Background

In 1944, President Franklin D. Roosevelt made a commitment that no  servicemen blinded in combat in World War II would be returned to their  homes without adequate training to meet the problems imposed by their  blindness, according to VA. From 1944 to 1947, the Army and Navy  provided this rehabilitation training. In 1947, responsibility for this training  was transferred to VA, and in 1948, VA opened its first BRC to provide  comprehensive inpatient care to legally blind veterans.
In 1956, blind rehabilitation services were expanded to include veterans  whose legal blindness was not service-connected. Because of this  expansion, the demographics of VA’s blind veteran population shifted  toward predominately older veterans whose legal blindness was caused by  age-related eye diseases. Expanded eligibility also caused an increase in  demand for services. VA responded to this demand by opening 9 additional  BRCs in the United States and Puerto Rico for a total of 10 facilities with  241 authorized beds. (See table 1.) As of May 5 2004, VA reported that  there were 2,127 legally blind veterans waiting for admission to BRCs.
In fiscal year 2003, VA estimated that about 157,000 veterans were legally  blind, with more than 60 percent age 75 or older. About 44,000 legally  blind veterans were enrolled in VA health care. VA estimated that through  2022, the number of legally blind veterans would remain stable. (See   fig. 1.)
The National Institutes of Health (NIH) considers the increase in age- related eye diseases to be an emerging major public health problem.  According to NIH, the four leading diseases that cause age-related legal  blindness are cataract, glaucoma, macular degeneration, and diabetic  retinopathy, each affecting vision differently. (See fig. 2 for illustrations of  how each disease affects vision.) Cataract is a clouding of the eye’s  normally clear lens. Most cataracts appear with advancing age, and by age  80, more than half of all Americans develop them. Glaucoma causes  gradual damage to the optic nerve—the nerve to the eye—that results in  decreasing peripheral vision. It is estimated that as many as 4 million  Americans have glaucoma. Macular degeneration results in the loss of  central visual clarity and contrast sensitivity. It is the most common cause  of legal blindness in older Americans and rarely affects those under the  age of 60. Diabetic retinopathy is a common complication of diabetes  impairing vision over time. It results in the loss of visual clarity, peripheral  vision, and color and contrast sensitivity. It also increases the eye’s  sensitivity to glare. Nearly half of all diabetics will develop some degree of  diabetic retinopathy, and the risk increases with veterans’ age and the  length of time they have had diabetes.
To assist legally blind veterans, VA established Visual Impairment Services  Team (VIST) coordinators who act as case managers and are responsible  for coordinating all medical services for these veterans, including  obtaining medical examinations and arranging for blind rehabilitation  services. There are about 170 VIST coordinators, who are located at VA  medical centers that have at least 100 enrolled legally blind veterans. VIST  coordinators are also responsible for certain administrative services such  as reviewing the veteran’s compensation and pension benefits. Almost all  of VA’s blind rehabilitation services for veterans are provided through  comprehensive inpatient care at BRCs, where veterans are trained to use  their remaining vision and other senses, as well as adaptive devices such  as canes, to help compensate for impaired vision. VA offers both basic and  computer training. (See table 2 for examples of the types of skills taught  during basic and computer training.)
In fiscal years 2002 and 2003, VA spent over $56 million each year for  inpatient training at BRCs. During this same time period, VA spent less  than $5 million each year to provide outpatient rehabilitation training for  legally blind veterans.

	Blind Rehabilitation Outpatient Services Are Available in Few VA Locations

VA offers three types of blind rehabilitation outpatient services to legally  blind veterans, but these services are available in few VA locations. The  three types of services include Visual Impairment Services Outpatient  Rehabilitation (VISOR), Visual Impairment Center to Optimize Remaining  Sight (VICTORS), and Blind Rehabilitation Outpatient Specialists (BROS).  The services range from short-term outpatient programs provided in VA  facilities to home-based services. Figure 3 identifies the locations  throughout the United States and Puerto Rico where these services are  offered.
VISOR is a 10-day outpatient program located at the VA medical center in  Lebanon, Pennsylvania, that offers training in the use of low vision  equipment, basic orientation and mobility, and living skills. Serving  veterans in the surrounding 13-county area, it is primarily for veterans who  can independently perform activities of daily living and who require only  limited training in visual skills and orientation and mobility, such as  traveling within and outside their homes. According to a VISOR official,  the program is meant to provide training to veterans while they wait for  admission to a BRC or to veterans who do not want to attend a BRC.  Veterans who participate in this program are housed in hoptel beds  within the medical facility. In fiscal year 2003, 54 veterans attended the  VISOR program; about 20 to 30 percent of these veterans were legally  blind. According to a VISOR official, there is no waiting list for this  program and the local medical center provides the necessary funding for  it.

