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Report to Congressional Requesters:

United States General Accounting Office:

GAO:

May 2003:

VA LONG-TERM CARE:

Service Gaps and Facility Restrictions Limit Veterans' Access to 
Noninstitutional Care:

GAO-03-487:

GAO Highlights:

Highlights of GAO-03-487, a report to Congressional Requesters 

Why GAO Did This Study:

With the aging of the veteran population, the Department of Veterans 
Affairs (VA) is likely to see a significant increase in demand for 
long-term care.  In response to recent GAO findings that variation 
exists in availability of noninstitutional services across VA, GAO was 
asked to update and expand its 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.  GAO surveyed VAs 
139 medical facilities, visited 4 of them and updated information 
collected from a fifth facility visited during earlier work, and 
interviewed headquarters and field officials.

What GAO Found:

Veterans access to the six noninstitutional services we reviewed is 
limited by service gaps and facility restrictions.  Of VAs 139 
facilities, 126 do not offer all six of these servicesadult day 
health care, geriatric evaluation, respite care, home-based primary 
care, homemaker/home health aide, and skilled home health care. 
Veterans have the least access to respite care, which is not offered at 106 facilities.  By contrast, skilled home health care is not offered at 7 facilities.  Veterans access is more limited than these numbers suggest, however, because even when facilities offer these services they often do so in only part of the geographic area they serve.  In fact, for four of the six services the majority of facilities either do not offer the service or do not provide access to all veterans living in their geographic service area.  Veterans access may be further limited by restrictions that individual facilities set for use of services they offer.  For example, at least 9 facilities limit veterans eligibility to receive noninstitutional services based on their level of disability related to military service, which conflicts with VAs eligibility standards. Further, restrictions placed by many facilities on the number of veterans who can receive noninstitutional services have resulted in veterans at 57 of VAs 139 facilities being placed on waiting lists for noninstitutional services. 

[See PDF for image]

[End of figure]
 
VAs lack of emphasis on increasing access to noninstitutional long-
term care services has contributed to service gaps and individual 
facility restrictions that limit access to care.  Without emphasis 
from VA headquarters on the provision of noninstitutional services, 
field officials faced with competing priorities have chosen to use 
available resources to address other priorities.  While VA has 
implemented a performance measure for fiscal year 2003 that encourages 
networks to increase veterans use of five of the six noninstitutional 
services, it does not require networks to ensure that all facilities 
provide veterans access to noninstitutional services.   

What GAO Recommends:

GAO is recommending that VA:

* ensure that facilities follow VAs eligibility standards when 
determining veteran eligibility for noninstitutional long-term care 
services, and  

* refine current performance measures to help ensure that all VA 
facilities provide veterans with access to required noninstitutional 
services. 

VA concurred with the recommendations.

www.gao.gov/cgi-bin/getrpt?GAO-03-487.

To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Cynthia A. Bascetta at (202) 512-7101.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

Veterans' Access Is Limited by Gaps in Service Availability and 
Facility Restrictions on Service Use:

Lack of Emphasis, Inadequate Guidance, and Other Factors Contribute to 
Limited Access:

Conclusions:

Recommendations for Executive Action:

Agency Comments:

Appendix I: VA Noninstitutional Long-Term Care Services in 
Our Review:

Appendix II: Scope and Methodology:

Appendix III: Availability and Utilization of Six Noninstitutional 
Long-Term Care Services by VA Medical Facility or Health Care System:

Appendix IV: Comments From the Department of Veterans Affairs:

Appendix V: GAO Contact and Staff Acknowledgments:

GAO Contact:

Acknowledgments:

Related GAO Products:

Tables:

Table 1: VA Long-Term Care Workload and Expenditures, by Care Setting, 
Fiscal Year 2002:

Table 2: Noninstitutional Services in Our Review Offered by the Five VA 
Facilities We Visited:

Table 3: Availability and Utilization of Six Noninstitutional Long-Term 
Care Services at VA Medical Facilities (July 2002):

Figures:

Figure 1: Noninstitutional Long-Term Care Services at VA's 139 Medical 
Facilities:

Figure 2: Noninstitutional Long-Term Care Services, Based on Geographic 
Areas, at VA's 139 Medical Facilities:

Abbreviations:

HCS: health care system:

VA: Department of Veterans Affairs:

United States General Accounting Office:

Washington, DC 20548:

May 9, 2003:

The Honorable Bob Graham
Ranking Minority Member
Committee on Veterans' Affairs
United States Senate:

The Honorable Lane Evans
Ranking Minority Member
Committee on Veterans' Affairs
House of Representatives:

The Honorable John D. Rockefeller IV
United States Senate:

The Department of Veterans Affairs (VA) spent about $23 billion on 
health care in fiscal year 2002, including about $3.3 billion on long-
term care. Demand for VA long-term care is likely to increase 
significantly during the next decade. Because of the aging of the 
veteran population, VA estimates that the number of veterans age 85 and 
older--those most in need of long-term care--will more than double, 
from about 640,000 currently to about 1.3 million in 2012. Due to 
changes in VA's eligibility standards more older veterans will be 
eligible to receive VA health care, including long-term care services.

In recent years, VA has increased the proportion of its long-term care 
spending on care in noninstitutional settings, such as veterans' own 
homes. This is consistent with the preference of many veterans and 
others to receive care in their homes or in other settings, such as 
adult day health care centers, that are less restrictive than 
institutions. For example, some veterans receive assistance in their 
homes with bathing and dressing provided by home health aides. However, 
VA has traditionally provided the bulk of veterans' long-term care in 
institutional settings, such as nursing homes, which is reflected in 
VA's spending for long-term care services. In fiscal year 2001, more 
than 90 percent of VA's long-term care spending was for institutional 
long-term care.

In November 1999, the Congress passed the Veterans Millennium Health 
Care and Benefits Act (Millennium Act),[Footnote 1] which required that 
VA provide veterans access to three servicesadult day health care, 
geriatric evaluation, and respite care. VA chose to meet the Millennium 
Act requirements by issuing a directive in October 2001 requiring that 
facilities provide adult day health care, noninstitutional geriatric 
evaluation, and noninstitutional respite care to veterans in need of 
such services.[Footnote 2]

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.[Footnote 3] Your offices 
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, you asked 
us to update and expand our previous work[Footnote 4] 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. The six 
noninstitutional services you asked us to examine are the three that VA 
requires as a result of the Millennium Act adult day health care, 
geriatric evaluation, and respite careand three additional 
noninstitutional services--home-based primary care, skilled home 
health care, and homemaker/home health aide. See appendix I for 
information on these six noninstitutional long-term care services.

To do our work, we surveyed each of VA's 139 medical facilities to 
obtain data on the types of services offered and the number of veterans 
receiving the six noninstitutional long-term care services,[Footnote 5] 
and where access to services was limited, we identified the reasons why 
services were limited. We compared these survey data to the data we 
obtained in our fall 2001 survey of VA long-term care services to 
determine the extent to which availability had changed since that 
survey. To gain an understanding of facilities' noninstitutional long-
term care operations we also interviewed VA officials in headquarters 
and in each of VA's 21 network offices,[Footnote 6] visited 4 VA 
medical facilities--located in Memphis, Tennessee; Richmond, Virginia; 
Tucson, Arizona; and Walla Walla, Washingtonand updated information 
collected from a fifth facility in Albany, New York, which we visited 
for our previous report on noninstitutional services. These five 
facilities were chosen based on variation in both the number and type 
of noninstitutional services they offered. In addition, we evaluated 
directives and regulations and other guidance related to these six 
noninstitutional services issued by VA headquarters, networks, and 
individual facilities. For a complete description of our scope and 
methodology, see appendix II. Our work was conducted from June 2002 
through April 2003 in accordance with generally accepted government 
auditing standards.

Results in Brief:

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 servicesnoninstitutional respite care, home-based primary care, 
adult day health care, and noninstitutional geriatric evaluationthe 
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.

To help ensure that veterans have access to noninstitutional long-term 
care services and that such services are offered uniformly throughout 
VA, we are recommending that VA take actions to increase emphasis on 
provision of these services, provide adequate guidance on their 
provision, and ensure that VA's eligibility standards are used to 
determine eligibility. VA concurred with our recommendations, discussed 
preliminary actions it plans to take, and stated that it will provide a 
detailed action plan to implement our recommendations after this report 
is issued.

Background:

Changes in VA's eligibility standards have resulted in an increase in 
the number of veterans who are eligible to receive VA health care, 
including noninstitutional long-term care services. The Veterans' 
Health Care Eligibility Reform Act of 1996[Footnote 7] authorized VA to 
provide health care services not previously available to veterans 
without service-connected disabilities or low incomes.[Footnote 8] As 
required by the act and due to an anticipated increase in demand for VA 
health care from these changes in eligibility, VA established an 
enrollment system to manage veterans' access to care. This system 
includes eight priority categories for enrollment, with higher priority 
given to veterans with service-connected disabilities, lower incomes, 
or other recognized statuses such as former prisoners of war. If 
sufficient resources are not available to provide care that is timely 
and acceptable in quality for all priority groups, the act requires VA 
to limit enrollment nationally, consistent with the eight priority 
groups. If needed, enrollment restrictions would begin with the lowest 
priority category. On January 17, 2003, VA announced that it would no 
longer enroll priority 8 veterans, those in the lowest priority 
category, for the duration of the year.[Footnote 9]

VA long-term care includes a continuum of services for the delivery of 
care to veterans needing assistance due to chronic illness or physical 
or mental disability. Assistance with veterans' needs takes many forms 
and is provided in varied settings, including institutional care in 
nursing homes or in noninstitutional settings preferred by many 
veterans, including in-home care services and community-based services 
such as adult day health care centers. Long-term care also includes 
respite care services that temporarily relieve a veteran's caregiver 
from the burden of caring for a chronically ill and disabled veteran in 
the home. VA offers long-term care services directly or through other 
providers with which VA contracts.

