 Advisory Committee on the Future of VA Long-Term Care,
which stated that VA long-term care--institutional as well as
noninstitutional--was not available universally and that access to
long-term care was often restricted. Similarly, a VA headquarters
official we spoke with noted that VA's noninstitutional long-term care
services are not equally accessible across the country. The services
offered by each VA facility during the September and October 2001
period, along with the number of veterans served in each, are shown in
enclosure II.
---------------------------------------------------------------------------
\5\ Skilled home health care consists of professional home health
care services, mostly nursing services, purchased by VA and delivered
by non-VA health care providers.
---------------------------------------------------------------------------
agency comments
We provided a draft of this letter to VA officials for comment and
received oral comments on March 19, 2002. In providing comments, VA's
acting chief consultant, Geriatrics and Extended Care Strategic
Healthcare Group, stated that VA agrees that its efforts to provide
certain noninstitutional long-term care services in response to the
Millennium Act's requirements are not complete, and that the
availability of noninstitutional services is uneven. The acting chief
consultant also noted that VA's home health care programs are widely
available as shown in our survey results. This official also provided
technical comments that we have incorporated as appropriate.
As arranged with your offices, unless you publicly announce this
letter's contents earlier we will make no further distribution until 30
days after its date. At that time, we will send copies to the secretary
of veterans affairs and interested congressional committees. The letter
will also be available on GAO's home page at http://www.gao.gov. If you
have questions, please contact me or James Musselwhite. Joe Buschy,
Steve Gaty, and Stefanie Weldon also made key contributions to this
letter.
Cynthia A. Bascetta,
Director, Health Care--Veterans' Health and Benefits Issues
Enclosure I--VA Long-Term Care Services
noninstitutional services
<bullet> Adult day health care: health maintenance and
rehabilitative services provided to frail elderly veterans in an
outpatient day setting.
<bullet> Alzheimer's/dementia care: specialized outpatient services
such as behavioral and medical management provided to veterans with
Alzheimer's disease or related dementias.
<bullet> Community residential care: a service in which veterans
who do not require hospital or nursing home care--but who (because of
medical or psychosocial health conditions) are unable to live
independently--live in VA-approved community residential care
facilities; VA pays administrative costs only.
<bullet> Geriatric evaluation: evaluation of veterans with
particular geriatric needs, generally provided by VA through one of two
services: (1) geriatric evaluation and management (GEM), in which
interdisciplinary health care teams of geriatric specialists evaluate
and manage frail elderly veterans, and (2) geriatric primary care, in
which outpatient primary care, including medical and nursing services,
preventive health care services, health education, and specialty
referral, is provided to geriatric veterans.\6\
---------------------------------------------------------------------------
\6\ Geriatric primary care was not among the services included in
our survey of VA facilities.
---------------------------------------------------------------------------
<bullet> Home-based primary care: primary medical care provided in
the home by VA physicians, nurses, and other VA healthcare
professionals to severely disabled, chronically ill veterans whose
conditions make them unsuitable for management in outpatient clinics.
<bullet> Homemaker/home health aide: home health aide and homemaker
services, such as grooming, housekeeping, and meal preparation
services.
<bullet> Home respite care: home-based services provided to
veterans on a short-term basis to give veterans' caregivers a period of
relief or respite.
<bullet> Hospice care: home-based palliative and supportive
services for veterans in the last phases of incurable disease so that
they may live as fully and as comfortably as possible.
<bullet> Skilled home health care: medical services provided to
veterans at home by non-VA health care providers.
institutional services
<bullet> Alzheimer's/dementia care: specialized inpatient services
such as behavioral and medical management provided to veterans with
Alzheimer's disease or related dementias.
<bullet> Community nursing home care: nursing home care provided to
veterans in community nursing facilities.
<bullet> Domiciliary care: residential rehabilitation and health
maintenance services provided to veterans who do not require hospital
or nursing home care but are unable to live independently because of
medical or psychiatric disabilities; may be provided in VA
domiciliaries or in state-owned and operated veterans'
domiciliaries.\7\
---------------------------------------------------------------------------
\7\ Because VA does not actively place veterans in state veterans'
domiciliaries or state veterans' nursing homes (rather, veterans must
apply to the facilities for admission, and admission requirements vary
by state), state veterans' domiciliary and state veterans' nursing home
services were not included in our survey of VA facilities.
---------------------------------------------------------------------------
<bullet> Geriatric evaluation and management (GEM): evaluation and
management of frail elderly veterans by interdisciplinary health care
teams of geriatric specialists; may be provided in a distinct GEM unit
or in existing nursing home or hospital beds.
<bullet> Hospice care: palliative and supportive inpatient services
for veterans in the last phases of incurable disease so that they may
live as fully and as comfortably as possible; may be provided in a
distinct hospice unit or in existing nursing home or hospital beds.
<bullet> Respite care: hospital or nursing home care provided to
veterans on a short-term basis to give veterans' caregivers a period of
relief or respite; may be provided in a distinct respite unit or in
existing nursing home or hospital beds and may be provided in VA
hospitals, VA nursing homes, or community nursing homes.
<bullet> State veterans' nursing home care: nursing home care
provided to veterans in state-owned and operated veterans' nursing
homes, for which VA pays a portion of daily costs.
<bullet> VA nursing home care: nonacute nursing care services,
variously referred to as subacute, skilled, intermediate, or custodial
nursing care, provided to veterans in a VA facility's nursing home care
unit.
Enclosure II--VA Long-Term Care Services by VA Facility
This enclosure provides information on the types and utilization of
long-term care services, both institutional and noninstitutional, that
VA's 139 facilities reported as of the September and October 2001 time
frame. Each table contains service utilization data for all VA
facilities in one of the 22 VA health care networks existing at the
time of our survey.\8\ Following are the key methods we used to collect
and present the data. Because of differences in the way utilization is
calculated, the numbers in this enclosure should not be compared to
those presented in table 1.
---------------------------------------------------------------------------
\8\ In 1995, VA created 22 Veterans Integrated Service Networks, a
new management structure to coordinate the activities of and allocate
funds to VA hospitals, outpatient clinics, nursing homes, and other
facilities in each region. In January 2002, VA announced the merger of
networks 13 and 14 into a single organization known as network 23. In
this enclosure, we report on these two networks separately because at
the time of our survey they were operating as individual networks.
---------------------------------------------------------------------------
<bullet> We obtained data on the number of veterans receiving or
authorized to receive services from each VA facility on the day the
survey was completed.\9\ For example, if a veteran was receiving
homemaker/home health aide services 3 days per week at the time of our
survey, that veteran would have been counted in the utilization total
even if the veteran was not receiving services on the particular day
the survey was filled out. As a result, the utilization we report may
exceed the average daily census for individual services, particularly
in noninstitutional services, because on a given day the number of
veterans authorized to receive services may be greater than the number
who actually receive services.
---------------------------------------------------------------------------
\9\ Although the surveys were sent out simultaneously, surveys for
each facility were not completed on the same day.
---------------------------------------------------------------------------
<bullet> Several facilities indicated they had ``other'' services--
that is, services other than those we specifically asked about in our
survey. In instances in which facilities reported ``other'' services
with utilization of greater than 1,000 veterans, we note the types of
``other'' services these facilities reported.
Table 2: Long-Term Care Services Offered by VA Facilities in Network 1, Boston, Mass. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care system (HCS)
---------------------------------------------------------------------------------------
VA service White Total <SUP>a</SUP>
Bedford Boston Connecticut Manchester Northampton Providence Togus River
HCS HCS Junction
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care................................. 68 80 49 13 19 4 48 281
Alzheimer's/dementia care............................. 200 125 325
Community residential care............................ 202 85 75 362
Geriatric evaluation and management................... 25 0 28 94 147
Home-based primary care............................... 15 132 .......... 63 210
Homemaker/home health aide............................ 45 235 52 28 115 12 42 13 542
Home respite care.....................................
Hospice care.......................................... ....... .......
Skilled home health care.............................. 1 68 29 .......... 40 30 90 37 295
Other noninstitutional................................ 368 0 368
Institutional long-term care services:
Alzheimer's/dementia care............................. 110 50 160
Community nursing home care........................... 32 95 62 15 34 53 23 11 325
Domiciliary care...................................... 42 42
Geriatric evaluation and management................... 24 13 0 4 41
Hospice care.......................................... 2 5 3 10 1 1 6 2 30
Respite care.......................................... 122 9 3 40 0 3 2 46 225
VA nursing home care.................................. 152 146 9 70 59 38 474
Other institutional...................................
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
service. Some veterans may thus appear in several services at one facility.
Table 3: Long-Term Care Services Offered by VA Facilities in Network 2, Albany, N.Y. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility
or health care system (HCS)
--------------------------------------------------
VA service Western Total <SUP>a</SUP>
New
Albany Bath Canandaigua Syracuse York
HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care.............................. 123 10 29 107 80 349
Alzheimer's/dementia care.......................... 100 49 318 222 689
Community residential care......................... 0 68 ........... ........ 68
Geriatric evaluation and management................ ........... 62 62
Home-based primary care............................ 140 160 109 762 259 1,430
Homemaker/home health aide......................... 60 104 211 129 261 765
Home respite care..................................
Hospice care....................................... 1 1 2
Skilled home health care........................... 21 0 5 168 194
Other noninstitutional............................. 2 13 15
Institutional long-term care services:
Alzheimer's/dementia care.......................... 24 24
Community nursing home care........................ 50 5 8 32 25 120
Domiciliary care................................... 203 203
Geriatric evaluation and management................
Hospice care....................................... 2 7 0 3 3 15
Respite care....................................... 1 4 1 4 6 16
VA nursing home care............................... 28 147 80 30 111 396
Other institutional................................
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 4: Long-Term Care Services Offered by VA Facilities in Network 3, Bronx, N.Y. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by
facility or health care system (HCS)
-----------------------------------------------
VA service New Total <SUP>a</SUP>
Hudson New York
Bronx Valley Jersey Northport Harbor
HCS HCS HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care................................. 3 4 34 67 108
Alzheimer's/dementia care............................. 321 29 350
Community residential care............................ 272 230 215 717
Geriatric evaluation and management...................
Home-based primary care............................... 107 65 143 45 137 497
Homemaker/home health aide............................ 35 196 159 127 517
Home respite care.....................................
Hospice care..........................................
Skilled home health care.............................. 22 6 38 35 19 120
Other noninstitutional................................ 241 241
Institutional long-term care services:
Alzheimer's/dementia care............................. 14 14
Community nursing home care........................... 19 36 47 4 106
Domiciliary care...................................... 133 165 50 348
Geriatric evaluation and management................... 2 2 3 7
Hospice care.......................................... 7 2 4 7 5 25
Respite care.......................................... 2 3 2 1 6 14
VA nursing home care.................................. 69 180 260 101 153 763
Other institutional................................... 11 11
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 5: Long-Term Care Services Offered by VA Facilities in Network 4, Pittsburgh, Pa. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care system (HCS)
------------------------------------------------------------------------------------------------------------ Total <SUP>a</SUP>
VA service Pittsburgh Wilkes-
Altoona Butler Clarksburg Coatesville Erie Lebanon Philadelphia HCS Barre Wilmington
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care............ 26 6 46 1 44 2 0 125
Alzheimer's/dementia care........ 200 200
Community residential care....... 0 32 115 181 ............ 91 4 423
Geriatric evaluation and 24 5 925 954
management......................
Home-based primary care.......... 31 0 56 123 210
Homemaker/home health aide....... 78 139 94 82 7 30 113 39 13 595
Home respite care................ ....... 0 0
Hospice care..................... 0 1 .......... 1
Skilled home health care......... 7 15 37 3 15 5 76 28 16 22 224
Other noninstitutional........... 50 2 0 26 1 79
Institutional long-term care
services:
Alzheimer's/dementia care........ 36 17 50 103
Community nursing home care...... 10 6 29 1 3 13 12 97 6 6 183
Domiciliary care................. 47 229 74 350
Geriatric evaluation and 6 6
management......................
Hospice care..................... 0 1 6 20 6 7 4 44
Respite care..................... 1 4 0 3 1 40 4 8 60 2 123
VA nursing home care............. 40 70 217 32 74 208 336 0 56 1,033
Other institutional.............. 38 12 0 50
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
service. Some veterans may thus appear in several services at one facility.
Table 6: Long-Term Care Services Offered by VA Facilities in Network 5, Baltimore, Md. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each
service, by facility or health
care system (HCS) Total <SUP>a</SUP>
VA service ------------------------------------
Maryland Washington,
Martinsburg HCS D.C.
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care............................................ 7 198 81 286
Alzheimer's/dementia care........................................ 148 148
Community residential care....................................... 0 50 50
Geriatric evaluation and management.............................. 0 1,150 1,150
Home-based primary care.......................................... 180 109 289
Homemaker/home health aide....................................... 18 252 117 387
Home respite care................................................ 0 0
Hospice care..................................................... 10 10
Skilled home health care......................................... 180 5 185
Other noninstitutional........................................... 42 3 45
Institutional long-term care services:
Alzheimer's/dementia care........................................ 0 0
Community nursing home care...................................... 22 26 65 113
Domiciliary care................................................. 281 50 331
Geriatric evaluation and management.............................. 24 24
Hospice care..................................................... 23 16 39
Respite care..................................................... 2 10 4 16
VA nursing home care............................................. 166 200 90 456
Other institutional.............................................. 101 101
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 7: Long-Term Care Services Offered by VA Facilities in Network 6, Durham, N.C. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care system (HCS)
---------------------------------------------------------------------------------- Total <SUP>a</SUP>
VA service Fayetteville
Asheville Beckley Durham (N.C.) Hampton Richmond Salem Salisbury
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care...................................... 61 16 18 70 14 179
Alzheimer's/dementia care.................................. 150 38 125 313
Community residential care................................. 21 30 200 251
Geriatric evaluation and management........................ 374 374
Home-based primary care.................................... 33 36 69
Homemaker/home health aide................................. 76 33 0 60 40 43 252
Home respite care..........................................
Hospice care............................................... 4 1 2 ....... 5 12
Skilled home health care................................... 94 8 70 21 65 ......... 258
Other noninstitutional..................................... ......... .......
Institutional long-term care services:
Alzheimer's/dementia care..................................
Community nursing home care................................ 7 11 22 33 26 9 5 41 154
Domiciliary care........................................... 151 151
Geriatric evaluation and management........................ 3 ............ ....... 13 10 26
Hospice care............................................... 5 3 10 5 4 10 2 8 47
Respite care............................................... 2 2 4 4 0 5 4 21
VA nursing home care....................................... 98 36 98 37 72 71 80 204 696
Other institutional........................................ 18 18
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
service. Some veterans may thus appear in several services at one facility.
Table 8: Long-Term Care Services Offered by VA Facilities in Network 7, Atlanta, Ga. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care system (HCS)
----------------------------------------------------------------------------------
VA service Central Total <SUP>a</SUP>
Atlanta Augusta Birmingham Alabama Charleston Columbia Dublin Tuscaloosa
HCS (S.C.)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care...................................... 19 0 8 10 29 66
Alzheimer's/dementia care.................................. 5 5
Community residential care................................. 31 174 124 30 359
Geriatric evaluation and management........................ 250 0 250
Home-based primary care.................................... 87 47 90 130 95 63 512
Homemaker/home health aide................................. 67 149 24 46 50 62 78 104 580
Home respite care.......................................... 0 0 0
Hospice care............................................... 6 0 8 5 19
Skilled home health care................................... 62 83 21 75 60 35 336
Other noninstitutional..................................... 10 144 1,139b 18 13 1,324
Institutional long-term care services:
Alzheimer's/dementia care.................................. 72 40 53 165
Community nursing home care................................ 71 53 23 4 12 51 27 5 246
Domiciliary care........................................... 60 60
Geriatric evaluation and management........................ 2 10 0 12
Hospice care............................................... 7 11 8 ....... 4 30
Respite care............................................... 0 0 4 5 ....... 1 10
VA nursing home care....................................... 100 53 80 28 81 115 116 573
Other institutional........................................ 0 ........ 20 20
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
service. Some veterans may thus appear in several services at one facility.
<SUP>b</SUP> Geriatric primary care.
Table 9: Long-Term Care Services Offered by VA Facilities in Network 8, Bay Pines, Fla. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or
health care system (HCS)
-------------------------------------------------------
North Total <SUP>a</SUP>
VA service Florida/ West
Bay Miami South San Tampa Palm
Pines Georgia Juan Beach
HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care......................... 43 29 13 85
Alzheimer's/dementia care.....................
Community residential care.................... 90 165 255
Geriatric evaluation and management........... 30 300 330
Home-based primary care....................... 100 150 195 82 143 670
Homemaker/home health aide.................... 100 75 280 19 45 50 569
Home respite care............................. 4 4
Hospice care.................................. 0 0
Skilled home health care...................... 154 18 35 5 180 4 396
Other noninstitutional........................ 1,528b 2,239c 373 4,140
Institutional long-term care services:
Alzheimer's/dementia care..................... 29 61 90
Community nursing home care................... 92 24 195 3 51 12 377
Domiciliary care.............................. 104 17 121
Geriatric evaluation and management........... 8 5 20 0 33
Hospice care.................................. 10 15 9 5 20 10 69
Respite care.................................. 8 4 7 5 11 3 38
VA nursing home care.......................... 102 127 116 116 161 98 720
Other institutional........................... 24 27 17 68
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
<SUP>b</SUP> Geriatric primary care and geriatric psychiatry care.
<SUP>c</SUP> Geriatric primary care.
Table 10: Long-Term Care Services Offered by VA Facilities in Network 9, Nashville, Tenn. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care
system (HCS)
-----------------------------------------------------------------
VA service Tennessee Total <SUP>a</SUP>
Huntington Lexington Louisville Memphis Mountain Valley
Home HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care.............. 18 12 30
Alzheimer's/dementia care.......... 259 100 359
Community residential care......... 42 96 90 213 441
Geriatric evaluation and management 338 84 422
Home-based primary care............ 95 95
Homemaker/home health aide......... 36 31 27 59 162 194 509
Home respite care..................
Hospice care....................... 4 1 5
Skilled home health care........... 28 65 325 214 178 810
Other noninstitutional............. 3 180 100 283
Institutional long-term care
services:
Alzheimer's/dementia care.......... 34 34
Community nursing home care........ 53 33 36 40 49 43 254
Domiciliary care................... 330 330
Geriatric evaluation and management 20 4 24
Hospice care....................... .......... 2 2 16 10 30
Respite care....................... 4 4 2 0 5 3 18
VA nursing home care............... 18 63 110 191
Other institutional................ 43 43
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 11: Long-Term Care Services Offered by VA Facilities in Network 10, Cincinnati, Ohio (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or
health care system (HCS) Total <SUP>a</SUP>
VA service ------------------------------------------------------
Chillicothe Cincinnati Cleveland Columbus Dayton
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care.......................... 2 85 13 26 29 155
Alzheimer's/dementia care......................
Community residential care..................... 267 22 278 19 63 649
Geriatric evaluation and management............ 80 201 691 197 1,169
Home-based primary care........................ 190 45 235
Homemaker/home health aide..................... 230 37 380 44 171 862
Home respite care..............................
Hospice care................................... 1 ........ 3 4
Skilled home health care....................... 235 167 175 697 180 1,454
Other noninstitutional.........................
Institutional long-term care services:
Alzheimer's/dementia care...................... 24 24
Community nursing home care.................... 30 13 41 16 39 139
Domiciliary care............................... 42 66 92 100 300
Geriatric evaluation and management............ 126 30 156
Hospice care................................... 7 .......... 14 22 43
Respite care................................... 5 2 2 3 12
VA nursing home care........................... 91 51 137 146 425
Other institutional............................
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 12: Long-Term Care Services Offered by VA Facilities in Network 11, Ann Arbor, Mich. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care
system (HCS)
---------------------------------------------------------------------- Total <SUP>a</SUP>
VA service Northern
Ann Battle Danville Detroit Indianapolis Indiana Saginaw
Arbor Creek HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care.......... 0 16 57 5 26 4 0 108
Alzheimer's/dementia care......
Community residential care..... 0 0 137 0 45 96 0 278
Geriatric evaluation and 28 28
management....................
Home-based primary care........ 12 21 1 19 2 55
Homemaker/home health aide..... 43 79 66 48 7 243
Home respite care.............. 0 0 0 0 0 0 0 0
Hospice care................... 3 4 7
Skilled home health care....... 1 2 6 6 17 22 1 55
Other noninstitutional.........
Institutional long-term care
services:
Alzheimer's/dementia care...... 23 23
Community nursing home care.... 19 17 34 15 54 35 5 179
Domiciliary care...............
Geriatric evaluation and 16 16
management....................
Hospice care................... 11 42 2 1 56
Respite care................... 2 3 1 2 ............ 1 2 11
VA nursing home care........... 15 86 125 62 125 70 483
Other institutional............
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 13: Long-Term Care Services Offered by VA Facilities in Network 12, Chicago, Ill. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care
system (HCS)
VA service ------------------------------------------------------------------ Total <SUP>a</SUP>
Chicago Iron North
HCS Hines Mountain Madison Milwaukee Chicago Tomah
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care.............. 29 60 1 5 73 28 125 321
Alzheimer's/dementia care.......... 73 73
Community residential care......... 20 0 20
Geriatric evaluation and management 440 805 300 106 1,651
Home-based primary care............ 92 219 115 115 541
Homemaker/home health aide......... 49 73 14 14 34 2 3 189
Home respite care..................
Hospice care....................... 1 6 5 12
Skilled home health care........... 48 87 15 37 2 189
Other noninstitutional............. 180 38 218
Institutional long-term care
services:
Alzheimer's/dementia care.......... 27 27
Community nursing home care........ 102 78 5 12 43 92 10 342
Domiciliary care................... 167 159 326
Geriatric evaluation and management 120 9 4 10 ....... 143
Hospice care....................... 15 5 30 7 4 61
Respite care....................... 12 6 2 0 4 0 2 26
VA nursing home care............... 75 33 93 157 200 558
Other institutional................ 33 ......... 33
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 14: Long-Term Care Services Offered by VA Facilities in Network 13, Minneapolis, Minn. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by
facility or health care system (HCS)
--------------------------------------------- Total <SUP>a</SUP>
VA service Black
Hills Fargo Minneapolis Sioux St.
HCS Falls Cloud
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care................................... 2 95 6 58 161
Alzheimer's/dementia care............................... 1 ...... 14 15
Community residential care.............................. 30 30
Geriatric evaluation and management..................... 5 10 15
Home-based primary care................................. 25 25
Homemaker/home health aide.............................. 35 49 195 5 51 335
Home respite care....................................... 0 ........... 1 0 1
Hospice care............................................ 4 1 12 2 0 19
Skilled home health care................................ 49 48 229 23 94 443
Other noninstitutional..................................
Institutional long-term care services:
Alzheimer's/dementia care...............................
