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83–022 PDF 2002

S. HRG. 107–778

OPTIONS TO NURSING HOME CARE—IS VA

PREPARED?

HEARING

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

SECOND SESSION

APRIL 25, 2002

Printed for the use of the Committee on Veterans’ Affairs

(
COMMITTEE ON VETERANS’ AFFAIRS

JOHN D. ROCKEFELLER IV, West Virginia, Chairman

BOB GRAHAM, Florida

JAMES M. JEFFORDS (I), Vermont

DANIEL K. AKAKA, Hawaii

PAUL WELLSTONE, Minnesota

PATTY MURRAY, Washington

ZELL MILLER, Georgia

E. BENJAMIN NELSON, Nebraska

ARLEN SPECTER, Pennsylvania

STROM THURMOND, South Carolina

FRANK H. MURKOWSKI, Alaska

BEN NIGHTHORSE CAMPBELL, Colorado

LARRY E. CRAIG, Idaho

TIM HUTCHINSON, Arkansas

KAY BAILEY HUTCHISON, Texas

WILLIAM E. BREW, Chief Counsel

WILLIAM F. TUERK, Minority Chief Counsel and Staff Director

(II)
CONTENTS

APRIL 25, 2002

SENATORS

Page

Murray, Hon. Patty, U.S. Senator from Washington, prepared statement ........ 73

Rockefeller, Hon. John D. IV, U.S. Senator from West Virginia, prepared

statement .............................................................................................................. 4

Specter, Hon. Arlen, U.S. Senator from Pennsylvania, prepared statement ...... 5

WITNESSES

Bascetta, Cynthia A., Director, Health Care, Veterans’ Health and Benefits

Issues, United States General Accounting Office .............................................. 6

Prepared statement .......................................................................................... 8

Dickerson, Gladys, R.N., Home-Based Primary Care Coordinator, Dallas VA

Medical Center ..................................................................................................... 37

Prepared statement .......................................................................................... 38

Hemmings, Paula, R.N., Department of Veterans Affairs’ Veterans Integrated

Service Network No. 2, Geriatrics and Extended Care Line Manager, representing the Alzheimer’s Association ................................................................ 42

Prepared statement .......................................................................................... 44

McClure, Thomas, LCSW, Coordinator, VA Medical Foster Home Program,

Little Rock VA Medical Center ........................................................................... 39

Prepared statement .......................................................................................... 40

Moye, Jennifer, Ph.D., Director of the Geriatric Mental Health/UPBEAT,

Brockton VA Medical Center, and Associate Professor of Psychology, Department of Psychiatry, Harvard Medical School ............................................. 48

Prepared statement .......................................................................................... 50

Roswell, Robert H., M.D., Under Secretary for Health, Department of Veterans Affairs ......................................................................................................... 58

Prepared statement .......................................................................................... 59

Response to written questions submitted by Hon. Patty Murray to Robert

Roswell ........................................................................................................... 64

APPENDIX

Alzheimer’s Association, prepared statement ........................................................ 75

Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, prepared statement ...................................................................................................................... 75

Davidson, Arlene, Vice President, Planning and Development, Evercare, a

Unitedhealth Group Affiliate, prepared statement ........................................... 80

Fischl, James R., Director, National Veterans Affairs and Rehabilitation Commission, The American Legion, prepared statement ......................................... 79

(III)

(1)

OPTIONS TO NURSING HOME CARE—IS VA

PREPARED?

THURSDAY, APRIL 25, 2002

U.S. SENATE, COMMITTEE ON VETERANS AFFAIRS, Washington, DC.

The committee met, pursuant to notice, at 10:25 a.m., in room

SR–418, Russell Senate Office Building, Hon. John D. Rockefeller

IV, chairman of the committee, presiding.

Present: Senators Rockefeller, Graham, Wellstone, Specter, and

Hutchinson.

Chairman ROCKEFELLER. The hearing will come to order, and I

will forego my opening statement for the moment and yield with

the permission of Senator Hutchinson to Senator Wellstone who

has another pressing engagement.

Senator WELLSTONE. Thank you so much for your graciousness,

and then I really guess that what I want to say today, and I am

going to try to be back for more of the committee hearing, Mr.

Chairman and Senator Hutchinson, is that I was excited when this

Millennium bill based in 1999 and would thank you for your leadership.

I mean having had two parents with Parkinson’s and kind of

going through this ourselves about what do you do. People get elderly and struggle with these illnesses. How do you help them stay

at home, live at home in as near normal circumstances with dignity, or if they need to go in a nursing home, how do we make sure

that we—or we need respite care and all the rest. I thought that

we in passing this legislation made a really significant commitment, and I guess my message for the VA today is you all have got

to follow through. We are not doing this.

I mean we did not pass a law just for symbolic reasons. We

passed this law to make this happen, and it is not happening, and

either the VA is going to have to sort of reorder its priorities and

figure out how with its staff and its resources it, in fact, lives up

to this mandate or to this vision or to this mission. You know it’s

noble.

Or if the VA needs more resources, then, you know, we need to

know how much more and why and what we need to do. I just put

it in the context of—I said to Secretary Principi, whom I think is

one the nicest, best people in government service, when he came

here, you are great and people love you in Minnesota, but this

budget is a straightjacket. And we got long waits and people are

not getting access to specialty care in Minnesota now, and we are

not having any more outreach community clinics.
2

This is a horrible budget, and I am getting increasingly impatient that the VA is not, in fact, making this piece of legislation a

reality in terms of actually providing help for a lot of our veterans

who are now senior citizens and need the help.

So there is a big missing piece here somewhere and this hearing

therefore is extremely important. I thank you. I am going to try to

come back, too.

Chairman ROCKEFELLER. Thank you, Senator Wellstone. I now

want to introduce Senator Hutchinson for the purpose of making

an introduction not on the first but on the second panel.

Senator HUTCHINSON. Mr. Chairman, I thank you for your willingness to allow me to do this, because our schedules are so crazy

up here, and I am afraid I will not be here when Tom testifies, and

I did want to take the opportunity to say a word of welcome to one

of my constituents who will be testifying on the second panel, and,

Mr. Chairman, I also want to thank you for calling the hearing

today. I think this is a very, very important topic, and the GAO

study is going to be, I think, revealing, and this is a timely hearing, and I thank you for doing that.

But it is my great privilege to welcome one of my constituents,

Tom McClure, from Hot Springs, AR. Tom has dedicated his entire

professional life to helping others, particularly veterans. He has

served in the VA for 27 years. In January of 2000, he was appointed as the coordinator for the VA Medical Care Foster Home

Program in central Arkansas.

The Foster Home Program that Tom oversees is really, I think,

a model, and it is also very much a win-win for the veterans and

the Veterans Administration because the program offers the veteran a loving, caring home to reside in at no cost to the Veterans

Administration.

The program maintains a comprehensive medical plan by a multidisciplinary team of care providers and increases customers’ satisfaction for the VA. Initially it was just a pilot program, but it was

so successful that the Arkansas VA continued to fund the Foster

Home Program out of their own operating funds.

So, Tom, we thank you for your work and the committee is

pleased to have you with us today. We look forward to your testimony. Thank you, Mr. Chairman.

Chairman ROCKEFELLER. Thank you, Senator Hutchinson, very

much. We appreciate your being here and making that introduction. I think I can probably go ahead as chairman and give my

opening statement.

So I will. And it basically is what Paul was saying and what Tim

was saying. In my mind, it is about the eighth hearing we have

had on this subject, and the Millennium bill passed in 1999. I remember every single second of the conference committee. I was surprised that the House went along with it to the extent that they

did, but they did.

It was the first time that long-term care coverage has happened

in public policy since Medicaid. It was an extremely exciting concept that we could actually do some long-term care on a non-institutional basis and absolutely nothing has happened.

That was in 1999, so it was 1999, 2000, 2001, 2002. I call this

an embarrassment because ignoring the single-most important de-
3

mand for long-term care will only intensify. And so we have hearings, and we ask why, and we get answers that are not satisfactory—OMB rules and regulations, this and that.

But it always occurs to me that the Department of Veterans Affairs is the second largest organization outside of the Department

of Defense in all of government, 220,000 people, led by a very able

administrator and health deputy, and it seems to me that 220,000

people collectively would be able to find a way to take a law that

was passed over 3 years ago, which addresses the primary concerns

of veterans, and put it into practice, and this particular senator is

now past the point of impatience.

I am very angry about it. Therefore, this hearing is being set up

in a very different way. We are having people who are making this

work. We are having a GAO report, and then we are having the

VA as the last panel so that the head of the health administration

can hear and be told about what others before him said, because

there are people who out there on their own are deciding to make

this work.

When Secretary Principi, who as Paul indicated is a wonderful

person and really is, and is beloved by veterans and by this chairman, when he was up for his confirmation, I said, you know, I said

the only question that is worth asking you really, because I know

you and you have been here before, is are you willing to go face

to face with the President of the United States, much less OMB,

on budget issues, and he said, yes, I will.

And I think the answer is no, he has not. And that is very clear

or else it seems to me that this, the most important issue of longterm care, the one thing other than death and taxes that we all absolutely are going to face at some point, either in the comfort of

home, as is contemplated here, or in a nursing home. For the first

time in many years a government action relating to long-term care

has been enacted, and then VA says, oh, by the way, we are hung

up on rules and regulations.

I do not buy that. I do not care if it is President Clinton. I do

not care if it is President Bush. I do not care who it is. It is inexcusable. It is absolutely inexcusable, and so this hearing is for the

purpose of either embarrassing or humiliating the VA into doing

something. It is therefore what I would call a constructive hearing

because its purpose is to get something going which is already in

law.

If there is a Federal law, we try to follow it. So I am ready to

hear about the lack of guidance from central offices and OMB and

regulations going back and forth, but they carry no—they create

not a ripple of interest on my part anymore. I am only interested

in a result, and I do not know, I am not seeking to do retribution

here, but I am getting very close to it. I am getting very close to

it because this is something that was not only really important to

me. I happened to negotiate this personally, and as I say, it is the

one thing everybody needs.

I had a mother who died from Alzheimer’s. That took 10 years.

It was not pleasant. I am not poor, so we were able to afford to

give her what she needed, but she needed a whole lot. And so do

veterans and many are poor and they cannot do it on their own.
4

So we have a law which is being ignored and excuses do not work

anymore.

So we have people who are doing things. You know it is not like

this cannot be done, because that is why we are going to have some

witnesses from some VA places who are going ahead with this on

their own. I do not know if they are in violation of VA rules or not,

but to me they are heroes, and we are going to hear from them.

There are more veterans today than ever seeking alternatives to

nursing homes—what is known as non-institutional care. They

want to remain in the community. They want to remain in their

home. My mother wanted to spend her last period of time in her

home listening to the music that she loved, and I mean that is

human nature. She was beyond the point of knowing where she

was at that point, but it was incredibly important to those who

cared about her. The Department of Veterans Affairs cares about

veterans, and they have to show that through what they do.

So 35 percent of the veteran population is 65 years or older. The

law and the demand gave VA a very clear mandate for action. It

was not—this would be a nice thing for you to consider. It is something you are going to do. Mandate is a strong word, not beloved

by the American people, but beloved by people who pass laws and

want to see them enacted.

So the VA has been excruciatingly slow. Today we are going to

try to get some answers about why this has happened and more

importantly what the VA is going to do to change their ways, and

I do not want to hear a lot about OMB because there are people

here who evidently are not worried about OMB and who are doing

things on their own.

Dr. Roswell, for whom I have enormous respect—his new job is

Under Secretary—needs to know and does, I am sure, the time for

action is immediate. So there are clinicians here who have gone

ahead. I am always gratified when you see people who work in

large organizations who go against the grain and do things because

they believe it. I want them to be applauded and showcased here

and for us to learn from them.

So I am not only no longer interested in dilatory tactics, but I

am going to find ways to get very difficult about this, and I suspect

that my good friend from Pennsylvania will join me in that effort.

I yield to him at this point.

[The prepared statement of Senator Rockefeller follows:]

PREPARED STATEMENT OF HON. JOHN D. ROCKEFELLER IV, U.S. SENATOR FROM

WEST VIRGINIA

I called today’s hearing to focus on VA’s inaction in making long-term care services available to veterans—especially those who can and wish to reside in the community. This inaction is a terrible failure, to be sure. Veterans need these services,

Congress was clear in demanding that they be provided, and for a variety of reasons, VA has chosen to both ignore the mandate and failed to meet veterans’ needs.

There is another side to this story: despite a dearth of guidance from Central Office, there are places on the VA landscape where some truly wonderful things are

happening to keep veterans well cared for and in the setting of their choice. Good

programs must be fostered, but in the VA environment, long-term care services are

frequently starved.

Today, more and more veterans are seeking alternatives to nursing homes. They

want to remain in the community and, with the right kind of support and care from

VA, are able to do so—even with chronic and debilitating conditions.
5

In 1999, Congress spoke clearly about the need for VA to step up its long-term

care effort, not because we had issues about quality, but because of the high demand for care. The numbers bear repeating: About 35 percent of the veteran population is 65 years or older—it is the single largest segment of today’s veteran population—and many need long-term care services. While the law and the demand gave

VA a clear mandate for action, VA has moved excruciatingly slow. Today we will

try to get some answers about why that has happened and, more importantly, about

what VA will do to correct the situation. With Dr. Roswell new in his job as Under

Secretary, the time is ripe for action.

As I noted, there are VA clinicians who, in grappling with the demand, have not

waited but have found some innovative solutions. I am always deeply gratified by

the level of dedication and innovation of VA employees, and I applaud those who

have moved forward.

While the focus of this hearing is on options to nursing homes, I note the need

for VA nursing home beds. For many veterans, non-institutional options will not

work, and because of this Congress is on record stating that VA must have sufficient

nursing home capacity. I am concerned, however, that the quest to maintain and

fill nursing home beds not overshadow the need for other options. I know that VA

is concerned about this as well, and is requesting some relief.

It is vital that VA’s role as a model for long-term care be recognized and rewarded, because we will have enormous problems with demand for this care in the

years ahead. The only entity of any scope, size, or capacity that is dealing with how

to meet the needs of an older population—albeit at a slower pace than I’d like— is VA. This role of VA must be highlighted and supported. I am here to do just that.

Senator SPECTER. Thank you very much, Mr. Chairman. I would

ask unanimous consent that my written statement be included in

the record.

Chairman ROCKEFELLER. Absolutely.

Senator SPECTER. I do not want to speak too long because I am

anxious to hear how nasty you are going to be. [Laughter.]

As I said to Senator Rockefeller on the floor a few minutes ago,

it is time to get tough about this. I will support strong action by

the chairman. We passed this legislation over a lot of objections in

the House and the Senate, and we meant it. We want it to be carried out. And I commend you, Mr. Chairman, for having convened

this oversight hearing.

I regret being a little late arriving. We had a markup in the Environment and Public Works Committee and Judiciary Committee

has scheduled an executive meeting later this morning, so I may

have to excuse myself. But I will stay as long as I can, and I will

review the record. I think this is a very, very important session,

and I have never seen you nasty, so I am looking forward to that.

[Laughter.]

[The prepared statement of Senator Specter follows:]

PREPARED STATEMENT OF HON. ARLEN SPECTER, U.S. SENATOR FROM PENNSYLVANIA

Thank you, Mr. Chairman, for convening this hearing on the important issue of

long-term care for our Nation’s veterans. I know you and I both agree this is a critical service for America’s veterans, their families, and for the Nation as a whole.

Mr. Chairman, in 1999, you and I worked together diligently here in the Senate,

and in Conference with the House of Representatives, to ensure that our veterans

would have universal access to noninstitutional long-term care provided by the Department of Veterans Affairs. At that time, our proposal was met with great hostility by the some Members of the House. However, we prevailed in our efforts to

make these services available to all of our aging veterans. Unfortunately, the VA

has failed to abide by the law.

As the testimony by our GAO witness will demonstrate, more than two and one

half years after the passage of the Veterans Millennium Health Care and Benefits

Act of 1999, VA is still not providing access to these crucial services for all of our

veterans in need of this care.

Fortunately, the need for these services has not gone unnoticed on the front lines

of some VA hospitals throughout the nation. As the testimony of the members of
6

our second panel show, innovation and compassion for our veteran patients is alive

and well in VA hospitals. Unique programs, such as foster care for elderly veterans

in Arkansas and vigorous case management of dementia patients in New York is

showing Congress, and more importantly, the leadership of VA Central Office, that

if the resources are available to assist in the creation of special programs, we can

do wonders for thousands of sick and elderly veterans.

Mr. Chairman, I sincerely expect that this hearing will light a fire in VA Central

Office at the highest levels, including the Secretary’s Office. VA must know that

when Congress passes a law, we expect—and we demand—that it be carried out.

Institutional and noninstitutional long-term care services are vital for our aging veteran population. Congress has said so in statute. Now VA must say so in action.

Thank you very much Mr. Chairman for holding this hearing. I look forward to

receiving the testimony of the witnesses.

Chairman ROCKEFELLER. So we are going to go right to our first

panel. And I would ask them to come to the table. They are representatives of the General Accounting Office, and they are going

to report on VA’s response to the long-term care provisions of the

Millennium Act. I welcome Cindy Bascetta, who is the Director of

Veterans’ Health Care Issues at GAO. I am comforted by that position, just knowing that it is there, Cynthia, so I am already happy

about you.

And also Jim Musselwhite, who is Assistant Director for Health

Care. Ms. Bascetta, why do you not go ahead? Now we have a 5-

minute rule.

Ms. BASCETTA. Right.

Chairman ROCKEFELLER. I am sure you have been warned about

that.

Ms. BASCETTA. Absolutely.

Chairman ROCKEFELLER. Nobody has ever disobeyed that.

[Laughter.]

Ms. BASCETTA. And I do not intend to.

STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR, HEALTH

CARE, VETERANS’ HEALTH AND BENEFITS ISSUES, UNITED

STATES GENERAL ACCOUNTING OFFICE, ACCOMPANIED BY

JIM MUSSELWHITE, ASSISTANT DIRECTOR, HEALTH CARE,

GAO

Ms. BASCETTA. Mr. Chairman, Senator Specter, thank you for inviting me here today to discuss our work on VA’s non-institutional

long-term care services. It is no surprise, as you have pointed out,

that demographic pressures will increase the demand for long-term

care. The number of veterans aged 85 and older, those most at risk

of needing long-term care, is expected to triple over the next decade. While not all of their needs can be met in non-institutional

settings, aging veterans are likely to be no different from other elderly Americans in preferring care that allows them to remain in

their homes or in other settings that are less restrictive than nursing homes.

As you know, although VA has been providing long-term care including non-institutional care on a discretionary basis, the Millennium Act requires adult day health care, geriatric evaluation, and

respite care for all eligible veterans.

Today, I would like to discuss our findings about VA’s efforts to

expand these services and highlight our early work on the availability of non-institutional services in general across the VA system.
7

Mr. Chairman, as you have pointed out, more than 2 years after

enactment, VA has not completed its response to the Millennium

Act. VA has issued proposed regulations that would make the three

services available in non-institutional settings, and we understand

that final regulations will be issued next week.

In the interim, however, I would like to point out that VA did

issue a policy directive in October 2001 requiring that all eligible

veterans have access to these services outside of institutions. Nevertheless, none of the three are universally available. In a survey

we conducted of all 139 medical facilities, 99 reported offering adult

day health care, 74 offered non-institutional geriatric evaluation,

and 29 offered non-institutional respite care.

According to VA, central monitoring of medical facilities to ensure that they provide non-institutional access to all three services

will begin soon.

Our survey also showed that the six other non-institutional services offered by VA also vary in their availability from network to

network. Most commonly offered by more than 120 medical facilities are homemaker and home health aide services as well as

skilled home health care. In contrast, non-institutional clinics for

Alzheimer’s and dementia care are available at fewer facilities with

only 32 reporting such care.

In addition, we found that several facilities reported offering at

least eight of the nine non-institutional long-term care services, but

some offered only one non-institutional service or none at all. The

results of our survey are similar to the distribution of services

noted almost 4 years ago by the Advisory Committee on the Future

of VA Long-Term Care. In its report, called ‘‘VA Long-Term Care

at the Crossroads,’’ the committee stated that despite a continuum

of offerings, VA services were not universally available and access

was often restricted.

VA headquarter’s officials agree today that non-institutional

services are not yet equally accessible across the country. Despite

this picture, VA has roughly doubled the proportion of long-term

care provided outside of institutions over the past decade. Nonetheless, like Medicaid, the largest payer of long-term care, VA costs for

non-institutional care remain dwarfed by its costs for nursing home

and other institutional care.

Over the next 10 years, the nation’s health system as well as VA

will face significant aging of the population particularly for those

85 years or older. Nearly 20 percent of individuals in this group report a disability compared to about 5 percent between the ages of

65 and 84.

Like its non-VA counterparts, VA needs to prepare for these demographic challenges. The task force and the Millennium Act reflect the importance of providing a continuum of non-institutional

services more evenly throughout the country to help meet this challenge.

Our ongoing review, conducted at your request, will assess the

reasons for the current unevenness in non-institutional long-term

care services across the networks. Providing more universal access

to non-institutional care could help VA meet the growth in demand

and at the same time offer veterans more options from which to
8

1Pub. L. No. 106–117, 113 Stat. 1545 (1999). 2 Although nursing home care and domiciliary care are also required by the act, we do not

address these requirements. 3 VA Long-Term Care: Implementation of Certain Millennium Act Provisions Is Incomplete,

and Availability of Noninstitutional Services Is Uneven (GAO–02–510R, March 29, 2002). 4 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. 5 66 Fed. Reg. 50,594 (2001).

choose. This concludes my prepared statement, and I would be

happy to answer any questions.

[The prepared statement of Ms. Bascetta follows:]

PREPARED STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR, HEALTH CARE, VETERANS’ HEALTH AND BENEFITS ISSUES, UNITED STATES GENERAL ACCOUNTING OFFICE

Mr. Chairman and Members of the Committee:

I am pleased to be here today to discuss noninstitutional long-term care services

offered by the Department of Veterans Affairs (VA). These services, such as homemaker services and adult day health care, are delivered to veterans in their own

homes and other locations in the community. VA will see increasing demand for

long-term care in the coming years as the veteran population ages. Of particular significance is the expected tripling of the number of veterans age 85 and older—the

group most in need of long-term care. Although not all veterans’ care needs can be

met in noninstitutional settings, veterans may prefer such care because it allows

them to remain in their homes or in other settings that are less restrictive than institutions.

VA generally provided or paid for long-term care on a discretionary basis until

passage of the Veterans Millennium Health Care and Benefits Act in November

1999.1 The Millennium Act required VA to offer certain long-term care services to

eligible veterans, including services provided in noninstitutional settings. In particular, adult day health care, geriatric evaluation, and respite care are to be made

available to eligible veterans.

As part of our ongoing work addressing the availability of noninstitutional longterm care in VA, you asked us to provide information on (1) VA’s efforts to expand

noninstitutional long-term care in response to the Millennium Act’s requirements,2

and (2) the noninstitutional long-term care services that VA’s medical facilities offer.

My statement focuses on the information we provided in a letter on VA’s noninstitutional long-term care services,3 which is being released today. That letter is based

on data from a survey of all 139 VA medical facilities,4 interviews with officials in

VA’s Geriatrics and Extended Care Strategic Healthcare Group, and interviews with

VA field officials responsible for long-term care services. To determine which noninstitutional long-term care services to include in our survey, we compiled a list of

the services as identified by VA officials and in VA documents. (Descriptions of

these noninstitutional services are provided in appendix I.)

In summary, more than 2 years after the act’s passage VA has not completed its

response to the act’s requirement that eligible veterans be offered adult day health

care, geriatric evaluation, and respite care. Although VA published proposed regulations that would make these three services available in noninstitutional settings to

eligible veterans,5 the regulations had not been made final as of April 17, 2002. To

be responsive to the act’s requirements before its draft regulations were made final,

VA issued a policy directive requiring that these three services be available in noninstitutional settings. VA also offers other noninstitutional services. At the time of

our review, however, both the services required as a result of the act and VA’s other

noninstitutional services were unevenly available across the VA system.

BACKGROUND

VA served about one-third of its fiscal year 2001 long-term care workload, or average daily census, in noninstitutional settings (see table 1). Noninstitutional care accounted for about 8 percent of VA’s long-term care costs during the same year.
9

6 66 Fed. Reg. 33,155 (June 18, 2001).

7The agencies were the Departments of Education, Health and Human Services, Housing and

Urban Development, Justice, and Labor, and the Social Security Administration. 8These data represent individuals reporting a problem with two or more of the following six

activities of daily living: bathing, dressing, eating, transferring between bed and chair, toileting,

and getting around inside the home. Data are from the Department of Health and Human Services’ 1994–95 National Health Interview Survey on Disability. 9Department of Veterans Affairs, VA Long-Term Care At The Crossroads: Report of the Federal Advisory Committee on the Future of VA Long-Term Care (Washington, D.C.: June 1998).

Table 1: VA Long-Term Care Workload and Costs, by Care Setting, Fiscal Year 2001

Long-term care setting Average daily census a Total cost

Institutional b ............................................................................................................... 45,033 $2,888,659,000

Noninstitutional ........................................................................................................... 23,205 239,939,000

Total ........................................................................................................... 68,238 $3,128,598,000

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. These figures may overstate the number of veterans receiving noninstitutional services because some veterans may receive more than one noninstitutional service on a particular day. b Institutional long-term care includes care that VA provides or pays for in nursing homes and other residential settings.

The proportion of VA’s long-term care costs for noninstitutional care has doubled

over the past decade, as shown in figure 1. This has occurred as part of a larger

trend within VA toward reducing its heavy reliance on inpatient care. Nevertheless,

VA’s costs for noninstitutional long-term care remain small relative to its costs for

institutional long-term care.

Figure 1: VA Long-Term Care Costs, By Care Setting, Fiscal Year 1991–Fiscal Year 2001

1991 2002

Noninstitutional long-term care ...................................................................................................................... 4% 8%

Institutional long-term care ............................................................................................................................ 96% 92%

Source: VA.

Medicaid—the nation’s largest purchaser of long-term care—has seen a similar increase in the proportion of its long-term care costs for noninstitutional services. As

in VA, the proportion of Medicaid’s long-term care costs for this purpose has doubled, from 13 percent in 1990 to 27 percent in 2000. However, similar to VA, the

bulk of Medicaid’s long-term care costs are still for institutional care.

VA is one of several federal agencies attempting to emphasize noninstitutional

long-term care. Executive Order 13217,6 signed in June 2001, directs six federal

agencies to evaluate their policies, programs, statutes, and regulations to determine

whether any should be revised or modified to improve the availability of noninstitutional services for qualified individuals with disabilities.7 Although VA was not

among the agencies named in the order, VA joined the effort on a voluntary basis

and subsequently reported that it will evaluate its noninstitutional long-term care

services to determine whether any could be expanded or modified to further promote

noninstitutional services to veterans with disabilities.

VA will face increasing demand for long-term care as our nation’s veteran population ages. VA statistics show that, although the total number of veterans will decline in the next 10 years, the number of veterans age 85 and older will triple during that time. This will significantly increase the need for VA’s long-term care resources because although a chronic physical or mental disability may occur at any

age, the older an individual becomes, the more likely it is that a disability will develop or worsen. Indeed, while about 4.8 percent of persons age 65–84 report a disability, the proportion nearly quadruples to 18.1 percent among those 85 and older.8

As a result of this demographic pressure, concerns have been raised for some time

about VA’s ability to meet the expected rise in demand for long-term care services.

In 1997 VA established a Federal Advisory Committee on the Future of VA LongTerm Care composed of national leaders in long-term care, and charged it with evaluating VA long-term care services and developing a strategy for meeting future

needs. In its June 1998 report,9 the committee stated that VA long-term care was

unevenly funded and recommended that VA expand noninstitutional long-term care
10

10Geriatric evaluation involves evaluation of veterans with particular geriatric needs and is

generally provided by VA through one of two services, geriatric evaluation and management or

geriatric primary care. Respite care is a program in which brief periods of care are provided

to veterans in order to give veterans’ regular caregivers a period of respite.

services and emphasize these services, when clinically appropriate, for veterans

needing long-term care.

VA’S RESPONSE TO THE MILLENNIUM ACT IS NOT COMPLETE

The Millennium Act requires VA to provide adult day health care—noninstitutional care in which health maintenance and rehabilitative services are provided to

frail elderly veterans in an outpatient day setting. The act also requires that VA

provide two additional services, geriatric evaluation and respite care,10 but does not

specify whether these services must be provided in institutional or noninstitutional

settings.

More than 2 years after the act’s passage, however, VA has not completed its response to the act’s requirement that all eligible veterans be offered these three services. In October 2001, VA published proposed regulations to add the three required

services in noninstitutional settings to its medical benefits package, the standard

health plan available to all veterans enrolled in VA’s health care system. As of April

17, 2002, final regulations had not been published, although VA officials told us that

VA sent draft final regulations to the Office of Management and Budget for approval on March 14, 2002.

To be responsive to the act’s requirements before its draft regulations were finalized, however, VA issued a policy directive in October 2001 requiring that its medical facilities ensure that veterans have access to adult day health care, geriatric

evaluation, and respite care in noninstitutional settings. A VA headquarters official

told us that VA headquarters will soon begin monitoring medical facilities to ensure

that they provide access to these three services in noninstitutional settings.

