Testimony 

Before the Committee on Veterans’ 

Affairs, House of Representatives 

United States General Accounting Office 

GAO

For Release on Delivery 

Expected at 12:00 noon EST 

Wednesday, January 28, 2004 VA LONG-TERM CARE 

Changes In Service Delivery 

Raise Important Questions 

Statement of Cynthia A. Bascetta 

Director, Health Care—Veterans’ 

Health and Benefits Issues 

GAO-04-425T 
www.gao.gov/cgi-bin/getrpt?GAO-04-425T.

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-04-425T, a testimony 

before the Committee on Veterans' Affairs, 

House of Representatives 

January 28, 2004

VA LONG-TERM CARE

Changes In Service Delivery Raise 

Important Questions 

Recent trends in VA nursing home care and noninstitutional service delivery 

raise important questions, particularly whether access to services is 

sufficient to meet the needs of a rapidly growing elderly veteran population. 

VA's overall nursing home workload—average daily census—was 33,214 in 

fiscal year 2003, 1 percent below its fiscal year 1998 workload. The 

workload was below the fiscal year 1998 level each year, decreasing by as 

much as 8 percent below the fiscal year 1998 level in fiscal year 2000. VA’s 

use of nursing home care by setting also changed over the 6-year period. 

First, the percentage of workload in state veterans’ nursing homes increased 

as the number of state veterans’ nursing homes receiving VA payments 

increased. Second, the percentage of workload in VA’s own nursing homes 

declined, in part, because VA decreased the number of long-stay patients and 

increased the number of short-stay patients it treats in the nursing homes it 

operates. This is consistent with VA’s increased emphasis on post-acute 

care. Third, the percentage of workload in community nursing homes 

declined from 17 to 13 percent. VA officials told us that now shorter-term 

contracts are often used to transition veterans to nursing home care, which 

is paid for by other payers such as Medicaid. 

Percentage of Nursing Home Workload By Setting, Fiscal Years 1998 and 2003 

Note: The workload measure is average daily census, which represents the total number of days of 

nursing home care provided in a year divided by the number of days in the year. 

VA's noninstitutional long-term care workload—average daily census—

increased by approximately 75 percent from fiscal years 1998 through 2003. 

Workload increased by 4,655 during this period to 10,892, reflecting a change 

in VA’s approach to care which includes meeting more long-term care need 

through noninstitutional services. Most of the growth in noninstitutional 

workload came from VA’s greater use of contract skilled home health care, 

which includes medical services provided to veterans at home, and 

homemaker/home health aide such as grooming and meal preparation. 

The Department of Veterans Affairs 

(VA) is likely to see a significant 

increase in long-term care need 

over the next decade. The number 

of veterans most in need of longterm care services—those 85 years 

old and older—is expected to 

increase from about 870,000 to 1.3 

million over this period. Many of 

these veterans will rely on VA to 

provide or pay for nursing home 

care or noninstitutional services 

that may help them remain at home 

and, for some, delay or prevent the 

need for nursing home care. VA 

operates its own nursing home care 

units in 132 locations. VA also pays 

for nursing home care under 

contract in non-VA nursing 

homes—referred to as community 

nursing homes. In addition, VA 

pays part of the cost of care for 

veterans at state veterans’ nursing 

homes and also pays a portion of 

the construction costs for some 

state veterans’ nursing homes. 

This Committee has expressed 

concerns about recent trends in VA 

long-term care service delivery and 

how VA plans to meet the nursing 

home care needs and related longterm care needs of veterans as the 

elderly population most in need of 

long-term care increases. GAO was 

asked to determine for fiscal years 

1998 through 2003 (1) how VA 

nursing home workload has 

changed and (2) how VA 

noninstitutional long-term care 

workload has changed. 
Page 1 GAO-04-425T 

Mr. Chairman and Members of the Committee: 

We are pleased to be here today to discuss veterans’ use of long-term care 

services, which include nursing home care and noninstitutional services 

provided or paid for by the Department of Veterans Affairs (VA). Concern 

with meeting veterans’ long-term care needs is increasing as the number of 

veterans most in need of these services—those 85 years old and older—is 

expected to increase from about 870,000 this year to 1.3 million over the 

next decade. Many of these veterans will seek assistance from VA to 

provide or pay for nursing home care or a range of noninstitutional 

services that may help them remain at home and, for some, delay or 

prevent the need for nursing home care. 