Community nursing home care............................. 11 16 84 10 11 132
Domiciliary care........................................ 132 105 237
Geriatric evaluation and management..................... 1 1
Hospice care............................................ 15 2 10 4 3 34
Respite care............................................ 4 1 4 3 6 18
VA nursing home care.................................... 63 31 76 30 215 415
Other institutional..................................... 41 41
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: In January 2002, VA announced the merger of networks 13 and 14 into a single organization known as
network 23. In this enclosure we report on these networks separately because at the time of our survey they
were operating as individual networks.
Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 15: Long-Term Care Services Offered by VA Facilities in Network
14, Lincoln, Neb. (Fall 2001)
------------------------------------------------------------------------
Number of veterans in each
service, by facility or
health care system (HCS)
VA service ---------------------------- Total <SUP>a</SUP>
Central Nebraska/
Iowa Iowa Western
HCS City Iowa HCS
------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care............ 4 53 2 59
Alzheimer's/dementia care........
Community residential care....... 0 0
Geriatric evaluation and 21 12 33
management......................
Home-based primary care.......... 33 33
Homemaker/home health aide....... 8 81 32 121
Home respite care................ ...... 2 2
Hospice care..................... 0 6 3 9
Skilled home health care......... 25 243 17 285
Other noninstitutional...........
Institutional long-term care
services:
Alzheimer's/dementia care........
Community nursing home care...... 25 17 58 100
Domiciliary care................. 68 14 82
Geriatric evaluation and 1 1
management......................
Hospice care..................... 13 3 3 19
Respite care..................... 1 0 2 3
VA nursing home care............. 179 54 233
Other institutional.............. 14 14
------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: In January 2002, VA announced the merger of networks 13 and 14
into a single organization known as network 23. In this enclosure we
report on these networks separately because at the time of our survey
they were operating as individual networks.
Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service
at the time of our survey. Dashes indicate that a facility reported
the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services
at each facility because veterans may be authorized to receive more
than one service. Some veterans may thus appear in several services at
one facility.
Table 16: Long-Term Care Services Offered by VA Facilities in Network 15, Kansas City, Mo. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care
system (HCS)
---------------------------------------------------------------- Total <SUP>a</SUP>
VA service Eastern
Columbia Kansas Kansas Marion Poplar St Wichita
(Mo.) HCS City (Ill.) Bluff Louis
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care................ 1 7 7 13 6 34
Alzheimer's/dementia care............
Community residential care........... 10 172 182
Geriatric evaluation and management.. 1,779 1,779
Home-based primary care.............. 104 114 218
Homemaker/home health aide........... 57 99 65 32 ....... 101 19 373
Home respite care.................... 0 ....... 0
Hospice care......................... 0 3 2 0 ....... 5
Skilled home health care............. 137 16 144 8 83 ....... 388
Other noninstitutional............... 384 ....... 384
Institutional long-term care services:
Alzheimer's/dementia care............
Community nursing home care.......... ........ 42 50 26 12 36 11 177
Domiciliary care..................... 176 36 212
Geriatric evaluation and management.. 12 8 20
Hospice care......................... 4 4 1 1 0 10
Respite care......................... 1 1 1 2 22 9 0 36
VA nursing home care................. 25 139 35 39 23 ....... 261
Other institutional.................. 0 20 5 25
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 17: Long-Term Care Services Offered by VA Facilities in Network 16, Jackson, Miss. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care system (HCS)
--------------------------------------------------------------------------------------------------------
VA service Central Gulf Total <SUP>a</SUP>
Alexandria Arkansas Fayetteville Coast Houston Jackson Muskogee New Oklahoma Shreveport
HCS (Ark.) HCS Orleans City
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care............... 14 75 11 18 43 43 7 211
Alzheimer's/dementia care........... 261 261
Community residential care.......... 62 217 0 9 11 299
Geriatric evaluation and management.
Home-based primary care............. 185 53 150 82 40 65 575
Homemaker/home health aide.......... 20 179 ....... 50 ....... 27 28 304
Home respite care................... ....... ........
Hospice care........................ ....... 0 ........ 0
Skilled home health care............ 16 76 6 111 ....... 56 9 38 73 385
Other noninstitutional.............. 0 236 236
Institutional long-term care services:
Alzheimer's/dementia care........... 16 32 44 92
Community nursing home care......... 52 44 17 17 27 22 34 17 24 25 279
Domiciliary care.................... ........ 66 66
Geriatric evaluation and management. 1 18 10 0 0 29
Hospice care........................ ............ 8 5 0 1 14
Respite care........................ 1 8 1 2 5 57 0 0 1 1 76
VA nursing home care................ 130 110 65 110 114 53 21 603
Other institutional................. 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
service. Some veterans may thus appear in several services at one facility.
Table 18: Long-Term Care Services Offered by VA Facilities in Network
17, Dallas, Tex. (Fall 2001)
------------------------------------------------------------------------
Number of veterans in
each service, by
facility or health care
system (HCS) Total <SUP>a</SUP>
VA service -------------------------
Central North South
Texas Texas Texas
HCS HCS HCS
------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care............... 1 11 40 52
Alzheimer's/dementia care........... 100 100
Community residential care.......... 67 0 67
Geriatric evaluation and management. 60 2,000 2,060
Home-based primary care............. 161 168 329
Homemaker/home health aide.......... 104 77 95 276
Home respite care................... 0 20 20
Hospice care........................ 8 0 8
Skilled home health care............ 48 65 113
Other noninstitutional.............. 12 230 242
Institutional long-term care services:
Alzheimer's/dementia care........... 4 15 58 77
Community nursing home care......... 102 59 90 251
Domiciliary care.................... 0 264 264
Geriatric evaluation and management. 10 8 18
Hospice care........................ 0 17 20 37
Respite care........................ 0 10 10 20
VA nursing home care................ 379 210 214 803
Other institutional................. 124 124
------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October
2001.
Empty cells indicate that a facility did not report offering the service
at the time of our survey. Dashes indicate that a facility reported
the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services
at each facility because veterans may be authorized to receive more
than one service. Some veterans may thus appear in several services at
one facility.
Table 19: Long-Term Care Services Offered by VA Facilities in Network 18, Phoenix, Ariz. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care
system (HCS)
VA service --------------------------------------------------------------------- Total <SUP>a</SUP>
Big
Albuquerque Amarillo Spring El Paso Phoenix Prescott Tucson
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care........... 5 42 37 25 109
Alzheimer's/dementia care....... 141 0 10 151
Community residential care...... 19 22 41
Geriatric evaluation and 111 40 177 114 442
management.....................
Home-based primary care......... 124 0 84 203 411
Homemaker/home health aide...... 174 ........ 57 2 138 371
Home respite care............... 6 6
Hospice care.................... 15 31 46
Skilled home health care........ 5 5 0 12 200 74 138 434
Other noninstitutional.......... 16 16
Institutional long-term care
services:
Alzheimer's/dementia care....... 16 7 23
Community nursing home care..... 70 4 4 64 16 56 214
Domiciliary care................ 120 120
Geriatric evaluation and ........ 3 28 31
management.....................
Hospice care.................... 11 3 0 14 10 17 55
Respite care.................... 9 0 0 4 0 6 19
VA nursing home care............ 3 117 40 46 57 1 264
Other institutional............. 4 16 20
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 20: Long-Term Care Services Offered by VA Facilities in Network 19, Denver, Colo. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care
system (HCS)
------------------------------------------------------------------ Total <SUP>a</SUP>
VA service Salt
Cheyenne Denver Fort Grand Montana Lake Sheridan
Lyon Junction HCS City
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care.............. 15 3 18
Alzheimer's/dementia care..........
Community residential care......... 132 ....... 132
Geriatric evaluation and management 150 150
Home-based primary care............ 72 ........ 120 192
Homemaker/home health aide......... 82 116 0 8 60 22 288
Home respite care.................. 0 0 0
Hospice care....................... ....... 3 2 5
Skilled home health care........... 3 65 172 20 11 40 26 337
Other noninstitutional............. ....... .......
Institutional long-term care
services:
Alzheimer's/dementia care.......... 8 8
Community nursing home care........ 2 57 ....... 7 33 28 2 129
Domiciliary care...................
Geriatric evaluation and management 4 ....... ....... 4
Hospice care....................... 5 10 ....... ........ 3 1 1 20
Respite care....................... 0 3 0 ........ 3 0 1 7
VA nursing home care............... 37 43 27 30 ....... 50 187
Other institutional................ 0 0 0
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 21: Long-Term Care Services Offered by VA Facilities in Network 20, Portland, Oreg. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health care system
(HCS)
-------------------------------------------------------------------------- Total <SUP>a</SUP>
VA service Puget
Alaska Boise Portland Sound Roseburg Spokane Walla White
HCS HCS Walla City
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term
care services:
Adult day health care...... 40 15 2 57
Alzheimer's/dementia care.. 125 410 535
Community residential care.
Geriatric evaluation and 175 ........ 175
management................
Home-based primary care.... 116 137 253
Homemaker/home health aide. 23 52 21 95 ........ 25 8 31 255
Home respite care.......... 20 20
Hospice care............... 1 1 46 8 3 ....... 59
Skilled home health care... 77 60 188 ....... 4 3 332
Other noninstitutional..... 99 3,127b 3,226
Institutional long-term care
services:
Alzheimer's/dementia care.. 18 14 32
Community nursing home care 11 17 51 150 20 40 7 9 305
Domiciliary care........... 192 658 850
Geriatric evaluation and 4 8 0 12
management................
Hospice care............... 6 7 6 3 4 ....... 26
Respite care............... 0 49 41 16 2 100 ....... 208
VA nursing home care....... 15 270 105 32 28 21 471
Other institutional........ 33 ........ 33
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
<SUP>b</SUP> Geriatric primary care, geriatric memory disorder care, and other services.
Table 22: Long-Term Care Services Offered by VA Facilities in Network 21, San Francisco, Calif. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by facility or health
care system (HCS)
--------------------------------------------------------------- Total <SUP>a</SUP>
VA service Central Northern
California Honolulu California Palo Reno San
HCS HCS Alto Francisco
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
services:
Adult day health care................. 2 6 20 6 6 40
Alzheimer's/dementia care............. .......... 100 130 230
Community residential care............
Geriatric evaluation and management... 300 423 100 823
Home-based primary care............... 39 61 117 35 7 75 334
Homemaker/home health aide............ 6 11 67 20 45 70 219
Home respite care.....................
Hospice care.......................... 2 0 5 5 12
Skilled home health care.............. 6 20 15 3 25 69
Other noninstitutional................ .......... 50 50
Institutional long-term care services:
Alzheimer's/dementia care............. 50 50
Community nursing home care........... 10 3 80 50 8 32 183
Domiciliary care...................... 100 100
Geriatric evaluation and management... 2 0 2
Hospice care.......................... 10 3 11 25 4 5 58
Respite care.......................... 300 4 5 200 3 3 515
VA nursing home care.................. 43 41 62 343 50 75 614
Other institutional................... 27 0 27
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Table 23: Long-Term Care Services Offered by VA Facilities in Network 22, Long Beach, Calif. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
Number of veterans in each service, by
facility or health care system (HCS)
-------------------------------------------
VA service Greater Total <SUP>a</SUP>
Los Loma Long Southern San
Angeles Linda Beach Nevada Diego
HCS HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
Adult day health care..................................... ....... 38 61 99
Alzheimer's/dementia care................................. 220 225 445
Community residential care................................ 44 0 44
Geriatric evaluation and management....................... 350 300 53 703
Home-based primary care................................... ....... 72 70 142
Homemaker/home health aide................................ 56 34 90
Home respite care......................................... 20 20
Hospice care.............................................. 59 0 59
Skilled home health care.................................. ....... 602 0 211 813
Other noninstitutional.................................... ....... .......
Institutional long-term care services:
Alzheimer's/dementia care................................. 28 28
Community nursing home care............................... 64 178 48 20 73 383
Domiciliary care.......................................... 247 247
Geriatric evaluation and management....................... 7 3 10
Hospice care.............................................. 10 14 6 30
Respite care.............................................. 10 54 3 3 70
VA nursing home care...................................... 240 89 76 25 430
Other institutional....................................... ....... 4 4
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
indicate that a facility reported the service but did not report the service's utilization.
<SUP>a</SUP> We did not calculate the total number of veterans receiving services at each facility because veterans may be
authorized to receive more than one service. Some veterans may thus appear in several services at one
facility.
Chairman Rockefeller. Thank you very much. Jim Musselwhite.
Mr. Musselwhite. I am available to answer questions.
Chairman Rockefeller. You indicated that OMB is going to
send over rules and regulations in a week. That does not mean
that they are not going to be sent back for further revision.
Why do you think really it has taken this long?
Ms. Bascetta. It is difficult for me to answer that
question. The focus of our work was on what was available and
the condition of universality of these services across the
networks and we spent less time in trying to figure out why the
agency had taken so long to actually promulgate regs. Our
understanding is that many of the issues they found to be
understandably complex, perhaps particularly issues related to
copayments, but we do not have the details of what went on
between OMB and the department.
I would also point that even if there had not been issues
with OMB, the rest of the Nation is also facing a pretty
significant challenge in trying to figure out how to provide
these services, so in other words, notwithstanding the
interactions in Washington, I think the decisions about how
best to provide care in the field are also difficult ones that
need to be made.
Chairman Rockefeller. But it is true, is it not, that the
Department of Veterans Affairs is meant to be the best in terms
of dealing with aging? In other words, that is why 50 percent
of all medical students do their training at VA hospitals
because that is where they get geriatric training. I mean VA is
meant to be good at this. This is not meant to be a discovery
process on their part.
Ms. Bascetta. That is correct. Certainly in geriatric
evaluation and geriatric medicine, the VA is perceived as a
leader. In terms of their provision of care in non-
institutional settings, we have done less to have an opinion
about how they stack up compared to other health care systems,
but I can tell you that the task force found that they were
pretty typical of the rest of the Nation, that the Nation is
not doing as well as it could be in recrafting how to shift
from institutional to non-institutional settings.
The task force also suggested that VA might want to look to
some states that are farther ahead in providing non-
institutional care.
Chairman Rockefeller. Well, we are going to hear from
those, and they obviously----
Ms. Bascetta. Right.
Chairman Rockefeller [continuing]. Were not bottled up by
the inertia----
Ms. Bascetta. That is correct.
Chairman Rockefeller [continuing]. That was taking place in
this and the past administration, and I am interested, if you
know about those, and why it is that some are willing to move
ahead irrespective of whatever consequences there might be and
could not care less because they know what their mission is.
Veterans are much older than the general population. Here
we have a really important medical mission, and all of a sudden
everybody freezes up except a few people from whom we will
hear.
Ms. Bascetta. Right. You are right that there is this
tremendous variability. We are hoping that in the study that we
are conducting for you now, we will better understand what the
reasons are for some of this unevenness, but clearly we have
seen in the VA area as well as in some states that where there
is a commitment it seems to unleash a great deal of creativity
in being able to provide non-institutional services in a very
cost effective way, but we are hoping to understand that much
better over the next few months.
Chairman Rockefeller. I will stop here, but I understand
when you say there are many technical problems and the Nation
is trying to figure out all of these things, but where there is
a clear direction, where there is a clear sort of triumphantly
conceived policy which speaks to such direct needs of veterans,
it just does not occur to me that sort of the technical problem
between OMB and VA or whoever is botching this thing up is a
particularly compelling excuse.
Ms. Bascetta. I agree.
Chairman Rockefeller. I mean if you are talking about the
Nation trying to figure it out, that is one thing. If you are
talking about VA trying to figure it out, that strikes me as
quite another.
Ms. Bascetta. I agree, and as you point out, others have
been able to proceed despite those kinds of problems.
Chairman Rockefeller. Thank you. Senator Specter.
Senator Specter. Thank you very much, Mr. Chairman. Ms.
Bascetta, how long have these regulations been languishing
awaiting OMB approval?
Ms. Bascetta. I am not sure I have the exact date. Do you
know, Jim?
Mr. Musselwhite. No, I do not.
Senator Specter. About 2\1/2\ years?
Ms. Bascetta. I think that is probably about right.
Senator Specter. Why?
Ms. Bascetta. As I said, I wish I had the details. I do not
know.
Senator Specter. I am not asking you for details. I am
asking you why 2\1/2\ years have elapsed and you still do not
have OMB approval of these regulations. You are silent. Let the
record show you are nodding. What action did the VA take to try
to get the regulations promulgated?
Ms. Bascetta. Dr. Roswell would be in a better position to
answer that. I do not know how much interaction there was
between OMB or VA. I do not know what their response is, what
OMB's response would have been to the draft regulations, or
whether they asked them to make revisions or the basis of those
kinds of revisions.
Senator Specter. Well, what is the view of VA generally
when Congress, by legislation, mandates--that word means
requires--that VA do certain things? Maintain nursing home care
capacity at 1998 levels, provide outpatient based long-term
geriatric care services, adult day care, adult day health care,
respite care, geriatric evaluations, to all VA patients in need
of such care. Does the Veterans Administration--this may seem
like an easy question--but does the Veterans Administration
take seriously a congressional mandate?
Ms. Bascetta. I certainly hope so.
Senator Specter. Well, then why is nothing done?
Ms. Bascetta. Well, they do need to promulgate regulations
and those do go through the Office of Management and Budget.
Senator Specter. Well, do you think the VA has some duty of
diligence----
Ms. Bascetta. Absolutely.
Senator Specter [continuing]. To push whoever is not
promulgating regulations to do that?
Ms. Bascetta. Yes, I do.
Senator Specter. I understand the VA has a series of
excuses that might be called reasons, but was any effort made
to come back to the Congress--to the relevant committees--to
say these are our problems?
Ms. Bascetta. Well, that is a good point, and I was going
to say that if there were problems, it would have at least been
beneficial certainly to us and to you to have an understanding
of what those problems might have been.
Senator Specter. Well, we have a very important piece of
legislation. We have a very strong stand taken by the Congress,
and we have inertia, inaction, indolence, and disregard by the
administration. What do you suggest that we do about it, Ms.
Bascetta? Go to court, get a contempt citation, put somebody in
jail?
Ms. Bascetta. Having this hearing I think is an important,
a very important signal, and the tone that Senator Rockefeller
set in laying out these very clear expectations, which should
have been clear all along, is certainly an important step in
moving this process along.
Senator Specter. How many hearings have we had on this
subject, Ms. Bascetta?
Ms. Bascetta. That I am not sure.
Senator Specter. Several. Well, we hope this hearing does
some good, but there has been certain turnover in the VA, and
it is easy to find excuses, but there are a lot of veterans out
there who are not getting the services which Congress has
decided, as a matter of public policy, ought to be given.
Ms. Bascetta. That is correct.
Senator Specter. Thank you, Mr. Chairman.
Chairman Rockefeller. Thank you, Senator Specter. Senator
Graham, we welcome you. There is kind of a somber mood around
here if you care to add to it. [Laughter.]
Senator Graham. I think that, Mr. Chairman, you and Senator
Specter have properly set the mood, and it is not necessary for
me to contribute to that level of seriousness. Obviously
representing a state with a very large population of veterans
and an especially large population of older veterans, these
issues of long-term care are extremely important, and I
appreciate your holding this hearing and giving us an
opportunity to both hear on the record what the status of
implementation of the 1999 legislation is to date and to hear
the recommendations such as those that Senator Specter just
propounded as to what alternatives are before us.
Senator Specter. Mr. Chairman, Senator Graham may want to
use our protocol when he convenes hearings on CIA failures.
Senator Graham. No comment.
Senator Specter. It is too late now, Bob.
Chairman Rockefeller. I just want to ask a question, and
then, Senator Graham, if you want to do so. You know I think in
your report, you say that 8 percent of dollars spent on VA
long-term care were in non-nursing home settings. So people say
resources are the excuse. My answer to that would be there may
be some increase in workload on the part of an incredibly loyal
work force in the VA, but you certainly cannot use cost as a
reason, because non-institutional care is going to be a lot
less expensive. Would you not agree?
Ms. Bascetta. On a per person basis, yes, that is correct,
it should be less expensive.
Chairman Rockefeller. So any time I hear resources used as
an excuse today, I am going to bear that very much in mind.
Ms. Bascetta. Right.
Chairman Rockefeller. Now, we do not wish to be--Senator
Graham, did you have any questions?
Senator Graham. No.
Chairman Rockefeller. OK. We do not wish to be short with
you in terms of time, but we want to move to some of these
folks who are making this thing work, so we thank you very much
for doing the work. I am extremely glad that you are both
there, and I thank you for coming.
Ms. Bascetta. Thank you.
Mr. Musselwhite. Thank you.
Chairman Rockefeller. OK. Panel two is our innovators
panel, and they have programs that are already at work. So
Gladys Dickerson, who runs a home-based program geared toward
those with dementia, will be one of our witnesses.
Tom McClure and his Medical Foster Care Program will be
another. Paula Hemmings, Network Number 2's geriatric and
extended care service line manager, but with us today
representing the Alzheimer's Association. And finally, Jennifer
Moye. Who is a researcher and a psychologist with a great story
to tell about what can be done in terms of geriatric mental
health. We are so glad you are here. Right now you are not
giving special time to your patients because you are away from
them, and I apologize for that, but I think that you understand
that we are talking here about the greater good. So I am very
grateful that you are here, and why do we not start, Ms.
Dickerson, with you on home-based dementia.
STATEMENT OF GLADYS DICKERSON, R.N., HOME-BASED PRIMARY CARE
COORDINATOR, DALLAS VA MEDICAL CENTER
Ms. Dickerson. Mr. Chairman and members of the committee, I
appreciate this opportunity to speak before you today regarding
alternatives to institutionalization for long-term care.
Hospital-based and Home-Based Primary Care--HBPC as it is
referred to--and other programs associated with HBPC ensures
that the right care at the right time in the right setting is
available to veterans all over the nation. Programs such as
HBPC, adult day care, telemedicine, advances in home-based
primary care for end of life in advancing dementia, which is
referred to as the AHEAD program, the senior companion program,
in-home respite and assisted living ensures that veterans
receive alternatives to institutional care.
These services can be provided at a much reduced cost to
the VA system and keep the patients out of acute care beds and
at home where they prefer. The number of veterans with long-
term care needs is increasing as the population ages.
Currently, we have an estimated 600,000 individuals with
dementia alone within the veteran population. Dementia and
similar diseases are progressive.
The victims are vulnerable to accidents, injuries which
ultimately make them completely dependent in all aspects of
their daily living. These diseases are projected to triple in
the veteran population over the age of 65. The incurable nature
of these diseases and long-term conditions, the suffering that
they cause the patient and their families, and the cost of
care, of managing diseases such as dementia, makes it a
priority to find alternatives to institutionalization.
Home and community-based care allows the veteran to live at
home rather than in an institution, making it a win-win
situation for such programs as the HBPC program and the AHEAD
project. Families are able to participate in quality of life
issues with the veterans in the home environment and the cost
of care is usually lower than the cost of skilled care nursing
facilities.