Both VA’s directive and its proposed regulations specify that geriatric evaluation

and respite care be provided in noninstitutional settings even though the act does

not state whether they must be provided in institutional or noninstitutional settings. (Adult day health care is by definition a noninstitutional service.) VA officials

told us that VA chose to make clear its intent to have these services provided in

noninstitutional settings because they were already widely offered in institutional

settings. In fact, prior to the act VA was not authorized to provide noninstitutional

respite care—until then, VA could provide respite care only in institutional settings.

In contrast, prior to the act VA provided both adult day health care and noninstitutional geriatric evaluation; VA headquarters encouraged facilities to offer these services and provided guidance for facilities to use when doing so.

When VA issued its policy directive in October 2001, it was far from its goal of

universal access to these three noninstitutional services, as shown in figure 2.

Among the three services, adult day health care was most widely available, followed

by geriatric evaluation and respite care. VA officials told us that noninstitutional

respite care is not widely offered because until the Millennium Act VA was not authorized to provide respite care in noninstitutional settings.
11

11Skilled home health care consists of professional home health care services, mostly nursing

services, purchased by VA and delivered by non-VA health care providers.

FIGURE 2: NUMBER OF 139 VA FACILITIES OFFERING CERTAIN LONG-TERM CARE SERVICES REQUIRED BY THE MILLENNIUM ACT AND AVAILABLE IN NONINSTITUTIONAL SETTINGS, FALL 2001

Source: GAO survey of VA facilities; VA headquarters data.

Note: Responses to our survey were submitted in September and October 2001.

a ‘‘Geriatric evaluation’’ encompasses facilities reporting geriatric evaluation and management services in our survey and additional facilities

reported by VA headquarters as offering geriatric primary care.

AVAILABILITY OF OTHER NONINSTITUTIONAL SERVICES IS ALSO UNEVEN

Uneven availability of noninstitutional services is not limited to the three services

that VA requires its facilities to offer in response to the Millennium Act. Although

at least nine different noninstitutional long-term care services are provided or contracted for by VA (including the three services that VA requires as a result of the

act), considerable unevenness exists in what services are offered by individual facilities. For example, 123 VA facilities reported offering skilled home health care,11

while about half as many facilities—63—reported offering community residential

care. Figure 3 shows the number of VA’s 139 facilities at which these nine noninstitutional long-term care services are offered.
12

FIGURE 3: NUMBER OF 139 VA FACILITIES AT WHICH NONINSTITUTIONAL LONG-TERM

CARE SERVICES ARE OFFERED, BY SERVICE (FALL 2001)

Source: GAO survey of VA facilities; VA headquarters data.

Note: Responses to our survey were submitted in September and October 2001.

a Includes facilities reporting geriatric evaluation and management services in our survey and additional facilities reported by VA headquarters

as offering geriatric primary care.

Similar variation exists in the number of services offered by individual facilities.

For example, while several facilities reported offering at least eight of the nine noninstitutional long-term care services we identified, one facility reported offering only

one noninstitutional service, and two more facilities reported offering none at all.

These results are similar to the distribution of services noted by the 1998 Advisory Committee on the Future of VA Long-Term Care, which stated that VA longterm care—institutional as well as noninstitutional—was not available universally

and that access to long-term care was often restricted. Similarly, a VA headquarters

official we spoke with noted that VA’s noninstitutional long-term care services are

not equally accessible across the country.

CONCLUDING OBSERVATIONS

As the veteran population ages, VA will face increasing demand for long-term care

services. Providing more even access to noninstitutional long-term care services

across VA facilities, including those services now required as a result of the Veterans Millennium Health Care and Benefits Act, could help VA meet this demand

while at the same time offering veterans more options from which to choose.

* * * * *

Mr. Chairman, this concludes my prepared statement. I will be happy to answer

any questions you or the other committee members may have.

CONTACTS AND ACKNOWLEDGMENTS

For more information regarding this testimony, please contact me or James

Musselwhite. Joe Buschy and Steve Gaty also made key contributions to this statement.
13

1Pub. L. No. 106–117, 113 Stat. 1545 (1999).

APPENDIX I: NONINSTITUTIONAL LONG-TERM CARE SERVICES OFFERED BY VA

• Adult day health care: health maintenance and rehabilitative services provided

to frail elderly veterans in an outpatient day setting. • Alzheimer’s/dementia care: specialized outpatient services such as behavioral

and medical management provided to veterans with Alzheimer’s disease or related

dementias. • Community residential care: a service in which veterans who do not require

hospital or nursing home care—but who (because of medical or psychosocial health

conditions) are unable to live independently—live in VA-approved community residential care facilities; VA pays administrative costs only. • Geriatric evaluation: evaluation of veterans with particular geriatric needs, generally provided by VA through one of two services: (1) geriatric evaluation and management (GEM), 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 medical care provided in the home by VA

physicians, nurses, and other VA healthcare professionals to severely disabled,

chronically ill veterans whose conditions make them unsuitable for management in

outpatient clinics.

• Homemaker/home health aide: home health aide and homemaker services, such

as grooming, housekeeping, and meal preparation services.

• Home respite care: home-based services provided to veterans on a short-term

basis to give veterans’ caregivers a period of relief or respite.

• Hospice care: home-based palliative and supportive services for veterans in the

last phases of incurable disease so that they may live as fully and as comfortably

as possible.

• Skilled home health care: medical services provided to veterans at home by nonVA health care providers.

UNITED STATES GENERAL ACCOUNTING OFFICE,

WASHINGTON, DC,

March 29, 2002.

Hon. John D. Rockefeller IV,

Chairman, Committee on Veterans’ Affairs,

U.S. Senate.

Hon. Lane Evans,

Ranking Democratic Member,

Committee on Veterans’ Affairs,

House of Representatives

Subject: VA Long-Term Care: Implementation of Certain Millennium Act Provisions

Is Incomplete, and Availability of Noninstitutional Services Is Uneven [GAO–02–

510R VA Long-Term Care Services]

The Department of Veterans Affairs (VA) spent about $3.1 billion on long-term

care in fiscal year 2001, an amount that is likely to increase in the coming years

as the veteran population ages. VA provides or pays for long-term care in institutional settings such as nursing homes and through noninstitutional care in veterans’

own homes and other locations in the community. VA generally provided or contracted for long-term care on a discretionary basis until passage of the Veterans Millennium Health Care and Benefits Act in November 1999.1 The Millennium Act required VA to offer certain long-term care services to eligible veterans, including care

in noninstitutional settings. As part of our ongoing work addressing the availability

of noninstitutional long-term care in VA, you asked us to provide the information

we have obtained to date on (1) VA’s efforts to expand noninstitutional long-term

care in response to the act’s requirements and (2) the noninstitutional long-term

care services that VA’s medical facilities offer. As agreed with your offices, we are

also providing data on the number of institutional services offered by VA’s facilities,

and their utilization, to place the noninstitutional services in perspective.

In summary, more than 2 years after the act’s passage VA has not completely implemented its response to the act’s requirement that all eligible veterans be offered
14

2 Although VA has 172 medical centers, in some instances two 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. 3 Although nursing home care and domiciliary care are also required by the act, we do not

address these requirements.

adult day health care, respite care, and geriatric evaluation. Although VA published

draft regulations that would make these three services available in noninstitutional

settings to eligible veterans, the regulations had not been made final as of March

19, 2002. To be responsive to the act’s requirements before its draft regulations were

finalized, VA issued a policy directive requiring that these three services be available in noninstitutional settings. At the time of our review, however, access to these

services was far from universal in VA. More generally, the availability of all VA

noninstitutional long-term care services, including the newly required services, is

uneven across the VA system. In commenting on a draft of this letter, VA officials

generally agreed with our assessment.

To determine the status of VA’s efforts to expand noninstitutional long-term care

in response to the Millennium Act’s requirements, we interviewed officials in VA’s

Geriatrics and Extended Care Strategic Healthcare Group and evaluated directives,

regulations, and other guidance that had been prepared in response to the act. To

determine which long-term care services are offered by each of VA’s 139 facilities,2

we compiled a list of the services as identified by VA officials and in VA documents.

We subsequently used a survey instrument to collect data on the types of services

offered at each of VA’s 139 facilities and the utilization of these services. In constructing this survey, we consulted with VA headquarters officials and pretested it

with VA field staff to ensure that it would be clear to the respondents. We received

responses for all 139 VA facilities. However, we did not conduct site visits or otherwise attempt to verify any of the data provided to us in the surveys. Our work was

conducted from September 2001 through March 2002 in accordance with generally

accepted government auditing standards.

BACKGROUND

VA served about one-third of its fiscal year 2001 long-term care workload, or average daily census, in noninstitutional settings (see table 1). Noninstitutional care accounted for about 8 percent of VA’s long-term care costs during the same year.

Table 1: VA Long-Term Care Workload and Costs, by Care Setting, Fiscal Year 2001

Long-term care setting Average daily census a Total cost

Institutional b ............................................................................................................... 45,033 $2,888,659,000

Noninstitutional ........................................................................................................... 23,205 239,939,000

Total ........................................................................................................... 68,238 $3,128,598,000

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. These figures may overstate the number of veterans receiving noninstitutional services because some veterans may receive more than one noninstitutional service on a particular day. b Institutional long-term care includes care that VA provides or pays for in nursing homes and other residential settings.

VA is not alone among federal agencies in spending a relatively small percentage

of its long-term care dollars in noninstitutional settings. Noninstitutional care also

accounts for a relatively small percentage of long-term care expenditures under

Medicaid, the nation’s largest purchaser of long-term care. In 2000, for example,

about 27 percent of Medicaid’s long-term care spending was devoted to noninstitutional care.

VA’S RESPONSE TO THE MILLENNIUM ACT IS NOT FULLY IMPLEMENTED

The Millennium Act requires VA to provide adult day health care—health maintenance and rehabilitative services provided to frail elderly veterans in an outpatient

day setting. The act also requires that VA provide two additional services—geriatric

evaluation (evaluation of veterans with particular geriatric needs, generally provided by VA through one of two services, geriatric evaluation and management or

geriatric primary care) and respite care (brief periods of care provided to veterans

in order to give veterans’ regular caregivers a period of respite)—but does not specify whether these services must be provided in institutional or noninstitutional settings.3 (Descriptions of these and other VA long-term care services are provided in
15

4Department of Veterans Affairs, VA Long-Term Care At The Crossroads: Report of the Federal Advisory Committee on the Future of VA Long-Term Care (Washington, D.C.: June 1998).

enclosure I.) The Millennium Act’s long-term care provisions were written partly in

response to the 1998 report of the Federal Advisory Committee on the Future of VA

Long-Term Care.4 The committee’s report stated that VA long-term care was

‘‘marginalized and unevenly funded’’ and recommended that noninstitutional longterm care become the preferred option, when clinically appropriate, for veterans

needing long-term care.

More than 2 years after the act’s passage, however, VA has not completely implemented its response to the act’s requirement that all eligible veterans be offered

adult day health care, respite care, and geriatric evaluation. In October 2001, VA

published draft regulations to add the three required services in noninstitutional

settings to its medical benefits package, the standard health plan available to all

veterans enrolled in VA’s health care system. As of March 19, 2002, final regulations had not been published, although VA officials told us that VA sent the regulations to the Office of Management and Budget for approval on March 14, 2002.

To be responsive to the act’s requirements before its draft regulations were finalized, however, VA issued a policy directive in October 2001 requiring medical facilities to ensure that veterans have access to adult day health care, respite care, and

geriatric evaluations in noninstitutional settings. VA’s directive—as well as its draft

regulations—specifies that respite care and geriatric evaluation be provided in noninstitutional settings even though the act does not state whether these two services

must be provided in institutional or noninstitutional settings. (Adult day health care

is by definition a noninstitutional service.) VA officials told us that VA made this

decision because respite care and geriatric evaluation were already widely offered

in institutional settings. A VA headquarters official told us that VA headquarters

will soon begin monitoring field facilities to ensure that they provide access to these

three services in noninstitutional settings.

When VA issued its policy directive in October 2001, it was far from its goal of

universal access to these three noninstitutional services, as shown in figure 1.

Among the three services, respite care was most widely available, although at most

facilities this care was still offered only in institutional settings. According to VA

officials, noninstitutional respite care is not widely offered because until the Millennium Act VA was not authorized to provide respite care in noninstitutional settings.

Second to respite care in availability was adult day health care, followed by geriatric

evaluation.
16

5Skilled home health care consists of professional home health care services, mostly nursing

services, purchased by VA and delivered by non-VA health care providers.

FIGURE 1: NUMBER OF 139 VA FACILITIES OFFERING CERTAIN LONG-TERM CARE SERVICES REQUIRED BY THE MILLENNIUM ACT AND AVAILABLE IN NONINSTITUTIONAL SETTINGS, DURING SEPTEMBER AND OCTOBER 2001

Source: GAO survey of VA facilities; VA headquarters data.

a Includes facilities reporting geriatric evaluation and management services in our survey and additional facilities reported by VA headquarters

as offering geriatric primary care.

AVAILABILITY OF OTHER NONINSTITUTIONAL SERVICES IS UNEVEN

Uneven availability of noninstitutional services is not limited to the three services

that VA requires its facilities to offer in response to the Millennium Act. Although

at least nine different noninstitutional long-term care services are provided or paid

for by VA (including the three services that VA requires as a result of the act), considerable unevenness exists in the number of these services offered by individual facilities and their utilization. For example, 123 VA facilities reported offering skilled

home health care,5 while about half as many facilities—63—reported offering community residential care. These results are similar to the distribution of services

noted by the 1998 Advisory Committee on the Future of VA Long-Term Care, which

stated that VA long-term care—institutional as well as noninstitutional—was not
17

6Geriatric primary care was not among the services included in our survey of VA facilities.

available universally and that access to long-term care was often restricted. Similarly, a VA headquarters official we spoke with noted that VA’s noninstitutional

long-term care services are not equally accessible across the country. The services

offered by each VA facility during the September and October 2001 period, along

with the number of veterans served in each, are shown in enclosure II.

AGENCY COMMENTS

We provided a draft of this letter to VA officials for comment and received oral

comments on March 19, 2002. In providing comments, VA’s acting chief consultant,

Geriatrics and Extended Care Strategic Healthcare Group, stated that VA agrees

that its efforts to provide certain noninstitutional long-term care services in response to the Millennium Act’s requirements are not complete, and that the availability of noninstitutional services is uneven. The acting chief consultant also noted

that VA’s home health care programs are widely available as shown in our survey

results. This official also provided technical comments that we have incorporated as

appropriate.

As arranged with your offices, unless you publicly announce this letter’s contents

earlier we will make no further distribution until 30 days after its date. At that

time, we will send copies to the secretary of veterans affairs and interested congressional committees. The letter will also be available on GAO’s home page at http:/

/www.gao.gov. If you have questions, please contact me or James Musselwhite. Joe

Buschy, Steve Gaty, and Stefanie Weldon also made key contributions to this letter.

CYNTHIA A. BASCETTA,

Director, Health Care—Veterans’ Health and Benefits Issues

ENCLOSURE I—VA LONG-TERM CARE SERVICES

NONINSTITUTIONAL SERVICES

• Adult day health care: health maintenance and rehabilitative services provided

to frail elderly veterans in an outpatient day setting.

• Alzheimer’s/dementia care: specialized outpatient services such as behavioral

and medical management provided to veterans with Alzheimer’s disease or related

dementias.

• Community residential care: a service in which veterans who do not require

hospital or nursing home care—but who (because of medical or psychosocial health

conditions) are unable to live independently—live in VA-approved community residential care facilities; VA pays administrative costs only.

• Geriatric evaluation: evaluation of veterans with particular geriatric needs, generally provided by VA through one of two services: (1) geriatric evaluation and management (GEM), 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.6

• Home-based primary care: primary medical care provided in the home by VA

physicians, nurses, and other VA healthcare professionals to severely disabled,

chronically ill veterans whose conditions make them unsuitable for management in

outpatient clinics.

• Homemaker/home health aide: home health aide and homemaker services, such

as grooming, housekeeping, and meal preparation services.

• Home respite care: home-based services provided to veterans on a short-term

basis to give veterans’ caregivers a period of relief or respite.

• Hospice care: home-based palliative and supportive services for veterans in the

last phases of incurable disease so that they may live as fully and as comfortably

as possible.

• Skilled home health care: medical services provided to veterans at home by nonVA health care providers.

INSTITUTIONAL SERVICES

• Alzheimer’s/dementia care: specialized inpatient services such as behavioral and

medical management provided to veterans with Alzheimer’s disease or related dementias.

• Community nursing home care: nursing home care provided to veterans in community nursing facilities.
18

7 Because VA does not actively place veterans in state veterans’ domiciliaries or state veterans’

nursing homes (rather, veterans must apply to the facilities for admission, and admission requirements vary by state), state veterans’ domiciliary and state veterans’ nursing home services

were not included in our survey of VA facilities. 8 In 1995, VA created 22 Veterans Integrated Service Networks, a new management structure

to coordinate the activities of and allocate funds to VA hospitals, outpatient clinics, nursing

homes, and other facilities in each region. In January 2002, VA announced the merger of networks 13 and 14 into a single organization known as network 23. In this enclosure, we report

on these two networks separately because at the time of our survey they were operating as individual networks. 9 Although the surveys were sent out simultaneously, surveys for each facility were not completed on the same day.

• Domiciliary care: residential rehabilitation and health maintenance services

provided to veterans who do not require hospital or nursing home care but are unable to live independently because of medical or psychiatric disabilities; may be provided in VA domiciliaries or in state-owned and operated veterans’ domiciliaries.7

• Geriatric evaluation and management (GEM): evaluation and management of

frail elderly veterans by interdisciplinary health care teams of geriatric specialists;

may be provided in a distinct GEM unit or in existing nursing home or hospital

beds.

• Hospice care: palliative and supportive inpatient services for veterans in the

last phases of incurable disease so that they may live as fully and as comfortably

as possible; may be provided in a distinct hospice unit or in existing nursing home

or hospital beds.

• Respite care: hospital or nursing home care provided to veterans on a shortterm basis to give veterans’ caregivers a period of relief or respite; may be provided

in a distinct respite unit or in existing nursing home or hospital beds and may be

provided in VA hospitals, VA nursing homes, or community nursing homes.

• State veterans’ nursing home care: nursing home care provided to veterans in

state-owned and operated veterans’ nursing homes, for which VA pays a portion of

daily costs.

• VA nursing home care: nonacute nursing care services, variously referred to as

subacute, skilled, intermediate, or custodial nursing care, provided to veterans in a

VA facility’s nursing home care unit.

ENCLOSURE II—VA LONG-TERM CARE SERVICES BY VA FACILITY

This enclosure provides information on the types and utilization of long-term care

services, both institutional and noninstitutional, that VA’s 139 facilities reported as

of the September and October 2001 time frame. Each table contains service utilization data for all VA facilities in one of the 22 VA health care networks existing at

the time of our survey.8 Following are the key methods we used to collect and

present the data. Because of differences in the way utilization is calculated, the

numbers in this enclosure should not be compared to those presented in table 1.

• We obtained data on the number of veterans receiving or authorized to receive

services from each VA facility on the day the survey was completed.9 For example,

if a veteran was receiving homemaker/home health aide services 3 days per week

at the time of our survey, that veteran would have been counted in the utilization

total even if the veteran was not receiving services on the particular day the survey

was filled out. As a result, the utilization we report may exceed the average daily

census for individual services, particularly in noninstitutional services, because on

a given day the number of veterans authorized to receive services may be greater

than the number who actually receive services.

• Several facilities indicated they had ‘‘other’’ services—that is, services other

than those we specifically asked about in our survey. In instances in which facilities

reported ‘‘other’’ services with utilization of greater than 1,000 veterans, we note the

types of ‘‘other’’ services these facilities reported.
19

Table 2: Long-Term Care Services Offered by VA Facilities in Network 1, Boston, Mass. (Fall

2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Bedford Boston

HCS

Connecticut

HCS

ManchesterNorthamptonProvidence Togus

White

River

Junction

Noninstitutional long-term care

services:

Adult day health care ........... 68 80 49 13 19 4 48 281

Alzheimer’s/dementia care .... 200 125 325

Community residential care .. 202 85 75 362

Geriatric evaluation and

management ..................... 25 0 28 94 147

Home-based primary care ..... 15 132 ............ 63 210

Homemaker/home health aide 45 235 52 28 115 12 42 13 542

Home respite care.

Hospice care .......................... ............ ............

Skilled home health care ...... 1 68 29 ............ 40 30 90 37 295

Other noninstitutional ........... 368 0 368

Institutional long-term care

services:

Alzheimer’s/dementia care .... 110 50 160

Community nursing home

care ................................... 32 95 62 15 34 53 23 11 325

Domiciliary care ..................... 42 42

Geriatric evaluation and

management ..................... 24 13 0 4 41

Hospice care .......................... 2 5 3 10 1 1 6 2 30

Respite care .......................... 122 9 3 40 0 3 2 46 225

VA nursing home care ........... 152 146 9 70 59 38 474

Other institutional.

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one service. Some veterans may thus appear in several services at one facility.

Table 3: Long-Term Care Services Offered by VA Facilities in Network 2, Albany, N.Y. (Fall 2001)

VA service

Number of veterans in each service, by facility or health

care system (HCS)

Total a

Albany Bath Canandaigua Syracuse

Western

New

York

HCS

Noninstitutional long-term care services:

Adult day health care ................................................... 123 10 29 107 80 349

Alzheimer’s/dementia care ............................................ 100 49 318 222 689

Community residential care .......................................... 0 68 .................. ............ 68

Geriatric evaluation and management ......................... .................. 62 62

Home-based primary care ............................................. 140 160 109 762 259 1,430

Homemaker/home health aide ...................................... 60 104 211 129 261 765

Home respite care.

Hospice care .................................................................. 1 1 2

Skilled home health care .............................................. 21 0 5 168 194

Other noninstitutional ................................................... 2 13 15

Institutional long-term care services:

Alzheimer’s/dementia care ............................................ 24 24

Community nursing home care ..................................... 50 5 8 32 25 120

Domiciliary care ............................................................ 203 203

Geriatric evaluation and management.

Hospice care .................................................................. 2 7 0 3 3 15

Respite care .................................................................. 1 4 1 4 6 16

VA nursing home care .................................................. 28 147 80 30 111 396
20

Table 3: Long-Term Care Services Offered by VA Facilities in Network 2, Albany, N.Y. (Fall

2001)—Continued

VA service

Number of veterans in each service, by facility or health

care system (HCS)

Total a

Albany Bath Canandaigua Syracuse

Western

New

York

HCS

Other institutional.

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 4: Long-Term Care Services Offered by VA Facilities in Network 3, Bronx, N.Y. (Fall 2001)

VA service

Number of veterans in each service, by facility or health

care system (HCS)

Total a

Bronx

Hudson

Valley

HCS

New Jersey HCS Northport

New

York

Harbor

HCS

Noninstitutional long-term care services:

Adult day health care ......................................................... 3 4 34 67 108

Alzheimer’s/dementia care ................................................. 321 29 350

Community residential care ............................................... 272 230 215 717

Geriatric evaluation and management.

Home-based primary care .................................................. 107 65 143 45 137 497

Homemaker/home health aide ............................................ 35 196 159 127 517

Home respite care.

Hospice care.

Skilled home health care ................................................... 22 6 38 35 19 120

Other noninstitutional ......................................................... 241 241

Institutional long-term care services:

Alzheimer’s/dementia care ................................................. 14 14

Community nursing home care .......................................... 19 36 47 4 106

Domiciliary care .................................................................. 133 165 50 348

Geriatric evaluation and management .............................. 2 2 3 7

Hospice care ....................................................................... 7 2 4 7 5 25

Respite care ........................................................................ 2 3 2 1 6 14

VA nursing home care ........................................................ 69 180 260 101 153 763

Other institutional .............................................................. 11 11

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.
21

Table 5: Long-Term Care Services Offered by VA Facilities in Network 4, Pittsburgh, Pa. (Fall 2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Altoona Butler Clarks- burg Coatesville Erie Lebanon Philadel- phia Pitts- burgh HCS Wilkes- Barre Wil- mington

Noninstitutional long-term care services:

Adult day health care ................................................................................................................. 26 6 46 1 44 2 0 125Alzheimer’s/dementia care .......................................................................................................... 200 200Community residential care ........................................................................................................ 0 32 115 181 ............ 91 4 423Geriatric evaluation and management ....................................................................................... 24 5 925 954Home-based primary care ........................................................................................................... 31 0 56 123 210Homemaker/home health aide .................................................................................................... 78 139 94 82 7 30 113 39 13 595Home respite care ....................................................................................................................... ............ 0 0Hospice care ................................................................................................................................ 0 1 ............ 1

Skilled home health care ............................................................................................................ 7 15 37 3 15 5 76 28 16 22 224

Other noninstitutional ................................................................................................................. 50 2 0 26 1 79

Institutional long-term care services:

Alzheimer’s/dementia care .......................................................................................................... 36 17 50 103

Community nursing home care ................................................................................................... 10 6 29 1 3 13 12 97 6 6 183Domiciliary care ........................................................................................................................... 47 229 74 350Geriatric evaluation and management ....................................................................................... 6 6Hospice care ................................................................................................................................ 0 1 6 20 6 7 4 44

Respite care ................................................................................................................................ 1 4 0 3 1 40 4 8 60 2 123

VA nursing home care ................................................................................................................. 40 70 217 32 74 208 336 0 56 1,033Other institutional ....................................................................................................................... 38 12 0 50

Source: GAO survey of VA facilities.Notes: Responses to our survey were submitted in September and October 2001.Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service but did not report the service’s utilization.aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one service. Some veterans may thus appear in several services at one facility.
22

Table 6: Long-Term Care Services Offered by VA Facilities in Network 5, Baltimore, Md. (Fall

2001)

VA service

Number of veterans in each

service, by facility or health care

system (HCS)

Total a

Martinsburg

Maryland

HCS

Washington,

D.C.

Noninstitutional long-term care services:

Adult day health care ........................................................................................... 7 198 81 286

Alzheimer’s/dementia care .................................................................................... 148 148

Community residential care .................................................................................. 0 50 50

Geriatric evaluation and management ................................................................. 0 1,150 1,150

Home-based primary care .................................................................................... 180 109 289

Homemaker/home health aide .............................................................................. 18 252 117 387

Home respite care ................................................................................................. 0 0

Hospice care ......................................................................................................... 10 10

Skilled home health care ...................................................................................... 180 5 185

Other noninstitutional ........................................................................................... 42 3 45

Institutional long-term care services:

Alzheimer’s/dementia care .................................................................................... 0 0

Community nursing home care ............................................................................ 22 26 65 113

Domiciliary care .................................................................................................... 281 50 331

Geriatric evaluation and management ................................................................. 24 24

Hospice care ......................................................................................................... 23 16 39

Respite care .......................................................................................................... 2 10 4 16

VA nursing home care .......................................................................................... 166 200 90 456

Other institutional ................................................................................................. 101 101

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 7: Long-Term Care Services Offered by VA Facilities in Network 6, Durham, N.C. (Fall 2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Asheville Beckley Durham

Fayetteville

(N.C.)

Hampton Richmond Salem Salisbury

Noninstitutional long-term care

services:

Adult day health care ........... 61 16 18 70 14 179

Alzheimer’s/dementia care .... 150 38 125 313

Community residential care .. 21 30 200 251

Geriatric evaluation and

management ..................... 374 374

Home-based primary care ..... 33 36 69

Homemaker/home health aide 76 33 0 60 40 43 252

Home respite care.

Hospice care .......................... 4 1 2 ............ 5 12

Skilled home health care ...... 94 8 70 21 65 ............ 258

Other noninstitutional ........... ............ ............

Institutional long-term care

services:

Alzheimer’s/dementia care.

Community nursing home

care ................................... 7 11 22 33 26 9 5 41 154

Domiciliary care ..................... 151 151

Geriatric evaluation and

management ..................... 3 ............ ............ 13 10 26

Hospice care .......................... 5 3 10 5 4 10 2 8 47

Respite care .......................... 2 2 4 4 0 5 4 21

VA nursing home care ........... 98 36 98 37 72 71 80 204 696
23

Table 7: Long-Term Care Services Offered by VA Facilities in Network 6, Durham, N.C. (Fall

2001)—Continued

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Asheville Beckley Durham

Fayetteville

(N.C.)

Hampton Richmond Salem Salisbury

Other institutional ................. 18 18

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 8: Long-Term Care Services Offered by VA Facilities in Network 7, Atlanta, Ga. (Fall 2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Atlanta Augusta

BirminghamCentral

Alabama

HCS

Charleston

Columbia

(S.C.)

Dublin Tuscaloosa

Noninstitutional long-term care

services:

Adult day health care ........... 19 0 8 10 29 66

Alzheimer’s/dementia care .... 5 5

Community residential care .. 31 174 124 30 359

Geriatric evaluation and

management ..................... 250 0 250

Home-based primary care ..... 87 47 90 130 95 63 512

Homemaker/home health aide 67 149 24 46 50 62 78 104 580

Home respite care ................. 0 0 0

Hospice care .......................... 6 0 8 5 19

Skilled home health care ...... 62 83 21 75 60 35 336

Other noninstitutional ........... 10 144 1,139b 18 13 1,324

Institutional long-term care

services:

Alzheimer’s/dementia care .... 72 40 53 165

Community nursing home

care ................................... 71 53 23 4 12 51 27 5 246

Domiciliary care ..................... 60 60

Geriatric evaluation and

management ..................... 2 10 0 12

Hospice care .......................... 7 11 8 ............ 4 30

Respite care .......................... 0 0 4 5 ............ 1 10

VA nursing home care ........... 100 53 80 28 81 115 116 573

Other institutional ................. 0 ............ 20 20

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one service. Some veterans may thus appear in several services at one facility. b Geriatric primary care.