VA provides most of its long-term care to veterans in institutional 
settings, such as VA nursing homes or state-owned veterans' homes 
rather than in noninstitutional settings. In fiscal year 2002, VA 
served about 36 percent of its long-term care workload, or average 
daily census, in noninstitutional settings (see table 1). That same 
year noninstitutional care accounted for 9 percent of VA's long-term 
care expenditures. In contrast, noninstitutional care accounted for 
about 29 percent of Medicaid's long-term care expenditures in fiscal 
year 2001, the most recent year for which data are available.[Footnote 
10]

Table 1: VA Long-Term Care Workload and Expenditures, by Care Setting, 
Fiscal Year 2002:

Long-term care setting: Institutional; Average daily census[A]: 43,363; 
Total expenditures: $2,979,156,000.

Long-term care setting: Noninstitutional; Average daily census[A]: 
24,126; Total expenditures: 283,098,000.

Long-term care setting: Total; Average daily census[A]: 67,489; Total 
expenditures: $3,262,254,000.

Source: VA.

[A] 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. Thus, the figures represent VA's workload 
during the year and not an unduplicated count of veterans in these 
settings because some veterans receive more than one service.

[End of table]

VA has delegated decision making regarding financing and service 
delivery for long-term care and other health care services to its 21 
health care networks. VA allocates resources for health care to each of 
the 21 networks primarily through the Veterans Equitable Resource 
Allocation system, in which networks are funded through a formula 
reflecting the number and types of veterans receiving care in the 
network, including those receiving long-term care.[Footnote 11] In 
turn, VA's networks have budget and management responsibilities that 
include allocating resources received from headquarters to facilities 
within their networks--including resources used to provide long-term 
care services.

Veterans' Access Is Limited by Gaps in Service Availability and 
Facility Restrictions on Service Use:

Veterans' access to the six noninstitutional services in our 
reviewadult day health care, geriatric evaluation, respite care, home-
based primary care, homemaker/home health aide, and skilled home health 
care--is limited due to gaps in availability and facility restrictions 
on use of the services. Of VA's 139 facilities, 126 do not offer all 
six noninstitutional services. Facilities that do offer a service do 
not always offer the service to veterans in the entire geographic area 
the facility serves. Further, veterans' access to the six 
noninstitutional services may be limited by restrictions that 
individual VA facilities place on service use. Some of these facility 
restrictions conflict with VA eligibility standards which state that 
most services are to be available to all enrolled veterans regardless 
of priority group. The restrictions include providing services only to 
certain veterans or limiting the number of veterans who can use 
services at any one time.

Access to Care Is Limited by Service Gaps Across VA:

Access to care is limited because many VA facilities do not offer the 
six noninstitutional services in our review. Of VA's 139 facilities, 
126 did not offer all of the six noninstitutional services in fall 
2002, a pattern similar to that in fall 2001. (See fig. 1.) The least 
commonly available service of the six we reviewed in 2001 and 2002 was 
noninstitutional respite care. This service was not available at 110 of 
VA's 139 facilities in fall 2001, and as of fall 2002, noninstitutional 
respite care was not available at 106 of VA's 139 facilities. In 
contrast, the most widely available service we reviewed was skilled 
home health care, which was offered at all but 7 facilities. For a 
complete list of the services each VA facility reported offering, see 
appendix III.

Figure 1: Noninstitutional Long-Term Care Services at VA's 139 Medical 
Facilities:

[See PDF for image]

Note: Includes services provided directly by facilities or through 
contracts with other providers as of fall 2001 and fall 2002.

[End of figure]

Veterans' access to these services is further limited because among 
facilities that offer services, many do so in only parts of the 
geographic area they serve. Our fall 2002 survey showed that for four 
of the six services noninstitutional respite care, home-based primary 
care, adult day health care, and noninstitutional geriatric 
evaluationthe majority of the facilities either did not offer the 
service or did not offer the service in the entire geographic area they 
serve. As shown in figure 2, 42 facilities did not offer adult day 
health care and an additional 76 facilities did not offer it in their 
entire geographic service area. As a result, where veterans live in a 
facility's geographic service area sometimes determines whether they 
can access the services offered by the facility. The remaining 21 
facilities reported that they offered adult day health care in all 
parts of their geographic service areas.

Figure 2: Noninstitutional Long-Term Care Services, Based on Geographic 
Areas, at VA's 139 Medical Facilities:

[See PDF for image]

Note: Includes services provided directly by facilities or through 
contracts with other providers as of fall 2002.

[End of figure]

VA may also arrange for veterans to access three noninstitutional long-
term care services from non-VA sources even though VA does not pay for 
these services. The Millennium Act and VA policy allow facilities to 
make available to veterans the services required as a result of the 
Millennium Actadult day health care, noninstitutional respite care, 
and noninstitutional geriatric evaluationthrough other providers or 
payers while still overseeing the care delivered using a case 
management approach.[Footnote 12] However, VA headquarters has neither 
issued guidance on the use of case management to meet this requirement 
under the Millennium Act nor has it monitored the extent to which 
facilities use this option. Further, the use of case management by VA 
to make these three services available to veterans is limited by the 
eligibility of veterans for these other sources of care. That is, if 
veterans are not eligible for other sources of care, such as Medicaid 
and Medicare, and VA does not provide the service, then veterans will 
likely not have access to the three services.

Veterans' Access to Care Is Further Limited by Individual Facility 
Restrictions:

Access to care is further limited by the restrictions that some 
facilities place on the six noninstitutional services in our review. 
These restrictions include (1) limiting services to veterans with 
certain levels of service-connected disability, (2) limiting the amount 
of service that veterans can receive, and (3) establishing a maximum 
number of veterans who can receive a service at any time.

Some Facilities Limit Access to Services Based on Veterans' Service-
Connected Disability Levels:

We found that nine VA facilities imposed their own eligibility 
restrictions on access to noninstitutional services based on veterans' 
service-connected disabilities. We identified five of these nine 
facilities through comments facilities made in our survey, although we 
did not systematically ask facilities this question in our survey. 
Because we did not systematically ask in our survey, it is possible 
that additional facilities may impose similar eligibility restrictions. 
Other VA facilities may have also instituted similar restrictions on 
access. These restrictions conflict with VA eligibility standards and 
result in inequitable access for veterans enrolled at these facilities. 
VA's eligibility standards state that most services are to be available 
to all enrolled veterans, regardless of priority group.[Footnote 13]

In our survey of VA's 139 facilities, 5 facilities provided additional 
comments indicating that they limit certain services--including adult 
day health care, homemaker/home health aide, skilled home health, and 
respite care--to veterans with service-connected disabilities. Four of 
the 5 facilities limit services to veterans with service-connected 
disabilities of 70 percent or greater. In addition, one of the 
facilities we visited provides homemaker/home health aide services to 
veterans with service-connected disabilities of 70 percent or greater. 
Another facility we visited provides the service primarily to veterans 
with service-connected disabilities of 70 percent or greater or 
veterans with service-connected disabilities of at least 60 percent for 
a single condition; other veterans may receive the service, but only 
for 6 months. In addition, one network official told us that 2 
facilities in his network limit homemaker/home health aide services to 
veterans with service-connected disabilities of 70 percent or greater 
because under the Millennium Act VA must pay for nursing home care when 
such veterans need it.[Footnote 14] According to this official, because 
homemaker/home health aide services can keep veterans in their own 
homes rather than in nursing homes, providing the service to such 
veterans can delay the need for nursing home care and the resultant 
financial obligation for the facilities.

Access Is also Limited by Restrictions on the Amount of Services 
Provided:

The amount of service veterans receive may depend on which facility 
provides their care. Facilities vary in the limits they set. Some 
facilities restrict the amount of a noninstitutional service a veteran 
can receive once the veteran has been authorized to receive care. For 
example, a network official told us that one network facility offers 
veterans up to 24 hours per week of homemaker/home health aide services 
while a facility official in another network told us their facility 
provides no more than 10 hours per week. A facility we visited in 
another network does not place any restrictions on the amount of 
homemaker/home health aide services provided.

Facility officials noted that they can serve more veterans if they 
limit the amount of service provided to each veteran. One facility we 
contacted provided veterans no more than 2 days per week of adult day 
health care. Because of this restriction, veterans whose medical needs 
require more adult day health care pay for the service themselves, find 
another payer such as Medicaid, or forego the additional service. At 
another facility we visited, veterans without service-connected 
disabilities were limited to 2 full days or 3 half days per week 
regardless of medical need. In 1998, this facility also reduced the 
number of homemaker/home health aide hours provided each week from 21 
to 8 in order to increase the number of veterans who could be provided 
the service. At both facilities, officials emphasized that the purpose 
of limits on the amount of service provided was to increase the number 
of veterans who could receive at least some of the service.

Access at Many Facilities Is Restricted by Limits on the Number of 
Veterans Served:

In our survey of VA facilities, 57 of 139 facilities reported 
maintaining a list of veterans waiting for at least one of the services 
in our review. These facilities told us in effect that they are not 
meeting all their veterans' needs for noninstitutional services. Many 
facilities place limits on the total number of veterans they serve by 
establishing a budget cap--the maximum number of veterans who can 
receive a particular service at any time. For three of the six services 
in our study--home-based primary care, homemaker/home health aide, and 
noninstitutional geriatric evaluation--most facilities reported in our 
survey that despite offering the service, they were currently unable to 
provide services to additional veterans within their budget caps. 
Additional veterans needing services would have to wait until space or 
resources became available.

Lack of Emphasis, Inadequate Guidance, and Other Factors Contribute to 
Limited Access:

A lack of VA emphasis on increasing access to noninstitutional long-
term care services, inadequate VA guidance on providing these services, 
and other factors have contributed to limited access for veterans. VA 
had not provided measurable standards for the provision of these 
services until fiscal year 2003 or oversight to monitor their provision 
as it has for high-priority services. VA guidance on the provision of 
noninstitutional long-term care services has left unclear to some 
facilities how one service is to be defined and provided and whether 
some of the services in our review are a part of what VA requires be 
made available to veterans who need them. Other factors, such as 
availability of contractors to provide a service, also contribute to 
the lack of access for specific services.