Across VHA, the data indicates that families prefer to keep
veterans at home, but they are unable to as the veteran becomes
more impaired. The AHEAD project through HBPC focuses on the
dementia patient's problems. Focus areas include earlier
identification, caregiver support, completion of advanced
directives and symptom management.
The project allows the veteran to receive appropriate care
in the location they prefer and help sustain caregivers in
their vital roles. The AHEAD project took 20 VA facilities
across the country and we completed a 9-month collaboration
committed to improve the care of veterans with dementia who
prefer to live at home.
These teams demonstrated notable success in early
identification of dementia, symptom management, caregiver
support and staff education. Home-based primary care is the
most cost effective way to deliver interdisciplinary home care.
The HBPC program offers long-term patients the kind of
alternative to nursing home placement. It minimizes the amount
of followup that they have to go through in the ambulatory care
clinic. It prevents premature admissions to the hospital by
early identification and premature admission to long-term care
facility. It also allows the patient the option of dying in the
home rather than in an institution.
The purpose of the Community Adult Day Care Program is to
establish functional impaired individuals with a supportive
professional environment so that they can be nurtured; to
facilitate the return of the older veteran to his home and to
coordinate their long-term care; to maintain the older veteran
at the highest level of function possible both physically,
socially, and medically; and to provide the family and
caregiver with professional support, enabling them to maintain
the disabled veteran in the community.
The Senior Companion Program often makes the difference
between living at home and in an institution. This translates
into major health cost savings for the senior, their family,
and the taxpayers. Nursing home costs is an average of $38,000
annually per patient per year. However, the cost of supporting
one senior companion for an entire year is $3,850. Telemedicine
technology also allows us to reduce costs, time, and efficiency
and eliminates distance.
In conclusion, funding an expansion of HBPC programs will
enable alternatives to institutionalization of long-term care
veterans, which we need expanded programs, innovative
approaches to long-term care, and this would mean a cost
savings to the VA. HBPC keeps families together and this
concludes my remarks, and I will be happy to answer any
questions.
Chairman Rockefeller. Thank you very, very much. Tom
McClure.
[The prepared statement of Ms. Dickerson follows:]
Prepared Statement of Gladys Dickerson, R.N., Home-Based Primary Care
Coordinator, Dallas VA Medical Center
Mr. Chairman and Members of the Committee:
I appreciate the opportunity to speak before you today regarding
alternatives to Institutionalization in Long Term Care. Home Based
Primary Care (HBPC) and those programs associated with HBPC; ensure
that the right care, at the right time, in the right setting is
available to veterans all over the nation. Programs such as HBPC, Adult
Day Care, Telemedicine, Advances in Home Based Primary Care for End of
Life in Advancing Dementia (AHEAD), Senior Companion, In-Home Respite,
and Assisted Living ensure veterans receive alternatives to
institutional care. These services can be provided at a much-reduced
cost to the VA system and keep the patient out of an acute care bed and
at home, where they prefer to remain.
non-institutional alternatives to long-term care
The number of veterans with long-term health care needs is
increasing as the population ages. Currently, there are an estimated
600,000 individuals with dementia within the veteran population.
Dementia and similar diseases are progressive. Their victims are
vulnerable to accidents and injuries that ultimately make them
completely dependent in all aspects of daily living. These diseases are
projected to triple in the veteran population over age 65. The
incurable nature of most long-term conditions, the suffering it causes
patients and their families, and the cost of care make managing
diseases such as dementia and others a priority to promote non-
institutional care for VA.
Veterans who receive the home and community based care that allows
them to live at home rather than in an institution, makes this a ``win-
win'' situation for such programs as the HBPC and AHEAD Project. The
family is able to participate in quality of life issues with the
veteran in their home environment. The cost of care is usually lower
than care provided in a skilled care facility.
Across the VHA, data indicates many families prefer to keep the
veteran at home but they are unable to, as the veteran becomes more
impaired. The AHEAD project through HBPC focuses on the dementia
patient's problems. Focus areas are, early identification, caregiver
support, completion of Advance Directives, and symptom management. The
project allows veterans to receive appropriate care in a location they
prefer and helps sustain caregivers in their vital role.
In the AHEAD Project, 20 VA facilities around the country completed
a nine-month collaboration, committed to improving care of veterans
with dementia who prefer to live at home. These teams demonstrated
notable success in early identification of dementia, symptom
management, caregiver support, and staff education. It has been shown
that the best place for veterans with long-term problems is in the HBPC
Programs across the country. Home Based Primary Care is the most cost
effective way to deliver interdisciplinary health care. This care is
defined as accessible, comprehensive, coordinated, continual,
accountable and acceptable.
The HBPC Program offers long-term patients this kind of care.
<bullet> An alternative to nursing home placement.
<bullet> Minimizes the amount of follow up in an Ambulatory Care
Clinic.
<bullet> Prevents premature admissions to long-term care
institutions.
<bullet> Maintains optimal physical, cognitive, and psychosocial
functioning.
<bullet> Allows the patient the option of dying at home rather than
in an institution.
The purposes of the Community Adult Day Care facilities are:
<bullet> To enable functionally impaired individuals to reside in a
supportive home environment rather than nursing home care facilities.
<bullet> To facilitate the return of older veterans to their homes
and to coordinate their long-term care.
<bullet> To maintain the older veteran at the highest level of
functioning possible (physical, social and medical).
<bullet> To provide the family and caregivers with professional
support, enabling them to maintain disabled veterans in the community.
The Senior Companion Program often makes the difference between
living at home or in an institutional setting. This translates into
major health care savings for seniors, their families, and taxpayers.
Nursing home care costs an average of $38,000 annually per person.
However, the cost of supporting one Senior Companion for an entire year
is $3,850.
Telemedicine technology allows us to reduce travel time and costs,
improves efficiency and provides better quality care.
In conclusion, funding and expansion of all HBPC Programs can
ensure alternatives to institutionalization for the long-term veteran
patient. With these expanded programs, innovative approaches to long-
term care can be established with a cost saving to VHA, patients and
their caregivers. HBPC keeps families together.
This concludes my remarks. I will be happy to respond to any
questions you may have.
STATEMENT OF THOMAS McCLURE, LCSW, COORDINATOR, VA MEDICAL
FOSTER HOME PROGRAM, LITTLE ROCK VA MEDICAL CENTER
Mr. McClure. I appreciate the strong language from this
committee because I think we need action, and I think I have
some good news. I am here to tell you about a unique and
exciting program that actually changes lives. The VA hospital
in Little Rock has taken the Medical Foster Home Program and
the HBPC programs and formed a partnership that provides an
extremely personal and comprehensive service that benefits not
only our disabled veterans, but it benefits our communities and
the VA hospital at a low cost.
This program has an excellent record of satisfaction among
the veterans and their families. The secret, these homes
provide a permanent home with private rooms. They provide 24
hour supervision, home cooked meals, a safeguard against abuse
and neglect. We have never had a case of abuse in our program.
We take sick, depressed veterans and turn them into grandpas,
father figures. We turn them into family members.
We fatten them up and make them laugh. They bring their
pets to these foster homes. They are allowed flexibility in
their routine. They are treated with dignity and respect,
because those are our standards. The Medical Foster Home
Program also provides a valuable service to our community, and
that is in the form of jobs and income. Also an opportunity to
work at home.
But the reason I am successful at recruiting good homes is
because this program provides a meaning and a purpose in these
caregivers' lives. Our community, the everyday people, have
defended our nation in war, they have run our factories, and
they have built our homes. These people can also care for our
frail elderly population if we support them. They can do it
better and they can do it with less cost than any other
alternative.
The program also provides a service to our VA hospital by
giving the discharge planners an alternative to nursing home
placement. Already, 50 percent of my referrals come from the VA
hospital, and that is growing. 25 percent come from the
community just by word of mouth. If I advertise this program, I
would be overwhelmed.
Eight of our 44 veterans living in foster homes are 100
percent service connected. They or their family choose to spend
their own money to live in a foster home rather than have VA
pay for their care in a nursing home. The cost of these two
programs, HBPC and the Medical Foster Home, in partnership is
$37 per day per patient. That is compared with $155 per day for
nursing home care. I got that in the April issue of the AARP
national average.
The foster home staff consists of myself, a part-time
secretary, one vehicle, one cell phone at $8 per day. I travel
15 to 2,200 miles per month. I am on call 24 hours a day, 7
days a week. But I have reached my limit. And we need action. I
have added 44 patients to the HBPC case load, and now they have
reached their limit. This is a win-win situation, and this is a
solution. This concludes my statement but not my ideas.
[The prepared statement of Mr. McClure follows:]
Prepared Statement of Thomas McClure, LCSW, Coordinator, VA Medical
Foster Home Program, Little Rock VA Medical Center
Mr. Chairman and members of the Committee:
My name is Tom McClure and I am a VA social worker at the
Central Arkansas Veterans Healthcare System. I am honored to be
here today because one of your staff, Kim Lipsky, heard me and
a colleague present our Medical Care Foster Home Project at a
recent national conference, and she thought you would be
interested. We recently finished a pilot, funded by VA, and we
are now disseminating our findings.
For 23 years I have been working in our Home Based Primary
Care Program. I saw firsthand how hard veterans worked to stay
in their own homes even though they had severe chronic
illnesses and disabilities, unsuitable housing, and poor social
supports. I often witnessed how difficult it was for elderly
spouses to continue to care for their very disabled husbands.
Time and time again I observed the unwillingness of veterans
and their families to consider placement in a nursing home.
We wanted to try to find ways for these patients to
continue to stay in the community and still get the care they
needed. A few times I helped our patients make informal
community arrangements to live in the home of a hired
caretaker. These situations worked out well for the veterans.
The Home-Based Primary Care (HBPC) team managed the medical
care. Then we heard about our Central Office's ``New Clinical
Initiative Funding.'' We asked for and were given the resources
to develop Medical Care Foster Homes for our veterans--$95,000
for each of 2 years. This money paid my salary so I could
develop foster homes full time. It also paid for my half time
assistant, travel costs and cell phone costs. We set about to
recruit caring families and individuals in the communities
served by our large HBPC program.
Now, 2 years later, we now have 35 foster homes and 45
patients. Our outside funding has ended, but the Medical Center
chose to continue at the same level of funding. Eight of our
Foster Care patients are 100 percent service connected; some of
them came directly from a community nursing home to our foster
home at their own expense.
Here is how our program works. When I recruit a foster
home, I assess their motivation, attitude, life experience, and
I explain the general needs of our disabled veterans. I check
their references and do a criminal background check. Our safety
engineer inspects the home environment. If everything checks
out, we approve the home and can begin to match the home with
patients who are interested in family living. We involve any
family or friends of the veteran in the process of selecting a
foster home. I encourage them to visit a few homes. I serve as
an intermediary between the veteran and the foster home
sponsors in agreeing on the monthly fee. This fee ranges from
$1000 to $1800 per month depending on the care needs of the
veteran. For this fee the veteran gets a private room, personal
care, 24-hour supervision, meals, laundry, and activities. This
is a permanent home. We do not uproot these veterans when they
become terminally ill and place them in a nursing home. They
remain in the foster home. It is understood that the VA will
provide medications, supplies, and health care. All the
veteran's needs are met.
The veterans pay for their Medical Foster Care with no
funding from VA. They use their Social Security, private
pensions, and VA pensions or service-connected disability
compensation. Most have spending money in reserve. The veterans
who qualify for non-service-connected pensions can have their
pensions increased to cover the costs of the Medical Foster
Care. We have a liaison in the Little Rock VA Regional Office
that assists us in processing claims in a timely manner, but
sometimes it does take several months.
Once in Medical Foster Care, the patients are visited
regularly by the HBPC team members, who conduct an
interdisciplinary geriatric assessment, develop a treatment
plan, provide medications and medical equipment, and educate
the foster family in the care of the veteran. Because of the
close partnership between our Foster Care Program and HBPC, we
safeguard against abuse.
So far we have recruited our Medical Care Foster Homes from
persons in the community who are experienced in caring for the
elderly, either former health care workers or those with
experience caring for family members. Even though the income is
important to foster home sponsors, we feel the most important
factor is that the program instills meaning and purpose to
their lives. This is why we can recruit good people. Also we
help our Foster Home Sponsors. They have 24-hour access to us.
We also offer respite 2-4 times a year so they can rest and
reduce stress levels.
We believe Medical Foster Care/HBPC is humane care and
affordable for VA and the Veteran. At our facility, with a
census of 45 patients in foster care, the VA direct care costs
are $29 per day for the HBPC portion of the care, plus $8 per
day for the Foster Home Program, for a total of $37 per day.
The Central Arkansas Veterans Healthcare System has formed
a partnership with the Medical Foster Care Program and the HBPC
Program, permitting us to provide this unique care environment.
Many states have adult foster care. But this program is just
for veterans and VA healthcare providers are actively involved
in caring for the patients and overseeing the homes. The most
important feature of this program is that it improves the
quality of life for our frail, disabled veterans in a family
atmosphere. We take sick, depressed veterans from our wards,
place them in a family environment and they become grandfather,
uncles, and father role models.
Here at Little Rock, we are at capacity for the number of
homes and patients can be managed with existing staff. HBPC's
census of 180 is now 25 percent Foster Care patients and
growing. With this program in its infancy, we are unable at
this time to predict the limits of its growth.
I believe VA Medical Centers could develop Medical Care
Foster Homes in conjunction with existing Home Based Primary
Care Programs. It is not easy work, but it is important and
gratifying work that would give our aging veterans a true
alternative to institutional care.
This concludes my statement. I will be happy to respond to
the Committee's questions.
Chairman Rockefeller. Or the obvious and clear emotion just
one inch below your words. You commitment is enormous.
Ms. Hemmings.
STATEMENT OF PAULA HEMMINGS, R.N., DEPARTMENT OF VETERANS
AFFAIRS' VETERANS INTEGRATED SERVICE NETWORK NO. 2, GERIATRICS
AND EXTENDED CARE LINE MANAGER, REPRESENTING THE ALZHEIMER'S
ASSOCIATION
Ms. Hemmings. Mr. Chairman and members of the committee,
thank you very much for giving me the opportunity to testify at
this important hearing. I am the Director of Geriatrics and
Extended Care Line for the Upstate New York Integrated Service
Network. However, I am here this morning on behalf of the
Alzheimer's Association and the views expressed do not
necessarily reflect the views of the Department of Veterans
Affairs.
The purpose of my appearance today is to explain how the
VISN 2 located in upstate New York was able to implement the
Chronic Care Networks for Alzheimer's disease project fully
utilizing the continuum of VA institutional and non-
institutional long-term care programs that are variable to the
veterans.
In 1996, VISN 2 was the only VA network that was a member
of the National Chronic Care Consortium. Membership in this
organization reflects commitment on the part of VA Central
Office as well as the executive support in VISN 2.
As members of the NCCC, the Alzheimer's Association and
VISN 2 leadership made a commitment to partner in the CCN/AD
project because of our strong belief that chronic care takes
many resources to work.
In upstate New York, the partners recognized that they had
a common goal. They also served the same target population,
individuals with dementia and their caregivers and families.
This recognition of commonality promoted pooling of experience,
experience and resources. Both agencies also recognized that no
one organization, no matter how complete its array of services
and programs, is sufficient to successfully manage the chronic
and progressive illness of dementia throughout its course.
VISN 2 is strongly motivated to partner with the community
organization to better serve an aging veteran population with
the prevalence of chronic illness. Nationally, the rate at
which a veteran population is aging surpasses the general
population. The 20 percent reduction in the overall veteran
population is offset by the significant growth of very elderly
veterans, thereby maintaining significant demand from health
care services in the next 10 years.
The CCN/AD's primary project goals are: identification of
individuals in the early stages of the condition;
implementation of state-of-the-art comprehensive care
guidelines; creation of a dual track to support both a person
with dementia and the family caregivers over time and across a
continuum of needed services; and modification of the care for
coexisting conditions with recognition of the underlying
dementia and its effects.
As a selected CCN/AD site, VISN 2 is active in the
development, piloting and demonstration of the model. Chapter
and VA partners quickly identified training as a major
component of the intervention. Primary care clinicians were
targeted for initial and ongoing training. Staff of both
partnering organizations was educated about the goals,
protocols and their role in addition to dementia topics.
Once the initial piece of the project was accomplished, the
role of the Dementia Care Manager became more important. This
is a staff role unique both to this project and within the VA.
These staff serve as a variety of diverse functions all
designed to advance the goals of the CCN/AD initiative.
The dementia care managers work diligently to ensure that
all veterans continue to have access to VHA resources and
services when they need it. This is a good illustration of a
model that strategically places VHA resources alongside
numerous community partners to work in concert in meeting the
needs of the chronically ill veterans.
Treatment and management of chronic illnesses such as
dementia fundamentally challenge the way health care service
delivery systems are currently delivered. Typically care
delivery centers around brief episodic office visits with the
primary care provider. The nature of the visit commonly focuses
on the medical aspects of presenting problems. Chronic care
management, however, presents fundamentally a different
reality.
Chronic progressive illness, such as Alzheimer's, needs to
be addressed over time and it must include the patient's family
and caregivers. Plans often need to include access to a full
range of non-institutional resources such as home-based primary
care, the homemaker home health aide, adult day health care,
and respite care, all service that the VA provides and
coordinates.
Planning has to include caregivers who oftentimes are as
old and as sick as the identified patients they care for, and
yet they are so crucial to the success or failure of the
management of the disease. Planning with them is important. VA
chose to use a CCN/AD program as a springboard to help
influence its medical model and culture of primary care to
better accommodate the needs of veterans and patients with
chronic illness.
It has expanded the provider's appreciation to where care
is actually delivered. It is delivered in the home. It
contributed to the provider's understanding that successful
management of our patients with dementia care means addressing
the needs of the family and patient as well. This project has
taught us that we must reach out to our partners in the
community who have common missions and work with them to offer
our veterans and their family caregivers what they need, not
just what we have. Thank you.
[The prepared statement of Ms. Hemmings follows:]
Prepared Statement of Paula Hemmings, R.N., Department of Veterans
Affairs' Veterans Integrated Service Network No. 2, Geriatrics and
Extended Care Line Manager, Representing the Alzheimer's Association
Mr. Chairman and members of the Committee, thank you very much for
giving me the opportunity to testify at this important hearing.
In my professional life I am the Director of the Geriatrics and
Extended Care Line for the upstate New York Veterans Integrated
Services Network (VISN 2). However, I am here this morning on behalf of
the Alzheimer's Association and the views that I express do not
necessarily reflect the views of the Department of Veterans Affairs.
The purpose of my appearance today is to explain how Veterans
Integrated Service Network (VISN 2), located in upstate New York, was
able to implement the Chronic Care Networks for Alzheimer's Disease
(CCN/AD) project fully utilizing the continuum of VA institutional and
non-institutional long-term care programs that are available to the
Veterans.
In 1996, VISN 2 was the only VA Network that was a member of the
National Chronic Care Consortium (NCCC). Membership in this
organization reflects commitment on the part of VHA Central Office as
well as executive support in VISN 2. As members of the NCCC, the
Alzheimer's Association and VISN 2 leadership made a commitment to
partner in the CCN/AD project because of our strong belief that chronic
care takes many resources to work. There were seven sites selected from
the NCCC applicants. VISN 2 and the upstate New York chapters of the
Alzheimer's Association were among those selected. The importance of
this project was recognized by the Robert Wood Johnson Foundation who
heavily underwrote the evaluation component of the VISN 2/upstate New
York Alzheimer's Association chapters site.
background on ccn/ad project
The following is a detailed description of the CCN/AD initiative
and VISN 2 and the upstate Alzheimer's Association chapters
participation. VISN 2 and the four upstate New York chapters of the
Alzheimer's Association formed a community partnership to participate
in the CCN/AD initiative, a national demonstration project. In Upstate
New York the partners recognized that they had a common goal. They also
served the same target population, individuals with dementia and their
caregivers and families. The partners strove to provide their clients
with the best quality care their agency resources allowed. This
recognition of commonality promoted pooling of experience, expertise
and resources. The Alzheimer's Association chapters have a history and
extensive experience providing support and education to diagnosed
individuals, their caregivers and families. The VA brought to the
partnership their clinical experience and expertise in the provision of
an enviable continuum of chronic care services. Both agencies have much
to offer individuals with dementia and their caregivers. Both agencies
also recognize, that no one organization, no matter how complete its
array of services and programs, is sufficient to successfully manage
the chronic and progressive illness of dementia throughout its course.
Partnership is essential. Partnering in CCN/AD meant that both
organizations could provide better access for their clients to a wider
arrangement of services. Also as important, the partnership in the CCN/
AD initiative would establish the foundation for development of a
disease management model of care in VISN 2. This model serves as a
guide for providing services and support throughout the course of the
disease at all care sites within the Network.
demographic profile of visn 2
VISN 2 is an integrated health care delivery system composed of
inpatient facilities, nursing homes, community clinics, non-
institutional care programs provided through contracts, and community
agency referrals. VISN 2 provides acute inpatient and nursing home care
services at five locations: Albany, Western New York, Syracuse, Bath
and Canandaigua, provides primary care at twenty-nine community-based
clinics that are located throughout the region. The VISN serves an area
of 42,925 square miles encompassing 47 counties in New York State as
well as two in northern Pennsylvania, with an estimated 573,546
veterans (17.7% of those veterans were treated in FY 2000).\1\ This is
approximately the same area (minus counties in northern Pennsylvania)
served by four Alzheimer's Association chapters. The chapters and VA
Medical Centers formed the partnerships based upon shared service
areas.
---------------------------------------------------------------------------
\1\ ``Veteran Demographics''. Department of Veterans Affairs Web
site. Available at: www.va.gov/visns/visn02/. Accessed December 6,
2001.
---------------------------------------------------------------------------
VISN 2 was strongly motivated to partner with a community
organization, such as the Alzheimer's Association, to better serve an
aging veteran population with a prevalence of chronic illness.
Nationally, the rate at which the veteran population is aging surpasses
the general population.
Highlights of veteran demographics for upstate NY:
<bullet> Over 52% of veterans treated in FY 2001 were 65 years of
age or older, with nearly one-quarter over age 75.
<bullet> Perhaps equally significant is that while our total
veteran population decreases, the number of veterans over age 85 will
nearly double in the same five-year period.
While veterans over age 65 historically use health care services at
a higher rate than younger veterans, greater demand is profoundly more
significant among those 85 and over, in all major care settings-acute
inpatient, ambulatory and nursing home care. The 20% reduction in the
overall veteran population is offset by the significant growth of very
elderly veterans, thereby maintaining significant demand for health
care services over the next ten years.\2\
---------------------------------------------------------------------------
\2\ Ibid.
---------------------------------------------------------------------------
These demographic data provided VISN 2 an incentive to participate
in the CCN/AD initiative addressing Alzheimer's disease, a chronic
illness whose prevalence increases with age. A disease which if left
undiagnosed could interfere with the management of their medical care
and cause them to be labeled as non compliant patients, possibly
leading to their death because they were not taking their medications
as prescribed.