Table 9: Long-Term Care Services Offered by VA Facilities in Network 8, Bay Pines, Fla. (Fall

2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Bay

Pines Miami

North

Florida/

South

Georgia

HCS

San

Juan Tampa

West

Palm

Beach

Noninstitutional long-term care services:

Adult day health care ......................................... 43 29 13 85

Alzheimer’s/dementia care.
24

Table 9: Long-Term Care Services Offered by VA Facilities in Network 8, Bay Pines, Fla. (Fall

2001)—Continued

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Bay

Pines Miami

North

Florida/

South

Georgia

HCS

San

Juan Tampa

West

Palm

Beach

Community residential care ............................... 90 165 255

Geriatric evaluation and management .............. 30 300 330

Home-based primary care .................................. 100 150 195 82 143 670

Homemaker/home health aide ............................ 100 75 280 19 45 50 569

Home respite care .............................................. 4 4

Hospice care ....................................................... 0 0

Skilled home health care ................................... 154 18 35 5 180 4 396

Other noninstitutional ......................................... 1,528b 2,239c 373 4,140

Institutional long-term care services:

Alzheimer’s/dementia care ................................. 29 61 90

Community nursing home care .......................... 92 24 195 3 51 12 377

Domiciliary care .................................................. 104 17 121

Geriatric evaluation and management .............. 8 5 20 0 33

Hospice care ....................................................... 10 15 9 5 20 10 69

Respite care ........................................................ 8 4 7 5 11 3 38

VA nursing home care ........................................ 102 127 116 116 161 98 720

Other institutional .............................................. 24 27 17 68

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility. b Geriatric primary care and geriatric psychiatry care.

c Geriatric primary care.

Table 10: Long-Term Care Services Offered by VA Facilities in Network 9, Nashville, Tenn. (Fall

2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

HuntingtonLexingtonLouisville Memphis

Mountain

Home

Tennessee

Valley

HCS

Noninstitutional long-term care services:

Adult day health care ......................................... 18 12 30

Alzheimer’s/dementia care ................................. 259 100 359

Community residential care ............................... 42 96 90 213 441

Geriatric evaluation and management .............. 338 84 422

Home-based primary care .................................. 95 95

Homemaker/home health aide ............................ 36 31 27 59 162 194 509

Home respite care.

Hospice care ....................................................... 4 1 5

Skilled home health care ................................... 28 65 325 214 178 810

Other noninstitutional ......................................... 3 180 100 283

Institutional long-term care services:

Alzheimer’s/dementia care ................................. 34 34

Community nursing home care .......................... 53 33 36 40 49 43 254

Domiciliary care .................................................. 330 330

Geriatric evaluation and management .............. 20 4 24

Hospice care ....................................................... ............ 2 2 16 10 30

Respite care ........................................................ 4 4 2 0 5 3 18

VA nursing home care ........................................ 18 63 110 191

Other institutional .............................................. 43 43

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.
25

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 11: Long-Term Care Services Offered by VA Facilities in Network 10, Cincinnati, Ohio (Fall

2001)

VA service

Number of veterans in each service, by facility or

health care system (HCS)

Total a

ChillicotheCincinnatiClevelandColumbus Dayton

Noninstitutional long-term care services:

Adult day health care ..................................................................... 2 85 13 26 29 155

Alzheimer’s/dementia care.

Community residential care ............................................................ 267 22 278 19 63 649

Geriatric evaluation and management ........................................... 80 201 691 197 1,169

Home-based primary care ............................................................... 190 45 235

Homemaker/home health aide ........................................................ 230 37 380 44 171 862

Home respite care.

Hospice care .................................................................................... 1 .......... 3 4

Skilled home health care ................................................................ 235 167 175 697 180 1,454

Other noninstitutional.

Institutional long-term care services:

Alzheimer’s/dementia care .............................................................. 24 24

Community nursing home care ....................................................... 30 13 41 16 39 139

Domiciliary care ............................................................................... 42 66 92 100 300

Geriatric evaluation and management ........................................... 126 30 156

Hospice care .................................................................................... 7 .......... 14 22 43

Respite care .................................................................................... 5 2 2 3 12

VA nursing home care ..................................................................... 91 51 137 146 425

Other institutional.

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 12: Long-Term Care Services Offered by VA Facilities in Network 11, Ann Arbor, Mich. (Fall

2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Ann

Arbor

Battle

Creek Danville Detroit Indianapolis

Northern

Indiana

HCS

Saginaw

Noninstitutional long-term care services:

Adult day health care ........................ 0 16 57 5 26 4 0 108

Alzheimer’s/dementia care.

Community residential care .............. 0 0 137 0 45 96 0 278

Geriatric evaluation and management .............................................. 28 28

Home-based primary care ................. 12 21 1 19 2 55

Homemaker/home health aide ........... 43 79 66 48 7 243

Home respite care ............................. 0 0 0 0 0 0 0 0

Hospice care ...................................... 3 4 7

Skilled home health care .................. 1 2 6 6 17 22 1 55

Other noninstitutional.

Institutional long-term care services:

Alzheimer’s/dementia care ................ 23 23

Community nursing home care ......... 19 17 34 15 54 35 5 179

Domiciliary care.

Geriatric evaluation and management .............................................. 16 16

Hospice care ...................................... 11 42 2 1 56

Respite care ....................................... 2 3 1 2 ............ 1 2 11

VA nursing home care ....................... 15 86 125 62 125 70 483
26

Table 12: Long-Term Care Services Offered by VA Facilities in Network 11, Ann Arbor, Mich. (Fall

2001)—Continued

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Ann

Arbor

Battle

Creek Danville Detroit Indianapolis

Northern

Indiana

HCS

Saginaw

Other institutional.

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 13: Long-Term Care Services Offered by VA Facilities in Network 12, Chicago, Ill. (Fall

2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Chicago

HCS Hines

Iron

MountainMadison Milwaukee

North

Chicago Tomah

Noninstitutional long-term care services:

Adult day health care ........................ 29 60 1 5 73 28 125 321

Alzheimer’s/dementia care ................ 73 73

Community residential care .............. 20 0 20

Geriatric evaluation and management .............................................. 440 805 300 106 1,651

Home-based primary care ................. 92 219 115 115 541

Homemaker/home health aide ........... 49 73 14 14 34 2 3 189

Home respite care.

Hospice care ...................................... 1 6 5 12

Skilled home health care .................. 48 87 15 37 2 189

Other noninstitutional ........................ 180 38 218

Institutional long-term care services:

Alzheimer’s/dementia care ................ 27 27

Community nursing home care ......... 102 78 5 12 43 92 10 342

Domiciliary care ................................. 167 159 326

Geriatric evaluation and management .............................................. 120 9 4 10 ............ 143

Hospice care ...................................... 15 5 30 7 4 61

Respite care ....................................... 12 6 2 0 4 0 2 26

VA nursing home care ....................... 75 33 93 157 200 558

Other institutional ............................. 33 ............ 33

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 14: Long-Term Care Services Offered by VA Facilities in Network 13, Minneapolis, Minn.

(Fall 2001)

VA service

Number of veterans in each service, by facility or

health care system (HCS)

Total a

Black

Hills

HCS

Fargo

Minneapolis

Sioux

Falls

St.

Cloud

Noninstitutional long-term care services:

Adult day health care ..................................................................... 2 95 6 58 161

Alzheimer’s/dementia care .............................................................. 1 .......... 14 15

Community residential care ............................................................ 30 30

Geriatric evaluation and management ........................................... 5 10 15

Home-based primary care ............................................................... 25 25

Homemaker/home health aide ........................................................ 35 49 195 5 51 335
27

Table 14: Long-Term Care Services Offered by VA Facilities in Network 13, Minneapolis, Minn.

(Fall 2001)—Continued

VA service

Number of veterans in each service, by facility or

health care system (HCS)

Total a

Black

Hills

HCS

Fargo

Minneapolis

Sioux

Falls

St.

Cloud

Home respite care ........................................................................... 0 .......... 1 0 1

Hospice care .................................................................................... 4 1 12 2 0 19

Skilled home health care ................................................................ 49 48 229 23 94 443

Other noninstitutional.

Institutional long-term care services:

Alzheimer’s/dementia care.

Community nursing home care ....................................................... 11 16 84 10 11 132

Domiciliary care ............................................................................... 132 105 237

Geriatric evaluation and management ........................................... 1 1

Hospice care .................................................................................... 15 2 10 4 3 34

Respite care .................................................................................... 4 1 4 3 6 18

VA nursing home care ..................................................................... 63 31 76 30 215 415

Other institutional ........................................................................... 41 41

Source: GAO survey of VA facilities.

Notes: In January 2002, VA announced the merger of networks 13 and 14 into a single organization known as network 23. In this enclosure

we report on these networks separately because at the time of our survey they were operating as individual networks.

Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 15: Long-Term Care Services Offered by VA Facilities in Network 14, Lincoln, Neb. (Fall

2001)

VA service

Number of veterans in each

service, by facility or health

care system (HCS)

Total a

Central

Iowa

HCS

Iowa

City

Nebraska/

Western

Iowa

HCS

Noninstitutional long-term care services:

Adult day health care ................................................................................................... 4 53 2 59

Alzheimer’s/dementia care.

Community residential care .......................................................................................... 0 0

Geriatric evaluation and management ......................................................................... 21 12 33

Home-based primary care ............................................................................................ 33 33

Homemaker/home health aide ...................................................................................... 8 81 32 121

Home respite care ......................................................................................................... .......... 2 2

Hospice care ................................................................................................................. 0 6 3 9

Skilled home health care .............................................................................................. 25 243 17 285

Other noninstitutional.

Institutional long-term care services:

Alzheimer’s/dementia care.

Community nursing home care .................................................................................... 25 17 58 100

Domiciliary care ............................................................................................................ 68 14 82

Geriatric evaluation and management ......................................................................... 1 1

Hospice care ................................................................................................................. 13 3 3 19

Respite care .................................................................................................................. 1 023

VA nursing home care .................................................................................................. 179 54 233

Other institutional ......................................................................................................... 14 14

Source: GAO survey of VA facilities.

Notes: In January 2002, VA announced the merger of networks 13 and 14 into a single organization known as network 23. In this enclosure

we report on these networks separately because at the time of our survey they were operating as individual networks.

Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.
28

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 16: Long-Term Care Services Offered by VA Facilities in Network 15, Kansas City, Mo. (Fall

2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total Colum- a

bia

(Mo.)

Eastern

Kansas

HCS

Kansas

City

Marion

(Ill.)

Poplar

Bluff St Louis Wichita

Noninstitutional long-term care services:

Adult day health care ........................ 1 7 7 13 6 34

Alzheimer’s/dementia care.

Community residential care .............. 10 172 182

Geriatric evaluation and management .............................................. 1,779 1,779

Home-based primary care ................. 104 114 218

Homemaker/home health aide ........... 57 99 65 32 ............ 101 19 373

Home respite care ............................. 0 ............ 0

Hospice care ...................................... 0 3 2 0 ............ 5

Skilled home health care .................. 137 16 144 8 83 ............ 388

Other noninstitutional ........................ 384 ............ 384

Institutional long-term care services:

Alzheimer’s/dementia care.

Community nursing home care ......... ............ 42 50 26 12 36 11 177

Domiciliary care ................................. 176 36 212

Geriatric evaluation and management .............................................. 12 8 20

Hospice care ...................................... 4 4 1 1 0 10

Respite care ....................................... 1 1 1 2 22 9 0 36

VA nursing home care ....................... 25 139 35 39 23 ............ 261

Other institutional ............................. 0 20 5 25

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one service. Some veterans may thus appear in several services at one facility.
29

Table 17: Long-Term Care Services Offered by VA Facilities in Network 16, Jackson, Miss. (Fall 2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a Alexandria Central Arkan- sas HCS Fayette- ville (Ark.) Gulf Coast HCS Houston Jackson Muskogee New Or- leans Okla- homa City Shreve- port

Noninstitutional long-term care services:

Adult day health care ................................................................................................................... 14 75 11 18 43 43 7 211

Alzheimer’s/dementia care ............................................................................................................ 261 261

Community residential care .......................................................................................................... 62 217 0 9 11 299Geriatric evaluation and management.Home-based primary care ............................................................................................................ 185 53 150 82 40 65 575Homemaker/home health aide ...................................................................................................... 20 179 ............ 50 ............ 27 28 304Home respite care ......................................................................................................................... ............ ............

Hospice care ................................................................................................................................. ............ 0 ............ 0Skilled home health care .............................................................................................................. 16 76 6 111 ............ 56 9 38 73 385

Other noninstitutional ................................................................................................................... 0 236 236

Institutional long-term care services:

Alzheimer’s/dementia care ............................................................................................................ 16 32 44 92

Community nursing home care .................................................................................................... 52 44 17 17 27 22 34 17 24 25 279Domiciliary care ............................................................................................................................ ............ 66 66Geriatric evaluation and management ......................................................................................... 1 18 10 0 0 29Hospice care ................................................................................................................................. ............ 8 5 0 1 14

Respite care .................................................................................................................................. 1 8 1 2 5 57 0 0 1 1 76VA nursing home care .................................................................................................................. 130 110 65 110 114 53 21 603

Other institutional ......................................................................................................................... 0 0 0

Source: GAO survey of VA facilities.Notes: Responses to our survey were submitted in September and October 2001.Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service but did not report the service’s utilization.aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one service. Some veterans may thus appear in several services at one facility.
30

Table 18: Long-Term Care Services Offered by VA Facilities in Network 17, Dallas, Tex. (Fall

2001)

VA service

Number of veterans in each

service, by facility or health

care system (HCS)

Total a

Central

Texas

HCS

North

Texas

HCS

South

Texas

HCS

Noninstitutional long-term care services:

Adult day health care ................................................................................................... 1 11 40 52

Alzheimer’s/dementia care ............................................................................................ 100 100

Community residential care .......................................................................................... 67 0 67

Geriatric evaluation and management ......................................................................... 60 2,000 2,060

Home-based primary care ............................................................................................ 161 168 329

Homemaker/home health aide ...................................................................................... 104 77 95 276

Home respite care ......................................................................................................... 0 20 20

Hospice care ................................................................................................................. 8 0 8

Skilled home health care .............................................................................................. 48 65 113

Other noninstitutional ................................................................................................... 12 230 242

Institutional long-term care services:

Alzheimer’s/dementia care ............................................................................................ 4 15 58 77

Community nursing home care .................................................................................... 102 59 90 251

Domiciliary care ............................................................................................................ 0 264 264

Geriatric evaluation and management ......................................................................... 10 8 18

Hospice care ................................................................................................................. 0 17 20 37

Respite care .................................................................................................................. 0 10 10 20

VA nursing home care .................................................................................................. 379 210 214 803

Other institutional ......................................................................................................... 124 124

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one service. Some veterans may thus appear in several services at one facility.

Table 19: Long-Term Care Services Offered by VA Facilities in Network 18, Phoenix, Ariz. (Fall

2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Albuquerque Amarillo Big

Spring El Paso Phoenix Prescott Tucson

Noninstitutional long-term care services:

Adult day health care ........................ 5 42 37 25 109

Alzheimer’s/dementia care ................ 141 0 10 151

Community residential care .............. 19 22 41

Geriatric evaluation and management .............................................. 111 40 177 114 442

Home-based primary care ................. 124 0 84 203 411

Homemaker/home health aide ........... 174 ............ 57 2 138 371

Home respite care ............................. 6 6

Hospice care ...................................... 15 31 46

Skilled home health care .................. 5 5 0 12 200 74 138 434

Other noninstitutional ........................ 16 16

Institutional long-term care services:

Alzheimer’s/dementia care ................ 16 7 23

Community nursing home care ......... 70 4 4 64 16 56 214

Domiciliary care ................................. 120 120

Geriatric evaluation and management .............................................. ............ 3 28 31

Hospice care ...................................... 11 3 0 14 10 17 55

Respite care ....................................... 9 0 0 4 0 6 19

VA nursing home care ....................... 3 117 40 46 57 1 264

Other institutional ............................. 4 16 20

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.
31

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 20: Long-Term Care Services Offered by VA Facilities in Network 19, Denver, Colo. (Fall

2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Cheyenne Denver Fort

Lyon

Grand

Junction

Montana

HCS

Salt

Lake

City

Sheridan

Noninstitutional long-term care services:

Adult day health care ........................ 15 3 18

Alzheimer’s/dementia care.

Community residential care .............. 132 ............ 132

Geriatric evaluation and management .............................................. 150 150

Home-based primary care ................. 72 ............ 120 192

Homemaker/home health aide ........... 82 116 0 8 60 22 288

Home respite care ............................. 0 0 0

Hospice care ...................................... ............ 3 2 5

Skilled home health care .................. 3 65 172 20 11 40 26 337

Other noninstitutional ........................ ............ ............

Institutional long-term care services:

Alzheimer’s/dementia care ................ 8 8

Community nursing home care ......... 2 57 ............ 7 33 28 2 129

Domiciliary care.

Geriatric evaluation and management .............................................. 4 ............ ............ 4

Hospice care ...................................... 5 10 ............ ............ 3 1 1 20

Respite care ....................................... 0 3 0 ............ 3 0 1 7

VA nursing home care ....................... 37 43 27 30 ............ 50 187

Other institutional ............................. 0 0 0

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.

Table 21: Long-Term Care Services Offered by VA Facilities in Network 20, Portland, Oreg. (Fall

2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Alaska

HCS Boise Portland

Puget

Sound

HCS

Roseburg Spokane Walla

Walla

White

City

Noninstitutional long-term care

services:

Adult day health care ........... 40 15 2 57

Alzheimer’s/dementia care ... 125 410 535

Community residential care.

Geriatric evaluation and

management .................... 175 ............ 175

Home-based primary care .... 116 137 253

Homemaker/home health

aide .................................. 23 52 21 95 ............ 25 8 31 255

Home respite care ................ 20 20

Hospice care ......................... 1 1 46 8 3 ............ 59

Skilled home health care ..... 77 60 188 ............ 4 3 332

Other noninstitutional ........... 99 3,127b 3,226

Institutional long-term care

services:

Alzheimer’s/dementia care ... 18 14 32

Community nursing home

care .................................. 11 17 51 150 20 40 7 9 305
32

Table 21: Long-Term Care Services Offered by VA Facilities in Network 20, Portland, Oreg. (Fall

2001)—Continued

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total a

Alaska

HCS Boise Portland

Puget

Sound

HCS

Roseburg Spokane Walla

Walla

White

City

Domiciliary care .................... 192 658 850

Geriatric evaluation and

management .................... 4 8 0 12

Hospice care ......................... 6 7 6 3 4 ............ 26

Respite care .......................... 0 49 41 16 2 100 ............ 208

VA nursing home care .......... 15 270 105 32 28 21 471

Other institutional ................ 33 ............ 33

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one service. Some veterans may thus appear in several services at one facility. b Geriatric primary care, geriatric memory disorder care, and other services.

Table 22: Long-Term Care Services Offered by VA Facilities in Network 21, San Francisco, Calif.

(Fall 2001)

VA service

Number of veterans in each service, by facility or health care system (HCS)

Total Central a

California

HCS

Honolulu

Northern

California

HCS

Palo Alto Reno

San

Francisco

Noninstitutional long-term care services:

Adult day health care ......................................... 2 6 20 6 6 40

Alzheimer’s/dementia care ................................. ............ 100 130 230

Community residential care.

Geriatric evaluation and management .............. 300 423 100 823

Home-based primary care .................................. 39 61 117 35 7 75 334

Homemaker/home health aide ............................ 6 11 67 20 45 70 219

Home respite care.

Hospice care ....................................................... 2 0 5 5 12

Skilled home health care ................................... 6 20 15 3 25 69

Other noninstitutional ......................................... ............ 50 50

Institutional long-term care services:

Alzheimer’s/dementia care ................................. 50 50

Community nursing home care .......................... 10 3 80 50 8 32 183

Domiciliary care .................................................. 100 100

Geriatric evaluation and management .............. 2 0 2

Hospice care ....................................................... 10 3 11 25 4 5 58

Respite care ........................................................ 300 4 5 200 3 3 515

VA nursing home care ........................................ 43 41 62 343 50 75 614

Other institutional .............................................. 27 0 27

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more

than one service. Some veterans may thus appear in several services at one facility.
33

Table 23: Long-Term Care Services Offered by VA Facilities in Network 22, Long Beach, Calif.

(Fall 2001)

VA service

Number of veterans in each service, by facility or

health care system (HCS)

Total a Greater

Los

Angeles

HCS

Loma

Linda

Long

Beach

Southern Nevada

HCS

San

Diego

Noninstitutional long-term care services:

Adult day health care ..................................................................... .......... 38 61 99

Alzheimer’s/dementia care .............................................................. 220 225 445

Community residential care ............................................................ 44 0 44

Geriatric evaluation and management ........................................... 350 300 53 703

Home-based primary care ............................................................... .......... 72 70 142

Homemaker/home health aide ........................................................ 56 34 90

Home respite care ........................................................................... 20 20

Hospice care .................................................................................... 59 0 59

Skilled home health care ................................................................ .......... 602 0 211 813

Other noninstitutional ..................................................................... .......... ..........

Institutional long-term care services:

Alzheimer’s/dementia care .............................................................. 28 28

Community nursing home care ....................................................... 64 178 48 20 73 383

Domiciliary care ............................................................................... 247 247

Geriatric evaluation and management ........................................... 7 3 10

Hospice care .................................................................................... 10 14 6 30

Respite care .................................................................................... 10 54 3 3 70

VA nursing home care ..................................................................... 240 89 76 25 430

Other institutional ........................................................................... .......... 4 4

Source: GAO survey of VA facilities.

Notes: Responses to our survey were submitted in September and October 2001.

Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the

service but did not report the service’s utilization.

aWe did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one service. Some veterans may thus appear in several services at one facility.

Chairman ROCKEFELLER. Thank you very much. Jim

Musselwhite.

Mr. MUSSELWHITE. I am available to answer questions.

Chairman ROCKEFELLER. You indicated that OMB is going to

send over rules and regulations in a week. That does not mean that

they are not going to be sent back for further revision. Why do you

think really it has taken this long?

Ms. BASCETTA. It is difficult for me to answer that question. The

focus of our work was on what was available and the condition of

universality of these services across the networks and we spent less

time in trying to figure out why the agency had taken so long to

actually promulgate regs. Our understanding is that many of the

issues they found to be understandably complex, perhaps particularly issues related to copayments, but we do not have the details

of what went on between OMB and the department.

I would also point that even if there had not been issues with

OMB, the rest of the Nation is also facing a pretty significant challenge in trying to figure out how to provide these services, so in

other words, notwithstanding the interactions in Washington, I

think the decisions about how best to provide care in the field are

also difficult ones that need to be made.

Chairman ROCKEFELLER. But it is true, is it not, that the Department of Veterans Affairs is meant to be the best in terms of dealing

with aging? In other words, that is why 50 percent of all medical

students do their training at VA hospitals because that is where
34

they get geriatric training. I mean VA is meant to be good at this.

This is not meant to be a discovery process on their part.

Ms. BASCETTA. That is correct. Certainly in geriatric evaluation

and geriatric medicine, the VA is perceived as a leader. In terms

of their provision of care in non-institutional settings, we have done

less to have an opinion about how they stack up compared to other

health care systems, but I can tell you that the task force found

that they were pretty typical of the rest of the Nation, that the Nation is not doing as well as it could be in recrafting how to shift

from institutional to non-institutional settings.

The task force also suggested that VA might want to look to

some states that are farther ahead in providing non-institutional

care.

Chairman ROCKEFELLER. Well, we are going to hear from those,

and they obviously——

Ms. BASCETTA. Right.

Chairman ROCKEFELLER [continuing]. Were not bottled up by the

inertia——

Ms. BASCETTA. That is correct.

Chairman ROCKEFELLER [continuing]. That was taking place in

this and the past administration, and I am interested, if you know

about those, and why it is that some are willing to move ahead irrespective of whatever consequences there might be and could not

care less because they know what their mission is.

Veterans are much older than the general population. Here we

have a really important medical mission, and all of a sudden everybody freezes up except a few people from whom we will hear.

Ms. BASCETTA. Right. You are right that there is this tremendous

variability. We are hoping that in the study that we are conducting

for you now, we will better understand what the reasons are for

some of this unevenness, but clearly we have seen in the VA area

as well as in some states that where there is a commitment it

seems to unleash a great deal of creativity in being able to provide

non-institutional services in a very cost effective way, but we are

hoping to understand that much better over the next few months.

Chairman ROCKEFELLER. I will stop here, but I understand when

you say there are many technical problems and the Nation is trying to figure out all of these things, but where there is a clear direction, where there is a clear sort of triumphantly conceived policy

which speaks to such direct needs of veterans, it just does not occur

to me that sort of the technical problem between OMB and VA or

whoever is botching this thing up is a particularly compelling excuse.

Ms. BASCETTA. I agree.

Chairman ROCKEFELLER. I mean if you are talking about the Nation trying to figure it out, that is one thing. If you are talking

about VA trying to figure it out, that strikes me as quite another.

Ms. BASCETTA. I agree, and as you point out, others have been

able to proceed despite those kinds of problems.

Chairman ROCKEFELLER. Thank you. Senator Specter.

Senator SPECTER. Thank you very much, Mr. Chairman. Ms.

Bascetta, how long have these regulations been languishing awaiting OMB approval?
35

Ms. BASCETTA. I am not sure I have the exact date. Do you know,

Jim?

Mr. MUSSELWHITE. No, I do not.

Senator SPECTER. About 21⁄2 years?

Ms. BASCETTA. I think that is probably about right.

Senator SPECTER. Why?

Ms. BASCETTA. As I said, I wish I had the details. I do not know.

Senator SPECTER. I am not asking you for details. I am asking

you why 21⁄2 years have elapsed and you still do not have OMB approval of these regulations. You are silent. Let the record show you

are nodding. What action did the VA take to try to get the regulations promulgated?

Ms. BASCETTA. Dr. Roswell would be in a better position to answer that. I do not know how much interaction there was between

OMB or VA. I do not know what their response is, what OMB’s response would have been to the draft regulations, or whether they

asked them to make revisions or the basis of those kinds of revisions.

Senator SPECTER. Well, what is the view of VA generally when

Congress, by legislation, mandates—that word means requires—

that VA do certain things? Maintain nursing home care capacity at

1998 levels, provide outpatient based long-term geriatric care services, adult day care, adult day health care, respite care, geriatric

evaluations, to all VA patients in need of such care. Does the Veterans Administration—this may seem like an easy question—but

does the Veterans Administration take seriously a congressional

mandate?

Ms. BASCETTA. I certainly hope so.

Senator SPECTER. Well, then why is nothing done?

Ms. BASCETTA. Well, they do need to promulgate regulations and

those do go through the Office of Management and Budget.

Senator SPECTER. Well, do you think the VA has some duty of

diligence——

Ms. BASCETTA. Absolutely.

Senator SPECTER [continuing]. To push whoever is not promulgating regulations to do that?

Ms. BASCETTA. Yes, I do.

Senator SPECTER. I understand the VA has a series of excuses

that might be called reasons, but was any effort made to come back

to the Congress—to the relevant committees—to say these are our

problems?

Ms. BASCETTA. Well, that is a good point, and I was going to say

that if there were problems, it would have at least been beneficial

certainly to us and to you to have an understanding of what those

problems might have been.

Senator SPECTER. Well, we have a very important piece of legislation. We have a very strong stand taken by the Congress, and we

have inertia, inaction, indolence, and disregard by the administration. What do you suggest that we do about it, Ms. Bascetta? Go

to court, get a contempt citation, put somebody in jail?

Ms. BASCETTA. Having this hearing I think is an important, a

very important signal, and the tone that Senator Rockefeller set in

laying out these very clear expectations, which should have been
36

clear all along, is certainly an important step in moving this process along.

Senator SPECTER. How many hearings have we had on this subject, Ms. Bascetta?

Ms. BASCETTA. That I am not sure.

Senator SPECTER. Several. Well, we hope this hearing does some

good, but there has been certain turnover in the VA, and it is easy

to find excuses, but there are a lot of veterans out there who are

not getting the services which Congress has decided, as a matter

of public policy, ought to be given.

Ms. BASCETTA. That is correct.

Senator SPECTER. Thank you, Mr. Chairman.

Chairman ROCKEFELLER. Thank you, Senator Specter. Senator

Graham, we welcome you. There is kind of a somber mood around

here if you care to add to it. [Laughter.]

Senator GRAHAM. I think that, Mr. Chairman, you and Senator

Specter have properly set the mood, and it is not necessary for me

to contribute to that level of seriousness. Obviously representing a

state with a very large population of veterans and an especially

large population of older veterans, these issues of long-term care

are extremely important, and I appreciate your holding this hearing and giving us an opportunity to both hear on the record what

the status of implementation of the 1999 legislation is to date and

to hear the recommendations such as those that Senator Specter

just propounded as to what alternatives are before us.

Senator SPECTER. Mr. Chairman, Senator Graham may want to

use our protocol when he convenes hearings on CIA failures.

Senator GRAHAM. No comment.

Senator SPECTER. It is too late now, Bob.

