a

GAO

United States Government Accountability Office

Report to the Secretary of Veterans 

Affairs

September 2004 VA LONG-TERM 

CARE

More Accurate 

Measure of 

Home-Based Primary 

Care Workload Is 

Needed

GAO-04-913
www.gao.gov/cgi-bin/getrpt?GAO-04-913.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Cynthia A. 

Bascetta at (202) 512-7101. 

Highlights of GAO-04-913, a report to the 

Secretary of Veterans Affairs 

September 2004

VA LONG-TERM CARE

More Accurate Measure of Home-Based 

Primary Care Workload Is Needed 

The amount of home-based primary care veterans receive is not accurately 

reflected in VA’s workload measurement for that service. VA measures 

home-based primary care workload using the number of days a veteran is 

enrolled in the program rather than the number of visits the veteran 

received. For example, if a veteran was enrolled in VA’s home-based 

primary care program for 1 week, and received two visits from VA providers 

that week, VA would calculate the workload using 7 days, rather than two 

visits. As a result, using enrolled days as the workload unit of measure 

overstates the amount of home-based primary care actually received by 

veterans. In fiscal year 2003, VA reported an average daily workload for 

home-based primary care of 8,370 using enrolled days; in contrast, GAO 

determined that using the number of visits results in a workload of 944. In 

addition, VA’s measurement of home-based primary care using enrolled days 

is inconsistent with the way it measures workload for the other 

noninstitutional long-term care services GAO reviewed. VA measures 

workload for these other services using the number of visits a veteran 

received. As a result, VA’s workload total for home-based primary care 

overstates that service’s use compared to other noninstitutional services VA 

provides. 

VA Noninstitutional Long-Term Care Workload, Fiscal Year 2003 

0

2,000

4,000

6,000

8,000

10,000

Home

respite care

Skilled

home

health care

Homemaker/

home health

aide

Adult day

health care

Home-based 

primary care

77 2

Workload (average daily census)

8,370

1,220

4,332 4,317

Source: VA data and GAO analysis of VA data.

Enrolled days

Visits

944

Home

hospice care

Note: VA reports all noninstitutional care workload measures except home-based primary care in 

visits. 

The Department of Veterans Affairs 

(VA) provides a variety of longterm care services that includes 

nursing home care and 

noninstitutional care provided in 

community-based settings or in the 

homes of veterans. One important 

noninstitutional service is homebased primary care, which uses a 

multidisciplinary team approach 

involving VA health care providers 

and others such as social workers 

to treat veterans who are 

homebound. As part of GAO’s 

work for the Committee on 

Veterans’ Affairs, House of 

Representatives, to assess how VA 

meets veterans’ long-term care 

needs, GAO reviewed how VA 

measures workload for homebased primary care and five other 

noninstitutional services. 

GAO recommends that VA measure 

and report the amount of homebased primary care services 

veterans receive by using visits. VA 

agreed that a more accurate 

measure of home-based primary 

care is needed but did not concur 

with GAO’s recommendation. 

However, VA plans to establish a 

combination of workload measures 

for home-based primary care and 

other long-term care programs in 

fiscal year 2005, including visits, 

which will be responsive to GAO’s 

recommendation. 
Page i GAO-04-913 VA Home-Based Primary Care Workload Measurement 

Letter 1

Results in Brief 2 

Background 3 

VA’s Workload Measurement for Home-Based Primary Care Does 

Not Accurately Reflect the Amount of Care Received by 

Veterans 4 

Conclusions 5 

Recommendation for Executive Action 6 

Agency Comments and Our Evaluation 6 

Appendix I Comments from the Department of Veterans Affairs 8 

Table 

Table 1: Selected VA Noninstitutional Long-Term Care Services 3 

Figure 

Figure 1: VA Noninstitutional Long-Term Care Workload, Fiscal 

Year 2003 5 

Abbreviation 

VA Department of Veterans Affairs 

Contents 

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Page 1 GAO-04-913 VA Home-Based Primary Care Workload Measurement 

September 8, 2004 

The Honorable Anthony J. Principi 

Secretary of Veterans Affairs 

Dear Mr. Secretary: 