In addition to the demographic challenges presented to us, VISN 2
was impelled by fiscal and budget realities to make effective changes,
rapidly, and to look outside itself for agencies with whom to
collaborate.
In VISN 2, Care Lines are structured along major program emphases.
In my case, the major program emphasis is Geriatrics and Extended Care
(GEC). In VISN 2, the Care Line Directors are given budgetary and
operating authority over all relevant programs in this new
organizational structure. Decisions about program operations are
matrixed with the Directors of the major Medical Centers in upstate New
York. This structure allows us to rapidly deploy and standardize the
best, efficient and effective practices across all sites of care
delivery within our Network. The Care Line organizational structure
lets administrators in our Network focus and concentrate on all the
pertinent issues and requirements relevant to aligning resources for
efficient and effective service delivery. It also impacts the speed of
implementation, in that, I can influence deployment across the entire
Network catchment area, and not just at one Medical Center at a time.
This structure allowed me to institute the CCN/AD initiative rapidly
throughout all of upstate NY and hire and put in place Dementia Care
Managers at each major site which I will talk about later.
ccn/ad project goals
The CCN/AD project's primary goals are: identification of
individuals in early stages of the condition, implementation of state
of the art comprehensive care guidelines, creation of a dual track to
support both the person with dementia and the family caregivers, over
time and across the continuum of needed services, and modification of
the care for coexisting conditions with recognition of the underlying
dementia and its affect. As a selected CCN/AD site, VISN 2 was active
in the development, piloting and demonstration of the CCN/AD model.
Chapters and VA partners quickly identified training as a major
component of the intervention. Primary care clinicians were targeted
for initial and ongoing training. Other staff in both partnering
organizations, were also trained in sessions specifically designed to
meet their needs. A site wide curriculum was developed that outlined a
basic introductory presentation with CME credit that the VA clinical
director of the Initiative delivered at each sub site. The purpose was
to assure that each location started with the same basic information.
During the clinical director's travels to the sub sites he met with key
personnel and along with dementia care managers recruited physician
``champions'' who would participate in or support future sessions.
the role of the dementia care manager
Recognizing the varied resources and needs of each sub site,
Dementia Care Managers and chapter coordinators determine future
educational needs for the staff at their facilities using the
curriculum as a guideline to identify target audiences and use a
variety of methods. Faculty was recruited from within the VA and more
frequently from universities, Alzheimer's Disease Centers and
Alzheimer's Disease Assistance Centers. Staff at both partnering
organizations were educated about the goals, protocols and their role
in addition to dementia topics. A milestone occurred when demands for
training came from numerous diverse staff themselves after hearing
about or experiencing the quality of Alzheimer's Association chapter
training sessions for direct care staff. Eventually, this led to use of
Alzheimer's Association chapters for train-the-trainer programs and
development of a plan to use those newly trained as instructors and
dementia resource individuals in their unit. The implementation of that
plan was the culmination of efforts to reach our goal to train the full
range of staff at VA facilities.
Once the initial piece of the project was accomplished, the role of
the Dementia Care Manager became more important. This is a unique staff
role; unique both for this project and within the VA. These staff serve
a variety of diverse functions all designed to advance the goals of the
CCN/AD initiative. The Dementia Care Manager is there to respond to
questions related to the tools after the education sessions and to
collect the necessary data for the project. The other responsibility of
the Dementia Care Manager is to work with the primary care provider to
establish the psychosocial support system for the Alzheimer's patient
in the community. Further these staff work with the family and the
Alzheimer's Association to provide family/caregiver support.
The Dementia Care Managers like the other VISN 2 Geriatrics and
Extended Care staff work diligently to insure that all veterans
continue to have access to VHA resources and services when they need
it. VISN 2 is one of the Networks nationally that met veteran resource,
use reliance target levels for both our institutional Nursing Home
programs as well as our non-institutional home care programs and
services. But the needs, both in nature and kind of need, of patients
with chronic illnesses and their families will always exceed the VHA's
ability to directly provide for them.
partnership with the alzheimer's association
Faced then with increasing numbers of aging veterans in the upstate
New York area and the competing healthcare budget needs previously
mentioned, geriatric and extended care program planners in our Network
factored in access to Alzheimer's Association community resources, as a
necessary component to compliment services for veterans with dementia
and their families. It is a good illustration of a model that
strategically places VHA resources along side numerous community
partners to work in concert to meeting the needs of chronically ill
veterans.
the chronic care challenge
Treatment and management of chronic illnesses, such as dementia,
fundamentally challenge the way healthcare service delivery systems are
currently configured.
Medical care delivery within VHA, as is the case with most medical
care systems, is well designed to manage health care problems of the
general population. Typically care delivery centers around brief,
episodic office visits with the primary care provider. The nature of
the visit commonly focuses on the medical aspects of presenting
problems. Patients are given prescriptions, advice on life style
changes and follow up appointments if necessary to track progress of
the condition for which they are being treated. At times, referrals may
be made to specialty clinics and if warranted to treat acute illness,
hospitalization. In addition, providers in these settings are busy.
They have high patient volume and are daily pressed to complete their
scheduled visits. As would be expected, resources in most health care
systems are aligned to meet this mission and model of healthcare
delivery.
Chronic care management, however, presents a fundamentally
different reality. Chronic progressive illness, such as Alzheimer's,
needs to be addressed in clinic, over time rather than episodically.
Also managing these patients, who are typically frail and elderly,
takes time. Time to plan access to a full range of non-institutional
resources such as Home Based Primary Care, Homemaker Home Health Aide,
Adult Day Health Care and Respite Care, all services that the VA
provides and/or coordinates. Providers are trained and trained well to
assess and treat on the medical level and patients with chronic illness
need this care. But often simultaneously, these patients and families
need assessment and care on several other non-medical dimensions as
well. These other domains that require attention and often intervention
and care planning include functional, social, financial, psychological,
behavioral and environmental dimensions. Further adding to the
complexity is the work that needs to be done with the family
caregivers. Caregivers often times are as old and sick as the
identified patients they care for, yet they are so crucial to the
success or failure of the management of the disease. Their needs must
be accounted for in care planning. Finally, the nature of chronic
progressive illness is such that it evolves, develops, and eventually
deteriorates over time. Changes in condition and circumstance must not
only be monitored but must be prepared for proactively. Patient's
changes in physical, behavioral and functional needs require different
mixes of supports, services and settings. Their caregivers' skills,
aptitudes, as well as their own family and agency supports available to
assist them need to be looked at as they progress through role changes
and the changing demands that their loved ones chronic illness places
on them. This is where the Dementia Care Managers come in and provide
invaluable assessment, coordination and support.
To successfully address chronic illness management, the mindset,
both clinically and in resource planning and deployment, needs to be
fundamentally different than an uncritical reliance on a system of
delivery designed to serve needs of a general population. The
consequences of dependence on episodic care delivery as it's currently
organized or premature reliance on costly institutional care for
management of chronic illness is to squander precious resources that
are and will be needed to treat the ever growing population of veterans
with chronic illness.
replication of the ccn/ad project
Given the complexity of what is described above, it is impractical
to think that any one agency, no matter how vast its resources, can
unilaterally provide all the care patients and their families with
chronic progressive illness will need. To begin to think like this, and
coordinate with community partners and monitor care over time outside
of the clinic encounter, is nothing short of a cultural change in
healthcare delivery. To actively change medical care delivery culture,
the endorsement and commitment from top leadership is required. VISN 2
chose to use the CCN/AD model as the springboard to help change it's
medical model and culture of primary care and to influence it over time
to better accommodate the needs of patients with chronic illnesses and
their families. Over a five year period, the VISN deployed dedicated
Dementia Care Managers to cover all the medical centers and major care
sites within the VISN. These staff are able to take the time medical
providers don't have to do detailed assessment of both patient and
caregiver needs. They also are a direct contact point and portal of
entry into the VA system and continuum of services. They are easily
reached by their partners at the Alzheimer's Association and help
sustain this inter-agency relationship. They collaborate with both VHA
providers and Chapter staff and work to integrate into care planning
relevant data about both patient and caregiver's current functioning.
conclusions
CCN/AD created in VISN 2, over time, the reality of viable
partnerships with community agencies such as the Alzheimer's
Association. It imparted to our providers the importance of addressing
caregiver needs and supporting them as they struggled to cope with
their loved ones illness on a day to day basis. It reaffirmed that
chronic care had to be managed across settings and over time. It
expanded the providers' appreciation as to where care was actually
delivered in the majority of instances. It contributed to the
provider's understanding that successful management of our patients
with dementia means addressing the needs of the patient's family
caregivers as well.
Our veteran patients, whom we correctly refer to as our nation's
heroes, who now come to us with dementia, along with their family
caregivers, who are quiet, unsung heroes in their own right, continue
to teach us. They teach us that to be true to our mission and
obligation to ``serve him who has borne the battle and his widow and
orphan'', we must continue to maximize our resources to serve the
extended care needs of our veterans as they age, become frail and more
heavily rely upon us. They teach us that to be successful in our
mission we cannot be solely focused on our identified patient, the
veteran. We must also focus on those in our veterans' lives who are
most intimately caught up in the provision of their extended care
needs. And finally, they teach us not to come to rely solely on VHA
resources to achieve our mission. They have taught us that we must
reach out to our partners in the community, who have common missions,
and work with them to offer our veterans and their family caregivers
what they need, not just what we have.
Chairman Rockefeller. Thank you very much, Ms. Hemmings.
Dr. Moye. And this will be geriatric mental health and your
study about that.
STATEMENT OF JENNIFER MOYE, PH.D., DIRECTOR, GERIATRIC MENTAL
HEALTH CLINIC/UPBEAT, BROCKTON VA MEDICAL CENTER, AND ASSOCIATE
PROFESSOR OF PSYCHOLOGY, DEPARTMENT OF PSYCHIATRY, HARVARD
MEDICAL SCHOOL
Ms. Moye. Right. Mr. Chairman and Senator Graham, my name
is Jennifer Moye. I am the Director of the Geriatric Mental
Health UPBEAT Clinic at the Boston VA Brockton Campus, and I am
an Assistant Professor of Psychology in the Department of
Psychiatry at Harvard Medical School.
I am pleased to testify today on the Unified
Psychogeriatric Biopsychosocial Evaluation and Treatment, or
UPBEAT program.
I have worked as a psychologist with medically and
neurologically frail older veterans with late onset mental
health concerns for the past 10 years, and I speak today as a
clinician. Our clinic was founded in 1995 as part of a 5-year,
nine-site clinical demonstration project that evaluated the
effectiveness of outpatient case management combined with
mental health treatment for elderly veterans who have
previously undiagnosed mental health problems in the context of
serious medical illness.
This program is based on two research findings, one, mental
health problems are underdiagnosed and inadequately treated in
the elderly. These are fellows who are not going to say to
their doctor, ``gee, I have been feeling sad, could I talk to a
psychologist?'' They are more likely to sort of buck up and
suffer, unfortunately.
And also, the second finding, elderly who have depression
or other mental health problems have more complex medical
management, have a more complicated recovery from illness, and
are more expensive for our health care system.
In the UPBEAT program, patients 60 years or older admitted
to medical or surgical inpatient services were screened for
depression, anxiety or alcohol use. 1,687 veterans with these
problems were randomly assigned to either a treatment group or
a usual care group.
In the treatment group, those fellows got an intensive
interdisciplinary assessment, followed by outpatient case
management combined with mental health treatment.
In the year following enrollment, veterans in the treatment
group had higher utilization of outpatient care, especially
mental health and telephone encounters, costing 1,171 more
dollars per patient per year than the usual care group.
However, that expanded outpatient cost was more than made
up for by savings in inpatient costs of $3,027, resulting in a
net savings on average of $1,856 per patient per year, or a
total savings for all patients enrolled in the treatment group
of approximately $1.5 million.
The savings were chiefly attributable to reduced length of
stay when those veterans were rehospitalized. We are starting
to look at other subgroups, and it looks like in specifically
targeted subgroups, such as patients with circulatory
conditions or more significant depressions, the savings may be
even greater, up to $5,000 per patient per year.
Let me share with you an example to illustrate the program.
One veteran in the UPBEAT program was enrolled at our site when
he was surgically hospitalized and he screened positive for
depression. The depression was triggered in part because the
current surgery he was having was reminiscent of the eight
surgeries he received in 1945 after he was injured by shrapnel.
This patient participated in six combat jumps in Africa,
Italy, France and Germany, including the Battle of the Bulge
and the Anzio and Normandy invasions for which he received the
Bronze Star for heroism.
Late in life when confronted with illness and
vulnerability, he became overwhelmed with depression, to the
point where he would retreat from everyone and stay in bed and
then that would compromise his health.
He entered our program at the age of 75 participating at
first very reluctantly, but eventually enthusiastically with
the case management as well as the psychotherapy, and in this
case some psychopharmacology to help him sleep. He was still
having nightmares of the war.
With that treatment, he was able to manage his mood better
when medically ill, and he successfully underwent a subsequent
surgery without that excess disability caused by depression.
Furthermore, as a result of speaking in psychotherapy about his
war experiences for the first time ever, he began to also share
these with his family.
None of his family members were previously aware of any of
the details of his military service, and this newfound capacity
for communication was tremendously appreciated by both the
veteran and the family.
What does the success of the UPBEAT program tell us about
outpatient case management programs? UPBEAT is a non-
institutional program that reduces institutional care and
reduces total cost of care. These findings are similar to other
studies that find case management of these high risk geriatric
patients can forestall a nursing home admission or other
institutional care use and be cost effective.
Key elements of successful programs are: interdisciplinary
teams, readily accessible primary care, home-based care, adult
day health care, the things my panel members have described,
integration of mental health treatment, case management to
coordinate that optimal utilization of the health care system,
and careful targeting of the patients to identify those most at
risk for institutional care and most likely to benefit from
such programming.
Patients with dementia require additional services
including travel and caregiver support. The ultimate success of
these programs will rely on appropriate case loads for
clinicians and case managers, and I really want to second Tom's
noting on how large the case loads are getting for the
clinicians these days, and clear program goals and performance
measures for clinicians and administrators.
In closing, I have felt very blessed to work with elderly
veterans and very grateful for that opportunity. I am also
grateful for the opportunity to speak with you today. Thank
you.
[The prepared statement of Ms. Moye follows:]
Prepared Statement of Jennifer Moye, Ph.D., Director of the Geriatric
Mental Health/UPBEAT, Brockton VA Medical Center, and Associate
Professor of Psychology, Department of Psychiatry, Harvard Medical
School
Mr. Chairman and Members of the Committee:
My name is Jennifer Moye. I am the Director of the Geriatric Mental
Health/UPBEAT clinic at the Boston VA, Brockton Campus, and an
Assistant Professor of Psychology in the Department of Psychiatry at
Harvard Medical School. I am pleased to testify today on the Unified
Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT)
program.
review of upbeat model
I have worked as a psychologist with medically and neurologically
frail older veterans with late onset mental health concerns for the
past ten years, and I speak today as a clinician. Our clinic was
founded in 1995 as part of a nine site clinical demonstration project
that evaluated the effectiveness of intensive outpatient case
management and mental health treatment for elderly veterans with
previously undiagnosed mental health problems in the context of serious
medical illness. The program is based on previous research
demonstrating: 1) mental health problems are under diagnosed and
inadequately treated in the elderly; 2) elderly who have depression or
other mental health problems have more complex medical management, a
more complicated recovery from illness, and are more expensive for the
health care system.
upbeat cost savings
In the UPBEAT program, patients 60 years and older admitted to
medical or surgical inpatient services were screened for depression,
anxiety, or alcohol abuse. 1,687 veterans with these problems were
randomly assigned to a treatment versus usual care group. The treatment
group received interdisciplinary assessment followed by outpatient care
coordination and mental health intervention. In the year following
enrollment, veterans in the treatment group had higher utilization of
outpatient care, especially mental health and telephone encounters,
costing $1,171 more per patient per year, than the usual care group.
However this expanded outpatient cost was more than made up for by
savings in inpatient costs of $3,027, resulting in a net savings of
$1,856 per patient per year, or a total savings for all patients
enrolled in the treatment group of approximately $1.5 million dollars.
Savings were attributable to a reduced length of stay when re-
hospitalized. Savings were even greater in targeted subgroups, such as
those with circulatory diseases or more significant depression,
estimated at $5,000 per patient per year. Additional analyses are
ongoing.
upbeat clinical example
One veteran in the UPBEAT program was enrolled at our site when he
was surgically hospitalized and screened positive for depression. The
depression was triggered in part because the current surgery was
reminiscent of the eight surgeries he received in 1945 after being
injured by shrapnel in World War II. This veteran participated in six
combat jumps as a paratrooper in Africa, Italy, France, and Germany,
including the Battle of the Bulge, and the Anzio and Normandy invasions
during which time he received the Bronze Star. Late in life when
confronted with illness and vulnerability, he became overwhelmed with
depression, to the point of remaining in bed constantly, compromising
his health. He entered our program at the age of 75, participating at
first reluctantly, then enthusiastically in case management and
individual psychotherapy with psychopharmacology. With treatment he was
able to manage his mood better when medically ill, and he successfully
underwent a subsequent surgery without the excess disability caused by
depression. Furthermore, as a result of speaking about his war
experiences for the first time in psychotherapy, he began to also share
these with his family. None of his family members were previously aware
of any details of his military service. This newly found capacity for
such communication was tremendously appreciated by both the veteran and
his family.
essentials of case management for at-risk veterans
What does the success of the UPBEAT program tell us about
outpatient based case management programs? UPBEAT is a non-
institutional program that reduces institutional care and reduces total
cost of care. These findings are similar to other studies that find
case management of at-risk geriatric patients can forestall nursing
home admission. Key elements of these programs are:
1) interdisciplinary teams;
2) readily accessible primary medical care;
3) home based care and support when indicated;
4) integration of mental health treatment;
5) case management to coordinate optimal utilization of the
health care system; and
6) careful targeting of patients and interventions to
identify those patients most at-risk for institutional care and
most likely to benefit from such programming.
Patients with dementia require additional services including
travel, caregiver support such as respite care, and adult day health
care. The ultimate success of such programs will rely on appropriate
caseloads for primary care clinicians and case managers, clear program
goals, and performance measures for clinicians and administrators.
In closing, I have been most grateful to work with our elderly
veterans, and I thank you for the opportunity to speak before you
today.
attachment
Kominski, G., et al (2001). UPBEAT: The impact of a psychogeriatric
intervention at VA Medical Centers. Medical Care, 39, 500-512.*
---------------------------------------------------------------------------
[* The information referred to has been retained in the committee's
files.]
Chairman Rockefeller. Thank you, Dr. Moye. A little off-
the-wall question here. None of you have particularly talked
about--you, I think, Ms. Dickerson talked about savings--none
of you have talked about the problem of resources that I assume
VA would care to bring forward, and I am wondering if that has
anything to do with the fact that some of you were told not to
bring up the subject of resources by the VA?
Ms. Dickerson. Particularly in my case, resources are
readily available. Alan Harper in North Texas Health Care
System is a very believer of HBPC, and he has seen the things
that we have done. So we have been able to get the resources.
What we did was that he transferred a lot of the nursing staff
from the inpatient to the outpatient.
Chairman Rockefeller. You found a way?
Ms. Dickerson. Yes, we found a way.
Chairman Rockefeller. And you found a way without
fundamentally compromising the health care of others?
Ms. Dickerson. Yes.
Chairman Rockefeller. Because you cared to take the
initiative?
Ms. Dickerson. Yes. So we have transferred from inpatient
occupational therapists, physical therapists, dieticians,
social workers and nurses. We even have a physician and a
physician's assistant that was transferred from other places in
the hospital.
Chairman Rockefeller. But it would be easy, it seems to me,
for VA to come forward and say, well, we cannot do this because
we do not have the budget that we have. I mean that is what
Senator Graham and I say every year, and that is what VA says
every year, and we are all right every year, and so they could
come forward and say that.
And what you are saying is, yes, they can come forward and
say that, but you, Ms. Dickerson, were able to undertake
something without compromising the health care and other
critical areas for the same population of veterans that we are
all talking about and do just exactly what the long-term care
law required.
Ms. Dickerson. That is exactly right. We also maintained a
$22 per day per patient for the last 5 years, so the cost has
not increased.
Chairman Rockefeller. And you also, as I think you
indicated, know that as time goes on, you will be saving more
money?
Ms. Dickerson. Yes. We have also increased our patient load
to over 200 patients.
Chairman Rockefeller. So the patient load has gone up, the
money can be handled, and the resources are not an excuse?
Ms. Dickerson. Yes.
Chairman Rockefeller. Anybody else wish to comment?
Ms. Moye. I just wanted to comment on the issue I want
people to appreciate the complexity of the older patients. As
the GAO reported, we are seeing this tripling in the over 85-
year-old veteran, and these are veterans who are already
expensive to the health care system, and we are saying let us
spend more money on them, so I cannot speak to fiscal issues. I
am a clinician, but I want to emphasize how very, very complex
these patients are, how they require more time to work in a
preventative fashion.
Our primary care clinicians currently have case loads of
1,200 patients. We have a waiting list of about 500 patients. I
know you have heard these things. That may be appropriate if
you are working in an HMO setting and you have lots of young
adults who you see once a year, but when you have very
complicated 85-year old patients, we really need to look at the
issue of directing resources to those needs.
Chairman Rockefeller. And I do understand that, but Ms.
Hemmings, who looks like she wants to say something, I want to
say to you that one of the things I certainly remember about my
mother in talking about complexities with older people is that
particularly in Alzheimer's you go through stages where there
is an enormous amount of violence, an enormous amount of just
sort of following people around houses or outdoors or down
streets. You are not quite sure where they are going to go.
They hit, they throw food, they scratch at certain points
and they stop, and they will take it up again. Often a single
caregiver if the person is larger in size cannot transport that
person to a bathroom, for example, or to a tub, and so what Dr.
Moye says becomes even more true, and that is that it is indeed
very complex, and in your field and in others manifestly
complex and yet you have handled it?
Ms. Hemmings. Well, I think the way it is handled, too, is
that we all talked about having some form of case management,
and I think that is really one of the real issues that we have
used. The nurse or the social worker, depending on what site
she is at, works with whatever level that patient is at. The
issue is to try and identify it early and through some of the
other medications and also give us a time to educate the family
how to deal with some of these behaviors.
If you learn how to do some diversional therapy and some of
the other things that are going to be coming up, you can also
handle the patient better at home, but it also gives us much
more time to work with the Alzheimer's Association to set up
support systems for the family. The caregiver really needs a
lot of support, and so while we are supporting the medical
needs of the veteran, the Alzheimer's Association provides
support from the community in terms of helping the caregiver,
who is usually a wife, cope with these things that are going
on, learn more skills and then we from the VA will offer,
respite care will offer homemaker home health aide.