VA Has Not Emphasized Increased Access to Noninstitutional Long-Term 
Care Services:

VA network and facility officials told us that VA headquarters has not 
emphasized increased access to noninstitutional long-term care services 
but emphasized other priorities. As a result, these officials said they 
use their resources for the priorities VA headquarters emphasizes 
rather than noninstitutional services. For example, officials in 9 of 
VA's 21 networks told us that VA headquarters' emphasis on the 
performance measure that requires networks to maintain workload in VA 
nursing homes has led them to devote resources to nursing home care 
that they might otherwise have used to provide noninstitutional 
services. One network director told us that the "pressure" from VA 
headquarters to maintain nursing home utilization is much greater than 
that to offer noninstitutional services. In another network, an 
official at a VA facility not offering three of the services in our 
study told us that these services were "victims of competition for 
resources." In other words, the facility had not funded these three 
noninstitutional services because facility officials had chosen to 
devote resources to other services. Another network director told us 
that, if forced to choose between funding different services, the 
network would allocate resources to services included in a performance 
measure.

One way VA emphasizes services is through performance measures, which 
VA establishes to monitor network officials' progress toward meeting 
certain VA strategic goals, such as increasing veteran access to 
services. VA has demonstrated that requiring network officials to meet 
measurable performance standards can promote change. For example, since 
their inception in fiscal year 1996 VA performance measures have 
included a measure for providing immunizations to prevent pneumonia to 
veterans age 65 and older and those at high risk of the disease. VA 
increased the percentage of veterans in this population who received 
the immunization from 26 percent in fiscal year 1996 to 81 percent in 
fiscal year 2002.

In October 2002, VA introduced a performance measure for 
noninstitutional long-term care which requires all networks to provide 
noninstitutional services to a portion of their enrolled veterans 
needing such services14.4 percent in fiscal year 2003 and 16 percent 
in fiscal year 2006.[Footnote 15] The fiscal year 2003 goal for this 
measure will require the majority of networks to increase utilization 
of their noninstitutional services. The performance measure includes 
five of the services in our review but does not include 
noninstitutional geriatric evaluation. However, the performance 
measure does not require networks to ensure that veterans can access 
noninstitutional long-term care services at all network facilities. 
Instead, network targets can be achieved in the current performance 
measure if networks increase utilization at facilities that already 
offer noninstitutional services.

VA Has Provided Inadequate Guidance on the Provision of 
Noninstitutional Respite Care:

VA headquarters has provided inadequate guidance to networks and 
facilities on the provision of noninstitutional respite care to address 
confusion in the field about what this service is and how it should be 
provided. This confusion exists, in part, because VA has limited 
experience with noninstitutional respite care and VA traditionally 
provided respite care in institutions such as nursing homes. 
Noninstitutional respite care, by contrast, is provided only in 
noninstitutional settings, such as a veteran's own home.

Although noninstitutional respite care has been required by VA for over 
a year, VA has not issued adequate guidance on the provision of 
noninstitutional respite care and VA staff told us they were unsure how 
to develop a noninstitutional respite care service. VA issued a 
directive in October 2001 that requires all facilities to provide 
noninstitutional respite care to veterans in need of the service yet it 
inadequately defines noninstitutional respite care and does not provide 
facilities with information regarding how to provide the service. For 
example, the directive states that noninstitutional respite care may be 
provided in a home or other noninstitutional settings. However, it does 
not specify which noninstitutional settings may be used for the purpose 
of respite care. In fact, officials in 6 of the 21 networks we 
contacted indicated that there was confusion in their networks about 
how to establish noninstitutional respite care programs and 1 of these 
networks reported this was the reason facilities in the network were 
not providing the service. Further, in our survey, six facilities 
reported that they offer noninstitutional respite care in community 
nursing homes, which are institutional settings, thus not meeting the 
requirement for noninstitutional respite care. VA headquarters 
officials said they are developing a handbook that will define and 
provide guidance on the provision of noninstitutional respite care.

VA Guidance Does Not Specify Which Home Health Services Are Required:

VA requires that facilities offer a home health service benefit as part 
of VA's medical benefits package.[Footnote 16] VA headquarters 
officials told us that the home services benefit includes home-based 
primary care, homemaker/home health aide, and skilled home health care. 
However, VA policy does not specify whether one, some combination, or 
all three home health services are required under the home health 
services benefit. Currently 138 out of VA's 139 facilities offer at 
least one of these three home health services, 59 facilities offer two 
of the three services, and 66 facilities offer all three. Without clear 
guidance to facilities on what services they must make available in 
order to fulfill the home health services benefit, facilities vary in 
their interpretation of what is included in the benefit and 
headquarters cannot ensure that veterans have access to the services to 
which they are entitled.

Because facilities and networks vary in their interpretation of what is 
included in the home health services benefit, facilities do not 
uniformly offer the same home health services. For example, at one 
facility we visited, an official told us that the facility interpreted 
the home health services benefit to mean that veterans must have access 
to skilled home health care--which the facility made available to all 
veterans. The facility restricted veterans' access to its homemaker/
home health aide and home-based primary care services because facility 
officials did not believe these services were required under the home 
health benefit. Similarly, in another network an official told us that 
the network interpreted the home health services benefit to include all 
three home care serviceshome-based primary care, homemaker/home health 
aide, and skilled home health care. As a result, access to these three 
services varies according to facility interpretation of what is 
required. Without clear guidance to facilities on what services they 
must make available in order to fulfill the home health care services 
requirement, headquarters cannot ensure that veterans have access to 
the home health services to which they are entitled and veterans are 
likely to experience variation in the benefits package.

Other Factors Limit the Availability of Noninstitutional Services:

Other factors limiting access to services include lack of contractors, 
difficulty hiring needed staff, and limitations imposed due to 
distances VA staff can travel. The lack of contractors is particularly 
important in adult day health care, where 62 facilities that either did 
not provide adult day health care at all or only did so in parts of 
their geographic service areas reported that they experienced 
difficulty in finding local contractors to provide the service. In 
addition, 63 facilities cited insufficient facility staff as the reason 
for not offering geriatric evaluation or only offering it to a portion 
of their geographic service area. Officials in VA headquarters told us 
that many facilities have been unable to recruit clinically trained 
geriatric staff, such as geriatricians and geriatric nurse 
practitioners, needed to operate this service.

For home-based primary care, 94 facilities that did not offer the 
service at all or did not do so in all parts of their geographic 
service area reported that they did not do so because many veterans 
live outside of the facility's home-based primary care service area. VA 
guidance limits the service to veterans who live within a locally 
established radius of the facility because home-based primary care 
staff travel from the facility to veterans' homes to deliver 
care.[Footnote 17]

Conclusions:

Veterans' access to the six noninstitutional long-term care services we 
reviewed is limited and highly variable across the country. Extensive 
gaps in services exist at many facilities either because they do not 
offer the services or do not offer it in all parts of their service 
areas. Moreover, individual facility restrictions on veterans' use of 
services means that access may be further restricted. These include 
facility restrictions based on veterans' levels of service-connected 
disability that are inconsistent with VA eligibility standards. 
Facility restrictions have resulted in waiting lists for services at 
many facilities. The end result is that veterans' access to these 
services is often limited or nonexistent based on where they live.

Shortfalls and unevenness in veterans' access to noninstitutional long-
term care services have resulted because VA headquarters has not 
provided adequate guidance and emphasis on making these services 
available. VA has not provided sufficient guidance to clear up 
confusion at facilities as to how noninstitutional respite care 
services are provided or to make clear which home health services 
facilities must provide. As a result, facilities vary in their 
interpretation of which services to provide, creating unevenness in 
their availability. Furthermore, VA has not sufficiently emphasized the 
importance of providing these services to encourage networks and 
facilities to make them a priority in their overall service continuum. 
In particular, VA has not developed a performance measure that would 
help ensure the provision of these services consistently across VA 
facilities.

Recommendations for Executive Action:

To increase access to noninstitutional long-term care services and make 
access more even across networks and facilities, we recommend that the 
Secretary of Veterans Affairs 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;

* define and provide guidance on noninstitutional respite care;

* 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; and:

* refine current performance measures to help ensure that all VA 
facilities provide veterans with access to required noninstitutional 
services.

Agency Comments:

In commenting on a draft of our report, VA agreed with our findings and 
conclusions and concurred with our recommendations. VA stated that it 
will add eligibility sections in each new directive and handbook it 
issues concerning noninstitutional long-term care programs and develop 
performance measures to underscore the importance VA places on its 
noninstitutional long-term care programs. VA, however, did not provide 
details on how it plans to address our recommendations, but instead 
stated that it will provide a detailed action plan to implement our 
recommendations in response to the issuance of this report. VA's 
written comments are in appendix IV.

As agreed with your office, unless you publicly announce its contents 
earlier, we will plan no further distribution of this report until 30 
days after its date. At that time, we will send copies to interested 
congressional committees and other parties. We also will make copies 
available to others upon request. In addition, the report is available 
at no charge on the GAO Web site at http://www.gao.gov. If you or your 
staffs have any questions about this report, please call me at (202) 
512-7101. Another contact and key contributors are listed in appendix 
V.

Cynthia A. Bascetta

Director, Health Care--Veterans' Health and Benefits Issues:

[End of section]

Appendix I: VA Noninstitutional Long-Term Care Services in Our Review:

* Adult day health care: health maintenance and rehabilitative services 
provided to frail elderly veterans in an outpatient setting during part 
of the day.

* Geriatric evaluation: evaluation of veterans with particular 
geriatric needs, generally provided by VA through one of two services: 
(1) geriatric evaluation and management, 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.

* Home-based primary care: primary health care, delivered by a VA 
physician-directed interdisciplinary team of VA staff including nurses 
and other healthcare professionals to homebound (often bedbound) 
veterans for whom return to an outpatient clinic is not practical.

* Homemaker/home health aide: personal care, such as grooming, 
housekeeping, and meal preparation services, provided in the home to 
veterans who would otherwise need nursing home care. It does not 
include skilled professional services.

* Respite care: services provided to temporarily relieve the veteran's 
caregiver from the burden of caring for a chronically ill and severely 
disabled veteran in the home. Noninstitutional settings for respite 
care include veterans' own homes.

* Skilled home health care: medical services provided to veterans at 
home by non-VA health care providers.

[End of section]

Appendix II: Scope and Methodology:

We reviewed the Department of Veterans Affairs' (VA) provision of six 
noninstitutional long-term care services in order to update and expand 
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. The six services we reviewed include the 
three services VA chose to require all facilities to provide to meet 
the Millennium Act requirements--adult day health care, 
noninstitutional geriatric evaluation, and noninstitutional respite 
care--and three additional noninstitutional services--home-based 
primary care, skilled home health care, and homemaker/home health aide.