The Department of Veterans Affairs (VA) provides a continuum of longterm care services that includes nursing home care and noninstitutional 

services provided in community-based settings or in the homes of 

veterans. One important noninstitutional service VA provides is homebased primary care, which uses a multidisciplinary team approach 

involving VA health care providers and others such as social workers to 

treat veterans who are homebound. Concerns about meeting veterans’ 

long-term care needs in both institutional and noninstitutional settings 

have increased in part because the veteran population is aging. The 

number of veterans 85 years old and older, who are most in need of longterm care, is expected to increase from about 870,000 to 1.3 million over 

the next decade. Through its noninstitutional long-term care program, VA 

provides or pays for services that may help veterans remain at home and 

delay, or prevent, their need for nursing home care. As part of our work 

for the Committee on Veterans’ Affairs, House of Representatives, to 

assess how VA met or addressed its long-term care workload needs from 

fiscal years 1998 through 2003, we reviewed how VA measures this 

workload for home-based primary care and other services.1

To conduct our review, we assessed veteran patient workload data for 

fiscal years 1998 through 2003. Because VA did not change how it 

measured workload for the noninstitutional services we reviewed from 

fiscal years 1998 through 2003, we focused on fiscal year 2003 for this 

report. We obtained data from VA on workload and information about how 

it is measured and we analyzed these data for six noninstitutional longterm care services: (1) home-based primary care, (2) adult day health care, 

(3) homemaker/home health aide, (4) skilled home health care, (5) home 

 1

See GAO, VA Long-Term Care: Changes In Service Delivery Raise Important Questions, 

GAO-04-425T (Washington, D.C.: Jan. 28, 2004). 

United States Government Accountability Office

Washington, DC 20548 
Page 2 GAO-04-913 VA Home-Based Primary Care Workload Measurement 

respite care, and (6) home hospice care.2 In doing our work, we tested the 

reliability of the data and determined they were adequate for our 

purposes. We conducted our review from January 2003 through August 

2004 in accordance with generally accepted government auditing 

standards. 

VA’s workload measurement of home-based primary care services does 

not accurately reflect the amount of care veterans receive. VA measures 

home-based primary care workload using the number of days a veteran is 

enrolled in the program rather than the number of visits received by a 

veteran. For example, if a veteran was enrolled in VA’s home-based 

primary care program for 1 week, and received two visits from VA 

providers that week, VA would calculate the workload using 7 days, rather 

than two visits. As a result, the use of enrolled days as the unit of measure 

for home-based primary care overstates the services actually received by 

veterans. Specifically, VA reported an average daily workload for homebased primary care of 8,370 using enrolled days in fiscal year 2003; in 

contrast, we determined that using the number of visits results in a 

workload of 944. In addition, VA’s measurement of home-based primary 

care using enrolled days is inconsistent with the way VA measures 

workload for the five other noninstitutional long-term care services we 

reviewed. For these other services, VA measures workload using the 

number of visits a veteran received. Because the number of visits is a more 

accurate measure of the home-based primary care services veterans 

receive than enrolled days, we are recommending that VA use visits to 

measure and report the amount of home-based primary care services 

veterans receive. 

In commenting on a draft of this report, VA agreed that a more accurate 

measure of home-based primary care is needed but did not concur with 

our recommendation. However, VA plans to establish a combination of 

workload measures for home-based primary care and other long-term care 

programs in fiscal year 2005, including visits, which will be responsive to 

our recommendation. This will provide useful information to Congress and 

other stakeholders for assessing the amount of home-based primary care 

services veterans receive from VA. 

 2

Combining workload for each of these services is not a measure of the number of unique 

veterans receiving these services because a patient may receive more than one 

noninstitutional long-term care service in the same day. 

Results in Brief 
Page 3 GAO-04-913 VA Home-Based Primary Care Workload Measurement 

VA provides noninstitutional services as an important part of its 

continuum of long-term care. VA provides these services to veterans in 

their own homes or in community settings using both its own employees 

and other providers available through contracts. Veterans may prefer such 

services, which allow them to remain in their homes or in other settings 

that are less restrictive than institutions. We reviewed six of the 

noninstitutional services that VA provides or pays for. (See table 1.) VA 

reported workload measures for these noninstitutional care services in 

appropriations requests and testimony to Congress.3

Table 1: Selected VA Noninstitutional Long-Term Care Services 

Service Description Care providers 

Home-based primary 

care 

Primary health care, delivered by a 

physician-directed interdisciplinary team 

of staff including nurses, to homebound 

(often bedbound) veterans for whom 

visits to an outpatient clinic are not 

practical. 

VA providers 

Homemaker/home 

health aide 

Personal care, such as grooming, 

housekeeping, and meal preparation 

services, provided in the home to 

veterans who would otherwise need 

nursing home care. 