So you are really combining the best of both worlds,
because a veteran is not just a veteran. He is a member of a
community, and his family is part of the community. So there is
a lot of other community services that can be called upon to
help with this relief and the support when it occurs. But I
think the initial part of helping to educate--that is why it is
so important to identify it early--helps the family then cope
when it becomes more difficult. But then rely on things like
home-based primary care when it becomes more difficult for the
family, and eventually sometimes the patients are not able to
stay at home anymore.
And then we use our VA nursing home, but in the meantime we
have kept them out in the community with their loved ones as
long as we possibly can and I think that is what really makes a
big difference is that partnering.
Chairman Rockefeller. If Senator Graham will forgive me, I
just want to ask one more question to Tom McClure feeding off
of what Dr. Moye said, and that is that the amazing complexity
as people get to be 85 or older, and sometimes younger than
that, and that is, you know, that is like saying that rain is
wet. I mean that is inevitable.
I am not trying to play doctor here, but that is the fact,
when you get to be that age, because there is an enormous range
of things that work together and then some manifest themselves
more than others. Some fit under the category of Parkinson's,
Alzheimer's, dementias, mental depression, schizophrenia,
stroke. But, I accept what you say, but that is manifestly true
across all fields of medicine, I would think.
And so I would like to get your response, Tom McClure, to
this general situation of resources and we just do not have the
money to do this.
Mr. McClure. Well, those eight service connected veterans
that are 70 percent and above that are on my program, that is
saving our hospital director about $320,000 a year. My budget
is $95,000. That is not to speak of the VERA allocation on
managing the medically complex patient of about 40 patients. I
know that is not generating actual revenue, but it is bringing
revenue into the VISN. But that is another good point about
this, and we are managing medically complex patients.
Chairman Rockefeller. And saving money?
Mr. McClure. And I think the other thing to look at in a
global view. Instead of just looking at the VA budget, if we
can take veterans and place them in foster homes with that
partnership, rather than into a nursing home, you know we are
saving our national budget by managing them with a cost-
effective program, not to speak of the VA budget. And I think
we must look at the entire budget of this nation in planning
these.
Chairman Rockefeller. Thank you, sir. Senator Graham.
Senator Graham. Thank you, Mr. Chairman. Again, thank you
for holding this hearing. One of the observations that has been
made about these long-term care services, particularly the non-
institutional services, is that they are uneven across the VA
system.
Ms. Dickerson, you just gave a very persuasive statement
about what you are doing in the Dallas area, as have each of
you in your own particular VA centers. Why is not what you just
described in Dallas or in Little Rock or among the Alzheimer's
patients or among the geriatric mental health, why is that not
the norm in VA as opposed to the exception?
Ms. Hemmings. I can answer in terms of the Alzheimer's
project. I think we were the pilot for the VA, and so we have
given this information in the beginning to everyone in long-
term care via teleconference, and when the project is----
Senator Graham. When did you provide that information?
Ms. Hemmings. Well, we told them we started the project
when we did in like 1997. We are having an evaluation finishing
up this year, and then we will go back to everyone with the
results of the project. We are in the middle of something, so
you kind of do not say it is successful until you finish it,
but I think we are always trying to keep people informed of
what we are doing. So some of this might be related to the fact
that you are in the middle of doing a project.
Ms. Dickerson. In my case, I do believe that these types of
programs will be successful all over the Nation once they
realize that the resources, you do not have to hire a lot of
people to do this, you just need to transfer around, move
people around from the inpatient to outpatient if that is
possible in other facilities as it was in our facility, because
that is simply what we did.
Senator Graham. You say whether it is possible to move from
inpatient institutional care to at-home community care. Is that
a constraint of physical facilities of people or what are the
limitations on making that transition?
Ms. Dickerson. There should not be any. There should not be
any limitations on moving people around where they are needed
and what is most cost effective and what is better for patient
care.
Senator Graham. Mr. McClure, what about in the area of
foster care?
Mr. McClure. Foster care, of course, I placed my first
veteran in a foster home in 1987 on an informal basis because I
did not have alternatives. But the VA in which I work for the
central office funded this program in the year of 2000 as a
pilot project and we just completed that. Our director, as I
said, has already put it in his budget, and I think now it is
time to act, and this is my own personal opinion and not that
of the VA, but this program should go nationwide and
immediately.
Senator Graham. Well, I agree with you, not only because it
is humane, but also you made the case that it is cost
effective, but even more fundamentally the people who are our
particular concerns, the veterans of America, they did not
defend Little Rock, they defended the United States of America,
and there ought to be an expectation of an evenness of service
whether you live in the far Northwest or the far Southeast of
the United States. We have a national system, and it ought to
be a national system in terms of benefits readily available.
Mr. McClure. And I do expect that.
Senator Graham. Dr. Moye, as you were describing your
program, I was struck with the fact that while you have been
conducting you say nine areas that you have centers that you
have been doing your pilot work?
Ms. Moye. It was at nine VA medical centers, yes.
Senator Graham. That this is not an issue that is peculiar
to America's veteran population. If you saw the front page of
today's Washington Post, there is an article that the President
has indicated that next week he is going to make an
announcement in support of parity for mental health treatment.
To what degree is the information that you have gathered in
your research applicable to the general American older
population, and to what degree is it peculiarly relevant to the
veteran population?
Ms. Moye. That is a wonderful question. We know that mental
health problems are underdiagnosed and undertreated in the
current cohort of all older adults. For the reason I just
suggested, I think there are stigma issues, there is lack of
familiarity with, ``OK, this is what depression looks like, and
when I have it I need to share it with my physician, I need to
get some treatment for it.''
However, I think the problem may be somewhat worse in the
veteran population. I think we do a good job of identifying and
treating serious mental illness such as schizophrenia, but not
these sort of low level, but clinically significant,
depression, anxiety, oftentimes related to war experiences. We
did a survey in our outpatient clinics. We interviewed veterans
waiting to see their doctors who were not in mental health
treatment. 40 percent had a combat trauma history; 15 percent
were to this day having problems with intrusive memories and
nightmares.
So I think when those things are also lurking and coming
into the picture and then suddenly you are having illness and
vulnerability and maybe a heart bypass surgery, that strains
your coping resources and may make it more likely that you have
some mental health issues arise.
Senator Graham. Thank you, Mr. Chairman.
Chairman Rockefeller. Senator Wellstone.
Senator Wellstone. Thank you, Mr. Chairman, and I
apologize. I had to go back and forth, and I missed your
testimony, and Perry Lange was just giving me a summary of some
of what you said, I think, and then I just was hearing Senator
Graham's question of mental health.
First of all, I want to thank you. I think really, you
know, you kind of light a candle and you show what we can do at
the community level, and I guess the only obvious question, and
I gather you maybe touched on some of this, is whether or not
you have received the kind of support that you would like to
have from the existing VA system, and if not, where do we need
to fill the gaps here, and if so, in what ways? That is, I
think, my only question, you know, asking for as honest an
answer as possible.
I mean you should know what can be done. The question is
are you getting the support from the existing VA system as is
or not, and if not, you know, we do not have to get into
acrimony, but where are the gaps? What do we need to start
doing to make this happen throughout the VA system in the
United States of America?
Ms. Hemmings. Well, related to the Alzheimer's project, we
received support by having us join the National Chronic Care
Consortium, so we have been under support all along for this
project, and then with our contacts with headquarters, when
this is done, we will use that support to roll it out. So I
think from that perspective, we have always had the support of
headquarters in this project, because it has been something
that we have identified as a real population need in our
veteran population. And then the programs already exist in the
VA. So that supported the types of home care that we needed.
Ms. Dickerson. I feel in Dallas we have received the kind
of support that we needed. When we wanted to start a Senior
Companion Program, we were given the go-ahead to start a Senior
Companion Program. We have 33 senior companions that, you know,
this gives the seniors an opportunity to do a great service to
stay with the veteran while the wife has a little respite.
We have also been able to start many other programs. The
telemedicine program, we received the support to start that,
and that just broke through all distances. We can go 100 miles
or 10 miles.
Senator Wellstone. What are the critical elements of the
support so that we can try to make these models be more and
kind of apply system wide?
Ms. Dickerson. I think system wide, the most important
thing was you needed nursing service support. If you do not
have the nurses who are the case managers, then your program
cannot grow. So we had tremendous nursing service support. They
closed beds in the hospital that were being underutilized and
moved those resources to outpatient facilities, and then, of
course, the director has to support what the nursing service
chief wants, but I think the nursing service support was one of
the biggest things that we had in Dallas.
Mr. McClure. I would like to add to that I worked for 9
years as a social worker with the HBPC program. I used every
resource I could find to keep them at home, and there is a
point in time when these veterans have to be removed. We can at
least keep them in a family setting-HBPC and foster care. Our
caregivers are ill and exhausted, and I feel like we need at
least to attach a foster home program to each one of our HBPC
programs in the Nation.
Mrs. Dickerson, it is a wonderful program, they keep
veterans at home as long as possible, but you can hire all the
aides, have all the nurses that you can get, but there is a
period of time where our veterans require 24-hour supervision.
In Little Rock, I am taking those patients when HBPC cannot
maintain them any longer, placing them in a capable foster home
with the VA support, and we are managing them until they die.
Ms. Moye. I spoke in my testimony about performance
measures for clinicians, and one of the things that has been
concerning for me is sort of, if I can come back to case load,
sort of a blunt instrument about case loads, that we are under
tremendous pressures to see as many patients as possible. And
folks look at just absolute number of patients, and I wonder if
it might be possible to develop some sophistication in this
such as is done in chronic psychiatry where patients are
described as maybe sustaining, moderate, intense and end of
life, and if you are working in the intense or end of life
area, then your case load expectation would be lower to
accommodate that, because we know it would pay off in the end,
and it would be what the veterans want.
But it is hard to do that when the main pressure you are
getting is see more people more quickly, you know, the absolute
number of patients you see is the performance measure by which
I am judged.
Ms. Hemmings. Can I just make one other comment? It is not
related to VA support, but I think as a part of what
realistically what is happening and why some things cannot be
done. I run the total geriatric program in upstate New York,
and from that perspective, sometimes it is not just what is
available in the community, and the other piece in terms of
trying to do some of these programs is the issue of getting
health care workers.
It is not the money from the VA. It is what is available
out in the community, and I think most of us that are in health
care today are finding it more difficult to find the health
care workers and the support that we need because people are
not going into health care. So sometimes you cannot implement
something you really want to implement just because the
resources in the community are not there in which to pull from,
and that is becoming extremely difficult for everyone in health
care these days.
I think that is another piece of it that has to be looked
at, because we are part of the community and we buy some of our
services from the community, and it is very difficult. People
want to do everything else but be a health care worker these
days.
Senator Wellstone. Thank you.
Chairman Rockefeller. Thank you, Senator Wellstone. I have
other questions I want to ask, but I think in view of time
constraints that I cannot or at least, I will not. And I want
to point out that each of the four of you have made an enormous
contribution. You have come from various distances, and you
have made a great contribution to this, and you have raised the
bar, I think, for our next witness, and for all of us.
Ingenuity is what has always separated invention, the
willingness to not fear that if you try to do something which
is new, and you work for some government bureaucracy, that you
are not going to be retaliated upon.
And, fortunately, there are people who exercise that sense
of ingenuity and risk taking. You might call it a model. You
might call it a pilot or whatever. Nevertheless, you all are
doing extraordinary things and helping people and loving it,
and wanting to see it done for everybody. So I thank you all
very, very much for taking your time to come.
Ms. Hemmings. Thank you.
Chairman Rockefeller. Our final panel today includes Dr.
Robert Roswell, who is the newly, and I need to say that, the
newly confirmed Under Secretary for Health. He is accompanied
by Marsha Goodwin, who is the Acting Chief Consultant for VA
Geriatrics.
As I indicated earlier in the hearing, I broke with the
usual protocol, to have Dr. Roswell not be the first but the
last witness, and I wanted him to be able to listen to the
testimony, both positive and less than positive, so that we can
talk about VA and what is the most vulnerable veteran segment
in the future. So, Dr. Roswell, welcome back. I am very glad
you are here, and we look forward to your statement.
STATEMENT OF ROBERT ROSWELL, M.D., UNDER SECRETARY OF HEALTH,
DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY MARSHA E.
GOODWIN, R.N., M.S.N., ACTING CHIEF CONSULTANT, GERIATRICS AND
EXTENDED CARE, AND DIRECTOR, GERIATRICS PROGRAM, DEPARTMENT OF
VETERANS AFFAIRS
Dr. Roswell. Well, thank you, Mr. Chairman. It is a
privilege to appear before you as the Under Secretary for
Health, and I appreciate your support in facilitating my
confirmation. Mr. Chairman, Senator Wellstone, it is a pleasure
to be here, and I want to thank both of you for calling
attention to what I truly believe is a tremendous problem that
we simply must do a better job in facing, and I salute you for
your efforts in convening this hearing.
You talked about deviations, and to allow a dialog I will
not be making a formal statement, although I would ask that my
statement by included in the record.
Chairman Rockefeller. It will be done.
Dr. Roswell. I have several concerns. You asked about OMB.
The interim rules for the three services that were specified
were actually published last year. The final rule will be
published in the Federal Register next week, so admittedly this
is too long, but those rules will be published very shortly,
and we will have that implemented.
I think this morning we have seen some truly wonderful
examples, not only of compassion and commitment to the needs of
veterans, but also in innovation in how we meet those needs.
The four examples we have just heard are heart-wrenching really
because there is such a great need, and there are many other
examples as well throughout the country, tremendous innovation
across our system.
It is clear that we need a full continuum of services to
meet the broad range of long-term care needs of America's
veterans. Just as no two patients are alike, no two set of
circumstances associated with long-term care are alike, and it
is important that we maintain a full continuum of care, and
nurture innovation in meeting and developing a full continuum
of care.
The cost of care per patient per year in long-term care
services can vary from as much as $140,000 a year per patient
in a VA staff nursing home bed to as little as $2,500 a year
for home care programs using interactive technology.
The Millennium Health Care bill focuses on our need to
provide that long-term care, but with all due respect, Mr.
Chairman, the one capacity that is measured is the most costly
on that continuum, and that is the institutional long-term
care, at an average cost of $140,000 per patient per year when
the average cost of non-institutional care is only $10,000 per
patient per year, meaning that we could serve 14 patients in a
non-institutional setting for the cost of one patient in an
institutional setting, and yet the Mil bill mandates that we
maintain our 1998 VA staff nursing home capacity at historical
levels.
We have submitted from the department a request for
legislation that would ask you to consider looking at the three
levels of VA nursing home care--VA staffed nursing home care,
state nursing home beds, and contract community nursing home
beds--in meeting that obligation for commitment.
I think that truly the most important part of this is
making sure that we can deploy the resources in a way that
meets the broad needs of our veterans. There are concerns now
with tremendous growth in the users in our system, lengthy
waiting times for access to care, and a statutory requirement
which admittedly we have not yet complied with, but hope to
comply with by 2004 to maintain the VA staff nursing home bed
capacity.
Those are the constraints that cause competition for the
dollars. The 2003 budget request submitted earlier this year,
however, would provide over $100 million for additional long-
term care services and would add staff to the 75 Home Based
Primary Care Programs like the ones Gladys Dickerson spoke of
throughout the country.
It would also add 30 additional of those programs so we are
committed to long-term care. We are committed to innovation. We
are looking at ways to provide the needs in new and less costly
ways, but more importantly that meet the needs of the veterans
in a less restrictive environment that allow better quality of
life and greater functional independence.
I would be happy to answer any questions you might have.
[The prepared statement of Dr. Roswell follows:]
Prepared Statement of Robert H. Roswell, M.D., Under Secretary for
Health, Department of Veterans Affairs
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.
veterans millennium health care and benefits act
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:
<bullet> 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;
<bullet> 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
<bullet> 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.
va long term care strategy
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:
<bullet> achieve an integrated care management system that
incorporates all of the patient's clinical care needs;
<bullet> provide more care in home and community-based settings as
opposed to inpatient settings, when appropriate;
<bullet> achieve greater consistency in access to and quality of
care provided in all settings;
<bullet> achieve greater consistency across the system in assessing
patients for extended care and in managing care, including post
institutional care;
<bullet> continue to emphasize VHA research and educational
initiatives that will improve delivery of services and outcomes for
VA's elderly veteran patients; and
<bullet> 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).
conclusion
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.
Attachment A.--Veteran Demographics and Population Projections
Between 2000 and 2010, the veteran population is currently
projected to decline by 17.7 percent (from 24.3 to 20.0 million).
However, this projection may change due to the current armed conflicts.
Over the same time period, the percent of veterans over the age of 65
will decline only by 9 percent (from 9.3 million to 8.5 million), while
those 75 and older will increase 12 percent (from 4 to 4.5 million),
and those over 85 will increase by 208 percent (from 422,000 to 1.3
million). To continue to provide the appropriate and needed service to
veterans, this ``demographic imperative'' must be addressed.
At present, about 38 percent of the veteran population is over 65,
compared to about 13 percent of the total U.S. population. Over 51
percent of veterans who have service-connected disabilities or are poor
are over 65. The number of veterans over age 65 peaked at 9.3 million
in the year 2000, when 66 percent of all American males aged 65 and
over were veterans. A second but smaller peak is expected to occur in
2015, with the aging of Vietnam-era veterans. The projected peak in the
number of elderly veterans during the first decade of the 21st century
is well in advance of the general United States population (which is
expected to peak in the year 2030). This is one of the driving forces
behind VHA's current efforts to find high quality, affordable extended
care solutions for meeting the needs and preferences of veterans.
The most vulnerable of our older veteran population, those over 75
and particularly those over 85, will continue to increase into the next
decade. This is notable since these persons are especially likely to
require institutional care and to need healthcare of all types. Also of
importance is the fact that current VA patients, compared to the
general population, are not only older, but they also generally have
lower incomes and no health insurance, and they are much more likely to
be disabled and unable to work. While it is important to maintain our
nursing home capacity to serve the post-acute rehabilitation, respite,
geriatric evaluation and hospice/palliative care needs of older,
chronically disabled veterans, it is equally important to expand our
home and community-based extended care options wherever possible and
appropriate.
Attachment B.--Current VHA Geriatric and Extended Care Programs
Today, VHA provides a comprehensive array of long term care
services that include direct VHA provided services, services purchased
in the local community, and services supported through construction and
per diem grants to states. VHA also assists veterans and families in
obtaining services through other publicly funded healthcare programs
such as Medicare and Medicaid, and provides assistance in obtaining
services that are personally financed by the veteran. While the array
of services provided by VHA is comprehensive, all services are not
available in all VA locations, and access to care is currently not
equitable across the system. The major long term care programs provided
by VA are described below:
State Veterans Homes. A significant part of VHA's long term care
strategy is effected through one of the longest existing Federal-State
partnerships, the State Home Grant program. Through this program, the
Department provides grants to states for the construction and support
of state veterans homes to provide long term care for frail, elderly
veterans. The construction grant program provides up to 65% federal
funding to states to assist in the cost of construction of new nursing
home and domiciliary facilities, or expansion or remodeling of existing
facilities. VA's per diem program, part of the Medical Care account,
assists states in providing domiciliary and nursing home care for
veterans through partial payment of per diem costs. Most recently,
regulations have been published on per diem payments for provision of
adult day health care in State homes. In FY 2001, over 16,000 veterans
on any given day were provided nursing home care in state veterans
homes. While this program dates back to the post-Civil War era, it has
grown dramatically over the past 10 years. The state home program
substantially augments VHA's capacity to provide a continuous residence
for veterans in need of long term care, especially for veterans in
rural areas.
The Geriatric Evaluation and Management (GEM) and Geriatric Primary
Care Programs. The majority of VA medical centers have GEM and/or
geriatric primary care programs. The GEMs provide both primary and
specialized care services to a targeted group of elderly patients on an
inpatient unit or in outpatient settings. On the inpatient GEM units,
an interdisciplinary team of geriatric experts performs comprehensive,
multidimensional evaluations of frail, elderly patients. The goals of
these intensive services are to improve functional status; to stabilize
the acute and chronic medical conditions and/or psychosocial problems;
and to discharge the patient to home, residential care, or to the least
restrictive environment feasible.
GEM clinics provide similar comprehensive care for geriatric
patients on an outpatient basis in addition to providing primary care
for frail, older patients to prevent unnecessary institutionalization.
The geriatric staffs also are available for specialty consultation on
elderly patients with complex problems being cared for by primary care
and other specialty services.
Geriatric primary care clinics have been expanding in VHA over the
past few years with the move from inpatient to outpatient care and
expansion of primary care throughout the system. These clinics provide
geriatric evaluation services and on-going primary care for geriatric
patients.
Nursing Home Care Units (NHCUs). VA nursing homes provide skilled
nursing and related medical services through an interdisciplinary
approach to meeting the multiple physical, social, psychological and
spiritual needs of patients. Most also provide sub-acute and post-acute
care. In general, these units are co-located with or are an integral
part of the VA medical center. In FY 2001, 41,934 veterans received
care in VA's 135 NHCUs.
Community Nursing Home Care. VHA contracts with approximately 2,800
community nursing homes to provide nursing home care for veterans
making a transition from the hospital to the community. Each community
nursing home is evaluated and inspected by VHA staff prior to selection
as a contract facility, and VHA staff provides follow-up visits to
assess the progress of veterans admitted to the facility and to monitor
the overall quality of care.
In order to improve access to community nursing homes and reduce
the administrative cost associated with maintaining hundreds of
individual contracts, VHA has recently developed contracts with multi-
state nursing home providers. In 1996, six multi-state contracts and
one single-state contract were awarded to corporations for quality
community nursing home care in 1,053 facilities. These seven contracts
together span 43 states and added nearly 600 nursing homes to VHA's
existing contract community nursing home program. Since 2000, VA has 11
Regional Contracts (replaced multi-state), which include 8,000
facilities. In 2001, nearly 28,800 veterans were treated in community
nursing homes at VA expense.
Adult Day Health Care (ADHC). This therapeutically oriented program
provides health maintenance and rehabilitation services to veterans in
a congregate, outpatient setting. VHA operates 14 ADHC programs, which
had an average daily attendance of 446 patients in FY 2001. VA also
contracts with an estimated 480 non-VA agencies for ADHC, which
provided services to an average of 804 veterans each day in FY 2001.
The contract program has been established by 66 VA facilities.
Alzheimer and Other Dementia Care Programs. Approximately 52 VA
medical centers have developed specialized programs for the care of
veterans with dementia. These programs include inpatient and outpatient
dementia diagnostic programs, behavior management programs, adapted
work therapy programs for patients with early to mid stage dementia,
Alzheimer's special care units within VA nursing homes and transitional
care units, and a model inpatient palliative care program for patients
with late stage dementia. Programs for family caregivers of dementia
patients include support groups and caregiver education, as well as
respite and adult day health care services for the patient that allow
``free time'' for the caregiver. Many of these specialized programs for
patients with dementia have been developed by VHA's Geriatric Research,
Education and Clinical Centers (GRECCs). Seven of the current 21 GRECCs
have a primary or secondary focus on Alzheimer's disease and related
dementias. These GRECCs have made significant contributions to both the
scientific understanding of dementia and improved models of care for
dementia patients.