To provide assistance to veterans with chronic illness or physical or 

mental disability, VA provides a continuum of institutional and 

noninstitutional long-term care services. VA provides care that its own 

employees deliver and contracts with other health care providers to 

deliver care. VA operates its own nursing home care units in 132 locations 

and also pays for nursing home care under contract in non-VA nursing 

homes—referred to as community nursing homes. In addition, VA pays 

part of the cost of care for veterans at state veterans’ nursing homes and 

also pays a portion of the construction costs for some state veterans’ 

nursing homes. VA also provides noninstitutional services to veterans in 

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

and through contracts with other providers. 

This Committee has expressed concerns about recent trends in VA longterm care service delivery and how VA plans to meet the nursing home 

care needs and related long-term care needs of veterans as the elderly 

population most in need of long-term care increases. To assist the 

Committee in its oversight responsibilities in this area, you asked us to 

determine for fiscal years 1998 through 2003 (1) how VA nursing home 

workload has changed and (2) how VA noninstitutional long-term care 

workload has changed. 

My testimony today is based on our ongoing review of long-term care 

workload for this Committee.1

 For this review, we measured nursing home 

 1

We reported preliminary findings on nursing home workload in a testimony to this 

Committee on May 8, 2003. U.S. General Accounting Office, Department of Veterans 

Affairs: Key Management Challenges in Health and Disability Programs GAO-03-756T

(Washington, D.C.: May 8, 2003). 
Page 2 GAO-04-425T 

workload as defined by average daily census, which reflects the average 

number of veterans receiving nursing home care on any given day during 

the course of the year. We also measured noninstitutional workload using 

average daily census; however, the number of veterans receiving these 

services may be less than workload because a veteran may receive more 

than one service in a day. We analyzed data on nursing home workload 

that VA provided to determine how workload had changed from fiscal 

years 1998 through 2003. We also verified VA’s nursing home workload 

numbers based on contacts with officials from VA’s 21 health care 

networks and VA headquarters. To determine how noninstitutional longterm care workload has changed during this period, we analyzed data on 

visits for six noninstitutional services which VA either provides directly or 

pays for others to provide: home-based primary care, adult day health 

care, homemaker/home health aide, skilled home health care, home 

respite care, and home hospice care. We also interviewed VA officials at 

headquarters and obtained information from the networks to better 

understand the reasons for changes in nursing home workload during this 

period. In doing our work, we tested the reliability of the data and 

determined they were adequate for our purposes. We did our work in 

accordance with generally accepted government auditing standards from 

January 2003 through January 2004. 

In summary, recent trends in VA nursing home and noninstitutional 

service delivery raise important questions, particularly whether access to 

services is sufficient to meet the needs of a rapidly growing elderly veteran 

population. VA’s overall nursing home workload—-average daily census—-

was 33,214 in fiscal year 2003, 1 percent below its fiscal year 1998 

workload. The workload was below the fiscal year 1998 level each year, 

decreasing by as much as 8 percent below the fiscal year 1998 level in 

fiscal year 2000. Fourteen of 21 networks experienced declines in nursing 

home workload during this period. Moreover, VA’s use of the three nursing 

home settings changed over this 6-year period. First, the percentage of 

workload met in state veterans’ nursing homes increased from 43 to 50 

percent as the number of state veterans’ nursing homes receiving VA 

payment increased. The percentage of workload met in state veterans’ 

nursing homes increased in 19 of VA’s 21 health care networks. Second, 

the percentage of workload in VA’s own nursing homes declined from 40 

to 37 percent. Thirteen networks provided a smaller percentage of 

workload in VA-operated homes during this period. The percentage of 

workload provided in VA-operated homes declined, in part, because VA 

decreased the number of long-stay patients and increased the number of 

short-stay patients it treats in its own nursing homes. This is consistent 

with VA’s policy to give priority to post-acute patients and certain other 
Page 3 GAO-04-425T 

nursing home patients. VA generally provides long-term nursing home 

care as resources permit. Third, the percentage of workload in community 

nursing homes declined from 17 to 13 percent. Seventeen networks 

reduced the percentage of their nursing home workload provided in 

community nursing homes during this period. 

