**Long Term Care and State Veterans Homes**

**Historical Background**

***(Excerpts from a presentation by Dr. Kizer to Congress in April
1999)***

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.

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.

***Some of the major long term care programs provided by VA are
described below:***

[State Veterans Homes.]{.underline} 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.

[Community Nursing Home Care]{.underline}. 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.

[Domiciliary Care]{.underline}. 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.