Home-Based Primary Care. This program is operated at 75 VA
facilities across the country to provide in-home primary medical care
to home-bound veterans with chronic diseases, as well as to patients
with a terminal illness. The patient's family provides the necessary
personal care under the coordinated supervision of an interdisciplinary
treatment team based at the VA facility. The team plans and provides
for the needed medical, nursing, social, rehabilitation, and dietetic
regimens and trains family members and the patient in supportive care.
In FY 2001, comprehensive primary care was provided in the home by VHA
staff to an average of 7,803 patients on any given day.
Contract Home Health Care. VHA also arranges with community home
health agencies to provide skilled home care services for veterans.
Under this program, VA pays a per-visit rate to the agency providing
the service, similar to what is done under the Medicare program. In FY
2001, 3,273 veterans were provided these services on any given day.
Domiciliary Care. Domiciliary care is provided in VA domiciliaries,
as well as State homes. VA domiciliaries provided care to 24,931 in FY
2001. Nearly 5,000 of those veterans were homeless and admitted for
specialized care. In addition to services for the homeless, the
domiciliary provides other specialized programs to facilitate the
rehabilitation of patients who suffer from head trauma, stroke, mental
illness, alcoholism, early dementia, and a number of other disabling
conditions. Although the average age of veterans overall in VA
domiciliaries is 59 years (43 years for those in the homeless program),
increased attention is being focused on older veterans who reside in VA
domiciliaries. For example, elderly domiciliary patients are encouraged
to become involved with programs in the community such as senior
centers and Foster Grandparents. These activities have facilitated
continued community involvement as well as reintegration into the
community. Many of the domiciliaries in state veterans homes provide
similar services, although patients in the state home domiciliaries
tend to be older. In FY 2001, 47 State Veterans Home domiciliaries in
33 states served more than 6,400 veterans.
Community Residential Care/Assisted Living. This program provides
room, board, personal care, and general health supervision for veterans
who, because of health conditions, are not able to live independently
and have no suitable family or social support system to provide needed
care. A multidisciplinary team of VHA staff inspects private homes that
provide residential care/assisted living services prior to including
the home in VHA's program and annually thereafter. Payment for services
provided in a residential care home is the responsibility of the
individual veteran. In FY 2001, 7,055 veterans received residential
care on a daily basis in homes approved and monitored by VHA.
Homemaker/Home Health Aide (H/HHA). This program enables selected
patients who meet the criteria for nursing home placement to remain at
home through the provision of personal care services. The H/HHA
services are purchased by VHA from public and private agencies in the
community. Case management is provided directly by VHA staff. During FY
2001, 120 VA facilities purchased these services for approximately
3,824 veterans on any given day.
Respite Care. Another program that enables the chronically ill,
disabled veteran to live at home longer than would be otherwise
possible is respite care. This program is available at nearly all VA
facilities and is designed to reduce the caregiving burden from the
spouse or other caregiver by admitting the veteran to a VA hospital or
nursing home for planned, brief periods, totaling no more than 30 days
per year. During the inpatient stay, patients are also provided with
evaluative and treatment services needed to maintain or improve
functional status, thus prolonging the veteran's capacity to remain at
home. A formal evaluation of this program, concluded in 1995, found a
high level of satisfaction among family caregivers and a high level of
enthusiasm for the program by VHA staff delivering the care. In FY
2001, nearly 700 veterans were receiving respite care on any given day.
Home respite was authorized under P.L. 106-117 and programs have been
initiated at a number of VA facilities, utilizing contract services and
piloting the use of volunteers to provide the respite services.
Hospice/Palliative Care. A number of VA medical centers have an
interdisciplinary hospice/palliative care consultation team that is
responsible for planning, developing and arranging for the local
provision of hospice care, directly by VA or through contract or
referral to community programs. Hospice/palliative care programs offer
pain management, symptom control, and other medical services to
terminally ill veterans or veterans in the late stages or chronic
disease process, as well as bereavement counseling and respite care to
their families. System-wide education and training was provided in the
early 1990's to facilitate the incorporation of hospice/palliative care
concepts into each VA facility's approach to the care of veterans at
the end of their lives. New education programs are being planned to
reinforce the concepts for current staff. Approximately 42 percent of
VA facilities have inpatient hospice/palliative beds but nearly 38
percent of facilities have neither inpatient beds nor consultative
services. The majority of VA facilities refers or contracts for hospice
services through community-based agencies. Hospice and palliative care
initiatives are currently being intensified throughout VHA to improve
end-of-life care for veterans. Specific strategies to increase the
availability of these services to veteran patients are currently under
development.
______
Response to Written Questions Submitted by Hon. Patty Murray to Robert
Roswell, MD
Question 1. Do you believe the VA should work with private home
health care providers to meet its obligations to provide veterans with
long term care opportunities?
Answer. Collaboration with private home health care agencies is
integral to VA's success in meeting the home health and long-term care
needs of veterans. Through the VA Community Health Nurse Coordinator
program, VA works with private home health agencies in providing needed
care to veterans. The majority of the effort in this program involves
referrals by VA staff of those veterans who choose to use their
Medicare eligibility to home health care (HHC) agencies. Additionally,
VA maintains arrangements with over 500 HHC agencies for the provision
of care at VA expense. In FY 2001, approximately 3,300 veterans were
enrolled in skilled private HHC, and another 3,800 were enrolled in
homemaker/home health aide services at VA expense on any given day.
Question 2. Without Medicare reimbursement, home health agencies
cannot survive, despite an infusion of VA funds. How can we address the
inequities in funding that may force many home health care providers to
leave?
Answer. Home Care expenditures from all payers totaled $32 billion
in FY 2000 (latest available data). In that year, private funds covered
47.8 percent of all HHC spending ($15.5 billion), and public, non-VA
funds (Medicare and Medicaid) covered 51.9 percent ($16.8 billion).
VA's expenditures of $108 million for skilled HHC and home health aide
services in FY 2000 represent only 0.3 percent of home care spending.
VA's current and planned efforts for purchasing home care services do
not indicate a major presence in the marketplace. This Department has
no opinion on the larger issues of Medicare reimbursement.
Question 3. Has the VA carefully considered access for all
veterans, regardless of where they live, when developing options to
nursing home care?
Answer. VA's planning model for long-term care (LTC) services, both
nursing home (NHC) and home and community based care (H&CBC), is based
on the enrolled veteran population, rather than the total veteran
population. To the extent that veterans who live at a distance from a
VA Medical Center are enrolled in VA for their health care, then their
needs for LTC are addressed. In this regard, nursing home care is
mandated for veterans with a 70% or more service-connected disability.
Veterans with less than a 70% service-connected disability receive care
on a resource available basis.
One of the advantages of contracting or purchasing home care is
that VA can address veterans' HHC needs without attempting to provide
it directly in geographic locations where demand for care could not
justify an efficient VA-operated program. At the same time, VA has been
successful in establishing Home Based Primary Care (HBPC) Programs at
VA clinics located at a distance far from the host VA medical center.
The HBPC Programs at Hot Springs, Arkansas and Joliet, Illinois are the
best examples of VA-operated satellite home care efforts.
Access to nursing home care for veterans is provided through VA's
three programs: VA nursing home care units (NHCU); contract community
nursing homes (CCNH); and State veteran nursing homes. There are
currently 135 VA NHCUs, contracts with 2,800 CCNHs and 11 regional
contracts, and 102 State nursing homes. Increased demand for nursing
home care will primarily be met in CCINIH and State nursing homes.
Construction of new State home beds, with VA providing up to 65 percent
of the cost, is based on veteran population need in each geographic
area.
Chairman Rockefeller. OK. I want to just deal, Dr. Roswell,
with your statement you have made. You are correct that
Congress has said that VA must not reduce nursing home beds,
and on the other, that VA must increase its efforts of non-
institutional long-term care. You would like to be relieved of
one to do more of the other.
Unfortunately, both are necessary elements to long-term
care. So you are not going to get that wish under the laws of
health care. Some people just do not stay in the community,
cannot stay in the community, should not stay in the community.
So you have asked for relief from VA staffed nursing home beds
requirement.
I am willing to entertain the possibility of some change. I
think we must be assured that VA retains sufficient capacity to
provide institutional long-term care for those who need such
services, and I want you to talk about those who do need such
services, and if you do not do it, then I will get Dr. Moye to
come back to do it.
So far, VA has not been able to do this in the area of
specialized services, and so I do not know how I am meant to
react to what you just said. In a sense you gave a reason why
you cannot comply--because it costs $140,000 per patient for
institutionalized care--knowing full well as you said that that
that is also going to continue and has to.
You said that the rules and regulations are going to be out
in a week. I hope, I assume that is to provide me with some
sense of comfort or a mission well done. Again I recognize you
have just been on the job, so I am talking more to predecessors
of yours, but I am talking to you, because you are now
responsible and you took the oath.
And so that is sort of a nice little wrap-up that you do
more of what the four folks were talking about, and that they
are wonderful. You have also got this other little burden,
which you and I know that you cannot get rid of, because all
people cannot go back to the community for long-term care.
So, I guess what I want to say is are you trying to kind of
slide by me on this one? And point out your problems? You have
not used resources. Others were told not to use resources, but
that was the first thing that came out of your mouth--I would
but I cannot--because these other institutionalized are too
expensive.
And is that, in terms of the outcome for the veteran,
unacceptable? I guess I cannot accept it, and if Ms. Dickerson
can find ways to do things and you are the second-largest
agency in the entire Federal Government outside of the
Department of Defense with over 200,000 people, I believe,
there must be some ways that you can say something other than
relieve me of this one and I will do the other. Care to
comment?
Dr. Roswell. Yes, Mr. Chairman, I appreciate the
opportunity to comment. First of all, I do agree with you. We
must maintain our institutional capacity. There is no question
that many veterans at some point will need institutional care.
We think we can delay that in many cases, put that off until
later stages of a disease process and in some cases avoid it
altogether, but there is no question, the institutional
capacity will be needed.
All I was suggesting is that our institutional capacity is
split across VA staff nursing home beds, which we own and
operate at an average cost of $380 per day, contract community
nursing home care, which we procure for veterans in an
institutional setting in the community at an average cost of
$185 a day, and skilled nursing home care in homes operated by
the states through the state grant program that provides
skilled nursing home care at an average cost to the VA of $50
per day.
There are three levels or three different types of
institutional long-term care, and I am suggesting that if we
aggregate the total amount in 1998 between those three, that we
be held accountable to the 1998 level of capacity for all of
our long-term care institutional beds as opposed to just the
skilled beds operated only by the VA.
Now, having said that, finding resources, yes, we have to
do both. We have to look at non-institutional programs as we
meet that institutional commitment. My point is that there is a
fierce demand for resources now as our system has grown, and
this year we will have over six million veterans enrolled with
over 4.3 million veterans using the system, reaching levels
that we have never ever attained in our history.
When we look at non-institutional care, we find that many
programs are being developed, and people are finding resources
just to----
Chairman Rockefeller. Can I interrupt for a second?
Dr. Roswell. Certainly.
Chairman Rockefeller. I apologize. You see that is what I
call sliding by me and Senator Wellstone. Because, of course,
there are endless requirements in health care, and of course
you have budget constraints which you have quickly brought up,
and of course you have the responsibility, and of course there
is a war on terrorism, and of course there is homeland
security, and of course we have gone from a $5.6 trillion
surplus to $100 billion deficit for a variety of reasons.
And, of course, you must do your duty and you shall take
care of these people. So I am not predisposed to say that
because you have so many veterans who are getting older and
their problems are getting more complex, that you take what can
possibly be identified as the most obvious and clearly the
fastest growing health care problem that you do and will face,
and say, well, we cannot comply.
Either VISN 2 is an anomaly or you set up some experiments
which you are going to keep as experiments, so that there is
always something good to say about what VA can do. Those regs
will be in effect in a week, but none of that gives me
confidence that you are going to actually go ahead and do it.
And I guess that is what Senator Wellstone and I are looking
for is that you are going to go ahead and you are going to do
these things, and you are going to be like Ms. Dickerson.
You are going to move ahead, and you are going to
understand what Dr. Moye says that things are going to get much
more complicated as patients get older. There is not only a law
and a mandate here, but it is one which seems to take kind of a
primacy among health care problems that the veterans face.
I mean it just sort of stands out and hits you, so to
speak. So I am just inpatient with your answer because I am not
sure what is going to come of it. We have hearings, and
somebody said these hearings are very useful. These hearings
can be very useful. They can also be a wonderful opportunity
for us to say things, sometimes in goodwill, sometimes in less
goodwill. Hearings always end. And people from the Federal
Government are extremely accustomed to handling them; some of
them handle them extremely well. They know exactly what answers
to give. Sometimes they tell witnesses what answers not to
give.
But in any event, the hearings pass, yet in many case the
problems persist. And what I think Senator Wellstone and I want
to know is that you are going to be doing something about this
on a broad scale and that your nursing home problem is going to
be right there, and you are still going to find a way around
it.
Dr. Roswell. Yes, Mr. Chairman. We have actually submitted
a plan to be fully compliant with the Mil bill requirements for
institutional VA long-term care capacity.
Chairman Rockefeller. To whom?
Dr. Roswell. To Chairman Smith of the House Veterans
Affairs Committee, because he requested it. That would bring us
into compliance with that requirement by the end of fiscal year
2004, reaching the 1998 VA staff census of 13,391. But that is
not enough.
Chairman Rockefeller. I mean is a point by point plan or is
it a series of generic goals? Plus I would like to have a copy,
if that would not be inconvenient?
Dr. Roswell. We can provide you with that.
Chairman Rockefeller. That would be very nice.
Dr. Roswell. The plan basically allocates an average daily
census to each of the 21 VISNs to be achieved this year, and
then an interim average daily census next year to bring us back
to that level. It will be at a cost of an additional $161.2
million to be able to get there, and that is money that will
have to come from somewhere, but, yes, it is a statutory
requirement, Mr. Chairman. I respect that. I honor that. We are
committed to it.
But there is a cost associated with that, but we will do
everything we can to move toward that statutory requirement. I
think the hearing--I wanted to focus, I think you wanted to
focus, on non-institutional care.
Chairman Rockefeller. Right.
Dr. Roswell. And that is----
Chairman Rockefeller. But I got very hung up when you
started dangling that $140,000 nursing home cost per year,
because I felt----
Dr. Roswell. Well, for example, as you know, I came into my
current position from being the VISN director in VISN 8. That
is a VISN I can talk greatly about. Our assigned ADC to
increase this year is 109 patients. That will cost probably in
excess of $10 million in additional staff to be able to move
the census to that level.
Two and a half years ago, I shared the concerns you have
echoed this morning and some of our panelists have echoed. I
took $5 million out of the VISN 8 budget because I found a way
to find those resources to create a program to meet long-term
care needs. With less than $5 million a year, we now operate a
community care coordination service.
The director is sitting here in the gallery today. That
community care coordination service provides care in a home
setting using interactive technology to over 1,300 patients.
Now the average cost per patient is $2,500 per year. Many of
those patients are at great risk for nursing home placement and
would only be in a home care environment were it not for this
particular program.
That is important to me. Would I like to expand that? Yes.
Which is a greater cost? Meeting our average daily census
requirement in VA staffed nursing home beds is a greater cost
to add 109 patients than it would be to double or to triple the
1,300 patients receiving home care services.
Chairman Rockefeller. Paul, just forgive me, and then I
will be quiet and go to you.
Senator Wellstone. I may have to leave anyway. You go
ahead. I may have to leave.
Chairman Rockefeller. I do not know why it was that I did
not leap up when you said we are going to have this all in
effect by 2004, because my instinctive reaction is that, No. 1,
this is 2002, and the bill was passed in 1999. So that is a
nice long chunk of time.
You do not have to go; do you?
Senator Wellstone. Actually I have people outside to go to
see. That is OK. You keep going.
Chairman Rockefeller. Then you go ahead and ask a question.
Senator Wellstone. No, no, no.
Chairman Rockefeller. No, you go ahead.
Senator Wellstone. Just tell me when you are done and I
will come right back in. I will do that.
Chairman Rockefeller. OK. I am not going to tell him when I
am done. [Laughter.]
Dr. Roswell, are you going to wait until 2004 and then all
of a sudden the firecrackers go off? I mean is the upper New
York model going to be replicated all over the place? I mean
you said you did it yourself, and you seem pretty happy about
it. So are we going to wait until 2004, or?
Dr. Roswell. No, it is a ramp up. Our current average daily
census is 11,000. Marsha can you help me. 11,506 approximately.
Ms. Goodwin. Yes; 11,506.
Dr. Roswell. So we have got to go from that number, 11,506,
to hit an end census of 13,391 by September 30, 2004.
Obviously, to staff those beds does not meet the statutory
requirement. The statutory requirement is that the patients in
the staff beds be at 13,391. So over time we will place
patients as we add staffing and identify patients that are
suitable candidates for VA staff nursing home care.
In the spirit of disclosure, though, it is important that
this committee understand that VA staffed nursing homes provide
a very high level of skilled rehabilitation care. 70 percent of
the people who receive care in VA staffed nursing home beds are
discharged to home. That is a remarkable statistic.
But it reflects not so much our clinical outcome as the
fact that the beds are used primarily for the rehabilitation of
acute medical and surgical problems, and it is truly not end-
of-life long-term care. That type of care is much more
compassionately and cost-effectively provided in State home
beds, the State Department of Veterans Affairs home beds, where
we have had a major growth over the last several years, and I
would hate to deter that growth in the State home program,
because it provides an ideal setting for veterans who have
continuous stay long-term care requirements and are not
suitable for care in the home environment.
Chairman Rockefeller. Secretary Rumsfeld did something
recently which I kind of liked. He sort of replaced some
generals who fought wars the way they used to be fought, with
generals who can fight wars the way they are going to have to
be fought. I have to assume that he took a lot of criticism for
that, and I do not know how deep it reaches. I have no idea
what he had to go through in order to do that.
The point of my question obviously is that if you go from
fighting land-massed wars to the kind of wars that we are now
fighting, you have to change what you do. Now, I am not on the
Armed Services Committee. I did not have a chance to ask him
how you get people to redirect their thinking.
But this is a war that is not waiting for you, and you have
raised problems. You have to change the culture of bureaucracy,
and I do not know that you have to change generals, but you
might, and I am interested in how you personally arrive at how
you implement this by people who will have to, let us say
unlike Ms. Dickerson, who is dealing with a specific situation.
I mean you are dealing with old roles and with people who
have been doing this for 30 years, and by golly, they are not
going to have some guy who has just come in as head of health
and tell them what to do. And so your battle plan for attacking
that and implementing all of this by 2004 ramped up or not?
Dr. Roswell. You know you make an excellent point, Mr.
Chairman. A lot of the way we approach long-term care is in
traditional models. Now, the 1,300 patients I spoke of in
Florida are not even counted in our long-term care count
because they do not fit a traditional model. They are not
institutional care. They are not adult day health care. They
are not home-based primary care. So they do not fit in any of
our traditional categories, and we do not even count them. so
they are not in our total workload capacity.
One of the things I will clearly be doing with the
leadership in the geriatrics and the extended care part of VHA
will be working to develop new programs, to develop new models
of care, to use field-based clinicians, like the talented
people you heard this morning, to define new programs, new
approaches to care, so that we can have a broader continuum of
care and we can define how that care is provided, and that will
lead us to replicate that across that system in a cost-
effective manner.
Chairman Rockefeller. OK. Look, I am interested in results.
I am also interested in Senator Wellstone coming back to ask
his question. [Laughter.]
And then I am going to dismiss the hearing, and here he is.
Senator Wellstone. Gee, I forgot. Actually I think, Dr.
Roswell, I think I do not find myself, it would not surprise
you, in disagreement with the chairman. I mean I think, you
know, I feel exactly the same way about it. The one thing that
also occurs to me, and it is just sort of one comment which is
in the form of a question, and react any way you want to, is
also I think there is, you know, look above and beyond our
saying come on, we are inpatient with the slowness, make this
happen. We have got models, let us do this. I also think,
though, that this debate about, Senator Rockefeller, about how
much it is institutional care versus how much is it going to be
home-based care.
You know what I worry about are these sort of zero sum
games that we are going to have to play. In other words, it is
a false choice, I mean if we have the resources, and I also
look at other parts of our health. In our region, we are seeing
some pretty darn severe strains right now.
We do not have the adequate funding. So the other thing I
want to say to you is, you know, if you do not have the
resources, you got to say it. I mean you got to come up here
and say to us, listen, we need to do both. We cannot like
cannibalize, you know, nursing home care for the sake of doing
home-based care, but home-based care makes a lot more, but
there is a lot of people that could benefit from that, and then
there are other needs as well, and you all need to give us the
resources we need.
So my appeal to you would be, you know, you have to say it.
And I frankly think you should. I mean I think a number of us
are going to work on a supplemental bill. We are going to argue
we need more resources. Now, Senator Rockefeller is going to
say there is lots of ways you can get your priorities right and
deliver some of this care right now, but I also think--I
personally think you got a big resource problem, and I think
the VA needs to be bolder in telling us that we need to step up
to the plate with the resources that you need, but I cannot
tell you what you need unless you tell me what you need. That
is the only thing I would add.
Dr. Roswell. Well, Senator Wellstone, thank you. I
appreciate your comments and I appreciate your support. In his
letter to Chairman Smith, Secretary Principi indicated the plan
to get there, and I do not know that he specified the exact
cost. He did. He identified that the cumulative shortfall to
meet the Mil bill requirements is $161.2 million.
That is an operational shortfall in our budget right now to
be able to meet the statutory requirement of the Mil bill just
as it applies to the VA staffed inpatient nursing home
requirement of the 1998 capacity at 13,391.
Senator Wellstone. That is on top of the $400 million
shortfall he identified last November as well?
Dr. Roswell. It is on top of the $142 million for priority
seven. Now, the $400 million included management efficiencies
that are being sustained by the various 21 VISN's, but that
information, Senator, I will be happy to leave is detailed in
that letter.
I guess my concern is that it is so much more than
institutional long-term care. There is so much we need to do.
We need to have VA staffed nursing home beds, but we need State
home beds, more State home beds. We need to use contract
community nursing home beds, because each meets a different
need. We clearly need to develop and nurture the innovation and
the commitment that was seen on the previous panel.
We need to develop models that allow greater functional
independence that offset the need for institutional care, to
preserve the quality of life as long as we possibly can.
Senator Wellstone. Well, I just want to interrupt you and
finish. I like what you are saying. I just think that, and, you
know, look, this is not the VA. I just would love for the VA to
be a model for the Nation, and I mean we have the same issue
with the population at large. We have, I think, Senator
Rockefeller, that we have our collective heads ducked in the
sand when it comes to the demographics of our country and the
number of people that are going to live to be 80 and 85, and
how are you going to have people staying at home in as near
normal circumstances as possible living with dignity that way,
and then when they can--I had a mother and father with
Parkinson's.