VA’s noninstitutional long-term care workload—-average daily census—-

increased by approximately 75 percent from fiscal years 1998 through 

2003. Workload increased by 4,655 during this period to 10,892, reflecting a 

change in VA’s approach to care which includes meeting more long-term 

care need through noninstitutional services. Most of the growth in 

noninstitutional workload came from VA’s greater use of contract skilled 

home health care, which includes medical services provided to veterans at 

home, and homemaker/home health aide services such as grooming and 

meal preparation. These services are most likely to help veterans prevent 

or delay the need for nursing home care. 

Meeting veterans’ long-term care needs has become a more pressing issue 

as the veteran population ages. The elderly veteran population most in 

need of long-term care—those 85 years and older—-grew dramatically 

from about 387,000 to about 764,000, an increase of about 100 percent 

from fiscal years 1998 to 2003. (See fig. 1.) 

Background 
Page 4 GAO-04-425T 

Figure 1: Growth in Veteran Population, 85 Years and Older, Fiscal Years 1998 

Through 2003 

Over the past two decades the provision of long-term care has been 

shifting away from institutions and nursing homes towards more 

noninstitutional long-term care services in VA and in other programs. In 

recognition of this change in approach to how long-term care is provided, 

the Federal Advisory Committee on the Future of VA Long-Term Care 

recommended, in 1998, that VA update its long-term care policy by 

meeting the growing demand for long-term care through significant 

expansion of its capacity to provide home and community-based 

services—also known as noninstitutional long-term care services—while 

maintaining its nursing home capacity at the 1998 level.2

VA provides a continuum of noninstitutional long-term care services to 

provide care to veterans needing assistance. Long-term care provided in 

noninstitutional settings—-including services provided in veterans’ homes 

and community-based services such as adult day health care centers—-is 

preferred by many veterans. Noninstitutional care also includes respite 

care services that temporarily relieve a veteran’s caregiver from the 

 2

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). 

387,243

439,837

509,782

586,363

671,713

763,956

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1998 1999 2000 2001 2002 2003

Veteran population

Fiscal years

Source: GAO analysis of VA data.
Page 5 GAO-04-425T 

burden of caring for a chronically ill and disabled veteran in the home. VA 

offers noninstitutional long-term care services directly or through other 

providers with which VA contracts. (See table 1 for the noninstitutional 

long-term care services in our review.) 

Table 1: Selected VA Noninstitutional Long-Term Care Services 

VA noninstitutional longterm care service Definition Source of care 

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. 

Contracted 

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. 

Veterans can also receive nursing home care and noninstitutional services 

financed by sources other than VA, including Medicaid and Medicare, 

private health or long-term care insurance, or self-financed. States design 

and administer Medicaid programs that include coverage for nursing home 

care and home and community-based services. Medicare primarily covers 

acute care health costs and therefore limits its nursing home coverage to 

short-term stays following hospitalization. Medicare also pays for home 

health care. State Medicaid programs are the principal funders of nursing 

home and home health care services, besides patients self-financing their 

care. We have estimated that private insurance pays for about 11 percent 

of nursing home and home health care expenditures.3

 3

See U.S. General Accounting Office, Long-Term Care: Aging Baby Boom Generation Will 

Increase Demand and Burden on Federal and State Budgets GAO-02-544T (Washington, 

D.C.: March 21, 2002). 
Page 6 GAO-04-425T 

VA’s overall nursing home workload—-average daily census—-was 33,214 

in fiscal year 2003, slightly below its fiscal year 1998 workload. However, 

the workload was below the fiscal year 1998 level each year, reaching its 

lowest level in fiscal year 2000. Over the last 6 years, VA’s use of nursing 

homes by setting changed. These changes in workload and use of different 

settings to provide nursing home care varied by network. 

VA’s nursing home workload was 33,214 in fiscal year 2003, 1 percent 

below its fiscal year 1998 workload. (See table 2.) Nursing home workload 

varied over this period but was consistently below the fiscal year 1998 

level, decreasing by as much as 8 percent in fiscal year 2000 from its fiscal 

year 1998 level. The distribution of the nursing home workload among the 

three nursing home settings shifted during this period. From fiscal years 

1998 through 2003, workload in the nursing homes VA operates declined 

by 1,014. In addition, workload in community nursing homes declined by 

1,434. In contrast, workload in state veterans’ homes increased by 2,032. 