To determine if veterans' access to the six noninstitutional long-term 
care services is limited and if it is limited, to what extent, we sent 
an electronic mail survey to VA's 139 medical facilities in September 
2002. We asked facilities to indicate which of the six services they 
offered and, for each service they offered, asked them to provide the 
number of veterans currently receiving or authorized to receive the 
service and the number of veterans who received the service during July 
2002.[Footnote 18] The month of July 2002 was chosen because workload 
data were likely to be available at the time the survey was completed 
by VA staff. We also asked facilities to indicate whether each offered 
service was available to veterans living in all parts of their 
geographic service areas. We compared these survey data to the data we 
obtained in our fall 2001 survey of VA long-term care services to 
determine the extent to which availability had changed since that 
survey. We also compared our current survey results to information 
provided by VA headquarters, and where we noted differences we 
contacted facility officials to clarify their survey responses.

To determine the factors that contribute to limited access to the six 
noninstitutional long-term care services we asked survey respondents to 
indicate the reasons why their facilities do not offer certain services 
and what factors influence the number of veterans using the services 
they do offer. We also conducted telephone interviews of officials in 
each of VA's 21 network offices to assess the role each network plays 
in deciding what noninstitutional services network facilities will 
offer and what criteria facilities will use in allocating services.

To augment information collected through our survey and telephone 
interviews, we visited four VA medical facilities to interview VA 
officials and clinicians on veteran demand for noninstitutional 
services and reasons for variation in access to the six 
noninstitutional services. We also updated information we collected 
from a site we visited during our earlier work on VA's noninstitutional 
services.[Footnote 19] As shown in table 2, the five facilities 
included in this report--Albany, New York; Memphis, Tennessee; 
Richmond, Virginia; Tucson, Arizona; and Walla Walla, 
Washingtonreflect differences in the number and type of 
noninstitutional long-term care services offered.

Table 2: Noninstitutional Services in Our Review Offered by the Five VA 
Facilities We Visited:

VA facility: Albany, New York; Number of services in our review offered 
at the time of our visit: 5; Home-based primary care: Yes; 
Homemaker/home health aide: Yes; Skilled home health care: Yes; 
Adult day health care: Yes; Geriatric evaluation: Yes; Respite care: No.

VA facility: Memphis, Tennessee; Number of services in our review 
offered at the time of our visit: 4; Home-based primary care: Yes; 
Homemaker/home health aide: Yes; Skilled home health care: Yes; 
Adult day health care: No; Geriatric evaluation: Yes; Respite care: No.

VA facility: Richmond, Virginia; Number of services in our review 
offered at the time of our visit: 2; Home-based primary care: No; 
Homemaker/home health aide: No; Skilled home health care: Yes; Adult 
day health care: No; Geriatric evaluation: Yes; Respite care: 
No.

VA facility: Tucson, Arizona; Number of services in our review offered 
at the time of our visit: 6; Home-based primary care: Yes; 
Homemaker/home health aide: Yes; Skilled home health care: Yes; 
Adult day health care: Yes; Geriatric evaluation: Yes; 
Respite care: Yes.

VA facility: Walla Walla, Washington; Number of services in our review 
offered at the time of our visit: 2; Home-based primary care: No; 
Homemaker/home health aide: Yes; Skilled home health care: Yes; 
Adult day health care: No; Geriatric evaluation: No; Respite care: 
No.

Source: GAO.

[End of table]

We selected the Memphis and Tucson VA facilities to visit because each 
offered at least four of the six services and had similar numbers of 
veterans enrolled. However, the number of veterans using their services 
differed substantially, which allowed us to explore the reasons for 
observed differences in service utilization. The Albany facility 
offered five of the six services and is located in a network that has 
extensive noninstitutional service offerings. In contrast, the Richmond 
and Walla Walla facilities were selected because they each offered two 
services; further, we selected the Walla Walla facility because it is 
located in a sparsely populated area.

We met with officials in VA's Geriatrics and Extended Care Strategic 
Healthcare Group and obtained documents on VA's noninstitutional long-
term care services, including service descriptions, policies, guidance, 
and other information. In addition, we interviewed the Deputy Under 
Secretary for Health for Operations and Management to determine the 
level of oversight that this office provides regarding the 
noninstitutional long-term care services offered by VA facilities, 
including the implementation and tracking of network performance 
measures related to noninstitutional care.

[End of section]

Appendix III: Availability and Utilization of Six Noninstitutional Long-
Term Care Services by VA Medical Facility or Health Care System:

Table 3 provides information on the availability and utilization of the 
six noninstitutional long-term care services reported by VA's 139 
medical facilities and health care systems for the month of July 
2002.[Footnote 20]

Table 3: Availability and Utilization of Six Noninstitutional Long-Term 
Care Services at VA Medical Facilities (July 2002):

VA medical facility or health care system (HCS): Network 1 (Boston):

VA medical facility or health care system (HCS): Bedford; Number of 
veterans receiving service[A]: Home-based primary care: 13; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 35; Number 
of veterans receiving service[A]: Skilled home health care: --; Number 
of veterans receiving service[A]: Adult day health care: 27; Number of 
veterans receiving service[A]: Geriatric evaluation: 22; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Boston HCS; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 107; 
Number of veterans receiving service[A]: Skilled home health care: 65; 
Number of veterans receiving service[A]: Adult day health care: 96; 
Number of veterans receiving service[A]: Geriatric evaluation: 20; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Connecticut HCS; 
Number of veterans receiving service[A]: Home-based primary care: 132; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
53; Number of veterans receiving service[A]: Skilled home health care: 
77; Number of veterans receiving service[A]: Adult day health care: 22; 
Number of veterans receiving service[A]: Geriatric evaluation: 115; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Manchester; Number of 
veterans receiving service[A]: Home-based primary care: 44; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 19; Number 
of veterans receiving service[A]: Skilled home health care: 26; Number 
of veterans receiving service[A]: Adult day health care: 7; Number of 
veterans receiving service[A]: Geriatric evaluation: [Empty]; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Northampton; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 101; 
Number of veterans receiving service[A]: Skilled home health care: 48; 
Number of veterans receiving service[A]: Adult day health care: 26; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Providence; Number of 
veterans receiving service[A]: Home-based primary care: 55; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 14; Number 
of veterans receiving service[A]: Skilled home health care: 52; Number 
of veterans receiving service[A]: Adult day health care: 8; Number of 
veterans receiving service[A]: Geriatric evaluation: [Empty]; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Togus; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 86; 
Number of veterans receiving service[A]: Skilled home health care: 500; 
Number of veterans receiving service[A]: Adult day health care: 1; 
Number of veterans receiving service[A]: Geriatric evaluation: 6; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): White River 
Junction[B]; Number of veterans receiving service[A]: Home-based 
primary care: [Empty]; Number of veterans receiving service[A]: 
Homemaker/: home health aide: 12; Number of veterans receiving 
service[A]: Skilled home health care: 49; Number of veterans receiving 
service[A]: Adult day health care: 45; Number of veterans receiving 
service[A]: Geriatric evaluation: 26; Number of veterans receiving 
service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 2 (Albany):

VA medical facility or health care system (HCS): Albany; Number of 
veterans receiving service[A]: Home-based primary care: 159; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 62; Number 
of veterans receiving service[A]: Skilled home health care: 22; Number 
of veterans receiving service[A]: Adult day health care: 107; Number of 
veterans receiving service[A]: Geriatric evaluation: 613; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Bath; Number of 
veterans receiving service[A]: Home-based primary care: 177; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 115; 
Number of veterans receiving service[A]: Skilled home health care: 
[Empty]; Number of veterans receiving service[A]: Adult day health 
care: 14; Number of veterans receiving service[A]: Geriatric 
evaluation: [Empty]; Number of veterans receiving service[A]: Respite 
care: 0.

VA medical facility or health care system (HCS): Canandaigua; Number of 
veterans receiving service[A]: Home-based primary care: 132; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 186; 
Number of veterans receiving service[A]: Skilled home health care: 
[Empty]; Number of veterans receiving service[A]: Adult day health 
care: 33; Number of veterans receiving service[A]: Geriatric 
evaluation: 15; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Syracuse; Number of 
veterans receiving service[A]: Home-based primary care: 273; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 147; 
Number of veterans receiving service[A]: Skilled home health care: 37; 
Number of veterans receiving service[A]: Adult day health care: 45; 
Number of veterans receiving service[A]: Geriatric evaluation: 216; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Western New York HCS; 
Number of veterans receiving service[A]: Home-based primary care: 263; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
285; Number of veterans receiving service[A]: Skilled home health care: 
68; Number of veterans receiving service[A]: Adult day health care: 
120; Number of veterans receiving service[A]: Geriatric evaluation: 26; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 3 (Bronx):

VA medical facility or health care system (HCS): Bronx; Number of 
veterans receiving service[A]: Home-based primary care: 120; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 15; Number 
of veterans receiving service[A]: Skilled home health care: 21; Number 
of veterans receiving service[A]: Adult day health care: [Empty]; 
Number of veterans receiving service[A]: Geriatric evaluation: 93; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Hudson Valley HCS; 
Number of veterans receiving service[A]: Home-based primary care: 71; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
48; Number of veterans receiving service[A]: Skilled home health care: 
6; Number of veterans receiving service[A]: Adult day health care: 3; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): New Jersey HCS; Number 
of veterans receiving service[A]: Home-based primary care: 132; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 262; 
Number of veterans receiving service[A]: Skilled home health care: 45; 
Number of veterans receiving service[A]: Adult day health care: 6; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Northport; Number of 
veterans receiving service[A]: Home-based primary care: 47; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 64; Number 
of veterans receiving service[A]: Skilled home health care: 32; Number 
of veterans receiving service[A]: Adult day health care: 12; Number of 
veterans receiving service[A]: Geriatric evaluation: 49; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): New York Harbor HCS; 
Number of veterans receiving service[A]: Home-based primary care: 210; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
219; Number of veterans receiving service[A]: Skilled home health care: 
16; Number of veterans receiving service[A]: Adult day health care: 
156; Number of veterans receiving service[A]: Geriatric evaluation: 
1,136; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 4 
(Pittsburgh):

VA medical facility or health care system (HCS): Altoona[B]; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 
[Empty]; Number of veterans receiving service[A]: Skilled home health 
care: 12; Number of veterans receiving service[A]: Adult day health 
care: [Empty]; Number of veterans receiving service[A]: Geriatric 
evaluation: [Empty]; Number of veterans receiving service[A]: Respite 
care: [Empty].

