VA Testimony of Kenneth W. Kizer, MD, MPH before Congress on April 22, 1999

STATEMENT
OF
KENNETH W. KIZER, M.D., M.P.H.
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
ON
LONG TERM CARE WITHIN THE VETERANS HEALTH ADMINISTRATION
BEFORE
THE
HOUSE VETERANS' AFFAIRS COMMITTEE
SUBCOMMITTEE ON HEALTH

Mr. Chairman and Members of the Committee, thank you for inviting me to discuss long term care provided by the Veterans Health Administration (VHA) and to apprise you of VHA's current strategy for developing potential solutions to the growing demand for long term care by veterans.

As you know, VHA has a long and distinguished history of providing high quality long term care for chronically ill, disabled and elderly veterans, and VHA is internationally recognized as a leader and innovator in the care of older persons.

While my comments today will provide detail about the report of the Federal Advisory Committee on the Future of VA Long Term Care, entitled VA Long Term Care at the Crossroads, I would be doing the Committee and VA a disservice if I did not put the Advisory Committee’s report in the context of VA’s longstanding commitment to addressing the needs of elderly veterans. To do so, I will provide you a brief historical perspective; outline the demographic imperative to examining and expanding VHA’s provision of long term care; and outline VHA’s current long term care programs, as well as its strategy for addressing future needs.

Precursor organizations to VA have provided care for older veterans since colonial times. The first domiciliary and medical facility for America’s veterans was authorized in 1811. In 1865, President Lincoln signed legislation creating what later became known as the National Homes for Disabled Volunteer Soldiers. These homes provided domiciliary and hospital care for large numbers of indigent and disabled veterans, although initially only for those who served in the Union Army. Because of this restriction, a few states established state operated veterans homes. By 1888, California, Illinois, Iowa, Massachusetts, Michigan, Pennsylvania, Vermont, Minnesota, Nebraska, Ohio, and Wisconsin had established state veterans homes. The first Federal support of these state homes was authorized in 1888 – a payment of $100 per year for each veteran domiciled in a state home.

For the first half of the 20^th century, VA provided long term care for veterans primarily in its own domiciliaries and psychiatric facilities, as well as through partnerships with states having state veterans homes. Some VA patients were also referred to community residential facilities. In 1963, VA’s nursing home program began. Throughout the next decade there was a steady expansion of VA and State nursing homes, as well as growing use of contracts with community nursing homes to provide long term care for veterans.

In the mid-1970’s, VA made what some have characterized as the single greatest commitment in U.S. history to advancing the care of older persons. In anticipation of the large cohort of aging World War II and Korean Conflict veterans, between 1975 and 1980, VA strategically planned and implemented the Geriatric Research, Education and Clinical Center (GRECC) program; established the first Geriatric Physician Fellowship programs; funded the specialized Geriatric Clinical Nurse Specialist and Geriatric Nurse Practitioner training programs; and established benchmark Interdisciplinary Team Training (ITTP) in Geriatrics. Likewise, VA pioneered the development of comprehensive home care programs, geriatric assessment units and state-of-the-art nursing home care units. An array of other long term care services, including contract community nursing home and home care, hospice, respite care, domiciliary, and adult day health care have been added over time and have greatly augmented VHA’s capacity to provide the full spectrum of needed extended care services. These investments have reaped great benefits for both veterans and all frail elderly persons in the U.S. VHA’s foresight has accelerated the pace of the nation’s knowledge about the aging process and the application of this knowledge to improved patient care, including long term care. Indeed, quoting from a recent letter I received from Dr. Jeffrey Halter, the President of the American Geriatrics Society –

"The VA is by far the largest institutional supporter of geriatric medicine in the United States. In fact, without the continued and ongoing advocacy for geriatrics by the Department of Veterans Affairs during the past 25 years, geriatric medicine as we know it would not exist and the AGS would be an entirely different organization." (August 31, 1998)

Somewhat similar to VHA health care in general, VHA’s approach to long term care is evolving from being a primarily institutionally-based care model to one that includes a complete menu of long term care services. Indeed, just as the VHA has redefined itself in the last four years as a "healthcare" system, instead of a "hospital" system, we believe our long-term care services must expand to accommodate the growing need and patient preferences for non-institutional care. Because of the aging veteran population and the needs associated with aging, VHA now has an urgent need to increase home- and community-based care. To be responsive to veterans’ needs in a resource-prudent manner, VHA needs to expand its current home-care programs, develop partnerships with community agencies that offer these services, and find new and better ways of organizing the continuum of long term care services.