Table 2: Change in Nursing Home Workload Provided or Paid for by VA in Fiscal Years 1998-2003 

Type of nursing home 1998 1999 2000 2001 2002 2003 Change 1998-2003 

VA-operated nursing homes 13,387 12,614 11,841 11,727 12,035 12,373 -1,014 

Community nursing homes 5,636 4,575 3,799 4,163 4,080 4,202 -1,434 

State veterans’ nursing homes 14,607 15,046 15,259 15,533 15,985 16,639 2,032 

Total 33,630 32,235 30,899 31,423 32,100 33,214 -416 

Source: VA. 

Note: The workload measure is average daily census, which represents the total number of days of 

nursing home care provided in a year divided by the number of days in the year. 

Although VA nursing home workload did not change greatly from fiscal 

years 1998 through fiscal year 2003, some networks experienced 

significant increases or decreases. Fourteen of VA’s 21 networks had 

lower nursing home workloads in fiscal year 2003 than in fiscal year 1998 

for all three settings combined. (See fig. 2.) Network 5 (Baltimore) had the 

largest decline in workload—19 percent. Seven networks’ nursing home 

workloads grew during this period. Network 17 (Dallas) had the largest 

increase in nursing home workload—42 percent. 

Nursing Home 

Workload Declined 

Slightly And Use Of 

Nursing Home Care 

By Setting Changed 

Nursing Home Workload 

Declined Slightly from 

Fiscal Year 1998 through 

Fiscal Year 2003 
Page 7 GAO-04-425T 

Figure 2: Change in Nursing Home Workload by VA Network, Fiscal Years 1998-2003 

Note: Nursing home workload is measured using average daily census combined for VA-operated 

nursing homes, community nursing homes, and state veterans’ nursing homes. Average daily census 

represents the total number of days of nursing home care provided in a year divided by the number of 

days in the year. VA merged networks 13 and 14 into network 23 in January 2002. 

VA’s use of nursing home care among the three settings changed from 

fiscal years 1998 through 2003. The percentage of workload met in state 

veterans’ nursing homes increased from 43 to 50 percent. (See fig. 3.) This 

increase is attributable in large part to 18 more state veterans’ nursing 

homes receiving payment from VA to provide such care. By fiscal year 

2003, 109 state veterans’ nursing homes received VA payment to provide 

this care. VA is authorized to pay for about two-thirds of the costs of 

Use of Nursing Home Care 

Setting Changed from 

Fiscal Year 1998 through 

2003 

100

Workload change from fiscal years 1998 to 2003

Source: GAO analysis of VA data.

1 (Boston)

2 (Albany)

3 (Bronx)

4 (Pittsburgh)

5 (Baltimore)

6 (Durham)

7 (Atlanta)

8 (Bay Pines)

9 (Nashville)

10 (Cincinnati)

11 (Ann Arbor)

12 (Chicago)

15 (Kansas City)

16 (Jackson)

17 (Dallas)

18 (Phoenix)

19 (Denver)

20 (Portland)

21 (San Francisco)

22 (Long Beach)

23 (Minneapolis)

-20

-10

0

10

20

30

40

50

Percentage

-.004

-7

-17

-10 -9

-19

1

-3

19

-7

-12

-4

-9

 22

1

42

9

-3

16

-3

-6
Page 8 GAO-04-425T 

construction of state veterans’ nursing homes and pays about a third of the 

costs per day to provide care to veterans in these homes. 

Figure 3: Percentage of Nursing Home Workload By Setting, Fiscal Years 1998 and 2003 

Note: The workload measure is average daily census, which represents the total number of days of 

nursing home care provided in a year divided by the number of days in the year. 

The percentage of workload provided in state veterans’ nursing homes 

increased in 19 of VA’s 21 health care networks. Network 17 (Dallas) had 

the largest increase in the percentage of workload provided by state 

veterans’ nursing homes. The percentage of nursing home care provided 

by state veterans’ nursing homes in this network increased from 0 to 30 

percent during this period after the opening of four state veterans’ nursing 

homes in Texas. By contrast, the percentage of workload provided by state 

veterans’ nursing homes declined in 2 networks: Network 5 (Baltimore) by 

3 percent and Network 21 (San Francisco) by 2 percent. 