VA medical facility or health care system (HCS): Butler; Number of 
veterans receiving service[A]: Home-based primary care: 36; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 123; 
Number of veterans receiving service[A]: Skilled home health care: 
[Empty]; Number of veterans receiving service[A]: Adult day health 
care: 58; Number of veterans receiving service[A]: Geriatric 
evaluation: [Empty]; Number of veterans receiving service[A]: Respite 
care: [Empty].

VA medical facility or health care system (HCS): Clarksburg; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 176; 
Number of veterans receiving service[A]: Skilled home health care: 23; 
Number of veterans receiving service[A]: Adult day health care: 6; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Coatesville; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 80; 
Number of veterans receiving service[A]: Skilled home health care: 0; 
Number of veterans receiving service[A]: Adult day health care: 24; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Erie; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 84; 
Number of veterans receiving service[A]: Skilled home health care: 16; 
Number of veterans receiving service[A]: Adult day health care: 3; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: 2.

VA medical facility or health care system (HCS): Lebanon; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 2; 
Number of veterans receiving service[A]: Skilled home health care: 7; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
67; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Philadelphia; Number 
of veterans receiving service[A]: Home-based primary care: [Empty]; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
16; Number of veterans receiving service[A]: Skilled home health care: 
17; Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
905; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Pittsburgh HCS; Number 
of veterans receiving service[A]: Home-based primary care: 133; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 129; 
Number of veterans receiving service[A]: Skilled home health care: 87; 
Number of veterans receiving service[A]: Adult day health care: 51; 
Number of veterans receiving service[A]: Geriatric evaluation: 16; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Wilkes-Barre; Number 
of veterans receiving service[A]: Home-based primary care: [Empty]; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
30; Number of veterans receiving service[A]: Skilled home health care: 
99; Number of veterans receiving service[A]: Adult day health care: 1; 
Number of veterans receiving service[A]: Geriatric evaluation: 76; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Wilmington; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 25; 
Number of veterans receiving service[A]: Skilled home health care: 4; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
5; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 5 (Baltimore):

VA medical facility or health care system (HCS): Martinsburg; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 73; 
Number of veterans receiving service[A]: Skilled home health care: 
[Empty]; Number of veterans receiving service[A]: Adult day health 
care: 16; Number of veterans receiving service[A]: Geriatric 
evaluation: [Empty]; Number of veterans receiving service[A]: Respite 
care: [Empty].

VA medical facility or health care system (HCS): Maryland HCS; Number 
of veterans receiving service[A]: Home-based primary care: 220; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 273; 
Number of veterans receiving service[A]: Skilled home health care: 52; 
Number of veterans receiving service[A]: Adult day health care: 287; 
Number of veterans receiving service[A]: Geriatric evaluation: 12; 
Number of veterans receiving service[A]: Respite care: 3.

VA medical facility or health care system (HCS): Washington, DC; Number 
of veterans receiving service[A]: Home-based primary care: 125; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 120; 
Number of veterans receiving service[A]: Skilled home health care: 6; 
Number of veterans receiving service[A]: Adult day health care: 85; 
Number of veterans receiving service[A]: Geriatric evaluation: 292; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 6 (Durham):

VA medical facility or health care system (HCS): Asheville; Number of 
veterans receiving service[A]: Home-based primary care: 35; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 90; Number 
of veterans receiving service[A]: Skilled home health care: 22; Number 
of veterans receiving service[A]: Adult day health care: 61; Number of 
veterans receiving service[A]: Geriatric evaluation: 26; Number of 
veterans receiving service[A]: Respite care: 61.

VA medical facility or health care system (HCS): Beckley; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 
[Empty]; Number of veterans receiving service[A]: Skilled home health 
care: 10; Number of veterans receiving service[A]: Adult day health 
care: [Empty]; Number of veterans receiving service[A]: Geriatric 
evaluation: [Empty]; Number of veterans receiving service[A]: Respite 
care: [Empty].

VA medical facility or health care system (HCS): Durham; Number of 
veterans receiving service[A]: Home-based primary care: 47; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 37; Number 
of veterans receiving service[A]: Skilled home health care: 130; Number 
of veterans receiving service[A]: Adult day health care: [Empty]; 
Number of veterans receiving service[A]: Geriatric evaluation: 97; 
Number of veterans receiving service[A]: Respite care: 1.

VA medical facility or health care system (HCS): Fayetteville (NC); 
Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 19; Number of veterans receiving service[A]: Skilled home 
health care: 18; Number of veterans receiving service[A]: Adult day 
health care: 11; Number of veterans receiving service[A]: Geriatric 
evaluation: 17; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Hampton; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 27; 
Number of veterans receiving service[A]: Skilled home health care: 29; 
Number of veterans receiving service[A]: Adult day health care: 13; 
Number of veterans receiving service[A]: Geriatric evaluation: 0; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Richmond; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 
[Empty]; Number of veterans receiving service[A]: Skilled home health 
care: 101; Number of veterans receiving service[A]: Adult day health 
care: 0; Number of veterans receiving service[A]: Geriatric evaluation: 
1,800; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Salem; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 40; 
Number of veterans receiving service[A]: Skilled home health care: 13; 
Number of veterans receiving service[A]: Adult day health care: 71; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: 3.

VA medical facility or health care system (HCS): Salisbury; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 35; 
Number of veterans receiving service[A]: Skilled home health care: 100; 
Number of veterans receiving service[A]: Adult day health care: 11; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 7 (Atlanta):

VA medical facility or health care system (HCS): Atlanta; Number of 
veterans receiving service[A]: Home-based primary care: 90; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 51; Number 
of veterans receiving service[A]: Skilled home health care: 52; Number 
of veterans receiving service[A]: Adult day health care: 7; Number of 
veterans receiving service[A]: Geriatric evaluation: 550; Number of 
veterans receiving service[A]: Respite care: 7.

VA medical facility or health care system (HCS): Augusta; Number of 
veterans receiving service[A]: Home-based primary care: 53; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 195; 
Number of veterans receiving service[A]: Skilled home health care: 88; 
Number of veterans receiving service[A]: Adult day health care: 2; 
Number of veterans receiving service[A]: Geriatric evaluation: 56; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Birmingham; Number of 
veterans receiving service[A]: Home-based primary care: 94; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 4; Number 
of veterans receiving service[A]: Skilled home health care: 62; Number 
of veterans receiving service[A]: Adult day health care: 0; Number of 
veterans receiving service[A]: Geriatric evaluation: 27; Number of 
veterans receiving service[A]: Respite care: 4.

VA medical facility or health care system (HCS): Central Alabama HCS; 
Number of veterans receiving service[A]: Home-based primary care: 135; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
57; Number of veterans receiving service[A]: Skilled home health care: 
48; Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
257; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Charleston; Number of 
veterans receiving service[A]: Home-based primary care: 96; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 57; Number 
of veterans receiving service[A]: Skilled home health care: 92; Number 
of veterans receiving service[A]: Adult day health care: 6; Number of 
veterans receiving service[A]: Geriatric evaluation: 169; Number of 
veterans receiving service[A]: Respite care: 10.

VA medical facility or health care system (HCS): Columbia (SC); Number 
of veterans receiving service[A]: Home-based primary care: 35; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 53; 
Number of veterans receiving service[A]: Skilled home health care: 82; 
Number of veterans receiving service[A]: Adult day health care: 20; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Dublin; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 68; 
Number of veterans receiving service[A]: Skilled home health care: 127; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Tuscaloosa; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 94; 
Number of veterans receiving service[A]: Skilled home health care: 15; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Network 8 (Bay Pines):

VA medical facility or health care system (HCS): Bay Pines[B]; Number 
of veterans receiving service[A]: Home-based primary care: 123; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 83; 
Number of veterans receiving service[A]: Skilled home health care: 44; 
Number of veterans receiving service[A]: Adult day health care: 23; 
Number of veterans receiving service[A]: Geriatric evaluation: 857; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Miami[B]; Number of 
veterans receiving service[A]: Home-based primary care: 224; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 75; Number 
of veterans receiving service[A]: Skilled home health care: 54; Number 
of veterans receiving service[A]: Adult day health care: 32; Number of 
veterans receiving service[A]: Geriatric evaluation: 397; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): N. Florida/S. Georgia 
HCS[B]; Number of veterans receiving service[A]: Home-based primary 
care: 248; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 270; Number of veterans receiving service[A]: Skilled home 
health care: 30; Number of veterans receiving service[A]: Adult day 
health care: 9; Number of veterans receiving service[A]: Geriatric 
evaluation: 647; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): San Juan; Number of 
veterans receiving service[A]: Home-based primary care: 193; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 0; Number 
of veterans receiving service[A]: Skilled home health care: 2; Number 
of veterans receiving service[A]: Adult day health care: [Empty]; 
Number of veterans receiving service[A]: Geriatric evaluation: 569; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Tampa[B]; Number of 
veterans receiving service[A]: Home-based primary care: 163; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 39; Number 
of veterans receiving service[A]: Skilled home health care: 155; Number 
of veterans receiving service[A]: Adult day health care: [Empty]; 
Number of veterans receiving service[A]: Geriatric evaluation: 300; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): West Palm Beach; 
Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 42; Number of veterans receiving service[A]: Skilled home 
health care: 23; Number of veterans receiving service[A]: Adult day 
health care: 2; Number of veterans receiving service[A]: Geriatric 
evaluation: [Empty]; Number of veterans receiving service[A]: Respite 
care: [Empty].

VA medical facility or health care system (HCS): Network 9 (Nashville):

VA medical facility or health care system (HCS): Huntington; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 60; 
Number of veterans receiving service[A]: Skilled home health care: 49; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Lexington; Number of 
veterans receiving service[A]: Home-based primary care: 23; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 32; Number 
of veterans receiving service[A]: Skilled home health care: 53; Number 
of veterans receiving service[A]: Adult day health care: [Empty]; 
Number of veterans receiving service[A]: Geriatric evaluation: 52; 
Number of veterans receiving service[A]: Respite care: 1.