Contracted 

providers 

Adult day health care Health maintenance and rehabilitative 

services provided to frail elderly veterans 

in an outpatient setting during part of the 

day. 

VA and contracted 

providers 

Skilled home health care Medical services provided to veterans at 

home. 

Contracted 

providers 

Home respite care Services provided at home to temporarily 

relieve the veteran’s caregiver from the 

burden of caring for a chronically 

disabled veteran in the home. 

Contracted 

providers 

 3

House Committee on Veterans’ Affairs, Statement of the Under Secretary for Health, 

Department of Veterans Affairs, VA’s Long-Term Care Programs, 108th Congress, 2nd 

session, January 28, 2004; House Subcommittee on Health, Committee on Veterans’ Affairs, 

Statement of the Under Secretary for Health, Department of Veterans Affairs. VA’s LongTerm Care Programs, 108th Congress, 1st session, May 22, 2003; Department of Veterans 

Affairs, Fiscal Year 2004 Budget Submission: Medical Programs Volume 2 of 5 Final 

(Washington, D.C.: March 2003), 2-148; and Department of Veterans Affairs, Fiscal Year 

2002 Budget Submission: Medical Programs, Volume 2 of 6 (Washington, D.C.: April 

2001), 2-101. 

Background 
Page 4 GAO-04-913 VA Home-Based Primary Care Workload Measurement 

Service Description Care providers 

Home hospice care Services provided at home to veterans 

whose primary goal of treatment is 

comfort rather than cure for an advanced 

disease that is life-limiting. 

Contracted 

providers 

Source: VA. 

VA’s workload measurement for home-based primary care does not 

accurately reflect the amount of care received by veterans. VA measures 

home-based primary care workload using the number of days the veteran 

is enrolled in the program to receive these services, including weekends. 

Veterans do not, however, typically receive a home-based primary care 

visit every day they are enrolled in the program. For example, if a veteran 

was enrolled in VA’s home-based primary care program for 1 week, and 

received two visits from VA providers that week, VA would calculate the 

workload using 7 days, rather than two visits. VA officials told us that VA 

used the number of enrolled days to measure access to home-based 

primary care. While the number of enrolled days may provide a measure of 

access it does not provide an accurate measure of the services veterans 

receive. Measuring workload on the basis of number of visits veterans 

receive is a more accurate measure of VA’s provision of this service. 

To more accurately reflect the services veterans received, we measured 

VA’s workload for home-based primary care using number of visits as the 

unit of measure. Using this method, we determined that the average daily 

workload for VA’s home-based primary care in fiscal year 2003 was 944. 

VA, however, reported an average daily workload for home-based primary 

care that year of 8,370 based on enrolled days. The use of enrolled days as 

a workload measure overstates the amount of home-based primary care 

services veterans received by a factor of 9 to 1. 

Moreover, the way VA measures home-based primary care workload is 

inconsistent with the way it measures workload for the five other 

noninstitutional long-term care services we reviewed.4

 For these other 

services, VA measures workload using the number of visits a veteran 

received from a health care provider rather than the number of days the 

veteran was enrolled in the program. In fiscal year 2003, VA’s use of 

 4

VA refers to measures of workload for the six services we reviewed as average daily 

census. 

VA’s Workload 

Measurement for 

Home-Based Primary 

Care Does Not 

Accurately Reflect the 

Amount of Care 

Received by Veterans 
Page 5 GAO-04-913 VA Home-Based Primary Care Workload Measurement 

enrolled days to measure home-based primary care workload resulted in 

that service having the largest workload (46 percent) in comparison to the 

five other noninstitutional services. In contrast, when using visits to 

measure the home-based primary care workload, home-based primary 

care constituted 9 percent of all noninstitutional care services and its 

workload was smaller than the workload for homemaker/home health 

aide, adult day health care, or skilled home health care. (See fig. 1.) 

Figure 1: VA Noninstitutional Long-Term Care Workload, Fiscal Year 2003 

Note: VA reports all noninstitutional care workload measures except home-based primary care in 

visits. 

VA’s use of enrolled days to measure home-based primary care workload 

does not accurately measure the amount of this service that veterans 

receive and overstates its usage compared with other noninstitutional care 

services. VA reported that in fiscal year 2003 the average daily workload 

for home-based primary care, based on enrolled days, was 8,370. Measured 

in visits, however, we determined that the average daily workload for 

home-based primary care was 944. Inaccurate measurement and 

overstated usage of home-based primary care, as reported by VA, makes it 

Conclusions 

0

2,000

4,000

6,000

8,000

10,000

Home

respite care

Skilled

home

health care

Homemaker/

home health

aide

Adult day

health care

Home-based 

primary care

77 2

Workload (average daily census)

8,370

1,220

4,332 4,317

Source: VA data and GAO analysis of VA data.