The percentage of nursing home workload provided in VA’s own nursing 

homes declined from 40 to 37 percent during this period. Thirteen 

networks provided a smaller percentage of nursing home care in VAoperated nursing homes in fiscal year 2003 than in fiscal year 1998. 

Network 17 (Dallas) had the largest decrease in the percentage of 
Page 9 GAO-04-425T 

workload provided by VA-operated nursing homes, declining from 68 

percent to 49 percent during this period. This resulted because the state 

veterans’ nursing home workload increased substantially. By contrast, the 

percentage of care provided in VA-operated homes increased in 8 

networks. Network 5 (Baltimore) had the largest increase, growing from 

50 percent in fiscal year 1998 to 64 percent in fiscal year 2003. In Network 

21 (San Francisco), the percentage of care in VA-operated nursing homes 

increased by 7 percent and in the remaining 6 networks the percentage of 

care in VA-operated nursing homes increased 3 percent or less. 

Our analysis of length-of stay trends in VA-operated nursing homes shows 

that the decline in the number of veterans with long stays—90 days or 

more—largely explains the decline in nursing home workload during this 

period. The number of long-stay veterans declined from about 14,200 in 

fiscal year 1998 to about 12,700 in fiscal year 2002, the most recent year for 

which data are available.4

 At the same time the number of short-stay 

veterans—-those with stays of less than 90 days—-increased from about 

26,700 to about 32,200. However, the increase in short-stay patients was 

not large enough to offset the decline in workload resulting from the 

decrease in long-stay patients. This results because multiple short-stay 

patients are required to generate the same workload as a single long-stay 

patient. For example, a single long-stay patient in a nursing home for 12 

months creates a workload of an average daily census of 1 over a year. By 

contrast, 12 short-stay patients staying in a nursing home for one month 

each creates the same average daily census. 

Among VA’s networks, 16 had declines in the number of long-stay patients 

in VA-operated homes during this period. Five networks, however, had 

increases in the number of long-stay patients: Network 1 (Boston), 

Network 5 (Baltimore), Network 7 (Atlanta), Network 12 (Chicago) and 

Network 21 (San Francisco). 

VA officials attribute some of the changes in nursing home workload in 

VA-operated facilities to an increased emphasis on short-term, post-acute 

rehabilitation care. VA’s policy is to provide nursing home care in its own 

nursing homes as a priority to post-acute patients, patients who cannot be 

adequately cared for in community nursing homes or in noninstitutional 

 4

This calculation requires complete data for the first 3 months of a fiscal year to determine 

if some patients in a prior fiscal year were in a VA-operated nursing home for 90 or more 

days. Data for the first 3 months of fiscal year 2004 were not available when we did our 

calculations. As a result, we provide our analysis for fiscal year 2002. 
Page 10 GAO-04-425T 

settings, and those patients who can be cared for more efficiently in VA’s 

own nursing homes. In addition, VA may provide nursing home care, to the 

extent resources are available, to other patients who need long-term care 

for chronic disabilities. Consistent with VA’s policy, the proportion of 

discharged veterans whose length of stays were less than 90 days in VAoperated nursing homes increased from 74 to 81 percent from fiscal years 

1998 through 2003. This is similar to lengths of stay provided in facilities 

certified by Medicare—-but not Medicaid—-that provide post-acute skilled 

nursing home care.5

 About 81 percent of discharged patients in these 

certified Medicare facilities had length of stays of less than 90 days in 

fiscal year 1999.6

The percentage of workload in community nursing homes declined from 

17 to 13 percent from fiscal year 1998 through fiscal year 2003. This 

decline occurred because VA reduced the number of patients served and 

the number of days paid for under contract in this setting. The number of 

patients in these settings declined from 28,893 to 14,032 during this 

period.7

 Some VA officials told us that in the past VA used community 

nursing homes for more patients and for longer-term contracts than 

currently. VA officials told us that now shorter-term contracts are often 

used to transition veterans to nursing home care, which is paid by other 

payers such as Medicaid. For example, some network officials told us that 

contracts for community nursing home care are often 30 days or less. 