VA medical facility or health care system (HCS): Louisville; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 29; 
Number of veterans receiving service[A]: Skilled home health care: 469; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
46; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Memphis[B]; Number of 
veterans receiving service[A]: Home-based primary care: 112; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 73; Number 
of veterans receiving service[A]: Skilled home health care: 227; Number 
of veterans receiving service[A]: Adult day health care: [Empty]; 
Number of veterans receiving service[A]: Geriatric evaluation: 560; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Mountain Home; Number 
of veterans receiving service[A]: Home-based primary care: [Empty]; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
158; Number of veterans receiving service[A]: Skilled home health care: 
42; Number of veterans receiving service[A]: Adult day health care: 14; 
Number of veterans receiving service[A]: Geriatric evaluation: 15; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Tennessee Valley HCS; 
Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 216; Number of veterans receiving service[A]: Skilled home 
health care: 129; Number of veterans receiving service[A]: Adult day 
health care: 13; Number of veterans receiving service[A]: Geriatric 
evaluation: --; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Network 10 
(Cincinnati):

VA medical facility or health care system (HCS): Chillicothe; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 186; 
Number of veterans receiving service[A]: Skilled home health care: 102; 
Number of veterans receiving service[A]: Adult day health care: 3; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Cincinnati; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 22; 
Number of veterans receiving service[A]: Skilled home health care: 60; 
Number of veterans receiving service[A]: Adult day health care: 71; 
Number of veterans receiving service[A]: Geriatric evaluation: 26; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Cleveland; Number of 
veterans receiving service[A]: Home-based primary care: 249; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 378; 
Number of veterans receiving service[A]: Skilled home health care: 26; 
Number of veterans receiving service[A]: Adult day health care: 9; 
Number of veterans receiving service[A]: Geriatric evaluation: 288; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Columbus; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 44; 
Number of veterans receiving service[A]: Skilled home health care: 13; 
Number of veterans receiving service[A]: Adult day health care: 25; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Dayton; Number of 
veterans receiving service[A]: Home-based primary care: 53; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 275; 
Number of veterans receiving service[A]: Skilled home health care: 179; 
Number of veterans receiving service[A]: Adult day health care: 37; 
Number of veterans receiving service[A]: Geriatric evaluation: 42; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 11 (Ann 
Arbor):

VA medical facility or health care system (HCS): Ann Arbor; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 88; 
Number of veterans receiving service[A]: Skilled home health care: 13; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
54; Number of veterans receiving service[A]: Respite care: 0.

VA medical facility or health care system (HCS): Battle Creek; Number 
of veterans receiving service[A]: Home-based primary care: 120; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 107; 
Number of veterans receiving service[A]: Skilled home health care: 22; 
Number of veterans receiving service[A]: Adult day health care: 31; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: 1.

VA medical facility or health care system (HCS): Danville; Number of 
veterans receiving service[A]: Home-based primary care: 96; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 117; 
Number of veterans receiving service[A]: Skilled home health care: --; 
Number of veterans receiving service[A]: Adult day health care: 40; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: 0.

VA medical facility or health care system (HCS): Detroit; Number of 
veterans receiving service[A]: Home-based primary care: 100; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 29; Number 
of veterans receiving service[A]: Skilled home health care: 100; Number 
of veterans receiving service[A]: Adult day health care: 1; Number of 
veterans receiving service[A]: Geriatric evaluation: 5; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Indianapolis; Number 
of veterans receiving service[A]: Home-based primary care: 111; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 109; 
Number of veterans receiving service[A]: Skilled home health care: 49; 
Number of veterans receiving service[A]: Adult day health care: 20; 
Number of veterans receiving service[A]: Geriatric evaluation: 48; 
Number of veterans receiving service[A]: Respite care: 0.

VA medical facility or health care system (HCS): Northern Indiana HCS; 
Number of veterans receiving service[A]: Home-based primary care: 96; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
180; Number of veterans receiving service[A]: Skilled home health care: 
87; Number of veterans receiving service[A]: Adult day health care: 1; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: 4.

VA medical facility or health care system (HCS): Saginaw; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 31; 
Number of veterans receiving service[A]: Skilled home health care: 15; 
Number of veterans receiving service[A]: Adult day health care: 2; 
Number of veterans receiving service[A]: Geriatric evaluation: 8; 
Number of veterans receiving service[A]: Respite care: 2.

VA medical facility or health care system (HCS): Network 12 (Chicago):

VA medical facility or health care system (HCS): Chicago HCS[B]; Number 
of veterans receiving service[A]: Home-based primary care: 94; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 30; 
Number of veterans receiving service[A]: Skilled home health care: 52; 
Number of veterans receiving service[A]: Adult day health care: 36; 
Number of veterans receiving service[A]: Geriatric evaluation: 12; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Hines; Number of 
veterans receiving service[A]: Home-based primary care: 183; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 64; Number 
of veterans receiving service[A]: Skilled home health care: 90; Number 
of veterans receiving service[A]: Adult day health care: 45; Number of 
veterans receiving service[A]: Geriatric evaluation: 133; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Iron Mountain; Number 
of veterans receiving service[A]: Home-based primary care: [Empty]; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
12; Number of veterans receiving service[A]: Skilled home health care: 
15; Number of veterans receiving service[A]: Adult day health care: 0; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Madison; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 21; 
Number of veterans receiving service[A]: Skilled home health care: --; 
Number of veterans receiving service[A]: Adult day health care: 5; 
Number of veterans receiving service[A]: Geriatric evaluation: 18; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Milwaukee; Number of 
veterans receiving service[A]: Home-based primary care: 146; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 30; Number 
of veterans receiving service[A]: Skilled home health care: 23; Number 
of veterans receiving service[A]: Adult day health care: 60; Number of 
veterans receiving service[A]: Geriatric evaluation: 60; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): North Chicago; Number 
of veterans receiving service[A]: Home-based primary care: 144; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 
[Empty]; Number of veterans receiving service[A]: Skilled home health 
care: 1; Number of veterans receiving service[A]: Adult day health 
care: 19; Number of veterans receiving service[A]: Geriatric 
evaluation: [Empty]; Number of veterans receiving service[A]: Respite 
care: [Empty].

VA medical facility or health care system (HCS): Tomah; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 5; 
Number of veterans receiving service[A]: Skilled home health care: 1; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Network 15 (Kansas 
City):

VA medical facility or health care system (HCS): Columbia (MO); Number 
of veterans receiving service[A]: Home-based primary care: 134; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 55; 
Number of veterans receiving service[A]: Skilled home health care: 18; 
Number of veterans receiving service[A]: Adult day health care: 0; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: 3.

VA medical facility or health care system (HCS): Eastern Kansas HCS; 
Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 61; Number of veterans receiving service[A]: Skilled home 
health care: 54; Number of veterans receiving service[A]: Adult day 
health care: 6; Number of veterans receiving service[A]: Geriatric 
evaluation: 18; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Kansas City; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 64; 
Number of veterans receiving service[A]: Skilled home health care: 16; 
Number of veterans receiving service[A]: Adult day health care: 3; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Marion; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 31; 
Number of veterans receiving service[A]: Skilled home health care: 215; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Poplar Bluff; Number 
of veterans receiving service[A]: Home-based primary care: [Empty]; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
38; Number of veterans receiving service[A]: Skilled home health care: 
22; Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): St. Louis; Number of 
veterans receiving service[A]: Home-based primary care: 75; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 78; Number 
of veterans receiving service[A]: Skilled home health care: 30; Number 
of veterans receiving service[A]: Adult day health care: 10; Number of 
veterans receiving service[A]: Geriatric evaluation: --; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Wichita[B]; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 35; 
Number of veterans receiving service[A]: Skilled home health care: 40; 
Number of veterans receiving service[A]: Adult day health care: 9; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 16 (Jackson):

VA medical facility or health care system (HCS): Alexandria; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 15; 
Number of veterans receiving service[A]: Skilled home health care: 21; 
Number of veterans receiving service[A]: Adult day health care: 7; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Central Arkansas 
HCS[B]; Number of veterans receiving service[A]: Home-based primary 
care: 187; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 145; Number of veterans receiving service[A]: Skilled home 
health care: 31; Number of veterans receiving service[A]: Adult day 
health care: 73; Number of veterans receiving service[A]: Geriatric 
evaluation: 719; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Fayetteville (AR); 
Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: [Empty]; Number of veterans receiving service[A]: Skilled 
home health care: 3; Number of veterans receiving service[A]: Adult day 
health care: [Empty]; Number of veterans receiving service[A]: 
Geriatric evaluation: [Empty]; Number of veterans receiving service[A]: 
Respite care: [Empty].

VA medical facility or health care system (HCS): Gulf Coast HCS; Number 
of veterans receiving service[A]: Home-based primary care: 75; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 51; 
Number of veterans receiving service[A]: Skilled home health care: 134; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
195; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Houston; Number of 
veterans receiving service[A]: Home-based primary care: 92; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 36; Number 
of veterans receiving service[A]: Skilled home health care: 60; Number 
of veterans receiving service[A]: Adult day health care: 6; Number of 
veterans receiving service[A]: Geriatric evaluation: 333; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Jackson; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 35; 
Number of veterans receiving service[A]: Skilled home health care: 115; 
Number of veterans receiving service[A]: Adult day health care: 28; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Muskogee[B]; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 
[Empty]; Number of veterans receiving service[A]: Skilled home health 
care: 8; Number of veterans receiving service[A]: Adult day health 
care: 38; Number of veterans receiving service[A]: Geriatric 
evaluation: [Empty]; Number of veterans receiving service[A]: Respite 
care: [Empty].

VA medical facility or health care system (HCS): New Orleans; Number of 
veterans receiving service[A]: Home-based primary care: 82; Number of 
veterans receiving service[A]: Homemaker/: home health aide: [Empty]; 
Number of veterans receiving service[A]: Skilled home health care: 12; 
Number of veterans receiving service[A]: Adult day health care: 35; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Oklahoma City; Number 
of veterans receiving service[A]: Home-based primary care: 32; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 34; 
Number of veterans receiving service[A]: Skilled home health care: 160; 
Number of veterans receiving service[A]: Adult day health care: 11; 
Number of veterans receiving service[A]: Geriatric evaluation: --; 
Number of veterans receiving service[A]: Respite care: --.