Enrolled days

Visits

944

Home

hospice care
Page 6 GAO-04-913 VA Home-Based Primary Care Workload Measurement 

difficult for decision makers to know the amount of care VA is providing 

with the resources it is expending. Using the number of visits instead of 

the number of enrolled days to measure home-based primary care 

workload would provide a more accurate measure of the amount of homebased primary care services that veterans receive and would provide a 

more appropriate comparison of home-based primary care with other 

noninstitutional long-term care services. 

Because the number of visits is a more accurate measure of the homebased primary care services veterans receive than enrolled days, we 

recommend that you direct the Under Secretary for Health to use visits to 

measure and report the amount of home-based primary care services 

veterans receive. 

In commenting on a draft of this report, VA agreed that a more accurate 

measure of home-based primary care is needed but did not concur with 

our recommendation to use visits to measure and report the amount of 

home-based primary care services veterans receive. However, VA plans to 

establish a combination of workload measures for home-based primary 

care and other long-term care programs in fiscal year 2005, including 

visits, which will be responsive to our recommendation. 

VA stated that it did not concur with our recommendation because using 

the number of visits alone, rather than incorporating ancillary work such 

as reviewing laboratory and other test results, does not entirely represent 

home-based primary care workload. VA stated that it made a deliberate 

decision to convert from using the number of visits received to the number 

of enrolled days as the primary workload measure because this would 

promote more efficient and comprehensive management of the patient 

population. However, VA’s use of enrolled days as a workload measure for 

home-based primary care services provides a misleading picture of VA’s 

noninstitutional long-term care services. This measure overstates the 

amount of services veterans received because VA measures home-based 

primary care workload using the number of days the veteran is enrolled in 

the program to receive these services, including weekends. Veterans do 

not, however, typically receive a home-based primary care visit every day 

they are enrolled in the program. Using enrolled days may be useful for 

management of a population in need of such services, as VA states, but not 

as a measure of the amount of services veterans received. 

Recommendation for 

Executive Action 

Agency Comments 

and Our Evaluation 
Page 7 GAO-04-913 VA Home-Based Primary Care Workload Measurement 

VA states that in fiscal year 2005 it will begin reporting two other workload 

measures in addition to enrolled days, the number of patients treated and 

the number of visits veterans receive. We believe that reporting the 

number of patients treated will provide useful information on the number 

of veterans receiving home-based primary care but still will not accurately 

measure the amount of such care veterans receive. We believe that 

measuring and reporting the number of visits veterans receive, as VA said 

it will do, will be responsive to our recommendation. This will provide 

useful information to Congress and other stakeholders for assessing the 

amount of home-based primary care services veterans receive from VA. If 

VA chooses to also include in its home-based primary care measure the 

amount of ancillary work involved in delivering such care, this could 

provide a more comprehensive workload measure. However, based on a 

discussion with VA officials, VA cannot currently provide data on the 

amount of ancillary work involved with delivering home-based primary 

care. VA’s written comments are in appendix I. 

We are sending copies of this report to the House Committee on Veterans’ 

Affairs; other interested congressional committees; and other interested 

parties. This report is also available at no charge on GAO’s Web site at 

http://www.gao.gov. If you have questions about this report, please contact 

me at (202) 512-7101 or James Musselwhite at (202) 512-7259. Also 

contributing to this report were Cheryl A. Brand, Janet L. Overton, and 

Thomas A. Walke. 

Sincerely yours, 

Cynthia A. Bascetta, 

Director, Health Care—Veterans’ 

 Health and Benefits Issues 
Appendix I: Comments from the Department 

of Veterans Affairs 

Page 8 GAO-04-913 VA Home-Based Primary Care Workload Measurement 

Appendix I: Comments from the Department 

of Veterans Affairs 
Appendix I: Comments from the Department 

of Veterans Affairs 

Page 9 GAO-04-913 VA Home-Based Primary Care Workload Measurement 
Appendix I: Comments from the Department 

of Veterans Affairs 

Page 10 GAO-04-913 VA Home-Based Primary Care Workload Measurement (290377) 
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