		VICTORS Services

VICTORS is a 3- to 7-day outpatient program for veterans in good health  whose vision loss affects their ability to perform activities of daily living,  such as personal grooming and reading mail. The program provides the  veterans with a specialized low vision eye examination, prescriptions for  and training in the use of low vision equipment, and counseling. There are  three VICTORS programs located in VA medical centers in Kansas City,  Missouri; Chicago, Illinois; and Northport, New York. Veterans are housed  in hoptel beds within the medical facility or in nearby hotels. In fiscal year  2003, VICTORS served over 900 veterans; about 25 to 30 percent of these  veterans were legally blind. According to VICTORS officials, the wait time  for admission to VICTORS varied from about 55 to about 170 days. The  medical center where the program is located funds the services.

		BROS Services

BROS are blind rehabilitation outpatient instructors who provide a variety  of short-term services to veterans in their homes and at VA facilities.  BROS train veterans prior to and following their participation in BRC  programs, as well as veterans who cannot or do not choose to attend a  BRC. BROS training addresses veterans’ immediate needs, especially those  involving safety issues such as reading prescriptions or simple cooking.  There are 23 BROS throughout VA’s health care system, with 7 located in  the VA network that covers Florida and Puerto Rico. In fiscal year 2003,  BROS trained about 2,700 veterans, almost all of whom were legally blind.  Wait time for BROS services varied from about 14 to 28 days according to  the BROS we interviewed. BROS are funded by the medical centers where  they are located.

	Outpatient Services Provide Opportunities to Benefit Veterans

VA officials who provide services to legally blind veterans told us that  some veterans could benefit from increased access to outpatient blind  rehabilitation services. We obtained this information by asking VA to  review all of the veterans who, as of March 31, 2004, were on the waiting  lists for admission to the five BRCs we visited and to determine whether  outpatient services could meet their needs. VA officials reported that 315  out of 1,501 of these veterans, or 21 percent, could potentially be better  served through access to outpatient blind rehabilitation services, if such  services were available. The types of veterans VA believes could  potentially benefit from outpatient services include those who are very  elderly or lack the physical stamina to participate in a comprehensive 28-  to 42-day BRC program and those who have medical needs that cannot be  provided by the BRC. For example, some BRCs are unable to accept  patients requiring kidney dialysis. In addition, some veterans do not want  to leave their families for long periods of time and some legally blind  veterans are primary caretakers for their spouses and are unable to leave  their homes. VA officials also told us that veterans in good health who can  independently perform activities of daily living and require only limited or  specialized training could also be served effectively on an outpatient basis.
A VA study concluded that there is a need for increased outpatient  services for legally blind veterans. In 1999, VA convened a Blind  Rehabilitation Gold Ribbon Panel to study concerns about the growing  number of legally blind veterans. The panel examined how VA historically  provided blind rehabilitation services and recommended that VA transition  from its primarily inpatient model of care to one that included both  inpatient and outpatient services. In 2000, VA established the VIAB to  implement the panel’s recommendations. The VIAB drafted guidance for a  uniform standard of care policy for visually impaired veterans throughout  VA’s health care system. This guidance outlined a continuum of care to  provide a range of services from basic low vision to comprehensive  inpatient rehabilitation training, including use of more outpatient services  from both VA and non-VA sources. In January 2004, a final draft of the  uniform standard of care policy was forwarded to VA’s Health Systems  Committee for approval. The committee believed additional information  was needed for its approval and requested additional analysis that  compared currently available blind rehabilitation services with anticipated  needs. VA plans to complete this analysis in the first quarter of fiscal year  2005 and then resubmit the uniform standard of care policy and the  additional analysis to the Health Systems Committee. VA officials were  unable to provide a timeframe for the Health Systems Committee’s  approval.
Some VIST coordinators have already provided outpatient services to  legally blind veterans by referring them to state and private blind  rehabilitation services. For example, in Florida a VIST coordinator  referred veterans to the Lighthouse for the Blind for computer training at  its outpatient facility if they did not live near and did not want to travel to  the BRC. A VIST coordinator in Oklahoma arranged contractor-provided  computer training in the veteran’s home for veterans with a 20 percent or  more service-connected disability. The coordinator issued the computer  equipment to a local contractor; the contractor then set up the equipment  in the veteran’s home and provided the training. Another VIST coordinator  in North Carolina referred all legally blind veterans to state service  agencies, including veterans waiting for admission to a BRC. Each county  in that state had a social worker for the blind that referred its citizens to  independent living programs for in-home training in orientation and  mobility and living skills. The state provided this training at no charge to  the veteran and VA paid for the equipment.
Recently, VA has begun to shift computer training from inpatient settings  at BRCs to private sector outpatient settings. VA’s goal was to remove  from the BRC waiting list by July 30, 2004, those veterans seeking  admission to a BRC only for computer training. In spring 2004, VA issued  instructions stating that the prosthetic budget of each medical center,  which already paid for computer equipment for legally blind veterans,  would now pay for computer training. Additionally, the Blind  Rehabilitation Service Program Office asked BRCs to identify all the  veterans waiting for admission for computer training and refer them back  to their VIST coordinator for local computer training. If BRC and VIST  coordinator staff determined that local computer training was not  available or appropriate for a veteran, they were to provide an explanation  to the program office. On May 5, 2004, 674 veterans were waiting for  admission to a BRC for computer training. As of July 1, 2004, 520 veterans  were removed from the BRC waiting list because arrangements were made  for them to receive computer training from non-VA sources or they no  longer wanted the training.