VA medical facility or health care system (HCS): Shreveport; Number of 
veterans receiving service[A]: Home-based primary care: 64; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 33; Number 
of veterans receiving service[A]: Skilled home health care: 80; Number 
of veterans receiving service[A]: Adult day health care: [Empty]; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 17 (Dallas):

VA medical facility or health care system (HCS): Central Texas HCS; 
Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 97; Number of veterans receiving service[A]: Skilled home 
health care: 23; Number of veterans receiving service[A]: Adult day 
health care: 2; Number of veterans receiving service[A]: Geriatric 
evaluation: 18; Number of veterans receiving service[A]: Respite care: 
0.

VA medical facility or health care system (HCS): North Texas HCS[B]; 
Number of veterans receiving service[A]: Home-based primary care: 195; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
98; Number of veterans receiving service[A]: Skilled home health care: 
39; Number of veterans receiving service[A]: Adult day health care: 18; 
Number of veterans receiving service[A]: Geriatric evaluation: 62; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): South Texas HCS; 
Number of veterans receiving service[A]: Home-based primary care: 189; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
128; Number of veterans receiving service[A]: Skilled home health care: 
57; Number of veterans receiving service[A]: Adult day health care: 44; 
Number of veterans receiving service[A]: Geriatric evaluation: 418; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 18 (Phoenix):

VA medical facility or health care system (HCS): Albuquerque[B]; Number 
of veterans receiving service[A]: Home-based primary care: 96; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 168; 
Number of veterans receiving service[A]: Skilled home health care: 3; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
135; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Amarillo[B]; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 
[Empty]; Number of veterans receiving service[A]: Skilled home health 
care: 82; Number of veterans receiving service[A]: Adult day health 
care: [Empty]; Number of veterans receiving service[A]: Geriatric 
evaluation: [Empty]; Number of veterans receiving service[A]: Respite 
care: [Empty].

VA medical facility or health care system (HCS): Big Spring; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 
[Empty]; Number of veterans receiving service[A]: Skilled home health 
care: [Empty]; Number of veterans receiving service[A]: Adult day 
health care: [Empty]; Number of veterans receiving service[A]: 
Geriatric evaluation: [Empty]; Number of veterans receiving service[A]: 
Respite care: [Empty].

VA medical facility or health care system (HCS): El Paso[B]; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 
[Empty]; Number of veterans receiving service[A]: Skilled home health 
care: 3; Number of veterans receiving service[A]: Adult day health 
care: [Empty]; Number of veterans receiving service[A]: Geriatric 
evaluation: 1; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Phoenix; Number of 
veterans receiving service[A]: Home-based primary care: 75; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 57; Number 
of veterans receiving service[A]: Skilled home health care: 250; Number 
of veterans receiving service[A]: Adult day health care: --; Number of 
veterans receiving service[A]: Geriatric evaluation: [Empty]; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Prescott; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 6; 
Number of veterans receiving service[A]: Skilled home health care: 72; 
Number of veterans receiving service[A]: Adult day health care: 38; 
Number of veterans receiving service[A]: Geriatric evaluation: --; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Tucson; Number of 
veterans receiving service[A]: Home-based primary care: 163; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 128; 
Number of veterans receiving service[A]: Skilled home health care: 156; 
Number of veterans receiving service[A]: Adult day health care: 39; 
Number of veterans receiving service[A]: Geriatric evaluation: 25; 
Number of veterans receiving service[A]: Respite care: 8.

VA medical facility or health care system (HCS): Network 19 (Denver):

VA medical facility or health care system (HCS): Cheyenne; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 107; 
Number of veterans receiving service[A]: Skilled home health care: 1; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Denver; Number of 
veterans receiving service[A]: Home-based primary care: 76; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 134; 
Number of veterans receiving service[A]: Skilled home health care: 66; 
Number of veterans receiving service[A]: Adult day health care: 61; 
Number of veterans receiving service[A]: Geriatric evaluation: 122; 
Number of veterans receiving service[A]: Respite care: 14.

VA medical facility or health care system (HCS): Fort Lyon; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 85; 
Number of veterans receiving service[A]: Skilled home health care: 165; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 0.

VA medical facility or health care system (HCS): Grand Junction[B]; 
Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: [Empty]; Number of veterans receiving service[A]: Skilled 
home health care: 6; Number of veterans receiving service[A]: Adult day 
health care: [Empty]; Number of veterans receiving service[A]: 
Geriatric evaluation: [Empty]; Number of veterans receiving service[A]: 
Respite care: [Empty].

VA medical facility or health care system (HCS): Montana HCS; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 
[Empty]; Number of veterans receiving service[A]: Skilled home health 
care: [Empty]; Number of veterans receiving service[A]: Adult day 
health care: [Empty]; Number of veterans receiving service[A]: 
Geriatric evaluation: [Empty]; Number of veterans receiving service[A]: 
Respite care: [Empty].

VA medical facility or health care system (HCS): Salt Lake City[B]; 
Number of veterans receiving service[A]: Home-based primary care: 127; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
115; Number of veterans receiving service[A]: Skilled home health care: 
98; Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
83; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Sheridan; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 25; 
Number of veterans receiving service[A]: Skilled home health care: 5; 
Number of veterans receiving service[A]: Adult day health care: 2; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 20 (Portland):

VA medical facility or health care system (HCS): Alaska HCS; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 15; 
Number of veterans receiving service[A]: Skilled home health care: 87; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Boise; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 45; 
Number of veterans receiving service[A]: Skilled home health care: 43; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
5; Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Portland; Number of 
veterans receiving service[A]: Home-based primary care: 119; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 26; Number 
of veterans receiving service[A]: Skilled home health care: 68; Number 
of veterans receiving service[A]: Adult day health care: [Empty]; 
Number of veterans receiving service[A]: Geriatric evaluation: 94; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Puget Sound HCS; 
Number of veterans receiving service[A]: Home-based primary care: 149; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
125; Number of veterans receiving service[A]: Skilled home health care: 
19; Number of veterans receiving service[A]: Adult day health care: 35; 
Number of veterans receiving service[A]: Geriatric evaluation: 144; 
Number of veterans receiving service[A]: Respite care: 0.

VA medical facility or health care system (HCS): Roseburg; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 25; 
Number of veterans receiving service[A]: Skilled home health care: 17; 
Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Spokane; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 28; 
Number of veterans receiving service[A]: Skilled home health care: 11; 
Number of veterans receiving service[A]: Adult day health care: 12; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: 10.

VA medical facility or health care system (HCS): Walla Walla[B]; Number 
of veterans receiving service[A]: Home-based primary care: [Empty]; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
14; Number of veterans receiving service[A]: Skilled home health care: 
--; Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): White City 
Domiciliary; Number of veterans receiving service[A]: Home-based 
primary care: [Empty]; Number of veterans receiving service[A]: 
Homemaker/: home health aide: 29; Number of veterans receiving 
service[A]: Skilled home health care: --; Number of veterans receiving 
service[A]: Adult day health care: 76; Number of veterans receiving 
service[A]: Geriatric evaluation: 60; Number of veterans receiving 
service[A]: Respite care: 3.

VA medical facility or health care system (HCS): Network 21 (San 
Francisco):

VA medical facility or health care system (HCS): Central California 
HCS[B]; Number of veterans receiving service[A]: Home-based primary 
care: 52; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 18; Number of veterans receiving service[A]: Skilled home 
health care: 19; Number of veterans receiving service[A]: Adult day 
health care: [Empty]; Number of veterans receiving service[A]: 
Geriatric evaluation: 38; Number of veterans receiving service[A]: 
Respite care: [Empty].

VA medical facility or health care system (HCS): Honolulu[B]; Number of 
veterans receiving service[A]: Home-based primary care: 65; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 11; Number 
of veterans receiving service[A]: Skilled home health care: 4; Number 
of veterans receiving service[A]: Adult day health care: 2; Number of 
veterans receiving service[A]: Geriatric evaluation: 75; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Northern California 
HCS; Number of veterans receiving service[A]: Home-based primary care: 
185; Number of veterans receiving service[A]: Homemaker/: home health 
aide: 78; Number of veterans receiving service[A]: Skilled home health 
care: 69; Number of veterans receiving service[A]: Adult day health 
care: 6; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Palo Alto; Number of 
veterans receiving service[A]: Home-based primary care: 115; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 29; Number 
of veterans receiving service[A]: Skilled home health care: 48; Number 
of veterans receiving service[A]: Adult day health care: 15; Number of 
veterans receiving service[A]: Geriatric evaluation: 90; Number of 
veterans receiving service[A]: Respite care: 10.

VA medical facility or health care system (HCS): Reno; Number of 
veterans receiving service[A]: Home-based primary care: 83; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 83; Number 
of veterans receiving service[A]: Skilled home health care: 83; Number 
of veterans receiving service[A]: Adult day health care: 9; Number of 
veterans receiving service[A]: Geriatric evaluation: 35; Number of 
veterans receiving service[A]: Respite care: 0.

VA medical facility or health care system (HCS): San Francisco; Number 
of veterans receiving service[A]: Home-based primary care: 99; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 69; 
Number of veterans receiving service[A]: Skilled home health care: 40; 
Number of veterans receiving service[A]: Adult day health care: 8; 
Number of veterans receiving service[A]: Geriatric evaluation: 80; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 22 (Long 
Beach):

VA medical facility or health care system (HCS): Greater Los Angeles 
HCS; Number of veterans receiving service[A]: Home-based primary care: 
245; Number of veterans receiving service[A]: Homemaker/: home health 
aide: 95; Number of veterans receiving service[A]: Skilled home health 
care: 12; Number of veterans receiving service[A]: Adult day health 
care: 57; Number of veterans receiving service[A]: Geriatric 
evaluation: 123; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Loma Linda; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 90; 
Number of veterans receiving service[A]: Skilled home health care: 210; 
Number of veterans receiving service[A]: Adult day health care: 25; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Long Beach; Number of 
veterans receiving service[A]: Home-based primary care: 115; Number of 
veterans receiving service[A]: Homemaker/: home health aide: [Empty]; 
Number of veterans receiving service[A]: Skilled home health care: 
[Empty]; Number of veterans receiving service[A]: Adult day health 
care: [Empty]; Number of veterans receiving service[A]: Geriatric 
evaluation: 119; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Southern Nevada HCS; 
Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: [Empty]; Number of veterans receiving service[A]: Skilled 
home health care: 33; Number of veterans receiving service[A]: Adult 
day health care: [Empty]; Number of veterans receiving service[A]: 
Geriatric evaluation: 34; Number of veterans receiving service[A]: 
Respite care: 0.