Chairman ROCKEFELLER. I just want to ask a question, and then,

Senator Graham, if you want to do so. You know I think in your

report, you say that 8 percent of dollars spent on VA long-term

care were in non-nursing home settings. So people say resources

are the excuse. My answer to that would be there may be some increase in workload on the part of an incredibly loyal work force in

the VA, but you certainly cannot use cost as a reason, because noninstitutional care is going to be a lot less expensive. Would you not

agree?

Ms. BASCETTA. On a per person basis, yes, that is correct, it

should be less expensive.

Chairman ROCKEFELLER. So any time I hear resources used as

an excuse today, I am going to bear that very much in mind.

Ms. BASCETTA. Right.

Chairman ROCKEFELLER. Now, we do not wish to be—Senator

Graham, did you have any questions?

Senator GRAHAM. No.

Chairman ROCKEFELLER. OK. We do not wish to be short with

you in terms of time, but we want to move to some of these folks

who are making this thing work, so we thank you very much for

doing the work. I am extremely glad that you are both there, and

I thank you for coming.

Ms. BASCETTA. Thank you.

Mr. MUSSELWHITE. Thank you.
37

Chairman ROCKEFELLER. OK. Panel two is our innovators panel,

and they have programs that are already at work. So Gladys

Dickerson, who runs a home-based program geared toward those

with dementia, will be one of our witnesses.

Tom McClure and his Medical Foster Care Program will be another. Paula Hemmings, Network Number 2’s geriatric and extended care service line manager, but with us today representing

the Alzheimer’s Association. And finally, Jennifer Moye. Who is a

researcher and a psychologist with a great story to tell about what

can be done in terms of geriatric mental health. We are so glad you

are here. Right now you are not giving special time to your patients

because you are away from them, and I apologize for that, but I

think that you understand that we are talking here about the

greater good. So I am very grateful that you are here, and why do

we not start, Ms. Dickerson, with you on home-based dementia.

STATEMENT OF GLADYS DICKERSON, R.N., HOME-BASED

PRIMARY CARE COORDINATOR, DALLAS VA MEDICAL CENTER

Ms. DICKERSON. Mr. Chairman and members of the committee,

I appreciate this opportunity to speak before you today regarding

alternatives to institutionalization for long-term care.

Hospital-based and Home-Based Primary Care—HBPC as it is

referred to—and other programs associated with HBPC ensures

that the right care at the right time in the right setting is available

to veterans all over the nation. Programs such as HBPC, adult day

care, telemedicine, advances in home-based primary care for end of

life in advancing dementia, which is referred to as the AHEAD program, the senior companion program, in-home respite and assisted

living ensures that veterans receive alternatives to institutional

care.

These services can be provided at a much reduced cost to the VA

system and keep the patients out of acute care beds and at home

where they prefer. The number of veterans with long-term care

needs is increasing as the population ages. Currently, we have an

estimated 600,000 individuals with dementia alone within the veteran population. Dementia and similar diseases are progressive.

The victims are vulnerable to accidents, injuries which ultimately make them completely dependent in all aspects of their

daily living. These diseases are projected to triple in the veteran

population over the age of 65. The incurable nature of these diseases and long-term conditions, the suffering that they cause the

patient and their families, and the cost of care, of managing diseases such as dementia, makes it a priority to find alternatives to

institutionalization.

Home and community-based care allows the veteran to live at

home rather than in an institution, making it a win-win situation

for such programs as the HBPC program and the AHEAD project.

Families are able to participate in quality of life issues with the

veterans in the home environment and the cost of care is usually

lower than the cost of skilled care nursing facilities.

Across VHA, the data indicates that families prefer to keep veterans at home, but they are unable to as the veteran becomes more

impaired. The AHEAD project through HBPC focuses on the dementia patient’s problems. Focus areas include earlier identifica-
38

tion, caregiver support, completion of advanced directives and

symptom management.

The project allows the veteran to receive appropriate care in the

location they prefer and help sustain caregivers in their vital roles.

The AHEAD project took 20 VA facilities across the country and we

completed a 9-month collaboration committed to improve the care

of veterans with dementia who prefer to live at home.

These teams demonstrated notable success in early identification

of dementia, symptom management, caregiver support and staff

education. Home-based primary care is the most cost effective way

to deliver interdisciplinary home care.

The HBPC program offers long-term patients the kind of alternative to nursing home placement. It minimizes the amount of followup that they have to go through in the ambulatory care clinic.

It prevents premature admissions to the hospital by early identification and premature admission to long-term care facility. It also

allows the patient the option of dying in the home rather than in

an institution.

The purpose of the Community Adult Day Care Program is to establish functional impaired individuals with a supportive professional environment so that they can be nurtured; to facilitate the

return of the older veteran to his home and to coordinate their

long-term care; to maintain the older veteran at the highest level

of function possible both physically, socially, and medically; and to

provide the family and caregiver with professional support, enabling them to maintain the disabled veteran in the community.

The Senior Companion Program often makes the difference between living at home and in an institution. This translates into

major health cost savings for the senior, their family, and the taxpayers. Nursing home costs is an average of $38,000 annually per

patient per year. However, the cost of supporting one senior companion for an entire year is $3,850. Telemedicine technology also

allows us to reduce costs, time, and efficiency and eliminates distance.

In conclusion, funding an expansion of HBPC programs will enable alternatives to institutionalization of long-term care veterans,

which we need expanded programs, innovative approaches to longterm care, and this would mean a cost savings to the VA. HBPC

keeps families together and this concludes my remarks, and I will

be happy to answer any questions.

Chairman ROCKEFELLER. Thank you very, very much. Tom

McClure.

[The prepared statement of Ms. Dickerson follows:]

PREPARED STATEMENT OF GLADYS DICKERSON, R.N., HOME-BASED PRIMARY CARE

COORDINATOR, DALLAS VA MEDICAL CENTER

Mr. Chairman and Members of the Committee:

I appreciate the opportunity to speak before you today regarding alternatives to

Institutionalization in Long Term Care. Home Based Primary Care (HBPC) and

those programs associated with HBPC; ensure that the right care, at the right time,

in the right setting is available to veterans all over the nation. Programs such as

HBPC, Adult Day Care, Telemedicine, Advances in Home Based Primary Care for

End of Life in Advancing Dementia (AHEAD), Senior Companion, In-Home Respite,

and Assisted Living ensure veterans receive alternatives to institutional care. These

services can be provided at a much-reduced cost to the VA system and keep the patient out of an acute care bed and at home, where they prefer to remain.
39

NON-INSTITUTIONAL ALTERNATIVES TO LONG-TERM CARE

The number of veterans with long-term health care needs is increasing as the

population ages. Currently, there are an estimated 600,000 individuals with dementia within the veteran population.

Dementia and similar diseases are progressive. Their victims are vulnerable to accidents and injuries that ultimately make them completely dependent in all aspects

of daily living. These diseases are projected to triple in the veteran population over

age 65. The incurable nature of most long-term conditions, the suffering it causes

patients and their families, and the cost of care make managing diseases such as

dementia and others a priority to promote non-institutional care for VA.

Veterans who receive the home and community based care that allows them to

live at home rather than in an institution, makes this a ‘‘win-win’’ situation for such

programs as the HBPC and AHEAD Project. The family is able to participate in

quality of life issues with the veteran in their home environment. The cost of care

is usually lower than care provided in a skilled care facility.

Across the VHA, data indicates many families prefer to keep the veteran at home

but they are unable to, as the veteran becomes more impaired. The AHEAD project

through HBPC focuses on the dementia patient’s problems. Focus areas are, early

identification, caregiver support, completion of Advance Directives, and symptom

management. The project allows veterans to receive appropriate care in a location

they prefer and helps sustain caregivers in their vital role.

In the AHEAD Project, 20 VA facilities around the country completed a ninemonth collaboration, committed to improving care of veterans with dementia who

prefer to live at home. These teams demonstrated notable success in early identification of dementia, symptom management, caregiver support, and staff education. It

has been shown that the best place for veterans with long-term problems is in the

HBPC Programs across the country. Home Based Primary Care is the most cost effective way to deliver interdisciplinary health care. This care is defined as accessible, comprehensive, coordinated, continual, accountable and acceptable.

The HBPC Program offers long-term patients this kind of care.

• An alternative to nursing home placement.

• Minimizes the amount of follow up in an Ambulatory Care Clinic.

• Prevents premature admissions to long-term care institutions.

• Maintains optimal physical, cognitive, and psychosocial functioning.

• Allows the patient the option of dying at home rather than in an institution.

The purposes of the Community Adult Day Care facilities are:

• To enable functionally impaired individuals to reside in a supportive home environment rather than nursing home care facilities.

• To facilitate the return of older veterans to their homes and to coordinate their

long-term care.

• To maintain the older veteran at the highest level of functioning possible (physical, social and medical).

• To provide the family and caregivers with professional support, enabling them

to maintain disabled veterans in the community.

The Senior Companion Program often makes the difference between living at

home or in an institutional setting. This translates into major health care savings

for seniors, their families, and taxpayers. Nursing home care costs an average of

$38,000 annually per person. However, the cost of supporting one Senior Companion

for an entire year is $3,850.

Telemedicine technology allows us to reduce travel time and costs, improves efficiency and provides better quality care.

In conclusion, funding and expansion of all HBPC Programs can ensure alternatives to institutionalization for the long-term veteran patient. With these expanded programs, innovative approaches to long-term care can be established with

a cost saving to VHA, patients and their caregivers. HBPC keeps families together.

This concludes my remarks. I will be happy to respond to any questions you may

have.

STATEMENT OF THOMAS McCLURE, LCSW, COORDINATOR, VA

MEDICAL FOSTER HOME PROGRAM, LITTLE ROCK VA MEDICAL CENTER

Mr. MCCLURE. I appreciate the strong language from this committee because I think we need action, and I think I have some

good news. I am here to tell you about a unique and exciting program that actually changes lives. The VA hospital in Little Rock
40

has taken the Medical Foster Home Program and the HBPC programs and formed a partnership that provides an extremely personal and comprehensive service that benefits not only our disabled

veterans, but it benefits our communities and the VA hospital at

a low cost.

This program has an excellent record of satisfaction among the

veterans and their families. The secret, these homes provide a permanent home with private rooms. They provide 24 hour supervision, home cooked meals, a safeguard against abuse and neglect.

We have never had a case of abuse in our program. We take sick,

depressed veterans and turn them into grandpas, father figures.

We turn them into family members.

We fatten them up and make them laugh. They bring their pets

to these foster homes. They are allowed flexibility in their routine.

They are treated with dignity and respect, because those are our

standards. The Medical Foster Home Program also provides a valuable service to our community, and that is in the form of jobs and

income. Also an opportunity to work at home.

But the reason I am successful at recruiting good homes is because this program provides a meaning and a purpose in these

caregivers’ lives. Our community, the everyday people, have defended our nation in war, they have run our factories, and they

have built our homes. These people can also care for our frail elderly population if we support them. They can do it better and they

can do it with less cost than any other alternative.

The program also provides a service to our VA hospital by giving

the discharge planners an alternative to nursing home placement.

Already, 50 percent of my referrals come from the VA hospital, and

that is growing. 25 percent come from the community just by word

of mouth. If I advertise this program, I would be overwhelmed.

Eight of our 44 veterans living in foster homes are 100 percent

service connected. They or their family choose to spend their own

money to live in a foster home rather than have VA pay for their

care in a nursing home. The cost of these two programs, HBPC and

the Medical Foster Home, in partnership is $37 per day per patient. That is compared with $155 per day for nursing home care.

I got that in the April issue of the AARP national average.

The foster home staff consists of myself, a part-time secretary,

one vehicle, one cell phone at $8 per day. I travel 15 to 2,200 miles

per month. I am on call 24 hours a day, 7 days a week. But I have

reached my limit. And we need action. I have added 44 patients to

the HBPC case load, and now they have reached their limit. This

is a win-win situation, and this is a solution. This concludes my

statement but not my ideas.

[The prepared statement of Mr. McClure follows:]

PREPARED STATEMENT OF THOMAS MCCLURE, LCSW, COORDINATOR, VA MEDICAL

FOSTER HOME PROGRAM, LITTLE ROCK VA MEDICAL CENTER

Mr. Chairman and members of the Committee:

My name is Tom McClure and I am a VA social worker at the Central Arkansas

Veterans Healthcare System. I am honored to be here today because one of your

staff, Kim Lipsky, heard me and a colleague present our Medical Care Foster Home

Project at a recent national conference, and she thought you would be interested.

We recently finished a pilot, funded by VA, and we are now disseminating our findings.
41

For 23 years I have been working in our Home Based Primary Care Program. I

saw firsthand how hard veterans worked to stay in their own homes even though

they had severe chronic illnesses and disabilities, unsuitable housing, and poor social supports. I often witnessed how difficult it was for elderly spouses to continue

to care for their very disabled husbands. Time and time again I observed the unwillingness of veterans and their families to consider placement in a nursing home.

We wanted to try to find ways for these patients to continue to stay in the community and still get the care they needed. A few times I helped our patients make

informal community arrangements to live in the home of a hired caretaker. These

situations worked out well for the veterans. The Home-Based Primary Care (HBPC)

team managed the medical care. Then we heard about our Central Office’s ‘‘New

Clinical Initiative Funding.’’ We asked for and were given the resources to develop

Medical Care Foster Homes for our veterans—$95,000 for each of 2 years. This

money paid my salary so I could develop foster homes full time. It also paid for my

half time assistant, travel costs and cell phone costs. We set about to recruit caring

families and individuals in the communities served by our large HBPC program.

Now, 2 years later, we now have 35 foster homes and 45 patients. Our outside

funding has ended, but the Medical Center chose to continue at the same level of

funding. Eight of our Foster Care patients are 100 percent service connected; some

of them came directly from a community nursing home to our foster home at their

own expense.

Here is how our program works. When I recruit a foster home, I assess their motivation, attitude, life experience, and I explain the general needs of our disabled veterans. I check their references and do a criminal background check. Our safety engineer inspects the home environment. If everything checks out, we approve the home

and can begin to match the home with patients who are interested in family living.

We involve any family or friends of the veteran in the process of selecting a foster

home. I encourage them to visit a few homes. I serve as an intermediary between

the veteran and the foster home sponsors in agreeing on the monthly fee. This fee

ranges from $1000 to $1800 per month depending on the care needs of the veteran.

For this fee the veteran gets a private room, personal care, 24-hour supervision,

meals, laundry, and activities. This is a permanent home. We do not uproot these

veterans when they become terminally ill and place them in a nursing home. They

remain in the foster home. It is understood that the VA will provide medications,

supplies, and health care. All the veteran’s needs are met.

The veterans pay for their Medical Foster Care with no funding from VA. They

use their Social Security, private pensions, and VA pensions or service-connected

disability compensation. Most have spending money in reserve. The veterans who

qualify for non-service-connected pensions can have their pensions increased to

cover the costs of the Medical Foster Care. We have a liaison in the Little Rock VA

Regional Office that assists us in processing claims in a timely manner, but sometimes it does take several months.

Once in Medical Foster Care, the patients are visited regularly by the HBPC team

members, who conduct an interdisciplinary geriatric assessment, develop a treatment plan, provide medications and medical equipment, and educate the foster family in the care of the veteran. Because of the close partnership between our Foster

Care Program and HBPC, we safeguard against abuse.

So far we have recruited our Medical Care Foster Homes from persons in the community who are experienced in caring for the elderly, either former health care

workers or those with experience caring for family members. Even though the income is important to foster home sponsors, we feel the most important factor is that

the program instills meaning and purpose to their lives. This is why we can recruit

good people. Also we help our Foster Home Sponsors. They have 24-hour access to

us. We also offer respite 2–4 times a year so they can rest and reduce stress levels.

We believe Medical Foster Care/HBPC is humane care and affordable for VA and

the Veteran. At our facility, with a census of 45 patients in foster care, the VA direct care costs are $29 per day for the HBPC portion of the care, plus $8 per day

for the Foster Home Program, for a total of $37 per day.

The Central Arkansas Veterans Healthcare System has formed a partnership

with the Medical Foster Care Program and the HBPC Program, permitting us to

provide this unique care environment. Many states have adult foster care. But this

program is just for veterans and VA healthcare providers are actively involved in

caring for the patients and overseeing the homes. The most important feature of

this program is that it improves the quality of life for our frail, disabled veterans

in a family atmosphere. We take sick, depressed veterans from our wards, place

them in a family environment and they become grandfather, uncles, and father role

models.
42

Here at Little Rock, we are at capacity for the number of homes and patients can

be managed with existing staff. HBPC’s census of 180 is now 25 percent Foster Care

patients and growing. With this program in its infancy, we are unable at this time

to predict the limits of its growth.

I believe VA Medical Centers could develop Medical Care Foster Homes in conjunction with existing Home Based Primary Care Programs. It is not easy work, but

it is important and gratifying work that would give our aging veterans a true alternative to institutional care.

This concludes my statement. I will be happy to respond to the Committee’s questions.

Chairman ROCKEFELLER. Or the obvious and clear emotion just

one inch below your words. You commitment is enormous.

Ms. Hemmings.

STATEMENT OF PAULA HEMMINGS, R.N., DEPARTMENT OF

VETERANS AFFAIRS’ VETERANS INTEGRATED SERVICE NETWORK NO. 2, GERIATRICS AND EXTENDED CARE LINE MANAGER, REPRESENTING THE ALZHEIMER’S ASSOCIATION

Ms. HEMMINGS. Mr. Chairman and members of the committee,

thank you very much for giving me the opportunity to testify at

this important hearing. I am the Director of Geriatrics and Extended Care Line for the Upstate New York Integrated Service

Network. However, I am here this morning on behalf of the Alzheimer’s Association and the views expressed do not necessarily reflect the views of the Department of Veterans Affairs.

The purpose of my appearance today is to explain how the VISN

2 located in upstate New York was able to implement the Chronic

Care Networks for Alzheimer’s disease project fully utilizing the

continuum of VA institutional and non-institutional long-term care

programs that are variable to the veterans.

In 1996, VISN 2 was the only VA network that was a member

of the National Chronic Care Consortium. Membership in this organization reflects commitment on the part of VA Central Office as

well as the executive support in VISN 2.

As members of the NCCC, the Alzheimer’s Association and VISN

2 leadership made a commitment to partner in the CCN/AD project

because of our strong belief that chronic care takes many resources

to work.

In upstate New York, the partners recognized that they had a

common goal. They also served the same target population, individuals with dementia and their caregivers and families. This recognition of commonality promoted pooling of experience, experience and

resources. Both agencies also recognized that no one organization,

no matter how complete its array of services and programs, is sufficient to successfully manage the chronic and progressive illness of

dementia throughout its course.

VISN 2 is strongly motivated to partner with the community organization to better serve an aging veteran population with the

prevalence of chronic illness. Nationally, the rate at which a veteran population is aging surpasses the general population. The 20

percent reduction in the overall veteran population is offset by the

significant growth of very elderly veterans, thereby maintaining

significant demand from health care services in the next 10 years.

The CCN/AD’s primary project goals are: identification of individuals in the early stages of the condition; implementation of stateof-the-art comprehensive care guidelines; creation of a dual track
43

to support both a person with dementia and the family caregivers

over time and across a continuum of needed services; and modification of the care for coexisting conditions with recognition of the underlying dementia and its effects.

As a selected CCN/AD site, VISN 2 is active in the development,

piloting and demonstration of the model. Chapter and VA partners

quickly identified training as a major component of the intervention. Primary care clinicians were targeted for initial and ongoing

training. Staff of both partnering organizations was educated about

the goals, protocols and their role in addition to dementia topics.

Once the initial piece of the project was accomplished, the role

of the Dementia Care Manager became more important. This is a

staff role unique both to this project and within the VA. These staff

serve as a variety of diverse functions all designed to advance the

goals of the CCN/AD initiative.

The dementia care managers work diligently to ensure that all

veterans continue to have access to VHA resources and services

when they need it. This is a good illustration of a model that strategically places VHA resources alongside numerous community

partners to work in concert in meeting the needs of the chronically

ill veterans.

Treatment and management of chronic illnesses such as dementia fundamentally challenge the way health care service delivery

systems are currently delivered. Typically care delivery centers

around brief episodic office visits with the primary care provider.

The nature of the visit commonly focuses on the medical aspects of

presenting problems. Chronic care management, however, presents

fundamentally a different reality.

Chronic progressive illness, such as Alzheimer’s, needs to be addressed over time and it must include the patient’s family and

caregivers. Plans often need to include access to a full range of noninstitutional resources such as home-based primary care, the homemaker home health aide, adult day health care, and respite care,

all service that the VA provides and coordinates.

Planning has to include caregivers who oftentimes are as old and

as sick as the identified patients they care for, and yet they are so

crucial to the success or failure of the management of the disease.

Planning with them is important. VA chose to use a CCN/AD program as a springboard to help influence its medical model and culture of primary care to better accommodate the needs of veterans

and patients with chronic illness.

It has expanded the provider’s appreciation to where care is actually delivered. It is delivered in the home. It contributed to the provider’s understanding that successful management of our patients

with dementia care means addressing the needs of the family and

patient as well. This project has taught us that we must reach out

to our partners in the community who have common missions and

work with them to offer our veterans and their family caregivers

what they need, not just what we have. Thank you.

[The prepared statement of Ms. Hemmings follows:]
44

1 ‘‘Veteran Demographics’’. Department of Veterans Affairs Web site. Available at:

www.va.gov/visns/visn02/. Accessed December 6, 2001.

PREPARED STATEMENT OF PAULA HEMMINGS, R.N., DEPARTMENT OF VETERANS AFFAIRS’ VETERANS INTEGRATED SERVICE NETWORK NO. 2, GERIATRICS AND EXTENDED CARE LINE MANAGER, REPRESENTING THE ALZHEIMER’S ASSOCIATION

Mr. Chairman and members of the Committee, thank you very much for giving

me the opportunity to testify at this important hearing.

In my professional life I am the Director of the Geriatrics and Extended Care Line

for the upstate New York Veterans Integrated Services Network (VISN 2). However,

I am here this morning on behalf of the Alzheimer’s Association and the views that

I express do not necessarily reflect the views of the Department of Veterans Affairs.

The purpose of my appearance today is to explain how Veterans Integrated Service Network (VISN 2), located in upstate New York, was able to implement the

Chronic Care Networks for Alzheimer’s Disease (CCN/AD) project fully utilizing the

continuum of VA institutional and non-institutional long-term care programs that

are available to the Veterans.

In 1996, VISN 2 was the only VA Network that was a member of the National

Chronic Care Consortium (NCCC). Membership in this organization reflects commitment on the part of VHA Central Office as well as executive support in VISN 2.

As members of the NCCC, the Alzheimer’s Association and VISN 2 leadership made

a commitment to partner in the CCN/AD project because of our strong belief that

chronic care takes many resources to work. There were seven sites selected from the

NCCC applicants. VISN 2 and the upstate New York chapters of the Alzheimer’s

Association were among those selected. The importance of this project was recognized by the Robert Wood Johnson Foundation who heavily underwrote the evaluation component of the VISN 2/upstate New York Alzheimer’s Association chapters

site.

BACKGROUND ON CCN/AD PROJECT

The following is a detailed description of the CCN/AD initiative and VISN 2 and

the upstate Alzheimer’s Association chapters participation. VISN 2 and the four upstate New York chapters of the Alzheimer’s Association formed a community partnership to participate in the CCN/AD initiative, a national demonstration project.

In Upstate New York the partners recognized that they had a common goal. They

also served the same target population, individuals with dementia and their caregivers and families. The partners strove to provide their clients with the best quality care their agency resources allowed. This recognition of commonality promoted

pooling of experience, expertise and resources. The Alzheimer’s Association chapters

have a history and extensive experience providing support and education to diagnosed individuals, their caregivers and families. The VA brought to the partnership

their clinical experience and expertise in the provision of an enviable continuum of

chronic care services. Both agencies have much to offer individuals with dementia

and their caregivers. Both agencies also recognize, that no one organization, no matter how complete its array of services and programs, is sufficient to successfully

manage the chronic and progressive illness of dementia throughout its course. Partnership is essential. Partnering in CCN/AD meant that both organizations could

provide better access for their clients to a wider arrangement of services. Also as

important, the partnership in the CCN/AD initiative would establish the foundation

for development of a disease management model of care in VISN 2. This model

serves as a guide for providing services and support throughout the course of the

disease at all care sites within the Network.

DEMOGRAPHIC PROFILE OF VISN 2

VISN 2 is an integrated health care delivery system composed of inpatient facilities, nursing homes, community clinics, non-institutional care programs provided

through contracts, and community agency referrals. VISN 2 provides acute inpatient

and nursing home care services at five locations: Albany, Western New York, Syracuse, Bath and Canandaigua, provides primary care at twenty-nine communitybased clinics that are located throughout the region. The VISN serves an area of

42,925 square miles encompassing 47 counties in New York State as well as two

in northern Pennsylvania, with an estimated 573,546 veterans (17.7% of those veterans were treated in FY 2000).1 This is approximately the same area (minus counties in northern Pennsylvania) served by four Alzheimer’s Association chapters. The
45

2 Ibid.

chapters and VA Medical Centers formed the partnerships based upon shared service areas.

VISN 2 was strongly motivated to partner with a community organization, such

as the Alzheimer’s Association, to better serve an aging veteran population with a

prevalence of chronic illness. Nationally, the rate at which the veteran population

is aging surpasses the general population.

Highlights of veteran demographics for upstate NY:

• Over 52% of veterans treated in FY 2001 were 65 years of age or older, with

nearly one-quarter over age 75. • Perhaps equally significant is that while our total veteran population decreases,

the number of veterans over age 85 will nearly double in the same five-year period.

While veterans over age 65 historically use health care services at a higher rate

than younger veterans, greater demand is profoundly more significant among those

85 and over, in all major care settings-acute inpatient, ambulatory and nursing

home care. The 20% reduction in the overall veteran population is offset by the significant growth of very elderly veterans, thereby maintaining significant demand for

health care services over the next ten years.2

These demographic data provided VISN 2 an incentive to participate in the CCN/

AD initiative addressing Alzheimer’s disease, a chronic illness whose prevalence increases with age. A disease which if left undiagnosed could interfere with the management of their medical care and cause them to be labeled as non compliant patients, possibly leading to their death because they were not taking their medications as prescribed.

In addition to the demographic challenges presented to us, VISN 2 was impelled

by fiscal and budget realities to make effective changes, rapidly, and to look outside

itself for agencies with whom to collaborate.

In VISN 2, Care Lines are structured along major program emphases. In my case,

the major program emphasis is Geriatrics and Extended Care (GEC). In VISN 2,

the Care Line Directors are given budgetary and operating authority over all relevant programs in this new organizational structure. Decisions about program operations are matrixed with the Directors of the major Medical Centers in upstate New

York. This structure allows us to rapidly deploy and standardize the best, efficient

and effective practices across all sites of care delivery within our Network. The Care

Line organizational structure lets administrators in our Network focus and concentrate on all the pertinent issues and requirements relevant to aligning resources

for efficient and effective service delivery. It also impacts the speed of implementation, in that, I can influence deployment across the entire Network catchment area,

and not just at one Medical Center at a time. This structure allowed me to institute

the CCN/AD initiative rapidly throughout all of upstate NY and hire and put in

place Dementia Care Managers at each major site which I will talk about later.

CCN/AD PROJECT GOALS

The CCN/AD project’s primary goals are: identification of individuals in early

stages of the condition, implementation of state of the art comprehensive care guidelines, creation of a dual track to support both the person with dementia and the

family caregivers, over time and across the continuum of needed services, and modification of the care for coexisting conditions with recognition of the underlying dementia and its affect. As a selected CCN/AD site, VISN 2 was active in the development, piloting and demonstration of the CCN/AD model.

Chapters and VA partners quickly identified training as a major component of the

intervention. Primary care clinicians were targeted for initial and ongoing training.

Other staff in both partnering organizations, were also trained in sessions specifically designed to meet their needs. A site wide curriculum was developed that outlined a basic introductory presentation with CME credit that the VA clinical director

of the Initiative delivered at each sub site. The purpose was to assure that each location started with the same basic information. During the clinical director’s travels

to the sub sites he met with key personnel and along with dementia care managers

recruited physician ‘‘champions’’ who would participate in or support future sessions.

THE ROLE OF THE DEMENTIA CARE MANAGER

Recognizing the varied resources and needs of each sub site, Dementia Care Managers and chapter coordinators determine future educational needs for the staff at

their facilities using the curriculum as a guideline to identify target audiences and

use a variety of methods. Faculty was recruited from within the VA and more fre-
46

quently from universities, Alzheimer’s Disease Centers and Alzheimer’s Disease Assistance Centers. Staff at both partnering organizations were educated about the

goals, protocols and their role in addition to dementia topics. A milestone occurred

when demands for training came from numerous diverse staff themselves after

hearing about or experiencing the quality of Alzheimer’s Association chapter training sessions for direct care staff. Eventually, this led to use of Alzheimer’s Association chapters for train-the-trainer programs and development of a plan to use those

newly trained as instructors and dementia resource individuals in their unit. The

implementation of that plan was the culmination of efforts to reach our goal to train

the full range of staff at VA facilities.

Once the initial piece of the project was accomplished, the role of the Dementia

Care Manager became more important. This is a unique staff role; unique both for

this project and within the VA. These staff serve a variety of diverse functions all

designed to advance the goals of the CCN/AD initiative. The Dementia Care Manager is there to respond to questions related to the tools after the education sessions

and to collect the necessary data for the project. The other responsibility of the Dementia Care Manager is to work with the primary care provider to establish the

psychosocial support system for the Alzheimer’s patient in the community. Further

these staff work with the family and the Alzheimer’s Association to provide family/

caregiver support.