Of the 21 networks, 17 reduced the percentage of nursing home workload 

provided in community nursing homes during this period. Four networks 

reduced the percentage of nursing home care provided in community 

nursing homes by about 11 percent: Network 4 (Pittsburgh), Network 5 

(Baltimore), Network 6 (Durham), and Network 17 (Dallas). By contrast, 

the percentage of workload provided in community nursing homes 

increased in 4 networks. The percentage of nursing home care provided in 

community nursing homes in Network 19 (Denver) increased by about 10 

percent. The percentage of nursing home care provided in community 

nursing homes among the other 3 networks—- Network 23 (Minneapolis), 

 5

Some nursing home facilities are certified only by Medicare to provide skilled nursing 

home care. Others are certified by both Medicare and Medicaid. 

6

See A. Jones, The National Nursing Home Survey: 1999 Summary. National Center for 

Health Statistics, Vital Health Stat 13(152), 2002. 

7

These patient numbers are based on discharges and are not unduplicated because a single 

patient may be admitted more than once in the same fiscal year. 
Page 11 GAO-04-425T 

Network 20 (Portland), and Network 18 (Phoenix)—-increased 3 percent 

or less. 

VA’s noninstitutional long-term care workload—-average daily census—-

for the six services in our review increased by approximately 75 percent 

from fiscal years 1998 through 2003. Workload increased by 4,655 during 

this period to 10,892. (See table 3.) Much of this growth came from 

increases in skilled home health and homemaker/home health aide care—

services that are most likely to help veterans prevent or delay the need for 

nursing home care. One of the services that grew most rapidly was skilled 

home health care which increased by 127 percent during this period. 

Although noninstitutional long-term care workload increased, all veterans 

may not have access to these services because there are limitations in the 

availability of these services. We previously reported a number of 

limitations in access to noninstitutional services that veterans experienced 

in the fall of 2002. At that time some facilities did not offer some of these 

noninstitutional services at all, or offered them only in certain parts of the 

geographic area they served.8

 For example, more than half of VA’s 139 

medical facilities did not provide home-based primary care or adult day 

health care in the fall of 2002.9

 8

U.S. General Accounting Office, VA Long-Term Care: Veterans’ Access to 

Noninstitutional Care Is Limited by Service Gaps and Facility Restrictions GAO-03-815T

(Washington, D.C.: May 22, 2003), and U.S. General Accounting Office, VA Long-Term 

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

Care GAO-03-487 (Washington, D.C.: May 9, 2003). 

9

We reported on 139 medical facilities, even though VA had 172 medical centers, because in 

some instances 2 or more medical centers had 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 had 139 facilities. 

VA Noninstitutional 

Long-Term Care 

Workload Increased 
Page 12 GAO-04-425T 

Table 3: Change in Noninstitutional Long-Term Care Workload Provided or Paid for by VA in Fiscal Years 1998-2003 

Type of noninstitutional service 1998 1999 2000 2001 2002 2003 Change 1998-2003 

Home-based primary care 923 964 890 908 903 944 21 

Adult day health carea 1,023 1,215 1,106 1,201 1,310 1,220 197 

Homemaker/home health aide 2,385 3,141 3,080 3,824 4,180 4,317 1,932 

Skilled home health care 1,906 2,148 2,555 3,273 3,851 4,332 2,426 

Home respite care b b b b b 2 2 

Home hospice care b b b b b 77 77 

Totalc 6,237 7,468 7,631 9,206 10,244 10,892 4,655 

Source: VA and GAO analysis of VA data. 

Note: Workload is measured by average daily census which represents the total number of visits of 

noninstitutional care provided in a year divided by the number of days in the year. The average daily 

census calculation for adult day health care uses 251 rather than 365 days because this service is not 

always provided 7 days a week. 

a

 Numbers include contracted adult day health care and VA-provided adult day health care. 

b

 Data not available. 

c

 Total workload is not a measure of unique patients daily because the same patient may receive 

more than one service in the same day. 