We lived all of this, and then we cannot, then there will
be good care, you know, high quality care, which we do not have
in our nursing homes right now, and so it is not just VA, but I
think the whole point of this legislation was for us to sort of
lead the way; am I correct? And that we are not doing. But we
can and you are committed to it, so I just would finish up
again and say let us make this happen, and at the point at
which I think you are trapped by your budget, I think frankly
veterans health care, quality veterans health care is on a
collision course with the tax cuts.
I think we cannot do everything. And we have to be honest
about how much tax cuts and how much revenue, and I think that
is part of what is facing you. But I am with you. I will work
with you.
Dr. Roswell. Thank you very much for your support.
Senator Wellstone. With you, too. I want to work with you.
Chairman Rockefeller. You may be more with him than I am.
[Laughter.]
Let me conclude with these comments. I think VA loves to
think of itself as being recognized as a national leader in the
care of the elderly. And the truth of the matter is that it is
within those who observe VA and health care, but elsewhere it
is not recognized as such. It gets an occasional burst and a
little bit here and there, but it is not. And it needs to be.
That is point No. 1.
Point No. 2, you know you have sort of General Motors and
you have the Federal Government, and sometimes I am not sure if
there is really any difference in the way they are run, and
this goes back to, I think, two points. One is that you cannot
give any testimony or Secretary Principi, and I assume yourself
that has not been previously cleared by OMB.
That ought to infuriate you as a health care professional.
Now, the deal, of course, is that everybody has to be on the
same page of the song. There have been those who have decided
not to be. Some have paid a price for it. I think Secretary
Derwinski could probably tell you something about that. Jesse
Brown used to be told by President Clinton what the budget was
going to be, and he said, oh, yeah, and then he would fight for
more money.
In other words, I am not making any Republican/Democratic
comparisons here. What I am saying is that the one main
question I asked Tony Principi when he came here for
confirmation, was, are you willing to go head to head with the
President if you do not get the budget you want? That is what I
care about more than anything else, that you will go to him,
demand time and argue your case, whether he likes it or not.
Just bull right past Andy Card. I mean he is bigger. You are
bigger than Andy Card. Just bull right past him. In your case,
you are an Under Secretary.
And I do not know Mitch Danielsvery well, but I encourage
you to sort of adopt that kind of mentality, because if you
mean what you have been saying this morning, then you are
obviously going to have to fight along with us.
And where everybody is concentrating on other issues which
have to do with national security and homeland security, which
is exactly what our first constitutional responsibility is. In
the meantime, a thousand veterans are suffering. How are they
dying and under what conditions? What is VA doing?
So that what I like to refer to as face time, and that is
putting yourself on the line, because ultimately that is what
we do here, if we are doing our jobs. There comes a time when
you simply have to put yourself on the line, and then you lose
sometimes, but if you put yourself on the line, people know
that you mean it. People know if you put yourself on the line,
if you have put your job at risk, if you have not been afraid
to offend somebody who is superior in position, then suddenly
they know that you mean it and all of a sudden you are listened
to more.
And that whole dynamic and the absence of its practice in
Washington is thoroughly not understood by the American people
who choose but sometimes wisely to ignore Washington all
together thinking that not much of anything happens here.
I happen to think a great deal happens here, and I happen
to know that an enormous amount happens here and only happens
here that affects long-term care and veterans. So that was not
just generally directed at you. It was an expression of
frustration on my part, but it is partly directly at you. At
some point people take stands, and, for heaven sakes, if you go
into public service, that is one thing. If you go into health
care, I mean you do that--for how long to become a doctor?
Dr. Roswell. Four years of medical school.
Chairman Rockefeller. Yes.
Dr. Roswell. An average of 4 to 5 years of residency, yes.
Chairman Rockefeller. So I mean, in other words, there is
sort of a large commitment in your life to doing health care
right, and I would like to see that work for the advantage of
long-term care in the Department of Veterans Affairs.
Dr. Roswell. Thank you, Mr. Chairman.
Chairman Rockefeller. And I thank you, and this hearing is
adjourned. Also, without objection, the written statement of
Senator Murray will be made a part of the record.
[The prepared statement of Senator Murray follows:]
Prepared Statement of Hon. Patty Murray, U.S. Senator From Washington
Thank you Mr. Chairman for calling this hearing. Like you, I'm very
concerned that veterans still do not have universal access to the
additional long term care benefits we provided for in the 1999
Millennium Health Care Act. I hope this hearing will help us move the
process forward quickly so that our older veterans can get the care
they need.
I'm also concerned that veterans are losing long-term care options
because of some of the larger changes that are taking place in health
care. In Washington State, nursing homes and home health care agencies
are closing their doors, in part, because of unfair Medicare and
Medicaid reimbursement rates that punish providers based on their
geographic location. It's an issue we've got to address to ensure that
veterans and all seniors have access to long-term care.
As I mentioned, in 1999, we passed the Millennium Health Care Act
to add extended care services to the VA benefits package. But the VA
has been extremely slow in making those benefits available to veterans.
As the chairman knows, the GAO recently found that:
``Two years after the passage of the act, VA has not
completely implemented its response to the act's requirement
that all eligible veterans be offered adult health care,
respite care, and geriatric evaluation.''
The report goes on to say that: ``access to these programs was far
from universal in the VA.''
I understand the VA has gone back to OMB for a third time trying to
get the final regulations approved so that they can comply with the
Millennium Act. Frankly, I don't understand why it's taken so long to
implement the Act. The VA has a legal and a moral obligation to our
veterans to ensure access to quality long-term care. Of course, today,
long-term care means much more than just nursing homes. It includes
home health care, adult day care, adult homes, and respite care.
When you look at the growing need for long-term care, it's clear
the VA is going to have to work with private health providers.
According to the GAO, in FY 2001 the VA spent about $3.1 billion on
long-term health care and the amount is likely to increase. It's
projected between the years 2000 to 2020 the US population over the age
of 85 will increase by 37%, and the veteran population will nearly
triple. I find these statistic particularly troubling when you consider
that VA nursing homes beds are very expensive, costing as much as
$50,000 per year for a veteran. That's nearly $20,000 dollars more
expensive than the national average.
Given these statistics, it's clear that the VA will have to
contract with private health care providers to meet the needs of our
veterans.
As the VA has done for ensuring access to nursing homes, we will
have to turn to private providers, like home health care agencies, to
help cover the full commitment to our veterans. Unfortunately, the VA
has committed very few resources to non-institutional settings. In
fact, of the $3.1 billion the VA spent on long-term care in 2001, only
8% was devoted to non-institutional settings.
There is no question that this Issue is resource driven. However,
it only makes sense to devote more resources to non-institutional
health care settings to increase our ability to provide for all
veterans. Home health care offers quality care that allows veterans to
stay in their home, with their family, in the community. It offers a
sense of relief as well for family members who are not equipped to
handle the health care needs of the patient, but who don't want to see
their loved ones in a nursing home.
As we have seen with Medicare, home health care offers real
solutions to acute care and long term care. Home health care providers
are well trained and can provide a wide range of highly skilled care to
veterans with special health care needs. However, for veterans in
Washington state, home health care may not be an option to nursing
homes.
Currently, Washington state ranks 45th in average per beneficiary
costs in comparison to other states. We are well below the national
average. For example, providers in Florida or Texas can receive almost
twice as much per home health visit than a provider in Washington
state.
This inequity, coupled with the scheduled 15% reduction in home
health care under Medicare, could cripple home health care in
Washington state. We've already seen agencies closing or scaling back
their home health care delivery areas. Hospitals that once actively
participated in home health care are leaving. This is quickly becoming
a crisis situation.
Medicare is penalizing home health care agencies, like doctors and
hospitals in Washington state for providing more cost effective care.
Over the lifetime of a Medicare beneficiary, this can mean thousands of
dollars less spent on their care in Washington state.
This inequity is already forcing many doctors to leave and causing
severe health care professional shortages in hospitals. Our hospitals
cannot compete with hospitals in other states that can pay more because
they receive significantly more from Medicare for providing the exact
same service.
These regional inequities have resulted in vastly different levels
of care and access to care. For example, in Florida many Medicare
beneficiaries have access to prescription drugs and prescription
eyeglasses in the Medicare+Choice program.
In Washington state, there are no plans available that offer
prescription drug coverage much less eyeglasses. I don't want to see
the same thing happen to our veterans.
Veterans, regardless of where they live, deserve access to quality
nursing home options. Unless the VA plans on creating competing home
health care agencies in Washington state for veterans only, there may
be limited access to this option.
It's unfair and unjust to provide vastly different levels of care
for veterans depending upon where they live.
I urge the VA to work with CMS to ensure that home health care
agencies in all states are stable and affordable. Home health care must
be an option for veterans. With the advances in medical research and
the aging veteran population, the VA has to explore and invest in
alternatives to nursing homes. In many cases, these alternatives
provide a more appropriate level of care.
I've been supportive of efforts to address these inequities, and
I'll continue to work on it. I again want to thank the Chairman for
holding this hearing and for helping to ensure our veterans have
options when they need long term care.
Chairman Rockefeller. Thank you. The hearing is adjourned.
[Whereupon, at 12:20 p.m., the committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Ben Nighthorse Campbell, U.S. Senator From
Colorado
Thank you, Mr. Chairman, for holding this hearing today. I look
forward to hearing from the panelists regarding the VA's efforts to
provide alternative long term care services.
In my meetings with veterans from Colorado, one of the issues of
greatest concern is health care. The vets want to know that they will
be able to get quality care when they need it.
I am encouraged that in recent years, Congress has invested
substantial resources to improve the quality and accessibility of VA
medical care and to make that care available to more veterans. As I
understand, the number of individual veterans served by the VA has
increased by 65% in the last 7 years. But, nearly all of that increase
has been in primary care provided by outpatient clinics.
Now, as the age of the our veterans population rises, we are
looking at services needed by older patients. In the 106th Congress,
under your leadership, Mr. Chairman, we enacted legislation directing
the VA to expand its geriatric services to include nursing home care,
assisted living arrangements and home care options.
Today, it is time to look at those programs to determine how we are
doing. Are our elderly and disabled veterans being offered the options
we have promised them? Are they able to choose home care rather than
institutional care? Can they find adult day care services? Are their
family caregivers able to find relief services?
Speaking as a veteran, I believe we need to do all we can to help
those who have so honorably served all of us.
Mr. Chairman, again, I thank you for holding this hearing and look
forward to hearing details of how the VA is addressing the long term
care needs of our vets.
______
Prepared Statement of the Alzheimer's Association
Mr. Chairman and members of the Committee:
The Alzheimer's Association appreciates the opportunity to submit
the following statement to the Committee on Veterans Affairs for the
hearing entitled ``Options to Nursing Homes: Is VA Prepared?''
The Alzheimer's Association is the premier source of information
and support for the four million Americans with Alzheimer's disease.
Through its national network of chapters, it offers a broad range of
programs and services for people with the disease, their families, and
caregivers and represents their interests on Alzheimer-related issues
before federal, state, and local government and with health and long-
term care providers.
Over the past few years, the VA has embarked on several exciting
projects to improve care for veterans with Alzheimer's disease and
other dementias. Our comments in this statement will focus on two
specific projects currently underway within the VA system.
advances in home based primary care for end of life in advanced
dementia (ahead)
Advances in Home Based Primary Care for End of Life in Advanced
Dementia (AHEAD) is a rapid-cycle improvement project intended to help
VA staff identify problems in dementia care, implement clearly defined
steps to address them, and evaluate outcomes. The first group of AHEAD
sites included teams of 3-5 VA staff members from Home Based Primary
Care units at 20 Veterans Integrated Service Networks (VISN's). The
teams worked from January-September 2001, and focused on four areas of
improvement: early intervention, symptom management, staff education,
and caregiver support. Outcome data show improvements in each of these
areas at many of the sites. A second group of AHEAD sites is now
underway.
chronic care networks for alzheimer's disease (ccn/ad)
Chronic Care Networks for Alzheimer's Disease (CCN/AD) is a longer-
term project that is being implemented in the VA's upstate New York
network (VISN 2). CCN/AD is a 7-site national demonstration project
that is jointly sponsored by the Alzheimer's Association and the
National Chronic Care Consortium (NCCC). It is intended to provide
coordinated health care and supportive services for people with
Alzheimer's disease and other dementias by linking Alzheimer's
Association chapters and health care systems. VISN 2 is the only VA
participant in the national demonstration. Since 1997, it has worked
closely with four local Alzheimer's Association chapters to coordinate
care and improve outcomes for veterans with dementia.
VISN2 leadership and staff have strongly and consistently supported
the development and implementation of CCN/AD. While the VA central
office and individual networks and medical centers have previously
provided extensive resources and leadership in Alzheimer's research and
demonstration projects to improve Alzheimer's and dementia care, this
is the first time VA and Alzheimer's Association chapters have worked
together at this level and with this intensity. The Alzheimer's
Association believes that the change and improvement in Alzheimer's and
dementia care in VISN 2 are truly impressive.
With the support of the Senate Committee on Veterans Affairs and
the VA central office, AHEAD and CCN/AD could be replicated in other VA
networks across the country, and the benefits of these innovative
projects could be extended to many more veterans with Alzheimer's
disease and other dementias. The Alzheimer's Association is especially
enthusiastic about the potential for replication of CCN/AD because of
the value of coordinated medical care and supportive services for
people with these conditions, and the remainder of our statement
focuses on this project. We would point out, however, that the
experience and knowledge developed by VISN 2 in its work with
Alzheimer's Association chapters over the past five years could provide
a valuable basis for similar working partnerships between VA facilities
and other community agencies. Such partnerships could improve the care
available to veterans with other chronic conditions, which, like
Alzheimer's disease, require both medical care and non-medical,
community-based services.
the visn2--alzheimer's association partnerships
In upstate New York, CCN/AD has been implemented through VA/
Alzheimer's Association partnerships at the network and VA medical
center levels. VA staff at the Albany, Bath, Canandaigua, Syracuse, and
Western New York VA medical centers have worked closely with the four
Alzheimer's Association chapters that serve the same geographic areas.
Overall policy has come from the network level, but detailed procedures
for training, referrals, assessments, and joint care management have
been developed at the medical center/chapter level.
The creation and maintenance of these working partnerships has
involved each partner learning about the organizational structure,
practices, and available services of the other. VA staff have learned
about training programs, informational materials, family educational
workshops, and support groups provided by the Alzheimer's Association
chapters. Chapters have learned about the wide array of institutional
and non-institutional services provided by the VA. VA medical centers
have designated a single point of contact for referrals from the
chapters. Likewise, if veterans and their families agree and give
formal, informed consent, VA staff can fax their names and contact
information to the chapters so that the chapters can reach out to them
with supportive services.
the ccn/ad model
The CCN/AD model was developed by physicians, other health care
professionals, and Alzheimer's Association chapters from the seven
participating sites, including VISN2 and the upstate New York chapters.
It is intended to address common problems in the care of people with
Alzheimer's disease and other dementias in VA and non-VA settings and
to meet the needs of the person as a whole, not just his/her
Alzheimer's disease or dementia.
The model includes recommended procedures and tools for
identification of people with possible dementia, diagnostic assessment,
ongoing care management, and family support. It is available from the
National Chronic Care Consortium's website at www.nccconline.org.
implementation of ccn/ad in visn2
CCN/AD was first implemented in Syracuse, with the Syracuse VA
Medical Center and the local Alzheimer's Association chapter
functioning as the pilot site for VISN 2. The Robert Wood Johnson
Foundation provided a one-year $100,000 grant to support the pilot
test.
Once the pilot test was completed successfully, the Foundation
provided an additional $700,000 grant for two years of full
implementation to be completed in October 2002.
Over the past three years, extensive training has been provided,
first in Syracuse and then in the other medical centers. Hundreds of VA
staff members have received training about Alzheimer's disease,
dementia, and effective approaches to care. As the project has matured
in the main medical centers, training has also been offered in some of
VISN 2's community-based outpatient centers (CBOCs), e.g., in Elmira,
Rochester, and Rome, NY.
VA staff throughout VISN 2 have been trained to recognize the
warning signs of dementia and to refer veterans with possible dementia
for a diagnostic evaluation and possible enrollment in CCN/AD. As of
April 2002, more than 450 veterans have been enrolled. Some of these
individuals are in the early stages of Alzheimer's disease or another
dementia, but others are in later stages and have simply not been
identified previously. Available data indicate that nationally, only
20-40 percent of people with dementia have received a diagnostic
evaluation. The numbers were probably somewhat higher in VISN2 even
before CCN/AD because some of the medical centers already had
diagnostic clinics. Still, however, many veterans with dementia had not
been identified and diagnosed. CCN/AD procedures and tools are helping
to address this problem. In addition to efforts by VA staff, the local
Alzheimer's Association chapters have begun asking callers whether they
are a veteran or a family caregiver of a veteran. If they are, the
chapter is able to make an expedited referral into the VA for that
individual or family.
Diagnostic assessment is occurring in all of the medical centers
and CBOCs. The CCN/AD model includes a recommended assessment that not
only supports the diagnostic process but also provides valuable
information about the veteran and his/her family that can be used for
care planning. Each VA medical center has made adaptations to the model
to fit with pre-existing practices at that center, available staff, and
other resources.
At each of the five main medical centers, VISN 2 has created a new
dementia care manager position. These five VA employees provide and
coordinate training, encourage, assist with, and oversee the CCN/AD
identification and assessment procedures, and work with Alzheimer's
Association chapter staff to develop project procedures and eliminate
barriers to better care.
Ongoing care management for veterans enrolled in the project is
provided by the dementia care managers, other VA specialists and
primary care providers, and chapter staff. The dementia care managers
and chapter staff talk frequently with each other about the needs of
particular veterans and their families and how those needs can be met.
Both the dementia care managers and chapter staff make referrals to
other community agencies. Occasionally, in particularly difficult
situations, the dementia care manager and a chapter staff member have
made joint home visits. More often, however, one or the other is able
to solve the problem and obtain the needed care for the veteran.
In VA medical centers were there is a dementia clinic, ongoing
medical and non-medical care management has been provided in the
dementia clinic. Over time, as the number of enrollees has increased
and primary care providers have become more knowledgeable and
comfortable with Alzheimer's and dementia care, these functions are
being shifted to primary care. In medical centers where there is no
dementia clinic, CCN/AD project staff have worked with VA primary care
physicians, physician assistants, nurse practitioners, and others from
the beginning to provide medical and non-medical care management.
In each of the five medical centers, resource rooms have been set
up with print and video materials about Alzheimer's and dementia for
veterans, their families and VA staff. Print materials are also
available in racks in public areas of the VA, and chapter staff contact
veterans' families to offer educational materials and other chapter
services. Support groups are provided at the medical center and in the
community by chapter staff or VA staff that have received training from
the chapters.
outcomes
The evaluation of CCN/AD will continue for another year with
funding from the Retirement Research Foundation and the Robert Wood
Johnson Foundation. Thus, final results are not yet available.
Responses to mail surveys of VA physicians, nurses, social workers, and
others show positive attitudes about the project model and the
partnership with the Alzheimer's Association chapters. Survey responses
also show general agreement that implementation of the CCN/AAD model
and participation in the partnership with chapters will lead to earlier
identification of dementia, improved communication between VA staff,
veterans with dementia, and their families, and greater awareness of
needed treatments and services. Preliminary findings from telephone
interviews with veterans who are still able to respond and their
families indicate high satisfaction with the care they are receiving
through the project.
Information about CCN/AD enrollees' use of VA and chapter services
will eventually be available to analyze the cost impact of the project.
Since there is no control group, cost information from the project will
only be suggestive, although it is possible that data from other VA
networks could be used for general comparison.
Many people with Alzheimer's disease and other dementias also have
serious coexisting conditions such as heart disease, diabetes, and
cancer. Available data show that these coexisting medical conditions
increase the cost of care for people with Alzheimer's and dementia.
Likewise, Alzheimer's and dementia increase the cost of coexisting
medical conditions. Thus, a person with Alzheimer's disease and
diabetes is likely to have higher medical costs than a person with only
Alzheimer's or only diabetes. Greater attention to the management of
coexisting Alzheimer's, dementia, and other serious medical conditions
could improve outcomes and reduce costs of care. Little work has been
done in this area thus far, primarily because of lack of knowledge
about Alzheimer's disease and dementia and widespread failure to
identify and diagnose these conditions in most health care systems. By
increasing staff knowledge about Alzheimer's and dementia and ensuring
identification and diagnosis of veterans with these conditions in VISN
2, CCN/AD has laid the necessary groundwork for future projects to
improve management of coexisting medical conditions, with likely
positive effects on both quality of care and costs.
potential for replication is other visns
The CCN/AD model is available for use by any health care system.
The model was originally designed to be flexible enough to work in the
diverse, real world settings of the seven participating sites. As noted
earlier, some adaptations to the model have been made at each of the
VISN2 medical centers, thus creating a rich array of procedures and
tools that could be adopted by other VA networks. The site has a
project manual that includes the CCN/AD model and tools, site policies,
work plans, budgets, timelines, and data collection instruments.
Training curricula are also available. Perhaps as valuable as these
formal products is the extensive experience VISN 2 has accumulated in
partnering with Alzheimer's Association chapters. These partnerships
are essential in providing coordinated care for people with Alzheimer's
disease, dementia, and many other chronic conditions, and VISN 2's
knowledge in this area is a potentially valuable resource for other VA
networks.
For the Alzheimer's Association, the CCN/AD project in upstate New
York has provided opportunities to reach physicians, other health care
professionals, veterans with dementia, and family caregivers we would
not have reached otherwise. We are impressed with the dedication and
skill of VISN 2 clinical and administrative staff, and we are grateful
for the time and resources the network has devoted to this project. We
hope the project will continue to grow in VISN 2 and that other VA
networks will want to replicate it in their health care systems.
recommendations
The Alzheimer's Association recommends that the Senate Committee on
Veterans Affairs and the Veterans Health Administration (VHA):
1. encourage and support replication of the AHEAD and CCN/AD
projects in VA networks and medical centers across the country.
Both projects require significant staff time and other
resources, but the VA is already serving huge numbers of
veterans with Alzheimer's disease and other dementias,
including many whose conditions have not yet been identified
and diagnosed. AHEAD and CCN/AD are vehicles for improving care
for these veterans. CCN/AD creates partnerships with
Alzheimer's Association chapters that can facilitate non-
institutional, community-based care and augment the efforts of
VA staff.
2. Given the groundwork already created by CCN/AD in VISN 2,
the Alzheimer's Association also recommends that the Committee
and the VHA encourage and support research and demonstration
projects to improve the management of coexisting medical
conditions in people with Alzheimer's disease and other
dementias. As noted earlier, this is an important next step in
improving quality and reducing cost of care for veterans with
these conditions.