Over the next 21 years, the veteran population will decline nearly 35 percent (assuming no major armed conflicts). At the same time, the percent of veterans over the age of 65 will decline only by 12 percent while those over 85 will increase by 333 percent. To continue to provide the appropriate and needed service to veterans, this "demographic imperative" must be addressed.

At present, about 38% of the veteran population is over 65, compared to about 13% of the total U.S. population. Over 51% of veterans who have service connected disabilities and/or who are poor are over 65. (Ninety-one percent 91% of current VA enrollees have service connected disabilities and/or are poor.) The number of veterans over age 65 is expected to peak at 9.3 million in the year 2000, when 66% of all American males aged 65 and over will be veterans. A second but smaller peak is expected to occur in 2015, with the aging of the Vietnam War-era veterans. The number of elderly veterans will peak during the first decade of the 21^st century, well in advance of the general U. S. population (which is expected to peak in the year 2030). This is the driving force behind VHA’s current efforts to find affordable long term care solutions for veterans.

Of note, while the number of veterans age 65 and older will peak in the year 2000, the number of very old veterans – i.e., those who are age 85 and over – will continue to increase until 2013. VA expects that this age group will increase from 327,000 in 1998 to 645,000 by 2003, and then expand several fold in subsequent years, peaking at about 1.3 million in 2013. 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.

Although VA has developed a full continuum of quality long term care services over the past twenty years, there are a number of problems with what is currently available. First, the system evolved from an institutionally-based care model and the investment of funds continues predominantly in that area. For example, VA spent $2 billion on long term care services in FY 1997; 83% for nursing home care, 7% for home- and community-based care and the remainder for residential care services. Second, while the overall VA healthcare system has been transforming from a hospital-based system to a primary care, outpatient-based system, the focus of that transformation has not been on the long term care component. Third, despite a continuum of long term care in VHA, some services are not universally available and access to some services is restricted. The Eligibility Reform Act of 1997 (P.L. 104-262) considerably enhanced VHA’s capacity to provide clinically appropriate care, but eligibility for nursing home, domiciliary and adult day health care was not changed by the Act, and therefore, they have remained as limited, discretionary services.

For the reasons outlined above, as well as a lack of consensus internally about the direction for long term care and the relative lack of resources to support those services, I created the Long Term Care Federal Advisory Committee. The charge to the Committee was to advise my office on VHA’s current and anticipated needs for long term care in an era of no-growth budgets in VA medical care, and on the adequacy of VHA’s present and planned programs for addressing these needs.

The Advisory Committee, chaired by Dr. John Rowe, President and CEO of the Mt. Sinai Medical Center and Medical School in New York City, met several times between March 1997 and February 1998.

In its report, VA Long Term Care at the Crossroads, the Federal Advisory Committee made 20 recommendations and 4 related suggestions on the operation and future of VA long term care services. These recommendations serve as the foundation for VHA’s national strategy to re-vitalize and re-engineer long term care services.

Importantly, the Advisory Committee concluded that long term care must remain an integral part of the veterans healthcare system, but should be invigorated to meet increased demand. Its major recommendations can be summarized in 5 points:

The Committee’s report was disseminated to VA stakeholders for review and comment. I then appointed an internal task force and charged them to review the Advisory Committee’s recommendations, considering stakeholder comments, and weave them into a comprehensive VHA long term care strategy.

In principle, the Veterans Health Administration endorses the Advisory Committee’s recommendations, and is developing strategies to implement them. Some of activities to do so have already begun. The President's proposed FY 2000 Budget contains the expectation of increased spending for home and community-based care, which addresses the Advisory Committee recommendations that emphasize the need for greater use of home and community-based care. As recommended by the Committee, work is underway on improving admission and discharge policies to assure that patients receive care in the most appropriate setting for their clinical needs. The Long Term Care Planning Model is being updated as recommended by the Committee, and work is progressing on implementing the Resident Assessment Instrument/ Minimum Data Set at all VA nursing homes.