	Factors that Affect Expansion of Blind Rehabilitation Outpatient Services

There are two factors that affect VA’s expansion of outpatient services  systemwide. One factor is the agency’s long-standing belief that  rehabilitation training for legally blind veterans can be best provided in a  comprehensive inpatient setting. The second reported factor is VA’s  method of allocating funds for blind rehabilitation outpatient services,  which provides local medical center management discretion to provide  funds for them.
Some VA officials told us that one factor affecting veterans’ access to  outpatient care has been the agency’s traditional focus on providing  comprehensive inpatient training at BRCs. VA has historically considered  the BRCs to be an exemplary model of care, and since 1948 BRCs have  been the primary source of care for legally blind veterans. However, this  delivery model has not kept pace with VA’s overall health care strategy  that reduces reliance on inpatient care and emphasizes outpatient care.  VA’s continued reliance on inpatient blind rehabilitation care is evident in  its recent decision to build two additional BRCs in Long Beach, California,  and Biloxi, Mississippi. We have, however, observed some recent changes  that may affect this reliance on inpatient services. For example, VA has  new leadership in its blind rehabilitation program that has expressed an  interest in providing a broad range of inpatient and outpatient services to  meet the training needs of legally blind veterans. Further, as previously  discussed, the VIAB’s draft continuum of care policy recommends a full  range of blind rehabilitation services, emphasizing more outpatient care,  including VICTORS, VISOR, and BROS.
VA blind rehabilitation officials also told us that they believe changes to  VA’s resource allocation method could provide an incentive to expand  blind rehabilitation services on an outpatient basis. The VIAB believes that  the funds allocated for basic outpatient care for legally blind veterans do  not cover the cost of providing blind rehabilitation services. Veterans  Integrated Service Networks (networks) are allocated funds to provide  basic outpatient care for veterans, which they then allocate to the medical  centers in their regions. Both the networks and the medical centers have  the discretion to prioritize the use of these funds for blind rehabilitation  services or any other medical care. Some networks and medical centers  have made outpatient blind rehabilitation training a priority and use these  funds to provide outpatient services. For example, the network that covers  Florida and Puerto Rico has used its allocations to fund seven BROS that  are located throughout the region to provide outpatient blind  rehabilitation services to legally blind veterans in their own homes or at  VA facilities. Currently, the VIAB is working with VA’s Office of Finance  and Allocation Resource Center to develop an allocation amount that  would better reflect the cost of providing blind rehabilitation services on  an outpatient basis, which could in turn, provide an incentive for networks  and medical centers to expand outpatient rehabilitation services for legally  blind veterans.