The Dementia Care Managers like the other VISN 2 Geriatrics and Extended

Care staff work diligently to insure that all veterans continue to have access to VHA

resources and services when they need it. VISN 2 is one of the Networks nationally

that met veteran resource, use reliance target levels for both our institutional Nursing Home programs as well as our non-institutional home care programs and services. But the needs, both in nature and kind of need, of patients with chronic illnesses and their families will always exceed the VHA’s ability to directly provide

for them.

PARTNERSHIP WITH THE ALZHEIMER’S ASSOCIATION

Faced then with increasing numbers of aging veterans in the upstate New York

area and the competing healthcare budget needs previously mentioned, geriatric and

extended care program planners in our Network factored in access to Alzheimer’s

Association community resources, as a necessary component to compliment services

for veterans with dementia and their families. It is a good illustration of a model

that strategically places VHA resources along side numerous community partners

to work in concert to meeting the needs of chronically ill veterans.

THE CHRONIC CARE CHALLENGE

Treatment and management of chronic illnesses, such as dementia, fundamentally

challenge the way healthcare service delivery systems are currently configured.

Medical care delivery within VHA, as is the case with most medical care systems,

is well designed to manage health care problems of the general population. Typically

care delivery centers around brief, episodic office visits with the primary care provider. The nature of the visit commonly focuses on the medical aspects of presenting

problems. Patients are given prescriptions, advice on life style changes and follow

up appointments if necessary to track progress of the condition for which they are

being treated. At times, referrals may be made to specialty clinics and if warranted

to treat acute illness, hospitalization. In addition, providers in these settings are

busy. They have high patient volume and are daily pressed to complete their scheduled visits. As would be expected, resources in most health care systems are aligned

to meet this mission and model of healthcare delivery.

Chronic care management, however, presents a fundamentally different reality.

Chronic progressive illness, such as Alzheimer’s, needs to be addressed in clinic,

over time rather than episodically. Also managing these patients, who are typically

frail and elderly, takes time. Time to plan access to a full range of non-institutional

resources such as Home Based Primary Care, Homemaker Home Health Aide, Adult

Day Health Care and Respite Care, all services that the VA provides and/or coordinates. Providers are trained and trained well to assess and treat on the medical

level and patients with chronic illness need this care. But often simultaneously,

these patients and families need assessment and care on several other non-medical

dimensions as well. These other domains that require attention and often intervention and care planning include functional, social, financial, psychological, behavioral

and environmental dimensions. Further adding to the complexity is the work that

needs to be done with the family caregivers. Caregivers often times are as old and

sick as the identified patients they care for, yet they are so crucial to the success

or failure of the management of the disease. Their needs must be accounted for in
47

care planning. Finally, the nature of chronic progressive illness is such that it

evolves, develops, and eventually deteriorates over time. Changes in condition and

circumstance must not only be monitored but must be prepared for proactively. Patient’s changes in physical, behavioral and functional needs require different mixes

of supports, services and settings. Their caregivers’ skills, aptitudes, as well as their

own family and agency supports available to assist them need to be looked at as

they progress through role changes and the changing demands that their loved ones

chronic illness places on them. This is where the Dementia Care Managers come

in and provide invaluable assessment, coordination and support.

To successfully address chronic illness management, the mindset, both clinically

and in resource planning and deployment, needs to be fundamentally different than

an uncritical reliance on a system of delivery designed to serve needs of a general

population. The consequences of dependence on episodic care delivery as it’s currently organized or premature reliance on costly institutional care for management

of chronic illness is to squander precious resources that are and will be needed to

treat the ever growing population of veterans with chronic illness.

REPLICATION OF THE CCN/AD PROJECT

Given the complexity of what is described above, it is impractical to think that

any one agency, no matter how vast its resources, can unilaterally provide all the

care patients and their families with chronic progressive illness will need. To begin

to think like this, and coordinate with community partners and monitor care over

time outside of the clinic encounter, is nothing short of a cultural change in

healthcare delivery. To actively change medical care delivery culture, the endorsement and commitment from top leadership is required. VISN 2 chose to use the

CCN/AD model as the springboard to help change it’s medical model and culture

of primary care and to influence it over time to better accommodate the needs of

patients with chronic illnesses and their families. Over a five year period, the VISN

deployed dedicated Dementia Care Managers to cover all the medical centers and

major care sites within the VISN. These staff are able to take the time medical providers don’t have to do detailed assessment of both patient and caregiver needs.

They also are a direct contact point and portal of entry into the VA system and continuum of services. They are easily reached by their partners at the Alzheimer’s Association and help sustain this inter-agency relationship. They collaborate with both

VHA providers and Chapter staff and work to integrate into care planning relevant

data about both patient and caregiver’s current functioning.

CONCLUSIONS

CCN/AD created in VISN 2, over time, the reality of viable partnerships with

community agencies such as the Alzheimer’s Association. It imparted to our providers the importance of addressing caregiver needs and supporting them as they

struggled to cope with their loved ones illness on a day to day basis. It reaffirmed

that chronic care had to be managed across settings and over time. It expanded the

providers’ appreciation as to where care was actually delivered in the majority of

instances. It contributed to the provider’s understanding that successful management of our patients with dementia means addressing the needs of the patient’s

family caregivers as well.

Our veteran patients, whom we correctly refer to as our nation’s heroes, who now

come to us with dementia, along with their family caregivers, who are quiet, unsung

heroes in their own right, continue to teach us. They teach us that to be true to

our mission and obligation to ‘‘serve him who has borne the battle and his widow

and orphan’’, we must continue to maximize our resources to serve the extended

care needs of our veterans as they age, become frail and more heavily rely upon us.

They teach us that to be successful in our mission we cannot be solely focused on

our identified patient, the veteran. We must also focus on those in our veterans’

lives who are most intimately caught up in the provision of their extended care

needs. And finally, they teach us not to come to rely solely on VHA resources to

achieve our mission. They have taught us that we must reach out to our partners

in the community, who have common missions, and work with them to offer our veterans and their family caregivers what they need, not just what we have.

Chairman ROCKEFELLER. Thank you very much, Ms. Hemmings.

Dr. Moye. And this will be geriatric mental health and your study

about that.
48

STATEMENT OF JENNIFER MOYE, PH.D., DIRECTOR, GERIATRIC MENTAL HEALTH CLINIC/UPBEAT, BROCKTON VA

MEDICAL CENTER, AND ASSOCIATE PROFESSOR OF PSYCHOLOGY, DEPARTMENT OF PSYCHIATRY, HARVARD MEDICAL SCHOOL

Ms. MOYE. Right. Mr. Chairman and Senator Graham, my name

is Jennifer Moye. I am the Director of the Geriatric Mental Health

UPBEAT Clinic at the Boston VA Brockton Campus, and I am an

Assistant Professor of Psychology in the Department of Psychiatry

at Harvard Medical School.

I am pleased to testify today on the Unified Psychogeriatric Biopsychosocial Evaluation and Treatment, or UPBEAT program.

I have worked as a psychologist with medically and

neurologically frail older veterans with late onset mental health

concerns for the past 10 years, and I speak today as a clinician.

Our clinic was founded in 1995 as part of a 5-year, nine-site clinical demonstration project that evaluated the effectiveness of outpatient case management combined with mental health treatment

for elderly veterans who have previously undiagnosed mental

health problems in the context of serious medical illness.

This program is based on two research findings, one, mental

health problems are underdiagnosed and inadequately treated in

the elderly. These are fellows who are not going to say to their doctor, ‘‘gee, I have been feeling sad, could I talk to a psychologist?’’ They are more likely to sort of buck up and suffer, unfortunately.

And also, the second finding, elderly who have depression or

other mental health problems have more complex medical management, have a more complicated recovery from illness, and are more

expensive for our health care system.

In the UPBEAT program, patients 60 years or older admitted to

medical or surgical inpatient services were screened for depression,

anxiety or alcohol use. 1,687 veterans with these problems were

randomly assigned to either a treatment group or a usual care

group.

In the treatment group, those fellows got an intensive interdisciplinary assessment, followed by outpatient case management

combined with mental health treatment.

In the year following enrollment, veterans in the treatment

group had higher utilization of outpatient care, especially mental

health and telephone encounters, costing 1,171 more dollars per patient per year than the usual care group.

However, that expanded outpatient cost was more than made up

for by savings in inpatient costs of $3,027, resulting in a net savings on average of $1,856 per patient per year, or a total savings

for all patients enrolled in the treatment group of approximately

$1.5 million.

The savings were chiefly attributable to reduced length of stay

when those veterans were rehospitalized. We are starting to look

at other subgroups, and it looks like in specifically targeted subgroups, such as patients with circulatory conditions or more significant depressions, the savings may be even greater, up to $5,000 per

patient per year.

Let me share with you an example to illustrate the program. One

veteran in the UPBEAT program was enrolled at our site when he
49

was surgically hospitalized and he screened positive for depression.

The depression was triggered in part because the current surgery

he was having was reminiscent of the eight surgeries he received

in 1945 after he was injured by shrapnel.

This patient participated in six combat jumps in Africa, Italy,

France and Germany, including the Battle of the Bulge and the

Anzio and Normandy invasions for which he received the Bronze

Star for heroism.

Late in life when confronted with illness and vulnerability, he became overwhelmed with depression, to the point where he would

retreat from everyone and stay in bed and then that would compromise his health.

He entered our program at the age of 75 participating at first

very reluctantly, but eventually enthusiastically with the case

management as well as the psychotherapy, and in this case some

psychopharmacology to help him sleep. He was still having nightmares of the war.

With that treatment, he was able to manage his mood better

when medically ill, and he successfully underwent a subsequent

surgery without that excess disability caused by depression. Furthermore, as a result of speaking in psychotherapy about his war

experiences for the first time ever, he began to also share these

with his family.

None of his family members were previously aware of any of the

details of his military service, and this newfound capacity for communication was tremendously appreciated by both the veteran and

the family.

What does the success of the UPBEAT program tell us about outpatient case management programs? UPBEAT is a non-institutional program that reduces institutional care and reduces total

cost of care. These findings are similar to other studies that find

case management of these high risk geriatric patients can forestall

a nursing home admission or other institutional care use and be

cost effective.

Key elements of successful programs are: interdisciplinary teams,

readily accessible primary care, home-based care, adult day health

care, the things my panel members have described, integration of

mental health treatment, case management to coordinate that optimal utilization of the health care system, and careful targeting of

the patients to identify those most at risk for institutional care and

most likely to benefit from such programming.

Patients with dementia require additional services including

travel and caregiver support. The ultimate success of these programs will rely on appropriate case loads for clinicians and case

managers, and I really want to second Tom’s noting on how large

the case loads are getting for the clinicians these days, and clear

program goals and performance measures for clinicians and administrators.

In closing, I have felt very blessed to work with elderly veterans

and very grateful for that opportunity. I am also grateful for the

opportunity to speak with you today. Thank you.

[The prepared statement of Ms. Moye follows:]
50

PREPARED STATEMENT OF JENNIFER MOYE, PH.D., DIRECTOR OF THE GERIATRIC

MENTAL HEALTH/UPBEAT, BROCKTON VA MEDICAL CENTER, AND ASSOCIATE PRO- FESSOR OF PSYCHOLOGY, DEPARTMENT OF PSYCHIATRY, HARVARD MEDICAL SCHOOL

Mr. Chairman and Members of the Committee:

My name is Jennifer Moye. I am the Director of the Geriatric Mental Health/UPBEAT clinic at the Boston VA, Brockton Campus, and an Assistant Professor of Psychology in the Department of Psychiatry at Harvard Medical School. I am pleased

to testify today on the Unified Psychogeriatric Biopsychosocial Evaluation and

Treatment (UPBEAT) program.

REVIEW OF UPBEAT MODEL

I have worked as a psychologist with medically and neurologically frail older veterans with late onset mental health concerns for the past ten years, and I speak

today as a clinician. Our clinic was founded in 1995 as part of a nine site clinical

demonstration project that evaluated the effectiveness of intensive outpatient case

management and mental health treatment for elderly veterans with previously

undiagnosed mental health problems in the context of serious medical illness. The

program is based on previous research demonstrating: 1) mental health problems

are under diagnosed and inadequately treated in the elderly; 2) elderly who have

depression or other mental health problems have more complex medical management, a more complicated recovery from illness, and are more expensive for the

health care system.

UPBEAT COST SAVINGS

In the UPBEAT program, patients 60 years and older admitted to medical or surgical inpatient services were screened for depression, anxiety, or alcohol abuse.

1,687 veterans with these problems were randomly assigned to a treatment versus

usual care group. The treatment group received interdisciplinary assessment followed by outpatient care coordination and mental health intervention. In the year

following enrollment, veterans in the treatment group had higher utilization of outpatient care, especially mental health and telephone encounters, costing $1,171

more per patient per year, than the usual care group. However this expanded outpatient cost was more than made up for by savings in inpatient costs of $3,027, resulting in a net savings of $1,856 per patient per year, or a total savings for all

patients enrolled in the treatment group of approximately $1.5 million dollars. Savings were attributable to a reduced length of stay when re-hospitalized. Savings

were even greater in targeted subgroups, such as those with circulatory diseases or

more significant depression, estimated at $5,000 per patient per year. Additional

analyses are ongoing.

UPBEAT CLINICAL EXAMPLE

One veteran in the UPBEAT program was enrolled at our site when he was surgically hospitalized and screened positive for depression. The depression was triggered in part because the current surgery was reminiscent of the eight surgeries he

received in 1945 after being injured by shrapnel in World War II. This veteran participated in six combat jumps as a paratrooper in Africa, Italy, France, and Germany, including the Battle of the Bulge, and the Anzio and Normandy invasions

during which time he received the Bronze Star. Late in life when confronted with

illness and vulnerability, he became overwhelmed with depression, to the point of

remaining in bed constantly, compromising his health. He entered our program at

the age of 75, participating at first reluctantly, then enthusiastically in case management and individual psychotherapy with psychopharmacology. With treatment

he was able to manage his mood better when medically ill, and he successfully underwent a subsequent surgery without the excess disability caused by depression.

Furthermore, as a result of speaking about his war experiences for the first time

in psychotherapy, he began to also share these with his family. None of his family

members were previously aware of any details of his military service. This newly

found capacity for such communication was tremendously appreciated by both the

veteran and his family.

ESSENTIALS OF CASE MANAGEMENT FOR AT-RISK VETERANS

What does the success of the UPBEAT program tell us about outpatient based

case management programs? UPBEAT is a non-institutional program that reduces

institutional care and reduces total cost of care. These findings are similar to other

studies that find case management of at-risk geriatric patients can forestall nursing

home admission. Key elements of these programs are:
51

[* The information referred to has been retained in the committee’s files.]

1) interdisciplinary teams;

2) readily accessible primary medical care;

3) home based care and support when indicated;

4) integration of mental health treatment;

5) case management to coordinate optimal utilization of the health care system; and

6) careful targeting of patients and interventions to identify those patients

most at-risk for institutional care and most likely to benefit from such programming.

Patients with dementia require additional services including travel, caregiver support such as respite care, and adult day health care. The ultimate success of such

programs will rely on appropriate caseloads for primary care clinicians and case

managers, clear program goals, and performance measures for clinicians and administrators.

In closing, I have been most grateful to work with our elderly veterans, and I

thank you for the opportunity to speak before you today.

ATTACHMENT

Kominski, G., et al (2001). UPBEAT: The impact of a psychogeriatric intervention

at VA Medical Centers. Medical Care, 39, 500–512.*

Chairman ROCKEFELLER. Thank you, Dr. Moye. A little off-thewall question here. None of you have particularly talked about—

you, I think, Ms. Dickerson talked about savings—none of you have

talked about the problem of resources that I assume VA would care

to bring forward, and I am wondering if that has anything to do

with the fact that some of you were told not to bring up the subject

of resources by the VA?

Ms. DICKERSON. Particularly in my case, resources are readily

available. Alan Harper in North Texas Health Care System is a

very believer of HBPC, and he has seen the things that we have

done. So we have been able to get the resources. What we did was

that he transferred a lot of the nursing staff from the inpatient to

the outpatient.

Chairman ROCKEFELLER. You found a way?

Ms. DICKERSON. Yes, we found a way.

Chairman ROCKEFELLER. And you found a way without fundamentally compromising the health care of others?

Ms. DICKERSON. Yes.

Chairman ROCKEFELLER. Because you cared to take the initiative?

Ms. DICKERSON. Yes. So we have transferred from inpatient occupational therapists, physical therapists, dieticians, social workers

and nurses. We even have a physician and a physician’s assistant

that was transferred from other places in the hospital.

Chairman ROCKEFELLER. But it would be easy, it seems to me,

for VA to come forward and say, well, we cannot do this because

we do not have the budget that we have. I mean that is what Senator Graham and I say every year, and that is what VA says every

year, and we are all right every year, and so they could come forward and say that.

And what you are saying is, yes, they can come forward and say

that, but you, Ms. Dickerson, were able to undertake something

without compromising the health care and other critical areas for

the same population of veterans that we are all talking about and

do just exactly what the long-term care law required.
52

Ms. DICKERSON. That is exactly right. We also maintained a $22

per day per patient for the last 5 years, so the cost has not increased.

Chairman ROCKEFELLER. And you also, as I think you indicated,

know that as time goes on, you will be saving more money?

Ms. DICKERSON. Yes. We have also increased our patient load to

over 200 patients.

Chairman ROCKEFELLER. So the patient load has gone up, the

money can be handled, and the resources are not an excuse?

Ms. DICKERSON. Yes.

Chairman ROCKEFELLER. Anybody else wish to comment?

Ms. MOYE. I just wanted to comment on the issue I want people

to appreciate the complexity of the older patients. As the GAO reported, we are seeing this tripling in the over 85-year-old veteran,

and these are veterans who are already expensive to the health

care system, and we are saying let us spend more money on them,

so I cannot speak to fiscal issues. I am a clinician, but I want to

emphasize how very, very complex these patients are, how they require more time to work in a preventative fashion.

Our primary care clinicians currently have case loads of 1,200

patients. We have a waiting list of about 500 patients. I know you

have heard these things. That may be appropriate if you are working in an HMO setting and you have lots of young adults who you

see once a year, but when you have very complicated 85-year old

patients, we really need to look at the issue of directing resources

to those needs.

Chairman ROCKEFELLER. And I do understand that, but Ms.

Hemmings, who looks like she wants to say something, I want to

say to you that one of the things I certainly remember about my

mother in talking about complexities with older people is that particularly in Alzheimer’s you go through stages where there is an

enormous amount of violence, an enormous amount of just sort of

following people around houses or outdoors or down streets. You

are not quite sure where they are going to go.

They hit, they throw food, they scratch at certain points and they

stop, and they will take it up again. Often a single caregiver if the

person is larger in size cannot transport that person to a bathroom,

for example, or to a tub, and so what Dr. Moye says becomes even

more true, and that is that it is indeed very complex, and in your

field and in others manifestly complex and yet you have handled

it?

Ms. HEMMINGS. Well, I think the way it is handled, too, is that

we all talked about having some form of case management, and I

think that is really one of the real issues that we have used. The

nurse or the social worker, depending on what site she is at, works

with whatever level that patient is at. The issue is to try and identify it early and through some of the other medications and also

give us a time to educate the family how to deal with some of these

behaviors.

If you learn how to do some diversional therapy and some of the

other things that are going to be coming up, you can also handle

the patient better at home, but it also gives us much more time to

work with the Alzheimer’s Association to set up support systems

for the family. The caregiver really needs a lot of support, and so
53

while we are supporting the medical needs of the veteran, the Alzheimer’s Association provides support from the community in terms

of helping the caregiver, who is usually a wife, cope with these

things that are going on, learn more skills and then we from the

VA will offer, respite care will offer homemaker home health aide.

So you are really combining the best of both worlds, because a

veteran is not just a veteran. He is a member of a community, and

his family is part of the community. So there is a lot of other community services that can be called upon to help with this relief and

the support when it occurs. But I think the initial part of helping

to educate—that is why it is so important to identify it early— helps the family then cope when it becomes more difficult. But then

rely on things like home-based primary care when it becomes more

difficult for the family, and eventually sometimes the patients are

not able to stay at home anymore.

And then we use our VA nursing home, but in the meantime we

have kept them out in the community with their loved ones as long

as we possibly can and I think that is what really makes a big difference is that partnering.

Chairman ROCKEFELLER. If Senator Graham will forgive me, I

just want to ask one more question to Tom McClure feeding off of

what Dr. Moye said, and that is that the amazing complexity as

people get to be 85 or older, and sometimes younger than that, and

that is, you know, that is like saying that rain is wet. I mean that

is inevitable.

I am not trying to play doctor here, but that is the fact, when

you get to be that age, because there is an enormous range of

things that work together and then some manifest themselves more

than others. Some fit under the category of Parkinson’s, Alzheimer’s, dementias, mental depression, schizophrenia, stroke. But,

I accept what you say, but that is manifestly true across all fields

of medicine, I would think.

And so I would like to get your response, Tom McClure, to this

general situation of resources and we just do not have the money

to do this.

Mr. MCCLURE. Well, those eight service connected veterans that

are 70 percent and above that are on my program, that is saving

our hospital director about $320,000 a year. My budget is $95,000.

That is not to speak of the VERA allocation on managing the medically complex patient of about 40 patients. I know that is not generating actual revenue, but it is bringing revenue into the VISN.

But that is another good point about this, and we are managing

medically complex patients.

Chairman ROCKEFELLER. And saving money?

Mr. MCCLURE. And I think the other thing to look at in a global

view. Instead of just looking at the VA budget, if we can take veterans and place them in foster homes with that partnership, rather

than into a nursing home, you know we are saving our national

budget by managing them with a cost-effective program, not to

speak of the VA budget. And I think we must look at the entire

budget of this nation in planning these.

Chairman ROCKEFELLER. Thank you, sir. Senator Graham.

Senator GRAHAM. Thank you, Mr. Chairman. Again, thank you

for holding this hearing. One of the observations that has been
54

made about these long-term care services, particularly the non-institutional services, is that they are uneven across the VA system.

Ms. Dickerson, you just gave a very persuasive statement about

what you are doing in the Dallas area, as have each of you in your

own particular VA centers. Why is not what you just described in

Dallas or in Little Rock or among the Alzheimer’s patients or

among the geriatric mental health, why is that not the norm in VA

as opposed to the exception?

Ms. HEMMINGS. I can answer in terms of the Alzheimer’s project.

I think we were the pilot for the VA, and so we have given this

information in the beginning to everyone in long-term care via teleconference, and when the project is—— Senator GRAHAM. When did you provide that information?

Ms. HEMMINGS. Well, we told them we started the project when

we did in like 1997. We are having an evaluation finishing up this

year, and then we will go back to everyone with the results of the

project. We are in the middle of something, so you kind of do not

say it is successful until you finish it, but I think we are always

trying to keep people informed of what we are doing. So some of

this might be related to the fact that you are in the middle of doing

a project.

Ms. DICKERSON. In my case, I do believe that these types of programs will be successful all over the Nation once they realize that

the resources, you do not have to hire a lot of people to do this,

you just need to transfer around, move people around from the inpatient to outpatient if that is possible in other facilities as it was

in our facility, because that is simply what we did.

Senator GRAHAM. You say whether it is possible to move from inpatient institutional care to at-home community care. Is that a constraint of physical facilities of people or what are the limitations

on making that transition?

Ms. DICKERSON. There should not be any. There should not be

any limitations on moving people around where they are needed

and what is most cost effective and what is better for patient care.

Senator GRAHAM. Mr. McClure, what about in the area of foster

care?

Mr. MCCLURE. Foster care, of course, I placed my first veteran

in a foster home in 1987 on an informal basis because I did not

have alternatives. But the VA in which I work for the central office

funded this program in the year of 2000 as a pilot project and we

just completed that. Our director, as I said, has already put it in

his budget, and I think now it is time to act, and this is my own

personal opinion and not that of the VA, but this program should

go nationwide and immediately.

Senator GRAHAM. Well, I agree with you, not only because it is

humane, but also you made the case that it is cost effective, but

even more fundamentally the people who are our particular concerns, the veterans of America, they did not defend Little Rock,

they defended the United States of America, and there ought to be

an expectation of an evenness of service whether you live in the far

Northwest or the far Southeast of the United States. We have a national system, and it ought to be a national system in terms of benefits readily available.

Mr. MCCLURE. And I do expect that.
55

Senator GRAHAM. Dr. Moye, as you were describing your program, I was struck with the fact that while you have been conducting you say nine areas that you have centers that you have

been doing your pilot work?

Ms. MOYE. It was at nine VA medical centers, yes.

Senator GRAHAM. That this is not an issue that is peculiar to

America’s veteran population. If you saw the front page of today’s

Washington Post, there is an article that the President has indicated that next week he is going to make an announcement in support of parity for mental health treatment.

To what degree is the information that you have gathered in

your research applicable to the general American older population,

and to what degree is it peculiarly relevant to the veteran population?

Ms. MOYE. That is a wonderful question. We know that mental

health problems are underdiagnosed and undertreated in the current cohort of all older adults. For the reason I just suggested, I

think there are stigma issues, there is lack of familiarity with,

‘‘OK, this is what depression looks like, and when I have it I need

to share it with my physician, I need to get some treatment for it.’’

However, I think the problem may be somewhat worse in the veteran population. I think we do a good job of identifying and treating serious mental illness such as schizophrenia, but not these sort

of low level, but clinically significant, depression, anxiety, oftentimes related to war experiences. We did a survey in our outpatient

clinics. We interviewed veterans waiting to see their doctors who

were not in mental health treatment. 40 percent had a combat

trauma history; 15 percent were to this day having problems with

intrusive memories and nightmares.

So I think when those things are also lurking and coming into

the picture and then suddenly you are having illness and vulnerability and maybe a heart bypass surgery, that strains your coping

resources and may make it more likely that you have some mental

health issues arise.

Senator GRAHAM. Thank you, Mr. Chairman.

Chairman ROCKEFELLER. Senator Wellstone.

Senator WELLSTONE. Thank you, Mr. Chairman, and I apologize.

I had to go back and forth, and I missed your testimony, and Perry

Lange was just giving me a summary of some of what you said, I

think, and then I just was hearing Senator Graham’s question of

mental health.

First of all, I want to thank you. I think really, you know, you

kind of light a candle and you show what we can do at the community level, and I guess the only obvious question, and I gather you

maybe touched on some of this, is whether or not you have received

the kind of support that you would like to have from the existing

VA system, and if not, where do we need to fill the gaps here, and

if so, in what ways? That is, I think, my only question, you know,

asking for as honest an answer as possible.

I mean you should know what can be done. The question is are

you getting the support from the existing VA system as is or not,

and if not, you know, we do not have to get into acrimony, but

where are the gaps? What do we need to start doing to make this
56

happen throughout the VA system in the United States of America?

Ms. HEMMINGS. Well, related to the Alzheimer’s project, we received support by having us join the National Chronic Care Consortium, so we have been under support all along for this project, and

then with our contacts with headquarters, when this is done, we

will use that support to roll it out. So I think from that perspective,

we have always had the support of headquarters in this project, because it has been something that we have identified as a real population need in our veteran population. And then the programs already exist in the VA. So that supported the types of home care

that we needed.

Ms. DICKERSON. I feel in Dallas we have received the kind of

support that we needed. When we wanted to start a Senior Companion Program, we were given the go-ahead to start a Senior

Companion Program. We have 33 senior companions that, you

know, this gives the seniors an opportunity to do a great service

to stay with the veteran while the wife has a little respite.

We have also been able to start many other programs. The telemedicine program, we received the support to start that, and that

just broke through all distances. We can go 100 miles or 10 miles.

Senator WELLSTONE. What are the critical elements of the support so that we can try to make these models be more and kind

of apply system wide?

Ms. DICKERSON. I think system wide, the most important thing

was you needed nursing service support. If you do not have the

nurses who are the case managers, then your program cannot

grow. So we had tremendous nursing service support. They closed

beds in the hospital that were being underutilized and moved those

resources to outpatient facilities, and then, of course, the director

has to support what the nursing service chief wants, but I think

the nursing service support was one of the biggest things that we

had in Dallas.

Mr. MCCLURE. I would like to add to that I worked for 9 years

as a social worker with the HBPC program. I used every resource

I could find to keep them at home, and there is a point in time

when these veterans have to be removed. We can at least keep

them in a family setting-HBPC and foster care. Our caregivers are

ill and exhausted, and I feel like we need at least to attach a foster

home program to each one of our HBPC programs in the Nation.

Mrs. Dickerson, it is a wonderful program, they keep veterans at

home as long as possible, but you can hire all the aides, have all

the nurses that you can get, but there is a period of time where

our veterans require 24-hour supervision. In Little Rock, I am taking those patients when HBPC cannot maintain them any longer,

placing them in a capable foster home with the VA support, and

we are managing them until they die.

Ms. MOYE. I spoke in my testimony about performance measures

for clinicians, and one of the things that has been concerning for

me is sort of, if I can come back to case load, sort of a blunt instrument about case loads, that we are under tremendous pressures to

see as many patients as possible. And folks look at just absolute

number of patients, and I wonder if it might be possible to develop

some sophistication in this such as is done in chronic psychiatry
57

where patients are described as maybe sustaining, moderate, intense and end of life, and if you are working in the intense or end

of life area, then your case load expectation would be lower to accommodate that, because we know it would pay off in the end, and

it would be what the veterans want.