While VHA accepts each recommendation, we must recognize that we face markedly increasing demand for long term care services with an essentially no-growth budget. Within this budget context, VHA will take steps to improve both the access to and consistency of the provision of long term care services across the system and intends to continue to expand home and community-based care, as proposed by the President’s Budget. Both the Advisory Committee and VHA recognize that, with the steps we can take, there will continue to be substantial gaps in service availability due to budget, community resources and legislative limitations. The legislative proposals recommended in the Advisory Committee report will be considered within the context of the FY 2001 Budget and overall Administration policy. VA will continue to work with communities at the local level to develop partnerships to fill gaps.

So that the Committee has a full and conveniently available reference to current treatment, research, and educational programs related to long term care as well as future need, I will describe the former in some detail and the latter, which is evolutionary, in brief.

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, regrettably, uneven.

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. In FY 1998, over 22,400 veterans 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) Program. Currently, 110 VA medical centers have GEM programs that include inpatient units and/or outpatient clinics, as well as consultation services. The GEMs provide both primary and specialized care services to a targeted group of elderly patients. 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.

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. Many 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 1998, more than 46,000 veterans received care in VA's 132 NHCUs. Approximately 75% of VA NHCU patients have a psychiatric diagnosis.

Community Nursing Home Care. VHA contracts with more than 3,000 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 provide regular 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. In 1998, more than 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 442 patients in FY 1998. VA also contracts with an estimated 480 non-VA agencies for ADHC services which provided services to an average of 615 veterans each day in FY 1998. The contract program has been established by 83 VA facilities.

Alzheimer and Other Dementia Care Programs. Approximately 56 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). Indeed, five of the current 18 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. In addition, a comprehensive Center for Alzheimer's Disease and Other Neurodegenerative Disorders has recently been established at the Oklahoma City VA Medical Center to focus specifically on development and evaluation of a rural health care model using an interdisciplinary, case management approach to dementia care.

Home-Based Primary Care. This program is operated at 71 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 1998, comprehensive primary care was provided in the home by VHA staff to an average of 6,348 patients on any given day.

Fee Basis Home 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. Approximately 15,000 veterans are served annually in this program.

Domiciliary Care. Domiciliary care is provided in VA domiciliaries, as well as in state veterans homes. VA currently has 40 domiciliaries, which provided care to more than 23,800 veterans in FY 1998. 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 only 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 1998, 46 State Veterans Home domiciliaries in 32 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 1998, 8,104 veterans received residential care on a daily basis in over 2,100 homes approved and monitored by VHA. Veterans in this program are visited monthly by VHA healthcare professionals who monitor the care provided in the home.

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 1998, 118 VA facilities purchased these services for approximately 2,400 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.

Hospice Care. All VA medical centers have, at a minimum, an interdisciplinary hospice consultation team that is responsible for planning, developing and arranging for the local provision of hospice care. The program offers pain management, symptom control, and other medical services to terminally ill veterans, as well as bereavement counseling and respite care to their families. Education and training also has been provided to facilitate the incorporation of hospice concepts into each VA facility's approach to the care of the terminally ill. Seventy-five VA facilities offer inpatient hospice care as well as consultative services. All VA medical centers also arrange for hospice services through community-based agencies. Hospice and palliative care initiatives have recently been intensified throughout VHA. Specific strategies to increase the availability of these services to veteran patients are under development.

VHA is widely recognized for its research programs related to aging and senior care. VHA’s intramural research program includes basic biomedical and clinical research, health services research, rehabilitation research, and cooperative studies. Because of the diverse nature of diseases associated with aging, it is difficult to define precisely the content of the aging research portfolio; however, if one takes a broad view of aging, then a substantial portion of VA research funds supports studies relevant to aging.

Aging is one of VHA’s Designated Research Areas (DRAs), which are priority areas recently identified for the research program. Other DRAs address issues related to health problems of the elderly, including the cancer, stroke, degenerative bone and joint diseases, dementias, and diabetes DRAs.

