STATEMENT OF
THE HONORABLE ROBERT H. ROSWELL, MD
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
ON
VA'S LONG-TERM CARE PROGRAMS
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON HEALTH
U. S. HOUSE OF REPRESENTATIVES

May 22, 2003

Mr. Chairman and Members of the Subcommittee:

     I am pleased to be here today to discuss VA's long-term care programs and issues related to the GAO report " VA Long-Term Care: Service Gaps and Facility Restrictions Limit Veterans' Access to Non institutional Care" ( GAO 03-487). With me today is Dr. James F. Burris, VA's Chief Consultant for the Geriatrics and Extended Care Strategic Health Group.

     Mr. Chairman, the need for effective and accessible long-term care services for veterans can hardly be overstated. Although we are currently projecting that between 2000 and 2010 the veteran population will decline from 24.3 million to 20 million, over that same period, the number of veterans age 75 and older will increase from 4 million to 4.5 million, and the number of those over 85 will triple to 1.3 million. These veterans, particularly those over 85, are the most vulnerable of the older veteran population and are especially likely to require not only long-term care, but also health care services of all types. VA patients are not only older in comparison to the general population, but they generally have lower incomes, lack health insurance, and are much more likely to be disabled and unable to work. The projected peak in the number of elderly veterans during the first decade of this century will occur approximately 20 years in advance of that in the general U.S. population. Thus the current demographics of the veteran population are one of the major driving forces in the design of the VA health care system.

     As the VA health care system redefined itself in recent years as a "health care" system instead of a "hospital" system, VA's approach to geriatrics and extended care evolved from an institution-focused model to one that is patient-centered. Institutional long-term care is very costly and may impair a long-standing spousal relationship and reduce overall quality of life. We believe that long-term care should focus on the patient and his or her needs, not on an institution. Such a patient-centered approach supports the wishes of most patients to live at home and in their own communities for as long as possible. Therefore, newer models of long-term care, both in VA and outside of VA, include a continuum of home and community-based extended care services in addition to nursing home care.

     In those situations where long-term care in the veteran's home is not practical, assisted living facilities may meet the needs of veterans and their spouses. VA recognizes that assisted living facilities are used in the private sector as a lower cost alternative to institutionalization, and more importantly, as an option which keeps the pair bond between the husband and wife intact, providing a higher quality of life. VA currently is operating an assisted living pilot project and will evaluate the impact of the pilot in terms of quality of care, veteran satisfaction, and cost.

     The technology and skills now exist to meet a substantial portion of long-term care needs in non-institutional settings, and VA is exploring utilization of new technologies, such as telemedicine, to expand care of veterans in the home and other community settings. Technology is increasingly available to provide the limited health care that is needed to support long-term care for many veterans in their homes or in assisted living facilities. Technology can be used to monitor how patients feel and whether they are taking their medications properly. Technology can also be used to monitor various health status indicators in the patient's home, such as blood pressure, blood glucose levels for diabetics, and weight for patients with heart failure. With tele-health support, many of our nation's veterans will be able to stay in their homes or in assisted living facilities with their spouses in the towns where they have a support network. Clearly, by using interactive technology to coordinate care and monitor veterans in the home or assisted-living environment, we can significantly reduce hospitalizations, emergency room visits, and prescription drug requirements, while providing veterans with a more rewarding quality of life and greater functional independence.

     I have directed the establishment of a new Office of Care Coordination in the Veterans Health Administration ( VHA) to capitalize on these new technologies and the broad range of home and community-based long term care services now available in the VA health care system. The Office of Care Coordination will work closely with the Geriatrics and Extended Care Strategic Health Group and other patient care services to use information and telehealth technologies to integrate the care of patients across the continuum of care and provide the appropriate level of care when and where the patient needs it.

     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 on the operation and future of VA long-term care services. These recommendations served as the foundation for VA's national strategy to revitalize and reengineer long-term care services. A major recommendation 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 in implementing that strategy.

     From 1998 to 2002, VA's average daily census ( ADC ) in home- and community-based care increased from 11,706 to 17,465. VHA has a budget performance measure that calls for an ambitious 22 percent increase in the number of veterans receiving home and community-based care between FY 2002 and FY 2003. Non-institutional home and community-based care ( H&CBC) workload has also been established as a VHA performance monitor and is reported in the Monthly Performance Report along with the nursing home workload. Each VISN has been assigned targets for increases in their non-institutional LTC workload. VA plans to achieve a level of 30,119 ADC in home- and community-based programs in FY 2006. VA will expand both the services it provides directly and those it purchases from affiliates and community partners. VA expects to meet most of the new need for long-term care through home health care, adult day health care, respite, and home-maker/home health aide services. Attachment 1 to my statement documents the growth in actual and projected workload from 1998 through 2004 in VA's non-institutional long-term care programs.

     The recent GAO report, " VA LONG-TERM CARE: Service Gaps and Facility Restrictions Limit Veterans' Access to Non-Institutional Care" ( GAO-03-487) implies that every veteran should have equal access to each of the non-institutional long-term care services in the VA health benefits package regardless of location or circumstances. We believe that is unrealistic. Some services could be offered only if appropriate providers are available in the local community. Delivery of others would be cost-effective only if there is a sufficient population of eligible veterans in the geographic area. Still others will require the implementation of care coordination on a broader scale. Certainly there is room for improvement, but a completely homogeneous system of long-term care is impractical and probably even impossible for reasons over which VA has no control.

      VA agrees with GAO's overall conclusion that implementation of non-institutional long-term care services is not yet complete, and that access to some of these services is uneven across the system. However, we do not agree with GAO's conclusion that there has been a lack of emphasis by VA on increasing access to non-institutional long-term care services. This is shown not only by the actual and projected growth in non-institutional long-term care workload (Attachment 1), but also through our aggressive actions to implement the extended care provisions of Public Law 106-117, the "Veterans Millennium Health Care and Benefits Act." I understand that your interest in VA's extended care services goes beyond the specific services discussed in GAO's recent report, and Attachment 2 of the statement outlines our efforts in implementing all of the related provisions of the Millennium Act.

      VA has several additional initiatives in progress or planned that will further respond to the recommendations in the GAO report. We will shortly issue a new Respite Care Handbook to provide guidance to VA field facilities. Several other handbooks and directives are being drafted and will be issued this fiscal year. A workgroup is refining our Long-Term Care planning model to adjust for gender differences, declining disability among the elderly, and lower rates of nursing home utilization. Several training initiatives are underway. As I mentioned earlier, a new Care Coordination office is being established. Performance monitors have been established and additional measures are under consideration to track our progress in enhancing access to non-institutional services. And of course, we are continuing the congressionally mandated pilots on Assisted Living and comprehensive long-term care for the elderly. Attachment 3 to my statement summarizes the ongoing and planned initiatives that constitute VA's action plan for responding to GAO report 03-487.

     Mr. Chairman, VA's plans for long-term care include an integrated care coordination system incorporating all of the patient's clinical care needs; more care in home- and community-based settings, when appropriate to the needs of the veteran; emphasis on research and educational initiatives to improve delivery of services and outcomes for VA's elderly veteran patients; and development of new models of care for diseases and conditions that are prevalent among elderly veterans. VA must also leverage its leadership in computerization and advanced technologies to better provide patient-centric care. This completes my statement. I will now be happy to address any questions that you and other members of the Subcommittee might have.