But it is hard to do that when the main pressure you are getting

is see more people more quickly, you know, the absolute number

of patients you see is the performance measure by which I am

judged.

Ms. HEMMINGS. Can I just make one other comment? It is not

related to VA support, but I think as a part of what realistically

what is happening and why some things cannot be done. I run the

total geriatric program in upstate New York, and from that perspective, sometimes it is not just what is available in the community, and the other piece in terms of trying to do some of these programs is the issue of getting health care workers.

It is not the money from the VA. It is what is available out in

the community, and I think most of us that are in health care

today are finding it more difficult to find the health care workers

and the support that we need because people are not going into

health care. So sometimes you cannot implement something you

really want to implement just because the resources in the community are not there in which to pull from, and that is becoming extremely difficult for everyone in health care these days.

I think that is another piece of it that has to be looked at, because we are part of the community and we buy some of our services from the community, and it is very difficult. People want to do

everything else but be a health care worker these days.

Senator WELLSTONE. Thank you.

Chairman ROCKEFELLER. Thank you, Senator Wellstone. I have

other questions I want to ask, but I think in view of time constraints that I cannot or at least, I will not. And I want to point

out that each of the four of you have made an enormous contribution. You have come from various distances, and you have made a

great contribution to this, and you have raised the bar, I think, for

our next witness, and for all of us.

Ingenuity is what has always separated invention, the willingness to not fear that if you try to do something which is new, and

you work for some government bureaucracy, that you are not going

to be retaliated upon.

And, fortunately, there are people who exercise that sense of ingenuity and risk taking. You might call it a model. You might call

it a pilot or whatever. Nevertheless, you all are doing extraordinary

things and helping people and loving it, and wanting to see it done

for everybody. So I thank you all very, very much for taking your

time to come.

Ms. HEMMINGS. Thank you.

Chairman ROCKEFELLER. Our final panel today includes Dr. Robert Roswell, who is the newly, and I need to say that, the newly

confirmed Under Secretary for Health. He is accompanied by Marsha Goodwin, who is the Acting Chief Consultant for VA Geriatrics.

As I indicated earlier in the hearing, I broke with the usual protocol, to have Dr. Roswell not be the first but the last witness, and

I wanted him to be able to listen to the testimony, both positive
58

and less than positive, so that we can talk about VA and what is

the most vulnerable veteran segment in the future. So, Dr. Roswell,

welcome back. I am very glad you are here, and we look forward

to your statement.

STATEMENT OF ROBERT ROSWELL, M.D., UNDER SECRETARY

OF HEALTH, DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY MARSHA E. GOODWIN, R.N., M.S.N., ACTING CHIEF

CONSULTANT, GERIATRICS AND EXTENDED CARE, AND DIRECTOR, GERIATRICS PROGRAM, DEPARTMENT OF VETERANS AFFAIRS

Dr. ROSWELL. Well, thank you, Mr. Chairman. It is a privilege

to appear before you as the Under Secretary for Health, and I appreciate your support in facilitating my confirmation. Mr. Chairman, Senator Wellstone, it is a pleasure to be here, and I want to

thank both of you for calling attention to what I truly believe is a

tremendous problem that we simply must do a better job in facing,

and I salute you for your efforts in convening this hearing.

You talked about deviations, and to allow a dialog I will not be

making a formal statement, although I would ask that my statement by included in the record.

Chairman ROCKEFELLER. It will be done.

Dr. ROSWELL. I have several concerns. You asked about OMB.

The interim rules for the three services that were specified were

actually published last year. The final rule will be published in the

Federal Register next week, so admittedly this is too long, but

those rules will be published very shortly, and we will have that

implemented.

I think this morning we have seen some truly wonderful examples, not only of compassion and commitment to the needs of veterans, but also in innovation in how we meet those needs. The four

examples we have just heard are heart-wrenching really because

there is such a great need, and there are many other examples as

well throughout the country, tremendous innovation across our system.

It is clear that we need a full continuum of services to meet the

broad range of long-term care needs of America’s veterans. Just as

no two patients are alike, no two set of circumstances associated

with long-term care are alike, and it is important that we maintain

a full continuum of care, and nurture innovation in meeting and

developing a full continuum of care.

The cost of care per patient per year in long-term care services

can vary from as much as $140,000 a year per patient in a VA staff

nursing home bed to as little as $2,500 a year for home care programs using interactive technology.

The Millennium Health Care bill focuses on our need to provide

that long-term care, but with all due respect, Mr. Chairman, the

one capacity that is measured is the most costly on that continuum,

and that is the institutional long-term care, at an average cost of

$140,000 per patient per year when the average cost of non-institutional care is only $10,000 per patient per year, meaning that we

could serve 14 patients in a non-institutional setting for the cost

of one patient in an institutional setting, and yet the Mil bill man-
59

dates that we maintain our 1998 VA staff nursing home capacity

at historical levels.

We have submitted from the department a request for legislation

that would ask you to consider looking at the three levels of VA

nursing home care—VA staffed nursing home care, state nursing

home beds, and contract community nursing home beds—in meeting that obligation for commitment.

I think that truly the most important part of this is making sure

that we can deploy the resources in a way that meets the broad

needs of our veterans. There are concerns now with tremendous

growth in the users in our system, lengthy waiting times for access

to care, and a statutory requirement which admittedly we have not

yet complied with, but hope to comply with by 2004 to maintain the

VA staff nursing home bed capacity.

Those are the constraints that cause competition for the dollars.

The 2003 budget request submitted earlier this year, however,

would provide over $100 million for additional long-term care services and would add staff to the 75 Home Based Primary Care Programs like the ones Gladys Dickerson spoke of throughout the

country.

It would also add 30 additional of those programs so we are committed to long-term care. We are committed to innovation. We are

looking at ways to provide the needs in new and less costly ways,

but more importantly that meet the needs of the veterans in a less

restrictive environment that allow better quality of life and greater

functional independence.

I would be happy to answer any questions you might have.

[The prepared statement of Dr. Roswell follows:]

PREPARED STATEMENT OF ROBERT H. ROSWELL, M.D., UNDER SECRETARY FOR

HEALTH, DEPARTMENT OF VETERANS AFFAIRS

Mr. Chairman and Members of the Committee:

Thank you for inviting me to discuss non-institutional alternatives to long-term

care provided by the Department of Veterans Affairs (VA).

VA has a long history of providing high quality geriatric and extended care to

chronically ill elderly veterans and is nationally recognized as a leader and innovator in the care of older persons. Today one of our greatest challenges is to find

ways to meet the increasing demand for extended care services in the most appropriate settings and within available resources.

As you know, veterans prefer to receive care in their homes and communities

when it is possible to do so. These programs are highly cost effective in comparison

to institutional care and allow VA to provide care to a greater number of veterans

than would be possible through increased reliance on institutional programs. However, our ability to expand these programs may be impacted by the interaction between competing requirements.

VETERANS MILLENNIUM HEALTH CARE AND BENEFITS ACT

Since Public Law 106–117, the Veterans Millennium Health Care and Benefits

Act, became effective in November 1999, VA has focused on implementation of the

extended care provisions of that law. To date, the following provisions have been implemented:

• Mandatory nursing home care for veterans rated 70% service-connected and

above and for any service-connected veteran who needs nursing home care for a

service-connected disability;

• Three pilot programs evaluating different models of all-inclusive care for the elderly (VA as sole provider, at the Dayton VAMC; VA/community partnership, at the

Denver VAMC; and VA as care coordinator, at the Columbia, SC, VAMC); and

• An assisted living pilot initiated in VISN 20 at all VA facilities in Alaska,

Washington, Oregon, and Idaho.
60

VA anticipates publication of final regulations on the medical benefits package

and co-payments for extended care next week. The regulations—to be effective 30

days from the date of publication—add three non-institutional extended care services, outpatient geriatric evaluation, adult day health care, and respite care, to VA’s

standard benefits package. Other important extended care services, e.g., home care,

hospice/palliative care, and inpatient respite care, were already in VA’s standard

benefits package. Also last October the Veterans Health Administration (VHA)

issued a policy directive requiring provision of these non-institutional services. Access to these services is not currently uniform throughout the VA system, but work

is ongoing to determine what barriers to access exist and to develop plans for addressing these barriers.

The requirement to maintain staffing and level of extended care services in VA

facilities no lower than the 1998 level is being met for non-institutional care (VA

home-based primary care and VA adult day health care) but not for institutional

care (VA nursing home care and VA domiciliary). Plans are in place to be in full

compliance by 2004. The Administration has recently proposed legislation to implement the President’s FY 2003 Budget that would revise the requirement for maintaining levels of extended-care services to veterans.

VA LONG TERM CARE STRATEGY

As the VA health care system has redefined itself in the last six years as a

‘‘health care’’ system instead of a ‘‘hospital’’ system, VA’s approach to extended care

has further evolved from an institutionally-focused care model to one that includes

a complete continuum of home and community-based extended care services in addition to nursing home care.

In its 1998 report, VA Long Term Care at the Crossroads, the Federal Advisory

Committee on the Future of Long-Term Care in VA, made 20 recommendations and

4 related suggestions on the operation and future of VA long term care services.

These recommendations served as the foundation for VHA’s national strategy to revitalize and re-engineer long term care services. One of the major recommendations

of the Committee was that VA should expand home and community-based care

while retaining its three nursing home programs (VA, contract community, and

State home).

VA is making progress on that strategy. Between 1997 and 2001, VHA average

daily census (ADC) in home and community-based care increased from 11,500 to

16,150. VHA has a Budget Performance Measure calling for an ambitious 34 percent

increase in the number of veterans receiving home and community-based care compared to FY 2001. We plan continued increases each year to achieve a level of

34,500 ADC in home and community-based programs in FY 2006. To achieve these

goals, we will expand both the services VA provides directly and those we purchase

from affiliates and community partners. We will meet most of the new need for longterm care through home health care, adult day health care, respite, and homemaker/home health aide services.

The piloting and evaluation of new models of care will be important. One example

you have heard about today is VA’s Advances in Home-Based Primary Care for End

of Life in Advancing Dementia (AHEAD) quality improvement project, which was

initiated in 2001 with 20 VA teams from 15 networks. AHEAD II is now underway

to include a wider variety of primary care settings that serve community-dwelling

veterans with dementia.

VA also must explore utilization of new technologies, such as telemedicine, to expand care of veterans in the home and other community settings. We have shown

that by using interactive technology to coordinate care and monitor veterans in the

home environment, we are able to significantly reduce hospitalizations, emergency

room visits, and prescription drug requirements, while improving patient satisfaction with the care they receive. Use of technology not only reduces the need for institutional long-term care, but also provides veterans with a more rewarding quality

of life and greater functional independence. For example, in FY 2000 VISN 8 developed an innovative alternative to institutional care known as the Community Care

Coordination Service (CCCS). CCCS provides care coordination of groups of clinically complex, high cost, chronically ill patients. With the use of technology, CCCS

has improved their quality of life and their perceived functional status, thus allowing them to remain both independent and at home. A recent survey of these patients

showed that 41 percent would be in a nursing home if not for enrollment in this

program. An Odds Ratio Analysis has shown that these patients were 77.7 percent

less likely to be admitted to a nursing home than a similar group that did not participate in the program. The innovative use of technology has also improved communication and clinical relationships with the State veterans domiciliary in Lake City,
61

FL, and has increased access to assisted living facilities. A care coordinator has become the primary communication link between the domiciliary and the local VA

medical center. This enhanced communication has reduced unscheduled clinic visits

by veterans in the State home by 29 percent.

To the extent that we can do so within the existing programmatic resources, VA’s

plans for long-term care are as follows:

• achieve an integrated care management system that incorporates all of the patient’s clinical care needs;

• provide more care in home and community-based settings as opposed to inpatient settings, when appropriate;

• achieve greater consistency in access to and quality of care provided in all settings;

• achieve greater consistency across the system in assessing patients for extended

care and in managing care, including post institutional care;

• continue to emphasize VHA research and educational initiatives that will improve delivery of services and outcomes for VA’s elderly veteran patients; and

• continue to develop new models of care for diseases and conditions that are

prevalent among elderly veterans. You have heard testimony today about VISN 2’s

participation in one such initiative to find better ways of caring for veterans with

severe dementia. To help find better ways of caring for these veterans, VHA is participating in a multi-site demonstration project on Alzheimer’s disease and care

management, which is co-sponsored by the Alzheimer’s Association and the National

Chronic Care Consortium (NCCC).

CONCLUSION

VA has made considerable progress toward organizing a geriatrics and LTC system that can respond to shifts in demand and to changes in local healthcare market

characteristics, and provide seamless care. We have launched major national initiatives to improve end-of-life care and pain management for veteran patients. We are

in the process of implementing an aggressive home- and community-based care

strategy.

Mr. Chairman, this concludes my prepared remarks. For information purposes, I

have included two attachments to my statement. The first addresses veteran demographics and population projections; the second discusses VA’s geriatric and extended care programs. I will now be happy to address any questions that you and

other members of the Committee might have.

ATTACHMENT A.—VETERAN DEMOGRAPHICS AND POPULATION PROJECTIONS

Between 2000 and 2010, the veteran population is currently projected to decline

by 17.7 percent (from 24.3 to 20.0 million). However, this projection may change due

to the current armed conflicts. Over the same time period, the percent of veterans

over the age of 65 will decline only by 9 percent (from 9.3 million to 8.5 million),

while those 75 and older will increase 12 percent (from 4 to 4.5 million), and those

over 85 will increase by 208 percent (from 422,000 to 1.3 million). To continue to

provide the appropriate and needed service to veterans, this ‘‘demographic imperative’’ must be addressed.

At present, about 38 percent of the veteran population is over 65, compared to

about 13 percent of the total U.S. population. Over 51 percent of veterans who have

service-connected disabilities or are poor are over 65. The number of veterans over

age 65 peaked at 9.3 million in the year 2000, when 66 percent of all American

males aged 65 and over were veterans. A second but smaller peak is expected to

occur in 2015, with the aging of Vietnam-era veterans. The projected peak in the

number of elderly veterans during the first decade of the 21st century is well in advance of the general United States population (which is expected to peak in the year

2030). This is one of the driving forces behind VHA’s current efforts to find high

quality, affordable extended care solutions for meeting the needs and preferences of

veterans.

The most vulnerable of our older veteran population, those over 75 and particularly those over 85, will continue to increase into the next decade. This is notable

since these persons are especially likely to require institutional care and to need

healthcare of all types. Also of importance is the fact that current VA patients, compared to the general population, are not only older, but they also generally have

lower incomes and no health insurance, and they are much more likely to be disabled and unable to work. While it is important to maintain our nursing home capacity to serve the post-acute rehabilitation, respite, geriatric evaluation and hospice/palliative care needs of older, chronically disabled veterans, it is equally impor-
62

tant to expand our home and community-based extended care options wherever possible and appropriate.

ATTACHMENT B.—CURRENT VHA GERIATRIC AND EXTENDED CARE PROGRAMS

Today, VHA provides a comprehensive array of long term care services that include direct VHA provided services, services purchased in the local community, and

services supported through construction and per diem grants to states. VHA also assists veterans and families in obtaining services through other publicly funded

healthcare programs such as Medicare and Medicaid, and provides assistance in obtaining services that are personally financed by the veteran. While the array of

services provided by VHA is comprehensive, all services are not available in all VA

locations, and access to care is currently not equitable across the system. The major

long term care programs provided by VA are described below:

State Veterans Homes. A significant part of VHA’s long term care strategy is effected through one of the longest existing Federal-State partnerships, the State

Home Grant program. Through this program, the Department provides grants to

states for the construction and support of state veterans homes to provide long term

care for frail, elderly veterans. The construction grant program provides up to 65%

federal funding to states to assist in the cost of construction of new nursing home

and domiciliary facilities, or expansion or remodeling of existing facilities. VA’s per

diem program, part of the Medical Care account, assists states in providing domiciliary and nursing home care for veterans through partial payment of per diem

costs. Most recently, regulations have been published on per diem payments for provision of adult day health care in State homes. In FY 2001, over 16,000 veterans

on any given day were provided nursing home care in state veterans homes. While

this program dates back to the post-Civil War era, it has grown dramatically over

the past 10 years. The state home program substantially augments VHA’s capacity

to provide a continuous residence for veterans in need of long term care, especially

for veterans in rural areas.

The Geriatric Evaluation and Management (GEM) and Geriatric Primary Care

Programs. The majority of VA medical centers have GEM and/or geriatric primary

care programs. The GEMs provide both primary and specialized care services to a

targeted group of elderly patients on an inpatient unit or in outpatient settings. On

the inpatient GEM units, an interdisciplinary team of geriatric experts performs

comprehensive, multidimensional evaluations of frail, elderly patients. The goals of

these intensive services are to improve functional status; to stabilize the acute and

chronic medical conditions and/or psychosocial problems; and to discharge the patient to home, residential care, or to the least restrictive environment feasible.

GEM clinics provide similar comprehensive care for geriatric patients on an outpatient basis in addition to providing primary care for frail, older patients to prevent unnecessary institutionalization. The geriatric staffs also are available for specialty consultation on elderly patients with complex problems being cared for by primary care and other specialty services.

Geriatric primary care clinics have been expanding in VHA over the past few

years with the move from inpatient to outpatient care and expansion of primary

care throughout the system. These clinics provide geriatric evaluation services and

on-going primary care for geriatric patients.

Nursing Home Care Units (NHCUs). VA nursing homes provide skilled nursing

and related medical services through an interdisciplinary approach to meeting the

multiple physical, social, psychological and spiritual needs of patients. Most also

provide sub-acute and post-acute care. In general, these units are co-located with

or are an integral part of the VA medical center. In FY 2001, 41,934 veterans received care in VA’s 135 NHCUs.

Community Nursing Home Care. VHA contracts with approximately 2,800 community nursing homes to provide nursing home care for veterans making a transition from the hospital to the community. Each community nursing home is evaluated and inspected by VHA staff prior to selection as a contract facility, and VHA

staff provides follow-up visits to assess the progress of veterans admitted to the facility and to monitor the overall quality of care.

In order to improve access to community nursing homes and reduce the administrative cost associated with maintaining hundreds of individual contracts, VHA has

recently developed contracts with multi-state nursing home providers. In 1996, six

multi-state contracts and one single-state contract were awarded to corporations for

quality community nursing home care in 1,053 facilities. These seven contracts together span 43 states and added nearly 600 nursing homes to VHA’s existing contract community nursing home program. Since 2000, VA has 11 Regional Contracts
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(replaced multi-state), which include 8,000 facilities. In 2001, nearly 28,800 veterans

were treated in community nursing homes at VA expense.

Adult Day Health Care (ADHC). This therapeutically oriented program provides

health maintenance and rehabilitation services to veterans in a congregate, outpatient setting. VHA operates 14 ADHC programs, which had an average daily attendance of 446 patients in FY 2001. VA also contracts with an estimated 480 nonVA agencies for ADHC, which provided services to an average of 804 veterans each

day in FY 2001. The contract program has been established by 66 VA facilities.

Alzheimer and Other Dementia Care Programs. Approximately 52 VA medical centers have developed specialized programs for the care of veterans with dementia.

These programs include inpatient and outpatient dementia diagnostic programs, behavior management programs, adapted work therapy programs for patients with

early to mid stage dementia, Alzheimer’s special care units within VA nursing

homes and transitional care units, and a model inpatient palliative care program

for patients with late stage dementia. Programs for family caregivers of dementia

patients include support groups and caregiver education, as well as respite and

adult day health care services for the patient that allow ‘‘free time’’ for the caregiver. Many of these specialized programs for patients with dementia have been developed by VHA’s Geriatric Research, Education and Clinical Centers (GRECCs).

Seven of the current 21 GRECCs have a primary or secondary focus on Alzheimer’s

disease and related dementias. These GRECCs have made significant contributions

to both the scientific understanding of dementia and improved models of care for

dementia patients.

Home-Based Primary Care. This program is operated at 75 VA facilities across the

country to provide in-home primary medical care to home-bound veterans with

chronic diseases, as well as to patients with a terminal illness. The patient’s family

provides the necessary personal care under the coordinated supervision of an interdisciplinary treatment team based at the VA facility. The team plans and provides

for the needed medical, nursing, social, rehabilitation, and dietetic regimens and

trains family members and the patient in supportive care. In FY 2001, comprehensive primary care was provided in the home by VHA staff to an average of 7,803

patients on any given day.

Contract Home Health Care. VHA also arranges with community home health

agencies to provide skilled home care services for veterans. Under this program, VA

pays a per-visit rate to the agency providing the service, similar to what is done

under the Medicare program. In FY 2001, 3,273 veterans were provided these services on any given day.

Domiciliary Care. Domiciliary care is provided in VA domiciliaries, as well as

State homes. VA domiciliaries provided care to 24,931 in FY 2001. Nearly 5,000 of

those veterans were homeless and admitted for specialized care. In addition to services for the homeless, the domiciliary provides other specialized programs to facilitate the rehabilitation of patients who suffer from head trauma, stroke, mental illness, alcoholism, early dementia, and a number of other disabling conditions. Although the average age of veterans overall in VA domiciliaries is 59 years (43 years

for those in the homeless program), increased attention is being focused on older

veterans who reside in VA domiciliaries. For example, elderly domiciliary patients

are encouraged to become involved with programs in the community such as senior

centers and Foster Grandparents. These activities have facilitated continued community involvement as well as reintegration into the community. Many of the domiciliaries in state veterans homes provide similar services, although patients in the

state home domiciliaries tend to be older. In FY 2001, 47 State Veterans Home

domiciliaries in 33 states served more than 6,400 veterans.

Community Residential Care/Assisted Living. This program provides room, board,

personal care, and general health supervision for veterans who, because of health

conditions, are not able to live independently and have no suitable family or social

support system to provide needed care. A multidisciplinary team of VHA staff inspects private homes that provide residential care/assisted living services prior to

including the home in VHA’s program and annually thereafter. Payment for services

provided in a residential care home is the responsibility of the individual veteran.

In FY 2001, 7,055 veterans received residential care on a daily basis in homes approved and monitored by VHA.

Homemaker/Home Health Aide (H/HHA). This program enables selected patients

who meet the criteria for nursing home placement to remain at home through the

provision of personal care services. The H/HHA services are purchased by VHA from

public and private agencies in the community. Case management is provided directly by VHA staff. During FY 2001, 120 VA facilities purchased these services for

approximately 3,824 veterans on any given day.
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Respite Care. Another program that enables the chronically ill, disabled veteran

to live at home longer than would be otherwise possible is respite care. This program is available at nearly all VA facilities and is designed to reduce the caregiving

burden from the spouse or other caregiver by admitting the veteran to a VA hospital

or nursing home for planned, brief periods, totaling no more than 30 days per year.

During the inpatient stay, patients are also provided with evaluative and treatment

services needed to maintain or improve functional status, thus prolonging the veteran’s capacity to remain at home. A formal evaluation of this program, concluded

in 1995, found a high level of satisfaction among family caregivers and a high level

of enthusiasm for the program by VHA staff delivering the care. In FY 2001, nearly

700 veterans were receiving respite care on any given day. Home respite was authorized under P.L. 106–117 and programs have been initiated at a number of VA

facilities, utilizing contract services and piloting the use of volunteers to provide the

respite services.

Hospice/Palliative Care. A number of VA medical centers have an interdisciplinary hospice/palliative care consultation team that is responsible for planning, developing and arranging for the local provision of hospice care, directly by VA or

through contract or referral to community programs. Hospice/palliative care programs offer pain management, symptom control, and other medical services to terminally ill veterans or veterans in the late stages or chronic disease process, as well

as bereavement counseling and respite care to their families. System-wide education

and training was provided in the early 1990’s to facilitate the incorporation of hospice/palliative care concepts into each VA facility’s approach to the care of veterans

at the end of their lives. New education programs are being planned to reinforce

the concepts for current staff. Approximately 42 percent of VA facilities have inpatient hospice/palliative beds but nearly 38 percent of facilities have neither inpatient

beds nor consultative services. The majority of VA facilities refers or contracts for

hospice services through community-based agencies. Hospice and palliative care initiatives are currently being intensified throughout VHA to improve end-of-life care

for veterans. Specific strategies to increase the availability of these services to veteran patients are currently under development.

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO ROBERT

ROSWELL, MD

Question 1. Do you believe the VA should work with private home health care providers to meet its obligations to provide veterans with long term care opportunities?

Answer. Collaboration with private home health care agencies is integral to VA’s

success in meeting the home health and long-term care needs of veterans. Through

the VA Community Health Nurse Coordinator program, VA works with private

home health agencies in providing needed care to veterans. The majority of the effort in this program involves referrals by VA staff of those veterans who choose to

use their Medicare eligibility to home health care (HHC) agencies. Additionally, VA

maintains arrangements with over 500 HHC agencies for the provision of care at

VA expense. In FY 2001, approximately 3,300 veterans were enrolled in skilled private HHC, and another 3,800 were enrolled in homemaker/home health aide services at VA expense on any given day.

Question 2. Without Medicare reimbursement, home health agencies cannot survive, despite an infusion of VA funds. How can we address the inequities in funding

that may force many home health care providers to leave?

Answer. Home Care expenditures from all payers totaled $32 billion in FY 2000

(latest available data). In that year, private funds covered 47.8 percent of all HHC

spending ($15.5 billion), and public, non-VA funds (Medicare and Medicaid) covered

51.9 percent ($16.8 billion). VA’s expenditures of $108 million for skilled HHC and

home health aide services in FY 2000 represent only 0.3 percent of home care

spending. VA’s current and planned efforts for purchasing home care services do not

indicate a major presence in the marketplace. This Department has no opinion on

the larger issues of Medicare reimbursement.

Question 3. Has the VA carefully considered access for all veterans, regardless of

where they live, when developing options to nursing home care?

Answer. VA’s planning model for long-term care (LTC) services, both nursing

home (NHC) and home and community based care (H&CBC), is based on the enrolled veteran population, rather than the total veteran population. To the extent

that veterans who live at a distance from a VA Medical Center are enrolled in VA

for their health care, then their needs for LTC are addressed. In this regard, nursing home care is mandated for veterans with a 70% or more service-connected dis-
65

ability. Veterans with less than a 70% service-connected disability receive care on

a resource available basis.

One of the advantages of contracting or purchasing home care is that VA can address veterans’ HHC needs without attempting to provide it directly in geographic

locations where demand for care could not justify an efficient VA-operated program.

At the same time, VA has been successful in establishing Home Based Primary Care

(HBPC) Programs at VA clinics located at a distance far from the host VA medical

center. The HBPC Programs at Hot Springs, Arkansas and Joliet, Illinois are the

best examples of VA-operated satellite home care efforts.

Access to nursing home care for veterans is provided through VA’s three programs: VA nursing home care units (NHCU); contract community nursing homes

(CCNH); and State veteran nursing homes. There are currently 135 VA NHCUs,

contracts with 2,800 CCNHs and 11 regional contracts, and 102 State nursing

homes. Increased demand for nursing home care will primarily be met in CCINIH

and State nursing homes. Construction of new State home beds, with VA providing

up to 65 percent of the cost, is based on veteran population need in each geographic

area.

Chairman ROCKEFELLER. OK. I want to just deal, Dr. Roswell,

with your statement you have made. You are correct that Congress

has said that VA must not reduce nursing home beds, and on the

other, that VA must increase its efforts of non-institutional longterm care. You would like to be relieved of one to do more of the

other.

Unfortunately, both are necessary elements to long-term care. So

you are not going to get that wish under the laws of health care.

Some people just do not stay in the community, cannot stay in the

community, should not stay in the community. So you have asked

for relief from VA staffed nursing home beds requirement.

I am willing to entertain the possibility of some change. I think

we must be assured that VA retains sufficient capacity to provide

institutional long-term care for those who need such services, and

I want you to talk about those who do need such services, and if

you do not do it, then I will get Dr. Moye to come back to do it.

So far, VA has not been able to do this in the area of specialized

services, and so I do not know how I am meant to react to what

you just said. In a sense you gave a reason why you cannot comply—because it costs $140,000 per patient for institutionalized

care—knowing full well as you said that that that is also going to

continue and has to.

You said that the rules and regulations are going to be out in a

week. I hope, I assume that is to provide me with some sense of

comfort or a mission well done. Again I recognize you have just

been on the job, so I am talking more to predecessors of yours, but

I am talking to you, because you are now responsible and you took

the oath.

And so that is sort of a nice little wrap-up that you do more of

what the four folks were talking about, and that they are wonderful. You have also got this other little burden, which you and I

know that you cannot get rid of, because all people cannot go back

to the community for long-term care.

So, I guess what I want to say is are you trying to kind of slide

by me on this one? And point out your problems? You have not

used resources. Others were told not to use resources, but that was

the first thing that came out of your mouth—I would but I cannot—because these other institutionalized are too expensive.

And is that, in terms of the outcome for the veteran, unacceptable? I guess I cannot accept it, and if Ms. Dickerson can find ways
66

to do things and you are the second-largest agency in the entire

Federal Government outside of the Department of Defense with

over 200,000 people, I believe, there must be some ways that you

can say something other than relieve me of this one and I will do

the other. Care to comment?

Dr. ROSWELL. Yes, Mr. Chairman, I appreciate the opportunity

to comment. First of all, I do agree with you. We must maintain

our institutional capacity. There is no question that many veterans

at some point will need institutional care. We think we can delay

that in many cases, put that off until later stages of a disease process and in some cases avoid it altogether, but there is no question,

the institutional capacity will be needed.