In 1975, VHA established centers of excellence in geriatrics called Geriatric Research, Education and Clinical Centers (GRECCs). The mission of the GRECC program is to improve the health and care of elderly veterans through research, education and training, and the development of improved clinical models of care. There are currently 18 GRECCs throughout the VA system, each with a distinct programmatic focus (e.g., interdisciplinary approaches to treatment of prostate cancer; neurobiology, epidemiology, and management of dementia; falls and instability; geropharmacology; cost-effective delivery of health care services to the elderly; and bioethical aspects of medical decision-making in aging). VA’s GRECCs are widely recognized as having provided leadership in geriatrics and gerontology throughout the nation.

The training of physicians and other healthcare professionals in geriatrics and gerontology has been a priority for the VHA since the mid-1970s, when three major initiatives were implemented. The first was the establishment of the GRECC program in 1975, mentioned already. This was followed by the development of a geriatric physician fellowship program in 1978, and the designation of 12 VHA Interdisciplinary Team Training Programs (ITTPs) in Geriatrics that same year. While comprehensive geriatric training for residents and associated health students was initially only provided at GRECC and ITTP sites, such training is now provided at more than 40 VA facilities nationwide.

Eighty percent of the nation’s academic leaders in geriatrics today received training in VHA, and VHA continues to be the largest single provider of geriatric training in the U.S. Special fellowship programs in geriatrics have been designated for psychiatrists, dentists, nurses, and psychologists. Beginning in 1994, additional positions were allocated to support residency training in long term care. Also, of the approximately 112,000 health professions students who receive clinical training experiences in VA facilities annually, many gain experience in care of the elderly by rotating through one or more of VA's geriatrics and extended care clinical programs.

Education and training opportunities are also provided for VHA employees. Continuing education programs are conducted at all VA facilities, in addition to regional and national training conferences conducted by VHA faculty. GRECC staff conduct, co-sponsor or serve as faculty at over 5,000 VHA geriatric care educational programs yearly. Resources related to the care of the elderly, including videos, journals, textbooks, conference tapes, clinical practice guidelines, and other health education materials developed by VA and non-VA sources, are available for VHA staff in VAMC libraries.

The prevalence of chronic diseases, episodes of acute illness and functional disabilities all increase with advanced age. The need for the full continuum of care, including long term care, also increases for the older, and particularly the "very old" population of veterans. All long term care patients benefit from an interdisciplinary, primary care approach that can be implemented across care settings. The site of care (e.g., home, clinic, hospital, adult day health care center) may change over time and depends more on the individual patient’s circumstances, including his or her functional ability in carrying out activities of daily living, than on a particular disease entity.

Our goal of providing comprehensive, coordinated services at the right time and right place for veterans in need of such services is vital to assisting veterans to maintain the highest possible functional level and quality of life.

As noted earlier, VA is developing a strategy to implement all of the Federal Advisory Committee’s recommendations. I will provide this document to the committee when it is completed. To the extent that we can do so within the existing authorities and programmatic resources, we will:

Achieve an integrated care management system that incorporates all of the patient’s clinical care needs;
Provide more care in home and community-based settings as opposed to inpatient settings, when appropriate;
Achieve greater consistency in access to and quality of care provided in all settings;
Achieve greater consistency across the system in assessing patients for long term care and in managing care, including post institutional care;
Continue to emphasize VHA research and educational initiatives that will improve delivery of services and outcomes for VA’s elderly veteran patients;
Continue to develop new models of care for diseases and conditions that are prevalent among elderly veterans. For example, by the year 2000, we project that there will be 600,000 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). (NCCC is a national nonprofit organization representing 30 of the nation’s leading healthcare networks serving the Medicare and Medicaid populations.)

As noted earlier, the Advisory Committee’s recommendations will be considered within the context of the FY2001 Budget and overall Administration policy.

VA has a long and proud tradition of delivering quality long term care services, and we believe we can improve our approach to long term care. VHA has the opportunity to again assume a national leadership role in providing care for older persons by developing innovative solutions to long term care. I believe that the manner in which VHA tackles its "demographic imperative" will provide critical experiential information and may even define the nation’s approach to long term care in the coming decades. At a minimum, the VHA experience will serve to inform the policy debate about the growing need for long term care for non-veterans.

That concludes my prepared remarks. I would be happy to try to address your questions now.