The noninstitutional workload numbers for home-based primary care in 

table 3 are different from those reported by VA in its appropriations 

submissions to Congress and in recent VA testimony.10 In its reports on 

noninstitutional workload, VA has measured home-based primary care 

services using enrolled days—-the number of days a veteran is enrolled to 

receive a service—-rather than the number of home-based primary care 

visits a veteran receives. However, VA has measured use of the other 

noninstitutional services in visits. Therefore, to ensure comparability 

across services, we used visits as the workload measure for home-based 

primary care. As a result, our workload total for home-based primary care 

is smaller than the number VA reports because veterans do not typically 

receive a home-based primary care visit for each day in which they are 

enrolled in home-based primary care. Specifically, we report the 2002 

home-based primary care workload as 903 while VA has reported it as 

 10House Subcommittee on Health, Committee on Veterans’ Affairs, Statement of the Under 

Secretary for Health, Department of Veterans Affairs, VA’s Long-Term Care Programs, 

108th Congress, 1st session, May 22, 2003, Department of Veterans Affairs FY 2004 Budget 

Submission: Medical Programs Volume 2 of 5 Final (Washington, D.C.: March 2003), 2-

148, and Department of Veterans Affairs FY 2002 Budget Submission: Medical Programs 

Volume 2 of 6 (Washington, D.C.: April 2001), 2-101.
Page 13 GAO-04-425T 

8,081. Our consistent measure of all services in visits results in a lower 

total noninstitutional workload than that reported by VA. 

Over the last 6 years, the veteran population most in need of long-term 

care has grown dramatically. During this period, VA’s use of nursing home 

care by setting has changed so that state veterans’ nursing homes now 

provide one-half of all nursing home workload provided or paid for by VA. 

At the same time, VA decreased the workload it serves in its own nursing 

homes consistent with VA’s policy to emphasize short-stay, post-acute care 

in its own nursing homes. VA also used community nursing home care less 

as it transitioned more veterans who needed such care to care paid for by 

other payers such as Medicaid. In addition, VA increased the long-term 

care workload provided in noninstitutional settings. 

These trends over the last 6 years raise important questions for how VA is 

meeting current long-term care need and what it may need to do to meet 

future long-term care need. 

• What does the significant variation in nursing home workload change 

among the networks over this 6-year period mean for meeting veterans’ 

long-term care needs in different parts of the country? 

• What are the implications for access, quality, and costs of VA’s significant 

shift to using state veterans’ nursing homes to provide one-half of its 

nursing home care? 

• How has VA’s increased emphasis on post-acute care in its own nursing 

homes affected its ability to continue providing long-term care in its 

nursing homes for veterans with chronic disabilities? 

• To what extent does total VA long-term care workload—-composed of a 

fairly constant nursing home workload and a rapidly expanding but 

smaller noninstitutional workload—-meet the needs of a rapidly growing 

elderly veteran population? 

The continuing rapid rise in the veteran population likely to be in greatest 

need of long-term care—-those 85 years and older—-poses a major 

challenge for VA health care. Answers to these four questions can help 

policymakers, VA, and its stakeholders better understand the best ways to 

meet VA’s long-term care challenge. We look forward to continuing to 

work with you on these significant issues. 

Concluding 

Observations 
Page 14 GAO-04-425T 

Mr. Chairman, this concludes my prepared remarks. I will be pleased to 

answer any questions you or other Members of the Committee may have. 

For further information regarding this testimony, please contact me at 

(202) 512-7101. Individuals making key contributions to this testimony 

include James C. Musselwhite, Thomas A. Walke, and Pamela A. Dooley. 

Contact and 

Acknowledgments 
Page 15 GAO-04-425T 

VA Long-Term Care: Veterans’ Access to Noninstitutional Care Is 

Limited by Service Gaps and Facility Restrictions. GAO-03-815T. 

Washington, D.C.: May 22, 2003. 

VA Long-Term Care: Service Gaps and Facility Restrictions Limit 

Veterans’ Access to Noninstitutional Care. GAO-03-487. Washington, D.C.: 

May 9, 2003. 

Department of Veterans Affairs: Key Management Challenges in Health 

and Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003. 

Long-Term Care: Availability of Medicaid Home and Community 

Services for Elderly Individuals Varies Considerably. GAO-02-1121. 

Washington, D.C.: September 26, 2002. 

Medicare: Utilization of Home Health Care by State. GAO-02-782R. 

Washington, D.C.: May 23, 2002. 

VA Long-Term Care: The Availability of Noninstitutional Services Is 

Uneven. GAO-02-652T. Washington, D.C.: April 25, 2002. 

VA Long-Term Care: Implementation of Certain Millennium Act 

Provisions Is Incomplete, and Availability of Noninstitutional Services 

Is Uneven. GAO-02-510R. Washington, D.C.: March 29, 2002. 

VA Long-Term Care: Oversight of Community Nursing Homes Needs 

Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001. 

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