All I was suggesting is that our institutional capacity is split

across VA staff nursing home beds, which we own and operate at

an average cost of $380 per day, contract community nursing home

care, which we procure for veterans in an institutional setting in

the community at an average cost of $185 a day, and skilled nursing home care in homes operated by the states through the state

grant program that provides skilled nursing home care at an average cost to the VA of $50 per day.

There are three levels or three different types of institutional

long-term care, and I am suggesting that if we aggregate the total

amount in 1998 between those three, that we be held accountable

to the 1998 level of capacity for all of our long-term care institutional beds as opposed to just the skilled beds operated only by the

VA.

Now, having said that, finding resources, yes, we have to do both.

We have to look at non-institutional programs as we meet that institutional commitment. My point is that there is a fierce demand

for resources now as our system has grown, and this year we will

have over six million veterans enrolled with over 4.3 million veterans using the system, reaching levels that we have never ever attained in our history.

When we look at non-institutional care, we find that many programs are being developed, and people are finding resources just

to——

Chairman ROCKEFELLER. Can I interrupt for a second?

Dr. ROSWELL. Certainly.

Chairman ROCKEFELLER. I apologize. You see that is what I call

sliding by me and Senator Wellstone. Because, of course, there are

endless requirements in health care, and of course you have budget

constraints which you have quickly brought up, and of course you

have the responsibility, and of course there is a war on terrorism,

and of course there is homeland security, and of course we have

gone from a $5.6 trillion surplus to $100 billion deficit for a variety

of reasons.

And, of course, you must do your duty and you shall take care

of these people. So I am not predisposed to say that because you

have so many veterans who are getting older and their problems

are getting more complex, that you take what can possibly be identified as the most obvious and clearly the fastest growing health

care problem that you do and will face, and say, well, we cannot

comply.
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Either VISN 2 is an anomaly or you set up some experiments

which you are going to keep as experiments, so that there is always

something good to say about what VA can do. Those regs will be

in effect in a week, but none of that gives me confidence that you

are going to actually go ahead and do it. And I guess that is what

Senator Wellstone and I are looking for is that you are going to go

ahead and you are going to do these things, and you are going to

be like Ms. Dickerson.

You are going to move ahead, and you are going to understand

what Dr. Moye says that things are going to get much more complicated as patients get older. There is not only a law and a mandate here, but it is one which seems to take kind of a primacy

among health care problems that the veterans face.

I mean it just sort of stands out and hits you, so to speak. So

I am just inpatient with your answer because I am not sure what

is going to come of it. We have hearings, and somebody said these

hearings are very useful. These hearings can be very useful. They

can also be a wonderful opportunity for us to say things, sometimes

in goodwill, sometimes in less goodwill. Hearings always end. And

people from the Federal Government are extremely accustomed to

handling them; some of them handle them extremely well. They

know exactly what answers to give. Sometimes they tell witnesses

what answers not to give.

But in any event, the hearings pass, yet in many case the problems persist. And what I think Senator Wellstone and I want to

know is that you are going to be doing something about this on a

broad scale and that your nursing home problem is going to be

right there, and you are still going to find a way around it.

Dr. ROSWELL. Yes, Mr. Chairman. We have actually submitted a

plan to be fully compliant with the Mil bill requirements for institutional VA long-term care capacity.

Chairman ROCKEFELLER. To whom?

Dr. ROSWELL. To Chairman Smith of the House Veterans Affairs

Committee, because he requested it. That would bring us into compliance with that requirement by the end of fiscal year 2004, reaching the 1998 VA staff census of 13,391. But that is not enough.

Chairman ROCKEFELLER. I mean is a point by point plan or is

it a series of generic goals? Plus I would like to have a copy, if that

would not be inconvenient?

Dr. ROSWELL. We can provide you with that.

Chairman ROCKEFELLER. That would be very nice.

Dr. ROSWELL. The plan basically allocates an average daily census to each of the 21 VISNs to be achieved this year, and then an

interim average daily census next year to bring us back to that

level. It will be at a cost of an additional $161.2 million to be able

to get there, and that is money that will have to come from somewhere, but, yes, it is a statutory requirement, Mr. Chairman. I respect that. I honor that. We are committed to it.

But there is a cost associated with that, but we will do everything we can to move toward that statutory requirement. I think

the hearing—I wanted to focus, I think you wanted to focus, on

non-institutional care.

Chairman ROCKEFELLER. Right.

Dr. ROSWELL. And that is——
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Chairman ROCKEFELLER. But I got very hung up when you start- ed dangling that $140,000 nursing home cost per year, because I

felt——

Dr. ROSWELL. Well, for example, as you know, I came into my

current position from being the VISN director in VISN 8. That is

a VISN I can talk greatly about. Our assigned ADC to increase this

year is 109 patients. That will cost probably in excess of $10 million in additional staff to be able to move the census to that level.

Two and a half years ago, I shared the concerns you have echoed this morning and some of our panelists have echoed. I took $5 million out of the VISN 8 budget because I found a way to find those

resources to create a program to meet long-term care needs. With

less than $5 million a year, we now operate a community care coordination service.

The director is sitting here in the gallery today. That community

care coordination service provides care in a home setting using

interactive technology to over 1,300 patients. Now the average cost

per patient is $2,500 per year. Many of those patients are at great

risk for nursing home placement and would only be in a home care

environment were it not for this particular program.

That is important to me. Would I like to expand that? Yes.

Which is a greater cost? Meeting our average daily census requirement in VA staffed nursing home beds is a greater cost to add 109

patients than it would be to double or to triple the 1,300 patients

receiving home care services.

Chairman ROCKEFELLER. Paul, just forgive me, and then I will

be quiet and go to you.

Senator WELLSTONE. I may have to leave anyway. You go ahead.

I may have to leave.

Chairman ROCKEFELLER. I do not know why it was that I did not

leap up when you said we are going to have this all in effect by

2004, because my instinctive reaction is that, No. 1, this is 2002,

and the bill was passed in 1999. So that is a nice long chunk of

time.

You do not have to go; do you?

Senator WELLSTONE. Actually I have people outside to go to see.

That is OK. You keep going.

Chairman ROCKEFELLER. Then you go ahead and ask a question.

Senator WELLSTONE. No, no, no.

Chairman ROCKEFELLER. No, you go ahead.

Senator WELLSTONE. Just tell me when you are done and I will

come right back in. I will do that.

Chairman ROCKEFELLER. OK. I am not going to tell him when I

am done. [Laughter.]

Dr. Roswell, are you going to wait until 2004 and then all of a

sudden the firecrackers go off? I mean is the upper New York

model going to be replicated all over the place? I mean you said you

did it yourself, and you seem pretty happy about it. So are we

going to wait until 2004, or?

Dr. ROSWELL. No, it is a ramp up. Our current average daily census is 11,000. Marsha can you help me. 11,506 approximately.

Ms. GOODWIN. Yes; 11,506.

Dr. ROSWELL. So we have got to go from that number, 11,506, to

hit an end census of 13,391 by September 30, 2004. Obviously, to
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staff those beds does not meet the statutory requirement. The statutory requirement is that the patients in the staff beds be at

13,391. So over time we will place patients as we add staffing and

identify patients that are suitable candidates for VA staff nursing

home care.

In the spirit of disclosure, though, it is important that this committee understand that VA staffed nursing homes provide a very

high level of skilled rehabilitation care. 70 percent of the people

who receive care in VA staffed nursing home beds are discharged

to home. That is a remarkable statistic.

But it reflects not so much our clinical outcome as the fact that

the beds are used primarily for the rehabilitation of acute medical

and surgical problems, and it is truly not end-of-life long-term care.

That type of care is much more compassionately and cost-effectively provided in State home beds, the State Department of Veterans Affairs home beds, where we have had a major growth over

the last several years, and I would hate to deter that growth in the

State home program, because it provides an ideal setting for veterans who have continuous stay long-term care requirements and

are not suitable for care in the home environment.

Chairman ROCKEFELLER. Secretary Rumsfeld did something recently which I kind of liked. He sort of replaced some generals who

fought wars the way they used to be fought, with generals who can

fight wars the way they are going to have to be fought. I have to

assume that he took a lot of criticism for that, and I do not know

how deep it reaches. I have no idea what he had to go through in

order to do that.

The point of my question obviously is that if you go from fighting

land-massed wars to the kind of wars that we are now fighting, you

have to change what you do. Now, I am not on the Armed Services

Committee. I did not have a chance to ask him how you get people

to redirect their thinking.

But this is a war that is not waiting for you, and you have raised

problems. You have to change the culture of bureaucracy, and I do

not know that you have to change generals, but you might, and I

am interested in how you personally arrive at how you implement

this by people who will have to, let us say unlike Ms. Dickerson,

who is dealing with a specific situation.

I mean you are dealing with old roles and with people who have

been doing this for 30 years, and by golly, they are not going to

have some guy who has just come in as head of health and tell

them what to do. And so your battle plan for attacking that and

implementing all of this by 2004 ramped up or not?

Dr. ROSWELL. You know you make an excellent point, Mr. Chairman. A lot of the way we approach long-term care is in traditional

models. Now, the 1,300 patients I spoke of in Florida are not even

counted in our long-term care count because they do not fit a traditional model. They are not institutional care. They are not adult

day health care. They are not home-based primary care. So they do

not fit in any of our traditional categories, and we do not even

count them. so they are not in our total workload capacity.

One of the things I will clearly be doing with the leadership in

the geriatrics and the extended care part of VHA will be working

to develop new programs, to develop new models of care, to use
70

field-based clinicians, like the talented people you heard this morning, to define new programs, new approaches to care, so that we

can have a broader continuum of care and we can define how that

care is provided, and that will lead us to replicate that across that

system in a cost-effective manner.

Chairman ROCKEFELLER. OK. Look, I am interested in results. I

am also interested in Senator Wellstone coming back to ask his

question. [Laughter.]

And then I am going to dismiss the hearing, and here he is.

Senator WELLSTONE. Gee, I forgot. Actually I think, Dr. Roswell,

I think I do not find myself, it would not surprise you, in disagreement with the chairman. I mean I think, you know, I feel exactly

the same way about it. The one thing that also occurs to me, and

it is just sort of one comment which is in the form of a question,

and react any way you want to, is also I think there is, you know,

look above and beyond our saying come on, we are inpatient with

the slowness, make this happen. We have got models, let us do

this. I also think, though, that this debate about, Senator Rockefeller, about how much it is institutional care versus how much is

it going to be home-based care.

You know what I worry about are these sort of zero sum games

that we are going to have to play. In other words, it is a false

choice, I mean if we have the resources, and I also look at other

parts of our health. In our region, we are seeing some pretty darn

severe strains right now.

We do not have the adequate funding. So the other thing I want

to say to you is, you know, if you do not have the resources, you

got to say it. I mean you got to come up here and say to us, listen,

we need to do both. We cannot like cannibalize, you know, nursing

home care for the sake of doing home-based care, but home-based

care makes a lot more, but there is a lot of people that could benefit from that, and then there are other needs as well, and you all

need to give us the resources we need.

So my appeal to you would be, you know, you have to say it. And

I frankly think you should. I mean I think a number of us are

going to work on a supplemental bill. We are going to argue we

need more resources. Now, Senator Rockefeller is going to say there

is lots of ways you can get your priorities right and deliver some

of this care right now, but I also think—I personally think you got

a big resource problem, and I think the VA needs to be bolder in

telling us that we need to step up to the plate with the resources

that you need, but I cannot tell you what you need unless you tell

me what you need. That is the only thing I would add.

Dr. ROSWELL. Well, Senator Wellstone, thank you. I appreciate

your comments and I appreciate your support. In his letter to

Chairman Smith, Secretary Principi indicated the plan to get there,

and I do not know that he specified the exact cost. He did. He identified that the cumulative shortfall to meet the Mil bill requirements is $161.2 million.

That is an operational shortfall in our budget right now to be

able to meet the statutory requirement of the Mil bill just as it applies to the VA staffed inpatient nursing home requirement of the

1998 capacity at 13,391.
71

Senator WELLSTONE. That is on top of the $400 million shortfall

he identified last November as well?

Dr. ROSWELL. It is on top of the $142 million for priority seven.

Now, the $400 million included management efficiencies that are

being sustained by the various 21 VISN’s, but that information,

Senator, I will be happy to leave is detailed in that letter.

I guess my concern is that it is so much more than institutional

long-term care. There is so much we need to do. We need to have

VA staffed nursing home beds, but we need State home beds, more

State home beds. We need to use contract community nursing

home beds, because each meets a different need. We clearly need

to develop and nurture the innovation and the commitment that

was seen on the previous panel.

We need to develop models that allow greater functional independence that offset the need for institutional care, to preserve the

quality of life as long as we possibly can.

Senator WELLSTONE. Well, I just want to interrupt you and finish. I like what you are saying. I just think that, and, you know,

look, this is not the VA. I just would love for the VA to be a model

for the Nation, and I mean we have the same issue with the population at large. We have, I think, Senator Rockefeller, that we have

our collective heads ducked in the sand when it comes to the demographics of our country and the number of people that are going

to live to be 80 and 85, and how are you going to have people staying at home in as near normal circumstances as possible living

with dignity that way, and then when they can—I had a mother

and father with Parkinson’s.

We lived all of this, and then we cannot, then there will be good

care, you know, high quality care, which we do not have in our

nursing homes right now, and so it is not just VA, but I think the

whole point of this legislation was for us to sort of lead the way;

am I correct? And that we are not doing. But we can and you are

committed to it, so I just would finish up again and say let us make

this happen, and at the point at which I think you are trapped by

your budget, I think frankly veterans health care, quality veterans

health care is on a collision course with the tax cuts.

I think we cannot do everything. And we have to be honest about

how much tax cuts and how much revenue, and I think that is part

of what is facing you. But I am with you. I will work with you.

Dr. ROSWELL. Thank you very much for your support.

Senator WELLSTONE. With you, too. I want to work with you.

Chairman ROCKEFELLER. You may be more with him than I am.

[Laughter.]

Let me conclude with these comments. I think VA loves to think

of itself as being recognized as a national leader in the care of the

elderly. And the truth of the matter is that it is within those who

observe VA and health care, but elsewhere it is not recognized as

such. It gets an occasional burst and a little bit here and there, but

it is not. And it needs to be. That is point No. 1.

Point No. 2, you know you have sort of General Motors and you

have the Federal Government, and sometimes I am not sure if

there is really any difference in the way they are run, and this goes

back to, I think, two points. One is that you cannot give any testi-
72

mony or Secretary Principi, and I assume yourself that has not

been previously cleared by OMB.

That ought to infuriate you as a health care professional. Now,

the deal, of course, is that everybody has to be on the same page

of the song. There have been those who have decided not to be.

Some have paid a price for it. I think Secretary Derwinski could

probably tell you something about that. Jesse Brown used to be

told by President Clinton what the budget was going to be, and he

said, oh, yeah, and then he would fight for more money.

In other words, I am not making any Republican/Democratic

comparisons here. What I am saying is that the one main question

I asked Tony Principi when he came here for confirmation, was,

are you willing to go head to head with the President if you do not

get the budget you want? That is what I care about more than anything else, that you will go to him, demand time and argue your

case, whether he likes it or not. Just bull right past Andy Card.

I mean he is bigger. You are bigger than Andy Card. Just bull

right past him. In your case, you are an Under Secretary.

And I do not know Mitch Danielsvery well, but I encourage you

to sort of adopt that kind of mentality, because if you mean what

you have been saying this morning, then you are obviously going

to have to fight along with us.

And where everybody is concentrating on other issues which

have to do with national security and homeland security, which is

exactly what our first constitutional responsibility is. In the meantime, a thousand veterans are suffering. How are they dying and

under what conditions? What is VA doing?

So that what I like to refer to as face time, and that is putting

yourself on the line, because ultimately that is what we do here,

if we are doing our jobs. There comes a time when you simply have

to put yourself on the line, and then you lose sometimes, but if you

put yourself on the line, people know that you mean it. People

know if you put yourself on the line, if you have put your job at

risk, if you have not been afraid to offend somebody who is superior

in position, then suddenly they know that you mean it and all of

a sudden you are listened to more.

And that whole dynamic and the absence of its practice in Washington is thoroughly not understood by the American people who

choose but sometimes wisely to ignore Washington all together

thinking that not much of anything happens here.

I happen to think a great deal happens here, and I happen to

know that an enormous amount happens here and only happens

here that affects long-term care and veterans. So that was not just

generally directed at you. It was an expression of frustration on my

part, but it is partly directly at you. At some point people take

stands, and, for heaven sakes, if you go into public service, that is

one thing. If you go into health care, I mean you do that—for how

long to become a doctor?

Dr. ROSWELL. Four years of medical school.

Chairman ROCKEFELLER. Yes.

Dr. ROSWELL. An average of 4 to 5 years of residency, yes.

Chairman ROCKEFELLER. So I mean, in other words, there is sort

of a large commitment in your life to doing health care right, and
73

I would like to see that work for the advantage of long-term care

in the Department of Veterans Affairs.

Dr. ROSWELL. Thank you, Mr. Chairman.

Chairman ROCKEFELLER. And I thank you, and this hearing is

adjourned. Also, without objection, the written statement of Senator Murray will be made a part of the record.

[The prepared statement of Senator Murray follows:]

PREPARED STATEMENT OF HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

Thank you Mr. Chairman for calling this hearing. Like you, I’m very concerned

that veterans still do not have universal access to the additional long term care benefits we provided for in the 1999 Millennium Health Care Act. I hope this hearing

will help us move the process forward quickly so that our older veterans can get

the care they need.

I’m also concerned that veterans are losing long-term care options because of some

of the larger changes that are taking place in health care. In Washington State,

nursing homes and home health care agencies are closing their doors, in part, because of unfair Medicare and Medicaid reimbursement rates that punish providers

based on their geographic location. It’s an issue we’ve got to address to ensure that

veterans and all seniors have access to long-term care.

As I mentioned, in 1999, we passed the Millennium Health Care Act to add extended care services to the VA benefits package. But the VA has been extremely

slow in making those benefits available to veterans.

As the chairman knows, the GAO recently found that:

‘‘Two years after the passage of the act, VA has not completely implemented

its response to the act’s requirement that all eligible veterans be offered adult

health care, respite care, and geriatric evaluation.’’

The report goes on to say that: ‘‘access to these programs was far from universal

in the VA.’’

I understand the VA has gone back to OMB for a third time trying to get the

final regulations approved so that they can comply with the Millennium Act. Frankly, I don’t understand why it’s taken so long to implement the Act. The VA has a

legal and a moral obligation to our veterans to ensure access to quality long-term

care. Of course, today, long-term care means much more than just nursing homes.

It includes home health care, adult day care, adult homes, and respite care.

When you look at the growing need for long-term care, it’s clear the VA is going

to have to work with private health providers.

According to the GAO, in FY 2001 the VA spent about $3.1 billion on long-term

health care and the amount is likely to increase. It’s projected between the years

2000 to 2020 the US population over the age of 85 will increase by 37%, and the

veteran population will nearly triple. I find these statistic particularly troubling

when you consider that VA nursing homes beds are very expensive, costing as much

as $50,000 per year for a veteran. That’s nearly $20,000 dollars more expensive

than the national average.

Given these statistics, it’s clear that the VA will have to contract with private

health care providers to meet the needs of our veterans.

As the VA has done for ensuring access to nursing homes, we will have to turn

to private providers, like home health care agencies, to help cover the full commitment to our veterans. Unfortunately, the VA has committed very few resources to

non-institutional settings. In fact, of the $3.1 billion the VA spent on long-term care

in 2001, only 8% was devoted to non-institutional settings.

There is no question that this Issue is resource driven. However, it only makes

sense to devote more resources to non-institutional health care settings to increase

our ability to provide for all veterans. Home health care offers quality care that allows veterans to stay in their home, with their family, in the community. It offers

a sense of relief as well for family members who are not equipped to handle the

health care needs of the patient, but who don’t want to see their loved ones in a

nursing home.

As we have seen with Medicare, home health care offers real solutions to acute

care and long term care. Home health care providers are well trained and can provide a wide range of highly skilled care to veterans with special health care needs.

However, for veterans in Washington state, home health care may not be an option

to nursing homes.

Currently, Washington state ranks 45th in average per beneficiary costs in comparison to other states. We are well below the national average. For example, pro-
74

viders in Florida or Texas can receive almost twice as much per home health visit

than a provider in Washington state.

This inequity, coupled with the scheduled 15% reduction in home health care

under Medicare, could cripple home health care in Washington state. We’ve already

seen agencies closing or scaling back their home health care delivery areas. Hospitals that once actively participated in home health care are leaving. This is quickly becoming a crisis situation.

Medicare is penalizing home health care agencies, like doctors and hospitals in

Washington state for providing more cost effective care. Over the lifetime of a Medicare beneficiary, this can mean thousands of dollars less spent on their care in

Washington state.

This inequity is already forcing many doctors to leave and causing severe health

care professional shortages in hospitals. Our hospitals cannot compete with hospitals in other states that can pay more because they receive significantly more from

Medicare for providing the exact same service.

These regional inequities have resulted in vastly different levels of care and access to care. For example, in Florida many Medicare beneficiaries have access to

prescription drugs and prescription eyeglasses in the Medicare+Choice program.

In Washington state, there are no plans available that offer prescription drug coverage much less eyeglasses. I don’t want to see the same thing happen to our veterans.

Veterans, regardless of where they live, deserve access to quality nursing home

options. Unless the VA plans on creating competing home health care agencies in

Washington state for veterans only, there may be limited access to this option.

It’s unfair and unjust to provide vastly different levels of care for veterans depending upon where they live.

I urge the VA to work with CMS to ensure that home health care agencies in all

states are stable and affordable. Home health care must be an option for veterans.

With the advances in medical research and the aging veteran population, the VA

has to explore and invest in alternatives to nursing homes. In many cases, these

alternatives provide a more appropriate level of care.

I’ve been supportive of efforts to address these inequities, and I’ll continue to work

on it. I again want to thank the Chairman for holding this hearing and for helping

to ensure our veterans have options when they need long term care.

Chairman ROCKEFELLER. Thank you. The hearing is adjourned.

[Whereupon, at 12:20 p.m., the committee was adjourned.]
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A P P E N D I X

PREPARED STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM

COLORADO

Thank you, Mr. Chairman, for holding this hearing today. I look forward to hearing from the panelists regarding the VA’s efforts to provide alternative long term

care services.

In my meetings with veterans from Colorado, one of the issues of greatest concern

is health care. The vets want to know that they will be able to get quality care when

they need it.

I am encouraged that in recent years, Congress has invested substantial resources

to improve the quality and accessibility of VA medical care and to make that care

available to more veterans. As I understand, the number of individual veterans

served by the VA has increased by 65% in the last 7 years. But, nearly all of that

increase has been in primary care provided by outpatient clinics.

Now, as the age of the our veterans population rises, we are looking at services

needed by older patients. In the 106th Congress, under your leadership, Mr. Chairman, we enacted legislation directing the VA to expand its geriatric services to include nursing home care, assisted living arrangements and home care options.

Today, it is time to look at those programs to determine how we are doing. Are

our elderly and disabled veterans being offered the options we have promised them?

Are they able to choose home care rather than institutional care? Can they find

adult day care services? Are their family caregivers able to find relief services?

Speaking as a veteran, I believe we need to do all we can to help those who have

so honorably served all of us.

Mr. Chairman, again, I thank you for holding this hearing and look forward to

hearing details of how the VA is addressing the long term care needs of our vets.

PREPARED STATEMENT OF THE ALZHEIMER’S ASSOCIATION

Mr. Chairman and members of the Committee:

The Alzheimer’s Association appreciates the opportunity to submit the following

statement to the Committee on Veterans Affairs for the hearing entitled ‘‘Options

to Nursing Homes: Is VA Prepared?’’

The Alzheimer’s Association is the premier source of information and support for

the four million Americans with Alzheimer’s disease. Through its national network

of chapters, it offers a broad range of programs and services for people with the disease, their families, and caregivers and represents their interests on Alzheimer-related issues before federal, state, and local government and with health and longterm care providers.

Over the past few years, the VA has embarked on several exciting projects to improve care for veterans with Alzheimer’s disease and other dementias. Our comments in this statement will focus on two specific projects currently underway within the VA system.

ADVANCES IN HOME BASED PRIMARY CARE FOR END OF LIFE IN ADVANCED DEMENTIA

(AHEAD)

Advances in Home Based Primary Care for End of Life in Advanced Dementia

(AHEAD) is a rapid-cycle improvement project intended to help VA staff identify

problems in dementia care, implement clearly defined steps to address them, and

evaluate outcomes. The first group of AHEAD sites included teams of 3–5 VA staff

members from Home Based Primary Care units at 20 Veterans Integrated Service

Networks (VISN’s). The teams worked from January-September 2001, and focused

on four areas of improvement: early intervention, symptom management, staff edu-
76

cation, and caregiver support. Outcome data show improvements in each of these

areas at many of the sites. A second group of AHEAD sites is now underway.

CHRONIC CARE NETWORKS FOR ALZHEIMER’S DISEASE (CCN/AD)

Chronic Care Networks for Alzheimer’s Disease (CCN/AD) is a longer-term project

that is being implemented in the VA’s upstate New York network (VISN 2). CCN/

AD is a 7-site national demonstration project that is jointly sponsored by the Alzheimer’s Association and the National Chronic Care Consortium (NCCC). It is intended to provide coordinated health care and supportive services for people with

Alzheimer’s disease and other dementias by linking Alzheimer’s Association chapters and health care systems. VISN 2 is the only VA participant in the national

demonstration. Since 1997, it has worked closely with four local Alzheimer’s Association chapters to coordinate care and improve outcomes for veterans with dementia.

VISN2 leadership and staff have strongly and consistently supported the development and implementation of CCN/AD. While the VA central office and individual

networks and medical centers have previously provided extensive resources and

leadership in Alzheimer’s research and demonstration projects to improve Alzheimer’s and dementia care, this is the first time VA and Alzheimer’s Association

chapters have worked together at this level and with this intensity. The Alzheimer’s

Association believes that the change and improvement in Alzheimer’s and dementia

care in VISN 2 are truly impressive.

With the support of the Senate Committee on Veterans Affairs and the VA central

office, AHEAD and CCN/AD could be replicated in other VA networks across the

country, and the benefits of these innovative projects could be extended to many

more veterans with Alzheimer’s disease and other dementias. The Alzheimer’s Association is especially enthusiastic about the potential for replication of CCN/AD because of the value of coordinated medical care and supportive services for people

with these conditions, and the remainder of our statement focuses on this project.

We would point out, however, that the experience and knowledge developed by

VISN 2 in its work with Alzheimer’s Association chapters over the past five years

could provide a valuable basis for similar working partnerships between VA facilities and other community agencies. Such partnerships could improve the care available to veterans with other chronic conditions, which, like Alzheimer’s disease, require both medical care and non-medical, community-based services.

THE VISN2—ALZHEIMER’S ASSOCIATION PARTNERSHIPS

In upstate New York, CCN/AD has been implemented through VA/Alzheimer’s Association partnerships at the network and VA medical center levels. VA staff at the

Albany, Bath, Canandaigua, Syracuse, and Western New York VA medical centers

have worked closely with the four Alzheimer’s Association chapters that serve the

same geographic areas. Overall policy has come from the network level, but detailed

procedures for training, referrals, assessments, and joint care management have

been developed at the medical center/chapter level.

The creation and maintenance of these working partnerships has involved each

partner learning about the organizational structure, practices, and available services of the other. VA staff have learned about training programs, informational materials, family educational workshops, and support groups provided by the Alzheimer’s Association chapters. Chapters have learned about the wide array of institutional and non-institutional services provided by the VA. VA medical centers have

designated a single point of contact for referrals from the chapters. Likewise, if veterans and their families agree and give formal, informed consent, VA staff can fax

their names and contact information to the chapters so that the chapters can reach

out to them with supportive services.

THE CCN/AD MODEL

The CCN/AD model was developed by physicians, other health care professionals,

and Alzheimer’s Association chapters from the seven participating sites, including

VISN2 and the upstate New York chapters. It is intended to address common problems in the care of people with Alzheimer’s disease and other dementias in VA and

non-VA settings and to meet the needs of the person as a whole, not just his/her

Alzheimer’s disease or dementia.

The model includes recommended procedures and tools for identification of people

with possible dementia, diagnostic assessment, ongoing care management, and family support. It is available from the National Chronic Care Consortium’s website at

www.nccconline.org.
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IMPLEMENTATION OF CCN/AD IN VISN2

CCN/AD was first implemented in Syracuse, with the Syracuse VA Medical Center and the local Alzheimer’s Association chapter functioning as the pilot site for VISN 2. The Robert Wood Johnson Foundation provided a one-year $100,000 grant

to support the pilot test.

Once the pilot test was completed successfully, the Foundation provided an addi- tional $700,000 grant for two years of full implementation to be completed in October 2002.

Over the past three years, extensive training has been provided, first in Syracuse

and then in the other medical centers. Hundreds of VA staff members have received

training about Alzheimer’s disease, dementia, and effective approaches to care. As

the project has matured in the main medical centers, training has also been offered

in some of VISN 2’s community-based outpatient centers (CBOCs), e.g., in Elmira,

Rochester, and Rome, NY.