VA medical facility or health care system (HCS): San Diego; Number of 
veterans receiving service[A]: Home-based primary care: 77; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 40; Number 
of veterans receiving service[A]: Skilled home health care: 15; Number 
of veterans receiving service[A]: Adult day health care: 50; Number of 
veterans receiving service[A]: Geriatric evaluation: 80; Number of 
veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Network 23 
(Minneapolis)[C]:

VA medical facility or health care system (HCS): Black Hills HCS; 
Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 105; Number of veterans receiving service[A]: Skilled home 
health care: 101; Number of veterans receiving service[A]: Adult day 
health care: [Empty]; Number of veterans receiving service[A]: 
Geriatric evaluation: [Empty]; Number of veterans receiving service[A]: 
Respite care: 1.

VA medical facility or health care system (HCS): Central Iowa HCS; 
Number of veterans receiving service[A]: Home-based primary care: 49; 
Number of veterans receiving service[A]: Homemaker/: home health aide: 
17; Number of veterans receiving service[A]: Skilled home health care: 
66; Number of veterans receiving service[A]: Adult day health care: 
[Empty]; Number of veterans receiving service[A]: Geriatric evaluation: 
[Empty]; Number of veterans receiving service[A]: Respite care: 
[Empty].

VA medical facility or health care system (HCS): Fargo; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 69; 
Number of veterans receiving service[A]: Skilled home health care: 240; 
Number of veterans receiving service[A]: Adult day health care: 2; 
Number of veterans receiving service[A]: Geriatric evaluation: [Empty]; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): Iowa City; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 182; 
Number of veterans receiving service[A]: Skilled home health care: 302; 
Number of veterans receiving service[A]: Adult day health care: 85; 
Number of veterans receiving service[A]: Geriatric evaluation: 352; 
Number of veterans receiving service[A]: Respite care: 4.

VA medical facility or health care system (HCS): Minneapolis; Number of 
veterans receiving service[A]: Home-based primary care: 116; Number of 
veterans receiving service[A]: Homemaker/: home health aide: 200; 
Number of veterans receiving service[A]: Skilled home health care: 130; 
Number of veterans receiving service[A]: Adult day health care: 200; 
Number of veterans receiving service[A]: Geriatric evaluation: 44; 
Number of veterans receiving service[A]: Respite care: 0.

VA medical facility or health care system (HCS): Nebraska/Western Iowa 
HCS; Number of veterans receiving service[A]: Home-based primary care: 
[Empty]; Number of veterans receiving service[A]: Homemaker/: home 
health aide: 94; Number of veterans receiving service[A]: Skilled home 
health care: 82; Number of veterans receiving service[A]: Adult day 
health care: 7; Number of veterans receiving service[A]: Geriatric 
evaluation: 36; Number of veterans receiving service[A]: Respite care: 
1.

VA medical facility or health care system (HCS): Sioux Falls; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 51; 
Number of veterans receiving service[A]: Skilled home health care: 50; 
Number of veterans receiving service[A]: Adult day health care: 2; 
Number of veterans receiving service[A]: Geriatric evaluation: 16; 
Number of veterans receiving service[A]: Respite care: [Empty].

VA medical facility or health care system (HCS): St. Cloud; Number of 
veterans receiving service[A]: Home-based primary care: [Empty]; Number 
of veterans receiving service[A]: Homemaker/: home health aide: 76; 
Number of veterans receiving service[A]: Skilled home health care: 105; 
Number of veterans receiving service[A]: Adult day health care: 87; 
Number of veterans receiving service[A]: Geriatric evaluation: 12; 
Number of veterans receiving service[A]: Respite care: 1.

Source: GAO.

Notes: Responses to our surveys were submitted September through 
November 2002.

Facility cells that are empty indicate that a facility did not report 
offering the service at the time of our survey. A dash indicates that a 
facility reported offering the service but did not report the service's 
July 2002 utilization.

[A] Services include those provided directly by VA staff or through 
contracts.

[B] Facility reported using only a volunteer service to provide 
noninstitutional respite care to veterans. We did not include volunteer 
respite care services in our number of facilities offering 
noninstitutional respite care.

[C] Network 23 was created when Networks 13 and 14 were merged into a 
single network in January 2002. VA currently has 21 networks.

[End of table]

[End of section]

Appendix IV: Comments From the Department of Veterans Affairs:

THE SECRETARY OF VETERANS AFFAIRS WASHINGTON:

April 7, 2003:

Ms. Cynthia A. Bascetta Director, Health Care-Veterans' Health and 
Benefits Issues Health Care Team:

U. S. General Accounting Office 441 G Street, NW Washington, DC 20548:

Dear Ms. Bascetta:

The Department of Veterans Affairs (VA) has reviewed your draft report, 
VA LONG-TERM CARE: Service Gaps and Facility Restrictions Limit 
Veterans' Access to Noninstitutional Care (GAO-03-487) and agrees with 
your findings and conclusions. VA concurs with your recommendations and 
offers these preliminary comments. The Veterans Health Administration 
will add eligibility sections in each new directive and handbook 
concerning Home and Community Based Care Programs. It will also develop 
performance measures to underscore the importance the Department places 
on its noninstitutional long-term care programs.

VA will provide its detailed action plan to implement GAO's 
recommendations when responding to your final report.

Thank you for the opportunity to comment on your draft report.

Sincerely yours,

Anthony J. Principi:

Signed by Anthony J. Principi:

[End of section]

Appendix V: GAO Contact and Staff Acknowledgments:

GAO Contact:

James C. Musselwhite, (202) 512-7259:

Acknowledgments:

In addition to the contact named above Pamela Dooley, Steve Gaty, 
Marcia Mann, and Kristin Wilson made key contributions to this report.

[End of section]

Related GAO Products:

Long-Term Care: Availability of Medicaid Home and Community Services 
for Elderly Individuals Varies Considerably. GAO-02-1121. Washington, 
D.C.: September 26, 2002.

VA Long-Term Care: The Availability of Noninstitutional Services Is 
Uneven. GAO-02-652T. Washington, D.C.: April 25, 2002.

VA Long-Term Care: Implementation of Certain Millennium Act Provisions 
Is Incomplete, and Availability of Noninstitutional Services Is Uneven. 
GAO-02-510R. Washington, D.C.: March 29, 2002.

Veterans' Affairs: Observations on Selected Features of the Proposed 
Veterans' Millennium Health Care Act. GAO/T-HEHS-99-125. Washington, 
D.C.: May 19, 1999.

FOOTNOTES

[1] Pub. L. No. 106-117, 113 Stat. 1545 (1999). 

[2] The act requires that VA provide noninstitutional extended care 
services to enrolled veterans until December 31, 2003. 

[3] U.S. General Accounting Office, VA Long-Term Care: The Availability 
of Noninstitutional Services Is Uneven, GAO-02-652T (Washington, D.C.: 
Apr. 25, 2002).

[4] U.S. General Accounting Office, VA Long-Term Care: Implementation 
of Certain Millennium Act Provisions Is Incomplete, and Availability of 
Noninstitutional Services Is Uneven, GAO-02-510R (Washington, D.C.: 
Mar. 29, 2002). 

[5] 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.

[6] VA originally created 22 networks, but in January 2002 VA merged 2 
networks into a single network, leaving the agency with 21 networks.

[7] Pub. L. No. 104-262  101, 104, 110 Stat. 3178-79, 3182-83 (1996).

[8] A service-connected disability is an injury or disease that was 
incurred or aggravated while on active military duty. VA classifies 
veterans with service-connected disabilities according to the extent of 
their disability. These classifications are expressed in terms of 
percentages--for example, the most severely disabled such veteran would 
be classified as having a service-connected disability of 100 percent. 
Percentages are assigned in increments of 10 percent. 

[9] Priority 8 veterans are primarily veterans with no service-
connected disabilities who have incomes above established limits for 
geographic regions set by the U.S. Department of Housing and Urban 
Development to reflect regional costs of living. Priority 8 veterans 
enrolled prior to January 17, 2003, remain enrolled to receive VA 
health care benefits. 

[10] Medicaid, the joint federal-state health-financing program for 
low-income individuals, is the nation's largest funding source for 
long-term care. In fiscal year 2001, Medicaid expenditures on long-term 
care totaled $75.3 billion. 

[11] For more information on VA's resource allocation system see U.S. 
General Accounting Office, VA Health Care: Allocation Changes Would 
Better Align Resources with Workload, GAO-02-338 (Washington, D.C.: 
Feb. 28, 2002).

[12] Case management includes assessment of the veteran's care needs, 
care planning and implementation, referral coordination, monitoring, 
and periodic reassessment of the veteran's care needs. 

[13] Although VA issued a regulation on September 17, 2002, granting 
priority for appointments to veterans with service-connected 
disabilities of at least 50 percent and veterans needing care for a 
service-connected disability, the regulation does not change other 
veterans' eligibility to receive services. 

[14] The Millennium Act requires that VA provide nursing home care to 
any veteran who needs such care and who has a service-connected 
disability of 70 percent or greater, or to any veteran needing such 
care specifically for a service-connected disability, even if the 
disability is less than 70 percent.

[15] According to VA, when it plans for noninstitutional services it 
assumes that the vast majority of veterans will choose to use their 
Medicare benefits for home health care. 

[16] The medical benefits package is the set of services to be 
available to all enrolled veterans.

[17] At two facilities we visited where home-based primary care is 
offered, officials told us that veterans would likely be provided home 
health care through a contract service if they lived outside of each 
facility's home-based primary care service area.

[18] The utilization data provided by VA facilities does not represent 
an unduplicated count of veterans in these settings because some 
veterans may receive more than one noninstitutional service.

[19] GAO-02-652T.

[20] 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.

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