Summary
In April 2002, at the request of the Senate Committee on Veterans' Affairs, we testified on variation in the availability of VA's noninstitutional long-term care services. Congress expressed concern that this variation could mean that some veterans did not have access to noninstitutional services because of gaps in service availability and because of the restrictions that some facilities might place on veterans' use of these services, such as limiting the amount of service a veteran may receive. To address these concerns, we updated and expanded our previous work to determine (1) whether veterans' access to six noninstitutional services is limited by service availability and restrictions on use and (2) if access is limited, what factors, contribute to limited access.
Veterans' access to the six noninstitutional long-term care services in our study is limited by the lack of service availability and restrictions on their use. Of VA's 139 facilities, 126 do not offer all six of the services. Veterans have the least access to noninstitutional respite care, which is not offered by 106 VA facilities. By contrast, skilled home health care is not offered at 7 facilities. Furthermore, veterans' access to care is more limited than these numbers suggest, because even when facilities offer these services they often do so in only parts of the geographic area they serve. In fact, for four of the six services--noninstitutional respite care, home-based primary care, adult day health care, and noninstitutional geriatric evaluation--the majority of facilities either do not offer the service or do not offer the service in the entire geographic area they serve. Veterans' access may be further limited by restrictions that individual facilities set for use of services they offer. For example, 9 facilities, in conflict with VA's eligibility standards, limited veterans' access to noninstitutional services based on their level of disability related to military service. Further, restrictions placed by many facilities on the number of veterans who can receive noninstitutional services have resulted in veterans at 57 of VA's 139 facilities being placed on waiting lists for noninstitutional services. VA's lack of emphasis on increasing access to noninstitutional long-term care services and a lack of guidance on the provision of these services have contributed to service gaps and individual facility restrictions. VA headquarters has not emphasized increasing access to these services by establishing measurable performance goals as it has for other priorities such as maintaining workloads in VA nursing homes. Without such performance measures, field officials faced with competing priorities have chosen to use available resources to address other priorities. VA has implemented a performance measure for fiscal year 2003 that encourages networks to increase veterans' use of five of the six noninstitutional services, but it does not require networks to ensure that all network facilities provide veterans access to noninstitutional services. Moreover, VA has not provided facilities with adequate guidance on the provision of noninstitutional respite care, even though most have had little experience in providing the service. Some networks and facilities are confused about how to provide the service and as a result some are not providing the service. VA has also not provided adequate guidance on which noninstitutional services are required. In particular, VA has not specified whether the home health services requirement includes one, all, or some combination of home-based primary care, homemaker/home health aide, and skilled home health care. In the absence of VA headquarters guidance on what home health services are required, VA facilities vary in their interpretations of what services they must provide.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change
from "In process" to "Implemented" or "Not implemented" based on our follow up work.
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Recommendations for Executive Action
Recommendation: To increase access to noninstitutional long-term care services and make access more even across networks and facilities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that facilities follow VA's eligibility standards when determining veteran eligibility for noninstitutional long-term care services.
Agency Affected: Department of Veterans Affairs
Status: Not Implemented
Comments: In previous updates VA had mentioned monitoring electronic waiting lists to ensure ongoing compliance, but now reports that such efforts are better directed in monitoring VISN workload activity in relation to assigned targets. VA states that reports on home & and community-based care (H&CBC) census levels in comparison to targets are generated for each network on a monthly basis and are shared with the Deputy Under Secretary for Health for Operations and Management and VISN leadership. As of September 2007, the agency has a particular focus on H&CBC workload in selected networks which had experienced difficulty in reaching target levels over the past three years. While these efforts could be useful in addressing the recommendation, they do not ensure that facilities follow VA's eligibility standards when determining eligibility for noninstitutional long-term care services.
Recommendation: To increase access to noninstitutional long-term care services and make access more even across networks and facilities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to define and provide guidance on noninstitutional respite care.
Agency Affected: Department of Veterans Affairs
Status: Implemented
Comments: VA issued a respite care handbook (VHA Handbook 1140.2) on May 15, 2003. The handbook provides a definition of respite care and gives guidance on the provision of respite care in noninstitutional settings. The handbook states that VA may provide noninstitutional respite care in-home as well as in adult day health care facilities. In-home respite care can be provided by homemaker/home health aide programs. In addition, the handbook clarifies that "a day" of noninstitutional respite is defined as any single day in which respite is provided for up to six hours of care in the home and greater than four hours of care in an adult day health care center.
Recommendation: To increase access to noninstitutional long-term care services and make access more even across networks and facilities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to specify in VA policy whether home-based primary care, homemaker/home health aide, and skilled home health care are to be available to all enrolled veterans.
Agency Affected: Department of Veterans Affairs
Status: Implemented
Comments: VA published an information letter on October 1, 2003, which clarified that, according to VA policy, home-based primary care, homemaker/home health aide, and skilled home health care are to be available for all enrolled, eligible veterans in need of such services. Facilities may directly provide or purchase these services for veterans. The letter was distributed to all facilities through email and is available on the VA web site.
Recommendation: To increase access to noninstitutional long-term care services and make access more even across networks and facilities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to refine current performance measures to help ensure that all VA facilities provide veterans with access to required noninstitutional services.
Agency Affected: Department of Veterans Affairs
Status: Not Implemented
Comments: VA reports that it has created a mandate that all Veterans Affairs Medical Centers (VAMC) operate a minimum number (six of eight or seven of nine) of home-based long-term care services. VA reports it also expanded its oversight and monitors for low performing networks. While these actions could be useful in addressing GAO's recommendation, it does not ensure that all services are offered at all facilities as required.