	Conclusions

Many legally blind veterans have some vision, which frequently can be  enhanced with optical low vision devices and training that includes  learning to perform everyday activities such as cooking, reading  prescription bottles, doing laundry, and paying bills. Since the 1940s, VA’s  preferred method of providing training to these veterans has been through  inpatient services offered by BRCs. Because of its predisposition toward  inpatient care, VA has developed little capacity to provide this care on an  outpatient basis uniformly throughout the country. For the last 10 years,  VA has been transitioning its overall health care system from a delivery  model based primarily on inpatient care to one incorporating more  outpatient care. Outpatient services for legally blind veterans, however,  have lagged behind this trend. Recently, VA drafted a uniform standard of  care policy that recommends a full range of blind rehabilitation services,  emphasizing more outpatient care, including more services provided by  VISOR, VICTORS, and BROS type programs. Making inpatient and  outpatient blind rehabilitation training services available to meet the needs  of legally blind veterans will help ensure that these veterans are provided  with options to receive the right type of care, at the right time, in the right  place.

	Recommendations

We are recommending that the Secretary of Veterans Affairs direct the  Under Secretary for Health to issue, as soon as possible in fiscal year 2005,  a uniform standard of care policy that ensures that a broad range of  inpatient and outpatient blind rehabilitation services are more widely  available to legally blind veterans.

	Agency Comments

We provided a draft of this testimony to VA for comment. In oral  comments, an official in VA’s Office of the Deputy Under Secretary for  Health informed us that VA concurred with our recommendation.
Mr. Chairman, this concludes my prepared remarks. I will be glad to  answer any questions you or other Members of the Committee may have.

	Contact and Acknowledgments

For further information regarding this testimony, please contact Cynthia  A. Bascetta at (202) 512-7101. Michael T. Blair, Jr., Cherie Starck, Cynthia  Forbes, and Janet Overton also contributed to this statement.
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Summary:
Why GAO Did This Study

In fiscal year 2003, the Department of Veterans Affairs (VA) estimated that about 157,000 veterans were legally blind, and about 44,000 of these veterans were enrolled in VA health care. The Chairman of the Subcommittee on Health, House Veterans' Affairs Committee, and the Ranking Minority Member, Senate Veterans' Affairs Committee expressed concerns about VA's rehabilitation services for blind veterans. GAO reviewed (1) the availability of VA outpatient blind rehabilitation services, (2) whether legally blind veterans benefit from VA and non-VA outpatient services, and (3) what factors affect VA's ability to increase veterans' access to blind rehabilitation outpatient services. GAO reviewed VA's blind rehabilitation policies; interviewed officials from VA, the Blinded Veterans Association, state and private nonprofit agencies, and visited five Blind Rehabilitation Centers (BRC).

What GAO Found

VA provides three types of blind rehabilitation outpatient training services. These services, which are available at a small number of VA locations, range from short-term programs provided in VA facilities to services provided in the veteran's own home. They are Visual Impairment Services Outpatient Rehabilitation, Visual Impairment Center to Optimize Remaining Sight, and Blind Rehabilitation Outpatient Specialists. VA reported to GAO that some legally blind veterans could benefit from increased access to outpatient blind rehabilitation services. When VA reviewed all of the veterans who, as of March 31, 2004, were on the waiting list for admission to the five BRCs GAO visited, VA officials reported that 315 out of 1,501 of them, or 21 percent, could potentially be better served through access to outpatient blind rehabilitation services, if such services were available. GAO also identified two factors that may affect the expansion of VA's outpatient blind rehabilitation services. The first involves VA's longstanding position that training for legally blind veterans is best provided in a comprehensive inpatient setting. The second reported factor is VA's method of allocating funds for medical care. VA is currently working to develop an allocation amount that would better reflect the cost of providing blind rehabilitation services on an outpatient basis.