VA staff throughout VISN 2 have been trained to recognize the warning signs of

dementia and to refer veterans with possible dementia for a diagnostic evaluation

and possible enrollment in CCN/AD. As of April 2002, more than 450 veterans have

been enrolled. Some of these individuals are in the early stages of Alzheimer’s disease or another dementia, but others are in later stages and have simply not been

identified previously. Available data indicate that nationally, only 20–40 percent of

people with dementia have received a diagnostic evaluation. The numbers were

probably somewhat higher in VISN2 even before CCN/AD because some of the medical centers already had diagnostic clinics. Still, however, many veterans with dementia had not been identified and diagnosed. CCN/AD procedures and tools are

helping to address this problem. In addition to efforts by VA staff, the local Alzheimer’s Association chapters have begun asking callers whether they are a veteran

or a family caregiver of a veteran. If they are, the chapter is able to make an expedited referral into the VA for that individual or family.

Diagnostic assessment is occurring in all of the medical centers and CBOCs. The

CCN/AD model includes a recommended assessment that not only supports the diagnostic process but also provides valuable information about the veteran and his/

her family that can be used for care planning. Each VA medical center has made

adaptations to the model to fit with pre-existing practices at that center, available

staff, and other resources.

At each of the five main medical centers, VISN 2 has created a new dementia care

manager position. These five VA employees provide and coordinate training, encourage, assist with, and oversee the CCN/AD identification and assessment procedures,

and work with Alzheimer’s Association chapter staff to develop project procedures

and eliminate barriers to better care.

Ongoing care management for veterans enrolled in the project is provided by the

dementia care managers, other VA specialists and primary care providers, and chapter staff. The dementia care managers and chapter staff talk frequently with each

other about the needs of particular veterans and their families and how those needs

can be met. Both the dementia care managers and chapter staff make referrals to

other community agencies. Occasionally, in particularly difficult situations, the dementia care manager and a chapter staff member have made joint home visits. More

often, however, one or the other is able to solve the problem and obtain the needed

care for the veteran.

In VA medical centers were there is a dementia clinic, ongoing medical and nonmedical care management has been provided in the dementia clinic. Over time, as

the number of enrollees has increased and primary care providers have become

more knowledgeable and comfortable with Alzheimer’s and dementia care, these

functions are being shifted to primary care. In medical centers where there is no

dementia clinic, CCN/AD project staff have worked with VA primary care physicians, physician assistants, nurse practitioners, and others from the beginning to

provide medical and non-medical care management.

In each of the five medical centers, resource rooms have been set up with print

and video materials about Alzheimer’s and dementia for veterans, their families and

VA staff. Print materials are also available in racks in public areas of the VA, and

chapter staff contact veterans’ families to offer educational materials and other

chapter services. Support groups are provided at the medical center and in the community by chapter staff or VA staff that have received training from the chapters.

OUTCOMES

The evaluation of CCN/AD will continue for another year with funding from the

Retirement Research Foundation and the Robert Wood Johnson Foundation. Thus,

final results are not yet available. Responses to mail surveys of VA physicians,
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nurses, social workers, and others show positive attitudes about the project model

and the partnership with the Alzheimer’s Association chapters. Survey responses

also show general agreement that implementation of the CCN/AAD model and participation in the partnership with chapters will lead to earlier identification of dementia, improved communication between VA staff, veterans with dementia, and

their families, and greater awareness of needed treatments and services. Preliminary findings from telephone interviews with veterans who are still able to respond

and their families indicate high satisfaction with the care they are receiving through

the project.

Information about CCN/AD enrollees’ use of VA and chapter services will eventually be available to analyze the cost impact of the project. Since there is no control

group, cost information from the project will only be suggestive, although it is possible that data from other VA networks could be used for general comparison.

Many people with Alzheimer’s disease and other dementias also have serious coexisting conditions such as heart disease, diabetes, and cancer. Available data show

that these coexisting medical conditions increase the cost of care for people with Alzheimer’s and dementia. Likewise, Alzheimer’s and dementia increase the cost of coexisting medical conditions. Thus, a person with Alzheimer’s disease and diabetes

is likely to have higher medical costs than a person with only Alzheimer’s or only

diabetes. Greater attention to the management of coexisting Alzheimer’s, dementia,

and other serious medical conditions could improve outcomes and reduce costs of

care. Little work has been done in this area thus far, primarily because of lack of

knowledge about Alzheimer’s disease and dementia and widespread failure to identify and diagnose these conditions in most health care systems. By increasing staff

knowledge about Alzheimer’s and dementia and ensuring identification and diagnosis of veterans with these conditions in VISN 2, CCN/AD has laid the necessary

groundwork for future projects to improve management of coexisting medical conditions, with likely positive effects on both quality of care and costs.

POTENTIAL FOR REPLICATION IS OTHER VISNS

The CCN/AD model is available for use by any health care system. The model was

originally designed to be flexible enough to work in the diverse, real world settings

of the seven participating sites. As noted earlier, some adaptations to the model

have been made at each of the VISN2 medical centers, thus creating a rich array

of procedures and tools that could be adopted by other VA networks. The site has

a project manual that includes the CCN/AD model and tools, site policies, work

plans, budgets, timelines, and data collection instruments. Training curricula are

also available. Perhaps as valuable as these formal products is the extensive experience VISN 2 has accumulated in partnering with Alzheimer’s Association chapters.

These partnerships are essential in providing coordinated care for people with Alzheimer’s disease, dementia, and many other chronic conditions, and VISN 2’s knowledge in this area is a potentially valuable resource for other VA networks.

For the Alzheimer’s Association, the CCN/AD project in upstate New York has

provided opportunities to reach physicians, other health care professionals, veterans

with dementia, and family caregivers we would not have reached otherwise. We are

impressed with the dedication and skill of VISN 2 clinical and administrative staff,

and we are grateful for the time and resources the network has devoted to this

project. We hope the project will continue to grow in VISN 2 and that other VA networks will want to replicate it in their health care systems.

RECOMMENDATIONS

The Alzheimer’s Association recommends that the Senate Committee on Veterans

Affairs and the Veterans Health Administration (VHA):

1. encourage and support replication of the AHEAD and CCN/AD projects in

VA networks and medical centers across the country. Both projects require significant staff time and other resources, but the VA is already serving huge numbers of veterans with Alzheimer’s disease and other dementias, including many

whose conditions have not yet been identified and diagnosed. AHEAD and CCN/

AD are vehicles for improving care for these veterans. CCN/AD creates partnerships with Alzheimer’s Association chapters that can facilitate non-institutional,

community-based care and augment the efforts of VA staff.

2. Given the groundwork already created by CCN/AD in VISN 2, the Alzheimer’s Association also recommends that the Committee and the VHA encourage and support research and demonstration projects to improve the management of coexisting medical conditions in people with Alzheimer’s disease and

other dementias. As noted earlier, this is an important next step in improving

quality and reducing cost of care for veterans with these conditions.
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The Alzheimer’s Association commends the Committee on Veterans Affairs for

calling this important hearing on non-institutional long term care issues in the VA.

Under Chairman Rockefeller’s stalwart direction, the Committee on Veterans Affairs has worked consistently to improve the quality of health care and to develop

a long term care system for our nation’s veterans that provides options for care at

home, in the community and in good care facilities.

In addition, the Association sincerely appreciates Chairman Rockefeller’s particular commitment to veterans with Alzheimer’s disease, not only in the area of

long term care but also in raising awareness about the need for increased research

funding both at the National Institutes of Health (NIH) and in the private sector.

Through the Blanchette Rockefeller Neurosciences Institute at the West Virginia

University Health Sciences Center, fundamental neurosciences research is underway to find practical solutions to Alzheimer’s disease and other cognitive impairments.

Thank you again for the opportunity to submit this statement for the record.

PREPARED STATEMENT OF JAMES R. FISCHL, DIRECTOR, NATIONAL VETERANS AFFAIRS

AND REHABILITATION COMMISSION, THE AMERICAN LEGION

Mr. Chairman and Members of the Committee:

As an advocate for veterans and the nation’s largest veterans service organization,

The American Legion feels compelled to submit, for the record, its views on the subject of your most recent hearing—Alternatives to Nursing Homes—Is VA Prepared?

With the ever-growing aging veteran population, it is critical that the Department

of Veterans Affairs (VA) position itself in such a way as to be able to adequately

take care of all the needs of these veterans to include long-term care.

With the VA health care system transforming itself from a ‘‘hospital’’ system to

an ‘‘integrated health care’’ system, so too has VA’s approach to long-term care

evolved from an institutional setting to a non-institutional, community based and

home based setting.

The enactment of Public Law (PL) 106–17, the Veterans Millennium Healthcare

and Benefits Act, marked the first step down the long road to ensuring, mapping

out and implementing a comprehensive long-term care plan for veterans.

While conceding that this legislation was complex, the VA has allowed nearly two

years to go by without fully implementing the provisions of the law. The law requires that all eligible veterans be offered adult day health care, respite care, and

geriatric evaluation. To date, VA has instituted only three of the provisions of the

law:

• Mandatory nursing home care for veterans rated 70% and above and for any

service-connected veteran who needs nursing home care for a service-connected disability;

• Pilot programs to evaluate varying models of all-inclusive care for the elderly;

and

• An assisted living pilot to evaluate that particular program was initiated in the

Pacific Northwest.

It will take two to three more years for the pilot programs to be fully evaluated

as to whether they are a cost-effective means of providing long-term care (LTC). In

the mean time, veterans continue to struggle to obtain LTC by the VA.

LTC within VA is a continuum of care provided over a period of time to veterans

who suffer from severe chronic service-connected disabilities and conditions of aging

and/or the disease process. Within VA, long-term care includes:

• home health care;

• adult day care;

• community residential care;

• specialized rehabilitation care, including Alzheimer’s and Dementia care;

• psychogeriatric care;

• domiciliary care;

• assisted living;

• hospice and respite care;

• geriatric assessment and management;

• skilled and unskilled care;

• nursing home care; and

• Geriatric Research, Education and Clinical Centers (GRECCS).

One of the more innovative approaches to LTC within VA has been the use of telemedicine. Telemedicine technology allows VA to reduce travel time and costs while

improving efficiency and providing better quality of care. The Senior Companion

Program is another example of saving money, yet keeping LTC in the home of the
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veteran. The Advances in Home Based Primary Care for End of Life in Advancing

Dementia (AHEAD) program is yet another alternative to institutional care that the

VA is evaluating. While all of these programs sound great, they are only offered to

a small portion of the veteran population in need of LTC.

VA’s plans for long-term care include: • achieve an integrated care management system that incorporates all of the patient’s clinical care needs;

• provide more care in home and community-based settings as opposed to inpatient settings, when appropriate;

• achieve greater consistency in access to and quality of care provided in all settings;

• achieve greater consistency across the system in assessing patients for extended

care and in managing care, including post institutional care;

• continue to emphasize Veteran Health Administration (VHA) research and educational initiatives that will improve delivery of services and outcomes for VA’s elderly veteran patients; and

• continue to develop new models of care for diseases and conditions that are

prevalent among elderly veterans.

These plans are honorable; however, the caveat to achieving these plans is that

it must be done within ‘‘existing programmatic resources.’’ In essence, VA can only

do so much and then the money runs out. When it does, the bill payer becomes the

veteran.

The evolution of LTC from an institutional setting to a non-institutional setting

brings with it many issues that need to be addressed. One of those is accountability

of the patient and for that matter, whether the veteran is informed and understands

exactly what is going on with his or her care. Another, of course, is quality of care

being provided by non-VA staff and how is this being monitored.

Finally, The American Legion strongly contends that veterans, who are accepted

into the health care delivery system provided by VA, must remain the responsibility

of the Department. VA’s charge includes providing quality improvement oversight

for LTC provided by the Department or through private contract. If a veteran is accepted as a long-term care patient, no matter when or under which existent provision of a law, he or she remains the responsibility of the VA medical care system

regardless of their medical condition.

Congress and the Executive Branch must recognize that it is incumbent upon

them to provide VA adequate resources for the purposes of providing LTC to the

nation’s veterans. VA must continue to meet the demand veterans will undoubtedly

place on the health care system in the next 30 years. The reality of quality LTC

for veterans requires a financial commitment on the part of the legislative and executive branches of this government, and a coordinated treatment effort on behalf of

VA.

We can never forget the commitment ‘‘. . . to care for him who shall have borne

the battle, and for his widow and his orphan.’’

Thank you for allowing The American Legion an opportunity to express its views

on this critical issue.

PREPARED STATEMENT OF ARLENE DAVIDSON, VICE PRESIDENT, PLANNING AND

DEVELOPMENT, EVERCARE, A UNITEDHEALTH GROUP AFFILIATE

Mr. Chairman and Members of the Committee:

Evercare is pleased to have the opportunity to provide testimony for the record

of this Committee hearing on long term care alternatives for veterans. Evercare is

a division within the Ovations business segment of UnitedHealth Group.

UnitedHealth Group is a diversified health care company that provides a broad

spectrum of resources and services to help people achieve improved health and wellbeing through all stages of life. United is comprised of five major business segments:

Ovations, UnitedHealthcare, Ingenix, Specialized Care Services and Uniprise.

United has been operating since 1974 and currently serves nearly 35 million Americans in all 50 states. The Ovations business segment, of which Evercare is part, is

dedicated to serving vulnerable individuals including the frail elderly, chronically ill,

disabled and low income families.

Evercare is dedicated to meeting the long term care needs of this nation and we

have on several occasions in the past offered testimony in support of the development of new long term care options for veterans. Our mission is to optimize the

health and well being of aging, vulnerable and chronically ill individuals. Evercare

was started in 1987 in Minnesota by two nurse practitioners and with its acquisition of Lifemark Corporation in 2001, has grown into a diversified award-winning
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healthcare organization participating in government programs in over 15 states.

During our 18 years in the long term care market, we have seen the emergence and

maturing of many Medicaid, Medicare and other government programs. Our demonstrated ability to address complex health care needs and to provide customized

services has consistently resulted in exceptional customer satisfaction, improved

clinical outcomes, and increased efficiency. Some of these results are discussed in

a recent article published by Robert L. Kane, MD in the April 2002 issue of the

Journal of the American Geriatrics Society. We applaud and offer support to this

Committee’s efforts in examining new models to address the long term care needs

of veterans and seeking effective ways to deliver quality long term care services.

Recently, Evercare was awarded a contract by the Southern Arizona Veterans Administration Health Care System (SAVAHCS) for a pilot case management program

for veterans living in the community and in need of long term care services. This

pilot, targeted to veterans living throughout the State of Arizona, is one example

of how the Evercare care management approach can be applied to offer new long

term care alternatives to veterans. In this testimony we provide not only an overview of our care management approach but also some examples of long term care

program models in which our approach has been effectively applied. It is our hope

that this testimony will help define options for future program development.

OUR CARE MANAGEMENT PHILOSOPHY AND MODEL

Central to any of the long term care program models in which we operate is

Evercare’s approach to care management. Our approach for aged and disabled individuals is a client-centered model that encourages the involvement of the client,

their family, caregivers, physicians or primary care provider and our care manager

in a collaborative effort. It is a holistic approach, designed to maintain the highest

quality of life and functional status of the individual while minimizing reliance on

services that are traditionally more restrictive and less effective in containing costs.

This inclusive philosophy supports an overall goal of coordinating timely, quality,

and appropriate health services while addressing medical, social, behavioral, environmental and financial considerations in each care plan. Our care managers

achieve this goal through collaboration with the enrolled individual and his or her

family to create a care plan that maximizes the individual’s self-determination and

respects individual wants and interests. In the coordination, facilitation and implementation of the full spectrum of acute and long term care needs, Evercare’s care

managers strive to maintain, and if possible, increase each enrollee’s level of independence, individuality, choice and health status.

Evercare care managers work with the individual, his or her family, the primary

care provider (PCP), our internal clinical experts, and other providers as partners

on a team to design, coordinate, and manage the plan of care that achieves the results specified by the individual’s goals. Care managers additionally identify the full

range of health care resources and medical coverage available to each client, including Medicaid, Medicare, or private long term care insurance policies. This design

and approach allows care managers to react immediately to changes in a client’s

condition, proactively intervene, coordinate care and service needs, and manage any

necessary changes in the individual’s plan or setting of care. In addition, the care

manager assists the individual and his or her family in identifying attainable health

and functional status goals, and provides education and supportive services on preventive medicine, healthy choices, and self-care techniques as appropriate.

COMPANY OVERVIEW

Our continuum of product lines includes Medicaid and Medicare health plans,

government contracts, and a nationwide information, consultation, care management and referral service, all designed for frail, elderly, disabled or chronically ill

individuals. Through these businesses we serve over 658,000 individuals, including

providing comprehensive care management for approximately 150,000 individuals

through publicly funded and managed care contracts. In addition, more than 2.5

million people have access to our nationwide information, referral, consultation, and

care management services.

Evercare has experience coordinating long term care services through the following program models:

• Stand alone care and disease management programs offered in a fee-for service

environment with reimbursement for administrative costs on a per participant per

month basis;

• Eldercare consultation and referral services provided on an as needed, fee-for

service basis through an insurer or payer as part of a greater long term care benefit

package;
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• Care management services delivered as part of a long term care single entry

point (SEP) and/or primary care case management (PCCM) program administration

contract;

• Capitated long term care health plan models designed to coordinate with traditional Medicaid acute care coverage; and

• Full-risk health plans (health maintenance organization or preferred provider

organization) integrating acute, behavioral, and long term care funding.

In addition to the overall program model type, other important program design

issues include whether participation is mandatory, how program eligibility is defined, what delivery settings are included, and the referral/outreach processes used

to identify and enroll eligible individuals. Differences among our existing programs

are described in the examples that follow.

Arizona Case Management Services for Veterans

CUSTOMER/CLIENT: Southern Arizona VA Health Care System

COMPANY/PRODUCT LINE: Lifemark Corporation, Evercare Connections

START DATE: January 2002

Through Evercare’s Lifemark division, we provide care management services to

referred veterans statewide with reimbursement for administrative costs on a per

participant per month basis. Program participants, referred through local Contracting Officer Technical Representatives (COTRs), must require a nursing home

level of care and reside in community settings. Care management services include

initial assessment, care planning, maintenance of a statewide home and community

based provider referral network, periodic reassessment, and ongoing management

with regular communication with VA providers and other personnel. Our approach

to cost containment includes a strong emphasis on coordination of benefits with

other payor sources, improving access to care in rural areas, introducing appropriate

social services and decreasing fragmentation of care delivery.

OUTCOMES: Since the program is new (January 2002), no outcome data is yet

available.

Arizona Medicaid/Elderly and Physically Disabled Long Term Care Management

CUSTOMER/CLIENT: Arizona Health Care Cost Containment System (AHCCCS),

Arizona Long Term Care System (ALTCS)

COMPANY/PRODUCT LINE: Evercare of Arizona, Evercare Select

START DATE: January 1989

Evercare of Arizona, through its Evercare Select product, has been an ALTCS program contractor since the inception of the program in 1989 through the Federal

Medicaid Section 1115 waiver program granted to the State of Arizona. As ALTCS’

largest private contractor, Evercare has demonstrated that services can be integrated cost effectively in a managed care environment through incorporating sound

principles of intensive care management, utilization management, and quality assurance.

Evercare’s care managers work with the enrollee, the enrollee’s family or guardian, and his or her Primary Care Provider (PCP) in order to blend and deliver services to assist the enrollee in maintaining the highest level of functioning through

the most appropriate, cost effective plan of care. Evercare enrollees have choices

within a wide array of primary care, acute care, ancillary services, behavioral health

services, nursing home placement, and home and community based services (HCBS).

Evercare’’ strong HCBS network allows our enrollees to have access to a full continuum of services, including adult foster care, assisted living homes, assisted living

centers, adult day health centers, attendant care services, emergency alert systems,

group respite, home health services, personal care, homemaker services, respite

care, hospice care, home delivered meals, and home modifications.

OUTCOMES: Independent evaluations have shown increased consumer satisfaction,

cost savings and decreased rates of institutionalization as a result of this program.

Evercare has increased its HCBS population from five percent participation of all

clients in 1989 to 51 percent in 2001, significantly decreasing institutionalization.

Other financial and utilization outcomes for this period showcase its strength in cost

effectiveness. During this period we reduced the hospital length of stay from seven

to five days and decreased nursing home expenses from $1,424 to $1,110 per member per month with an estimated overall medical cost savings of over $2.5 million.

By offering a breadth of HCBS services through a highly developed network,

Evercare has been able to develop a program that has improved access, financing,

service delivery and follow-up while eliminating fragmentation, duplication of services, and unnecessary utilization. These findings have been substantiated by a 1996

Evaluation of Arizona’s Health Care Cost Containment System Demonstration report by Laguna Research Associates. In addition, an October 2000 report by the
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AHCCCS showed that consumers are very satisfied to satisfied with their long term

care services.

Texas STAR+PLUS Medicaid Long Term Care Health Plan

CUSTOMER/CLIENT: State of Texas Department of Human Services

COMPANY/PRODUCT LINE: Evercare of Texas/HMO Blue STAR+PLUS

START DATE: January 1998

Since 1998, Evercare has provided administrative services and care management

for HMO Blue STAR+PLUS. The STAR+PLUS Medicaid long term care program is

designed to foster care coordination for individuals dually eligible for Medicare and

Medicaid, and elderly and disabled people eligible for Medicaid-only. STAR+PLUS

bundles Medicaid covered services into one integrated coordinated care program designed to control health care costs while improving access and coordination of services to enrolled individuals. STAR+PLUS provides incentives for dual eligibles to enroll in Medicare+Choice plans to further integrate health care services. For all Medicaid enrollees, including dual eligibles, Evercare is at-risk for the cost of home and

community based services that are covered by Medicaid. In addition, Evercare provides a seamless transition along the continuum of health care services by coordinating acute care services reimbursed under the Medicare program. We have applied to become a Medicare+Choice program to assume risk for these services, to

complete the integration. This care management function enhances continuity of

care and the enrollee/care manager relationship. The Evercare program includes assignment of care managers to match the cultural and language aspects of Houston’s

diverse population (i.e., Vietnamese, African American, Asian American, Russian,

and Hispanic).

OUTCOMES: Independent evaluations of the STAR+PLUS program have also

shown increased consumer satisfaction, cost savings and improved quality. Evidence

of our success in managing the STAR+PLUS population is demonstrated by an internal cohort study of 310 enrollees in the program, who experienced, over a twoyear period, a decrease in inpatient days and days per thousand of 43 percent, and

a decrease in paid claims of 22 percent. Furthermore, a 1999 study by the Public

Policy Research Institute of Texas A&M University (STAR+PLUS Medicaid Managed Care Waiver Study: An Independent Assessment of Access, Quality and CostEffectiveness) found that this waiver program saved the State of Texas over $6 million without impeding access to care or quality of care. Furthermore, a 1999 overall

enrollee satisfaction survey conducted by the Texas Health Quality Alliance showed

results of ‘‘seven or higher on a scale of zero to ten’’, where ten is most satisfied

and zero is least satisfied.

Florida Diversion and Long Term Care Programs

CUSTOMER/CLIENT: Florida Department of Elder Affairs and Agency for Health

Care Administration

COMPANY/PRODUCT LINE: Health and Home Connection; ElderCare

START DATES: 1998 (Health and Home Connection); 1987 (ElderCare)

Evercare operates two separate Medicaid programs in Florida aimed at assisting

frail elders and disabled individuals to live in the community. Health and Home

Connection is a Florida Diversion Project serving enrollees over the age of 65 in

Osceola, Orange and Seminole counties under a 1915(c) waiver and monitored by

the Department of Elder Affairs. These complex health care individuals require assistance with activities of daily living, have dementia or some other chronic illness

or degenerative disease requiring daily nursing intervention. There are currently

446 voluntary enrollees whose health care needs are managed through our extensive

care coordination programs and services. ElderCare is a similar program in South

Florida (Dade and Broward counties) funded by the Frail Elder project and monitored by the Agency for Health Care Administration. ElderCare is for persons over

the age of 21 at risk of institutionalization due to chronic illness, disability and/or

in need of assistance with activities of daily living. There are 3,700 voluntary enrollees.

OUTCOMES: Estimated savings for the State of Florida from the Office of Program

Policy Analysis and Cost Accountability are $18 million per year for the Diversion

Project. ElderCare has potential savings estimated at $8.6 to $25.7 million per year.

The savings are estimated for diversion of enrollees from institutionalization to

more cost-effective community-based settings enabled by our comprehensive care

management approach. A November 2001 study by the Department of Elder Affairs

found Health and Home Connection had the highest average rating of satisfaction

with our care managers and highest satisfaction (89 percent) with overall long term

care services when compared to other participating contractors.
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New Mexico LTC Link Single Entry Point Administration

CUSTOMER/CLIENT: New Mexico Human Services Department/Medical Assistance

Division

COMPANY/PRODUCT LINE: Evercare Connections

START DATE: July 2001

LTCLinkNM is an information and referral service specializing in long-term care

services for disabled, elderly, chronically ill and vulnerable individuals of any age

within the State of New Mexico. The service was implemented and is managed by

Evercare’s comprehensive national database of long term care providers, which includes both institutional and home and community based providers. The State of

New Mexico created this program in July of 2001 to help eliminate the need for individuals to make numerous calls or trips to various organizations in the hopes of

finding appropriate resources. Through this information service, Evercare assists individuals and other concerned parties in locating services to maximize their independence and quality of life.

This type of centralized information system is used by states to simplify the process for individuals as they access publicly funded programs for medical or social

services. Other states, such as Colorado, rely on similar providers (in Colorado,

called Single Entry Point Agencies, or SEPs) to provide initial screening and ongoing case management and assessments. A program such as this may be particularly

beneficial for the VA, due to the intricacy of the benefit structure and the complexity of the care needs of many veterans. Evercare is capable of providing care

management services coupled with single entry point administration.

Nationwide Medicare+Choice Long Term Care Demonstration Project and PPO

CUSTOMER/CLIENT: Centers for Medicare and Medicaid Services (CMS)

COMPANY/PRODUCT LINE: Evercare, Evercare Choice

START DATE: January 1987

Since 1987, Evercare has operated a Medicare program, called Evercare Choice,

serving the frail elderly in institutional settings. This program has been operating

under a CMS demonstration since 1995. Through a unique care management program that utilizes teams of nurse practitioners and primary care physicians, the

Evercare model coordinates care for nursing home residents with an emphasis on

areas such as prevention, early detection, collaboration with the primary physician,

and communication with families and nursing staff. This geriatric clinical model

seeks to avoid costly and traumatic transfers to the hospital and improve enrollees’

quality of life. As a result of clinical success and superior cost effectiveness,

Evercare Choice has expanded to include sites in six states, including participating

in the Minnesota Senior Health Options program for dual eligibles and has led to

the development of additional Medicare+Choice (M+C) plans reaching a total of over

23,000 individuals. Last year, Evercare opened the nation’s first M+C PPO in Ohio.

This year, Evercare will launch a new M+C HMO product for community-based dual

eligibles in Texas and further expand the PPO model to additional states. Over 70

percent of the enrollees in Evercare Choice are dual eligibles, the average age our

enrollees is 85 and 85 percent suffer from some form of dementia.

OUTCOMES: Evercare is one of the most successful Medicare demonstration

projects and has produced impressive results in reducing hospitalizations, improving

quality of care and family satisfaction. The success of the nurse practitioner model

of care coordination is highlighted in studies conducted measuring affects on hospital admissions, clinical outcomes and enrollee satisfaction. Specifically, Kane discusses in the JAGS article higher satisfaction among Evercare enrollees when compared to a control group. The project has demonstrated 26–50 percent reduction in

hospital admissions with a slight decrease in mortality while improving clinical indicators and consistently achieving 95 percent satisfaction rates with the families of

this frail population. Excluding deaths, the disenrollment rate for enrollees in this

program is less than one percent, data further underscoring the overall programmatic excellence.

Nationwide Eldercare Consultation, Information and Referral

CUSTOMER/CLIENT: The Lutheran Brotherhood

COMPANY/PRODUCT LINE: Evercare Connections

START DATE: July 1997

The Lutheran Brotherhood contracts with Evercare Connections to provide elder

consultation, information and resources to their long term care insurance policyholders on a nationwide basis. This contract has been in place since July 1997 and

over 50,000 Lutheran Brotherhood policyholders currently have access to this valuable service.
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Under the terms of this agreement, Lutheran Brotherhood policyholders may call

a dedicated toll-free telephone number and speak with an Elder Care Specialist who

assists in determining the type and availability of services necessary to support

their elder care needs. The Elder Care Specialist will offer multiple provider or service options in the desired geographic location drawn from Evercare Connections’ provider database. This national database contains detailed information on over 90,000

long term care providers and community based services. The policyholder will receive an information packet that contains information relevant to their need. This

information packet contains detailed provider profiles and other helpful information

such as educational brochures and guides to assist in evaluating a provider. If desired, the Elder Care Specialist may assist the policyholder by scheduling provider

appointments or implementing services.

SUMMARY

Evercare has experience in operating a number of different long term care program models tailored for the unique needs of veterans, Medicaid, Medicare and/or

fee-for-service individuals. We provide service to government and private entities

that are based on the care principles of a client-centered approach, integration, and

the least restrictive and safest setting. Our experience and expertise in implementing and managing these programs can serve as a best practices resource to the

Veterans Administration. We are thankful for the opportunity to present our capabilities and ideas to the Senate Committee on Veterans Affairs and look forward to

future opportunities to collaborate with the Committee and the VA on the development of new long term care alternatives for veterans.

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