The Alzheimer's Association commends the Committee on Veterans
Affairs for calling this important hearing on non-institutional long
term care issues in the VA. Under Chairman Rockefeller's stalwart
direction, the Committee on Veterans Affairs has worked consistently to
improve the quality of health care and to develop a long term care
system for our nation's veterans that provides options for care at
home, in the community and in good care facilities.
In addition, the Association sincerely appreciates Chairman
Rockefeller's particular commitment to veterans with Alzheimer's
disease, not only in the area of long term care but also in raising
awareness about the need for increased research funding both at the
National Institutes of Health (NIH) and in the private sector. Through
the Blanchette Rockefeller Neurosciences Institute at the West Virginia
University Health Sciences Center, fundamental neurosciences research
is underway to find practical solutions to Alzheimer's disease and
other cognitive impairments.
Thank you again for the opportunity to submit this statement for
the record.
______
Prepared Statement of James R. Fischl, Director, National Veterans
Affairs and Rehabilitation Commission, The American Legion
Mr. Chairman and Members of the Committee:
As an advocate for veterans and the nation's largest veterans
service organization, The American Legion feels compelled to submit,
for the record, its views on the subject of your most recent hearing--
Alternatives to Nursing Homes--Is VA Prepared? With the ever-growing
aging veteran population, it is critical that the Department of
Veterans Affairs (VA) position itself in such a way as to be able to
adequately take care of all the needs of these veterans to include
long-term care.
With the VA health care system transforming itself from a
``hospital'' system to an ``integrated health care'' system, so too has
VA's approach to long-term care evolved from an institutional setting
to a non-institutional, community based and home based setting.
The enactment of Public Law (PL) 106-17, the Veterans Millennium
Healthcare and Benefits Act, marked the first step down the long road
to ensuring, mapping out and implementing a comprehensive long-term
care plan for veterans.
While conceding that this legislation was complex, the VA has
allowed nearly two years to go by without fully implementing the
provisions of the law. The law requires that all eligible veterans be
offered adult day health care, respite care, and geriatric evaluation.
To date, VA has instituted only three of the provisions of the law:
<bullet> Mandatory nursing home care for veterans rated 70% and
above and for any service-connected veteran who needs nursing home care
for a service-connected disability;
<bullet> Pilot programs to evaluate varying models of all-inclusive
care for the elderly; and
<bullet> An assisted living pilot to evaluate that particular
program was initiated in the Pacific Northwest.
It will take two to three more years for the pilot programs to be
fully evaluated as to whether they are a cost-effective means of
providing long-term care (LTC). In the mean time, veterans continue to
struggle to obtain LTC by the VA.
LTC within VA is a continuum of care provided over a period of time
to veterans who suffer from severe chronic service-connected
disabilities and conditions of aging and/or the disease process. Within
VA, long-term care includes:
<bullet> home health care;
<bullet> adult day care;
<bullet> community residential care;
<bullet> specialized rehabilitation care, including Alzheimer's and
Dementia care;
<bullet> psychogeriatric care;
<bullet> domiciliary care;
<bullet> assisted living;
<bullet> hospice and respite care;
<bullet> geriatric assessment and management;
<bullet> skilled and unskilled care;
<bullet> nursing home care; and
<bullet> Geriatric Research, Education and Clinical Centers
(GRECCS).
One of the more innovative approaches to LTC within VA has been the
use of telemedicine. Telemedicine technology allows VA to reduce travel
time and costs while improving efficiency and providing better quality
of care. The Senior Companion Program is another example of saving
money, yet keeping LTC in the home of the veteran. The Advances in Home
Based Primary Care for End of Life in Advancing Dementia (AHEAD)
program is yet another alternative to institutional care that the VA is
evaluating. While all of these programs sound great, they are only
offered to a small portion of the veteran population in need of LTC.
VA's plans for long-term care include:
<bullet> achieve an integrated care management system that
incorporates all of the patient's clinical care needs;
<bullet> provide more care in home and community-based settings as
opposed to inpatient settings, when appropriate;
<bullet> achieve greater consistency in access to and quality of
care provided in all settings;
<bullet> achieve greater consistency across the system in assessing
patients for extended care and in managing care, including post
institutional care;
<bullet> continue to emphasize Veteran Health Administration (VHA)
research and educational initiatives that will improve delivery of
services and outcomes for VA's elderly veteran patients; and
<bullet> continue to develop new models of care for diseases and
conditions that are prevalent among elderly veterans.
These plans are honorable; however, the caveat to achieving these
plans is that it must be done within ``existing programmatic
resources.'' In essence, VA can only do so much and then the money runs
out. When it does, the bill payer becomes the veteran.
The evolution of LTC from an institutional setting to a non-
institutional setting brings with it many issues that need to be
addressed. One of those is accountability of the patient and for that
matter, whether the veteran is informed and understands exactly what is
going on with his or her care. Another, of course, is quality of care
being provided by non-VA staff and how is this being monitored.
Finally, The American Legion strongly contends that veterans, who
are accepted into the health care delivery system provided by VA, must
remain the responsibility of the Department. VA's charge includes
providing quality improvement oversight for LTC provided by the
Department or through private contract. If a veteran is accepted as a
long-term care patient, no matter when or under which existent
provision of a law, he or she remains the responsibility of the VA
medical care system regardless of their medical condition.
Congress and the Executive Branch must recognize that it is
incumbent upon them to provide VA adequate resources for the purposes
of providing LTC to the nation's veterans. VA must continue to meet the
demand veterans will undoubtedly place on the health care system in the
next 30 years. The reality of quality LTC for veterans requires a
financial commitment on the part of the legislative and executive
branches of this government, and a coordinated treatment effort on
behalf of VA.
We can never forget the commitment ``. . . to care for him who
shall have borne the battle, and for his widow and his orphan.''
Thank you for allowing The American Legion an opportunity to
express its views on this critical issue.
______
Prepared Statement of Arlene Davidson, Vice President, Planning and
Development, Evercare, a Unitedhealth Group Affiliate
Mr. Chairman and Members of the Committee:
Evercare is pleased to have the opportunity to provide testimony
for the record of this Committee hearing on long term care alternatives
for veterans. Evercare is a division within the Ovations business
segment of UnitedHealth Group. UnitedHealth Group is a diversified
health care company that provides a broad spectrum of resources and
services to help people achieve improved health and well-being through
all stages of life. United is comprised of five major business
segments: Ovations, UnitedHealthcare, Ingenix, Specialized Care
Services and Uniprise. United has been operating since 1974 and
currently serves nearly 35 million Americans in all 50 states. The
Ovations business segment, of which Evercare is part, is dedicated to
serving vulnerable individuals including the frail elderly, chronically
ill, disabled and low income families.
Evercare is dedicated to meeting the long term care needs of this
nation and we have on several occasions in the past offered testimony
in support of the development of new long term care options for
veterans. Our mission is to optimize the health and well being of
aging, vulnerable and chronically ill individuals. Evercare was started
in 1987 in Minnesota by two nurse practitioners and with its
acquisition of Lifemark Corporation in 2001, has grown into a
diversified award-winning healthcare organization participating in
government programs in over 15 states. During our 18 years in the long
term care market, we have seen the emergence and maturing of many
Medicaid, Medicare and other government programs. Our demonstrated
ability to address complex health care needs and to provide customized
services has consistently resulted in exceptional customer
satisfaction, improved clinical outcomes, and increased efficiency.
Some of these results are discussed in a recent article published by
Robert L. Kane, MD in the April 2002 issue of the Journal of the
American Geriatrics Society. We applaud and offer support to this
Committee's efforts in examining new models to address the long term
care needs of veterans and seeking effective ways to deliver quality
long term care services.
Recently, Evercare was awarded a contract by the Southern Arizona
Veterans Administration Health Care System (SAVAHCS) for a pilot case
management program for veterans living in the community and in need of
long term care services. This pilot, targeted to veterans living
throughout the State of Arizona, is one example of how the Evercare
care management approach can be applied to offer new long term care
alternatives to veterans. In this testimony we provide not only an
overview of our care management approach but also some examples of long
term care program models in which our approach has been effectively
applied. It is our hope that this testimony will help define options
for future program development.
our care management philosophy and model
Central to any of the long term care program models in which we
operate is Evercare's approach to care management. Our approach for
aged and disabled individuals is a client-centered model that
encourages the involvement of the client, their family, caregivers,
physicians or primary care provider and our care manager in a
collaborative effort. It is a holistic approach, designed to maintain
the highest quality of life and functional status of the individual
while minimizing reliance on services that are traditionally more
restrictive and less effective in containing costs. This inclusive
philosophy supports an overall goal of coordinating timely, quality,
and appropriate health services while addressing medical, social,
behavioral, environmental and financial considerations in each care
plan. Our care managers achieve this goal through collaboration with
the enrolled individual and his or her family to create a care plan
that maximizes the individual's self-determination and respects
individual wants and interests. In the coordination, facilitation and
implementation of the full spectrum of acute and long term care needs,
Evercare's care managers strive to maintain, and if possible, increase
each enrollee's level of independence, individuality, choice and health
status.
Evercare care managers work with the individual, his or her family,
the primary care provider (PCP), our internal clinical experts, and
other providers as partners on a team to design, coordinate, and manage
the plan of care that achieves the results specified by the
individual's goals. Care managers additionally identify the full range
of health care resources and medical coverage available to each client,
including Medicaid, Medicare, or private long term care insurance
policies. This design and approach allows care managers to react
immediately to changes in a client's condition, proactively intervene,
coordinate care and service needs, and manage any necessary changes in
the individual's plan or setting of care. In addition, the care manager
assists the individual and his or her family in identifying attainable
health and functional status goals, and provides education and
supportive services on preventive medicine, healthy choices, and self-
care techniques as appropriate.
company overview
Our continuum of product lines includes Medicaid and Medicare
health plans, government contracts, and a nationwide information,
consultation, care management and referral service, all designed for
frail, elderly, disabled or chronically ill individuals. Through these
businesses we serve over 658,000 individuals, including providing
comprehensive care management for approximately 150,000 individuals
through publicly funded and managed care contracts. In addition, more
than 2.5 million people have access to our nationwide information,
referral, consultation, and care management services.
Evercare has experience coordinating long term care services
through the following program models:
<bullet> Stand alone care and disease management programs offered
in a fee-for service environment with reimbursement for administrative
costs on a per participant per month basis;
<bullet> Eldercare consultation and referral services provided on
an as needed, fee-for service basis through an insurer or payer as part
of a greater long term care benefit package;
<bullet> Care management services delivered as part of a long term
care single entry point (SEP) and/or primary care case management
(PCCM) program administration contract;
<bullet> Capitated long term care health plan models designed to
coordinate with traditional Medicaid acute care coverage; and
<bullet> Full-risk health plans (health maintenance organization or
preferred provider organization) integrating acute, behavioral, and
long term care funding.
In addition to the overall program model type, other important
program design issues include whether participation is mandatory, how
program eligibility is defined, what delivery settings are included,
and the referral/outreach processes used to identify and enroll
eligible individuals. Differences among our existing programs are
described in the examples that follow.
Arizona Case Management Services for Veterans
Customer/Client: Southern Arizona VA Health Care System
Company/Product Line: Lifemark Corporation, Evercare Connections
Start Date: January 2002
Through Evercare's Lifemark division, we provide care management
services to referred veterans statewide with reimbursement for
administrative costs on a per participant per month basis. Program
participants, referred through local Contracting Officer Technical
Representatives (COTRs), must require a nursing home level of care and
reside in community settings. Care management services include initial
assessment, care planning, maintenance of a statewide home and
community based provider referral network, periodic reassessment, and
ongoing management with regular communication with VA providers and
other personnel. Our approach to cost containment includes a strong
emphasis on coordination of benefits with other payor sources,
improving access to care in rural areas, introducing appropriate social
services and decreasing fragmentation of care delivery.
Outcomes: Since the program is new (January 2002), no outcome data
is yet available.
Arizona Medicaid/Elderly and Physically Disabled Long Term Care
Management
Customer/Client: Arizona Health Care Cost Containment System
(AHCCCS), Arizona Long Term Care System (ALTCS)
Company/Product Line: Evercare of Arizona, Evercare Select
Start Date: January 1989
Evercare of Arizona, through its Evercare Select product, has been
an ALTCS program contractor since the inception of the program in 1989
through the Federal Medicaid Section 1115 waiver program granted to the
State of Arizona. As ALTCS' largest private contractor, Evercare has
demonstrated that services can be integrated cost effectively in a
managed care environment through incorporating sound principles of
intensive care management, utilization management, and quality
assurance.
Evercare's care managers work with the enrollee, the enrollee's
family or guardian, and his or her Primary Care Provider (PCP) in order
to blend and deliver services to assist the enrollee in maintaining the
highest level of functioning through the most appropriate, cost
effective plan of care. Evercare enrollees have choices within a wide
array of primary care, acute care, ancillary services, behavioral
health services, nursing home placement, and home and community based
services (HCBS). Evercare'' strong HCBS network allows our enrollees to
have access to a full continuum of services, including adult foster
care, assisted living homes, assisted living centers, adult day health
centers, attendant care services, emergency alert systems, group
respite, home health services, personal care, homemaker services,
respite care, hospice care, home delivered meals, and home
modifications.
Outcomes: Independent evaluations have shown increased consumer
satisfaction, cost savings and decreased rates of institutionalization
as a result of this program. Evercare has increased its HCBS population
from five percent participation of all clients in 1989 to 51 percent in
2001, significantly decreasing institutionalization. Other financial
and utilization outcomes for this period showcase its strength in cost
effectiveness. During this period we reduced the hospital length of
stay from seven to five days and decreased nursing home expenses from
$1,424 to $1,110 per member per month with an estimated overall medical
cost savings of over $2.5 million. By offering a breadth of HCBS
services through a highly developed network, Evercare has been able to
develop a program that has improved access, financing, service delivery
and follow-up while eliminating fragmentation, duplication of services,
and unnecessary utilization. These findings have been substantiated by
a 1996 Evaluation of Arizona's Health Care Cost Containment System
Demonstration report by Laguna Research Associates. In addition, an
October 2000 report by the AHCCCS showed that consumers are very
satisfied to satisfied with their long term care services.
Texas STAR+PLUS Medicaid Long Term Care Health Plan
Customer/Client: State of Texas Department of Human Services
Company/Product Line: Evercare of Texas/HMO Blue STAR+PLUS
Start Date: January 1998
Since 1998, Evercare has provided administrative services and care
management for HMO Blue STAR+PLUS. The STAR+PLUS Medicaid long term
care program is designed to foster care coordination for individuals
dually eligible for Medicare and Medicaid, and elderly and disabled
people eligible for Medicaid-only. STAR+PLUS bundles Medicaid covered
services into one integrated coordinated care program designed to
control health care costs while improving access and coordination of
services to enrolled individuals. STAR+PLUS provides incentives for
dual eligibles to enroll in Medicare+Choice plans to further integrate
health care services. For all Medicaid enrollees, including dual
eligibles, Evercare is at-risk for the cost of home and community based
services that are covered by Medicaid. In addition, Evercare provides a
seamless transition along the continuum of health care services by
coordinating acute care services reimbursed under the Medicare program.
We have applied to become a Medicare+Choice program to assume risk for
these services, to complete the integration. This care management
function enhances continuity of care and the enrollee/care manager
relationship. The Evercare program includes assignment of care managers
to match the cultural and language aspects of Houston's diverse
population (i.e., Vietnamese, African American, Asian American,
Russian, and Hispanic).
Outcomes: Independent evaluations of the STAR+PLUS program have
also shown increased consumer satisfaction, cost savings and improved
quality. Evidence of our success in managing the STAR+PLUS population
is demonstrated by an internal cohort study of 310 enrollees in the
program, who experienced, over a two-year period, a decrease in
inpatient days and days per thousand of 43 percent, and a decrease in
paid claims of 22 percent. Furthermore, a 1999 study by the Public
Policy Research Institute of Texas A&M University (STAR+PLUS Medicaid
Managed Care Waiver Study: An Independent Assessment of Access, Quality
and Cost-Effectiveness) found that this waiver program saved the State
of Texas over $6 million without impeding access to care or quality of
care. Furthermore, a 1999 overall enrollee satisfaction survey
conducted by the Texas Health Quality Alliance showed results of
``seven or higher on a scale of zero to ten'', where ten is most
satisfied and zero is least satisfied.
Florida Diversion and Long Term Care Programs
Customer/Client: Florida Department of Elder Affairs and Agency for
Health Care Administration
Company/Product Line: Health and Home Connection; ElderCare
Start Dates: 1998 (Health and Home Connection); 1987 (ElderCare)
Evercare operates two separate Medicaid programs in Florida aimed
at assisting frail elders and disabled individuals to live in the
community. Health and Home Connection is a Florida Diversion Project
serving enrollees over the age of 65 in Osceola, Orange and Seminole
counties under a 1915(c) waiver and monitored by the Department of
Elder Affairs. These complex health care individuals require assistance
with activities of daily living, have dementia or some other chronic
illness or degenerative disease requiring daily nursing intervention.
There are currently 446 voluntary enrollees whose health care needs are
managed through our extensive care coordination programs and services.
ElderCare is a similar program in South Florida (Dade and Broward
counties) funded by the Frail Elder project and monitored by the Agency
for Health Care Administration. ElderCare is for persons over the age
of 21 at risk of institutionalization due to chronic illness,
disability and/or in need of assistance with activities of daily
living. There are 3,700 voluntary enrollees.
Outcomes: Estimated savings for the State of Florida from the
Office of Program Policy Analysis and Cost Accountability are $18
million per year for the Diversion Project. ElderCare has potential
savings estimated at $8.6 to $25.7 million per year. The savings are
estimated for diversion of enrollees from institutionalization to more
cost-effective community-based settings enabled by our comprehensive
care management approach. A November 2001 study by the Department of
Elder Affairs found Health and Home Connection had the highest average
rating of satisfaction with our care managers and highest satisfaction
(89 percent) with overall long term care services when compared to
other participating contractors.
New Mexico LTC Link Single Entry Point Administration
Customer/Client: New Mexico Human Services Department/Medical
Assistance Division
Company/Product Line: Evercare Connections
Start Date: July 2001
LTCLinkNM<SUP><dbl-dagger> </SUP>is an information and referral
service specializing in long-term care services for disabled, elderly,
chronically ill and vulnerable individuals of any age within the State
of New Mexico. The service was implemented and is managed by Evercare's
comprehensive national database of long term care providers, which
includes both institutional and home and community based providers. The
State of New Mexico created this program in July of 2001 to help
eliminate the need for individuals to make numerous calls or trips to
various organizations in the hopes of finding appropriate resources.
Through this information service, Evercare assists individuals and
other concerned parties in locating services to maximize their
independence and quality of life.
This type of centralized information system is used by states to
simplify the process for individuals as they access publicly funded
programs for medical or social services. Other states, such as
Colorado, rely on similar providers (in Colorado, called Single Entry
Point Agencies, or SEPs) to provide initial screening and ongoing case
management and assessments. A program such as this may be particularly
beneficial for the VA, due to the intricacy of the benefit structure
and the complexity of the care needs of many veterans. Evercare is
capable of providing care management services coupled with single entry
point administration.
Nationwide Medicare+Choice Long Term Care Demonstration Project and PPO
Customer/Client: Centers for Medicare and Medicaid Services (CMS)
Company/Product Line: Evercare, Evercare Choice
Start Date: January 1987
Since 1987, Evercare has operated a Medicare program, called
Evercare Choice, serving the frail elderly in institutional settings.
This program has been operating under a CMS demonstration since 1995.
Through a unique care management program that utilizes teams of nurse
practitioners and primary care physicians, the Evercare model
coordinates care for nursing home residents with an emphasis on areas
such as prevention, early detection, collaboration with the primary
physician, and communication with families and nursing staff. This
geriatric clinical model seeks to avoid costly and traumatic transfers
to the hospital and improve enrollees' quality of life. As a result of
clinical success and superior cost effectiveness, Evercare Choice has
expanded to include sites in six states, including participating in the
Minnesota Senior Health Options program for dual eligibles and has led
to the development of additional Medicare+Choice (M+C) plans reaching a
total of over 23,000 individuals. Last year, Evercare opened the
nation's first M+C PPO in Ohio. This year, Evercare will launch a new
M+C HMO product for community-based dual eligibles in Texas and further
expand the PPO model to additional states. Over 70 percent of the
enrollees in Evercare Choice are dual eligibles, the average age our
enrollees is 85 and 85 percent suffer from some form of dementia.
Outcomes: Evercare is one of the most successful Medicare
demonstration projects and has produced impressive results in reducing
hospitalizations, improving quality of care and family satisfaction.
The success of the nurse practitioner model of care coordination is
highlighted in studies conducted measuring affects on hospital
admissions, clinical outcomes and enrollee satisfaction. Specifically,
Kane discusses in the JAGS article higher satisfaction among Evercare
enrollees when compared to a control group. The project has
demonstrated 26-50 percent reduction in hospital admissions with a
slight decrease in mortality while improving clinical indicators and
consistently achieving 95 percent satisfaction rates with the families
of this frail population. Excluding deaths, the disenrollment rate for
enrollees in this program is less than one percent, data further
underscoring the overall programmatic excellence.
Nationwide Eldercare Consultation, Information and Referral
Customer/Client: The Lutheran Brotherhood
Company/Product Line: Evercare Connections
Start Date: July 1997
The Lutheran Brotherhood contracts with Evercare Connections to
provide elder consultation, information and resources to their long
term care insurance policyholders on a nationwide basis. This contract
has been in place since July 1997 and over 50,000 Lutheran Brotherhood
policyholders currently have access to this valuable service.
Under the terms of this agreement, Lutheran Brotherhood
policyholders may call a dedicated toll-free telephone number and speak
with an Elder Care Specialist who assists in determining the type and
availability of services necessary to support their elder care needs.
The Elder Care Specialist will offer multiple provider or service
options in the desired geographic location drawn from Evercare
Connections' provider database. This national database contains
detailed information on over 90,000 long term care providers and
community based services. The policyholder will receive an information
packet that contains information relevant to their need. This
information packet contains detailed provider profiles and other
helpful information such as educational brochures and guides to assist
in evaluating a provider. If desired, the Elder Care Specialist may
assist the policyholder by scheduling provider appointments or
implementing services.
summary
Evercare has experience in operating a number of different long
term care program models tailored for the unique needs of veterans,
Medicaid, Medicare and/or fee-for-service individuals. We provide
service to government and private entities that are based on the care
principles of a client-centered approach, integration, and the least
restrictive and safest setting. Our experience and expertise in
implementing and managing these programs can serve as a best practices
resource to the Veterans Administration. We are thankful for the
opportunity to present our capabilities and ideas to the Senate
Committee on Veterans Affairs and look forward to future opportunities
to collaborate with the Committee and the VA on the development of new
long term care alternatives for veterans.
-