United States General Accounting Office

GAO Report to the Ranking Minority Member,

Committee on Veterans’ Affairs,

U.S. Senate

March 1996 VETERANS’ HEALTH

CARE

VA’s Approaches to

Meeting Veterans’

Home Health Care

Needs

G O A

years

1921 - 1996

GAO/HEHS-96-68

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-257587 

March 15, 1996

The Honorable John D. Rockefeller, IV

Ranking Minority Member

Committee on Veterans’ Affairs

United States Senate

Dear Senator Rockefeller:

In fiscal year 1994, the Department of Veterans Affairs (VA) provided or

facilitated the delivery of home health care services to more than 40,000

veterans at a cost of $64 million to VA and millions more to Medicare. By

providing veterans with home health care services, VA allows these

veterans to continue living at home and in their community, rather than

caring for them in an institutional setting. Veterans may need home health

care for a variety of reasons: Older veterans may have chronic medical

conditions, such as heart disease, and need periodic attention to remain

living at home. Others may be discharged from VA medical centers

following treatment for illness or injury and continue to need such care as

the changing of dressings or administration of medications. The number of

veterans needing home health care is expected to grow as the veteran

population ages and as VA more quickly discharges patients from its

hospitals to reduce the costs of hospitalization.

Because of your interest in this important service for veterans, you asked

us to develop information on how VA meets veterans’ home health care

needs. We are providing information on (1) the characteristics and

services of the home health care programs VA uses, (2) the available data

describing program costs, and (3) how VA ensures that veterans receive

quality home health care services.

We did our work at 3 of VA’s 173 hospitals, in Boston and West Roxbury,

Massachusetts, and in Tampa, Florida. As part of our work, we visited 30

veterans in their homes to understand better how home health care

services are provided. Additionally, we sent a questionnaire to 158 VA

medical centers1 and 7 other VA health care facilities asking for

information on how they provide and evaluate home health care services

for veterans. (See app. I for more detail on our methodology.) We

performed this review from May 1994 to December 1995 in accordance

with generally accepted government auditing standards.

1

Several medical centers have more than one hospital.

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Results in Brief VA’s efforts to meet veterans’ home health care needs focus on providing

long-term services to address veterans’ chronic medical conditions as well

as shorter-term services to address their acute medical conditions. VA’s

Hospital-Based Home Care (HBHC) program most often provides primary

care to those with chronic conditions. Under HBHC, VA staff provide

in-home physician, nursing, social work, and dietician services to veterans

who often need such services for a year or longer. Veterans requiring

short-term, skilled care, often following a stay in a VA hospital for an acute

medical condition, generally receive services from community-based

providers. VA either arranges for Medicare to pay for eligible veterans to

receive home care from community-based providers or, under its

fee-based program, pays community-based providers itself to provide care

to those who are not eligible for Medicare.

VA data portray the costs of VA’s HBHC and fee-based programs differently.

For example, VA’s fee-based program cost figures represent payments

made to community-based providers but exclude administrative and other

costs associated with patients; HBHCs’ cost figures, on the other hand,

include administrative costs. Lacking useful cost data, VA hospital

administrators are making decisions about whether or not to have an HBHC

program on the basis of their perceptions of the relative costs of VA’s HBHC

and community-based programs.

Regardless of which home health care program is used, VA monitors the

quality of care provided, but it monitors care provided by its HBHC

programs more directly than it does the community-based care.

Nevertheless, licensing and certification assessments of community-based

providers give VA some assurance that veterans receive care from qualified

home health care providers. In addition, Medicare has primary

responsibility for ensuring that community-based providers provide quality

care to Medicare-eligible veterans for whom VA arranges such care.

Background VA arranges for the delivery of home health care services to veterans

through two methods. Under its HBHC programs, teams of VA hospital staff

deliver primary care services directly to veterans in their homes. Under

VA’s second method, community-based providers deliver home health care

services to veterans. VA pays for these community-based provider services

through its fee-based home health services program unless the veteran is

covered by Medicare’s home health care benefit. Generally, for these

veterans, VA hospital staff facilitate the delivery of these services and

Medicare pays for them.

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Begun in July 1972, VA’s HBHC program consists of individual HBHC

programs affiliated with hospitals and medical centers around the country.

HBHC is an extended care program designed to meet the long-term care

needs of veterans who have chronic multiple medical and psychosocial

problems, a terminal illness, or a need for post-hospital rehabilitation or

monitoring. The objectives of the program are to provide primary care

services to homebound patients in their homes; create a therapeutic and

safe home environment; support the caregiver—the veteran’s spouse,

other family member, or friend—in caring for the patient; reduce the need

for, and provide an alternative to, hospitalization or other

institutionalization; promote timely discharge of patients from hospitals or

nursing homes; and provide an academic and clinical setting for students

of the health professions. Veterans may or may not be charged a fee for

HBHC services, depending upon their eligibility for outpatient services. In

fiscal year 1994, VA served 9,953 veterans under this program.

VA’s fee-based home health services program pays community-based

providers to provide home health care services to veterans who received

inpatient care for an acute condition at a medical center and have been

discharged. It also pays for skilled medical treatment for other veterans

entitled to VA medical care. Whether veterans are charged fees for services

under this program depends upon their eligibility for outpatient services.

In fiscal year 1994, VA served 12,800 patients under this program.

In addition to the veterans receiving hospital-based and fee-based care, VA

facilities referred at least 19,000 Medicare-eligible veterans to

Medicare-certified health care agencies in fiscal year 1994.

For hospitals with an HBHC program, the decision about whether a patient

receives HBHC or community-based care is made by hospital staff on the

basis of such factors as the patient’s medical condition and the types of

services needed. If HBHC would best meet the patient’s needs, staff would

try to use that program to provide home health care. If the hospital does

not have an HBHC or if staff determine that community-based care would

meet the veteran’s needs, the next step is determined by the veteran’s

Medicare eligibility. Generally, if a veteran’s care would not be covered by

Medicare, VA will pay for a veteran’s home health care services under the

fee-based program. VA staff facilitate the delivery of home health care to

veterans with Medicare coverage by referring them to community-based

providers with the understanding that Medicare will pay for their services.

However, VA continues to provide all medical care follow-up, drugs, and

supplies that are not paid for by Medicare.

Page 3 GAO/HEHS-96-68 Veterans’ Home Health Care
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Characteristics and

Services of VA’s HBHC

Programs

VA hospitals are not required to have HBHC programs, and most do not. In

fiscal year 1995, VA operated 74 HBHC programs: 73 of its 173 hospitals had

an HBHC program, and one additional program was operated by an

outpatient clinic. A VA hospital can operate an HBHC program if it meets

certain criteria and receives VA approval. For example, guidance from VA’s

Central Office requires hospitals to demonstrate that they discharge a

required number of veterans with specified medical conditions and that

they have staff to provide services to the veterans once they are

discharged. Hospitals may also terminate their HBHC programs in response

to other demands on their staff and budget. Between fiscal years 1990 and

1995, the number of programs increased from 72 to 74, with five VA

hospitals initiating HBHC programs and three terminating their programs

during this time.

HBHC patients tend to be chronically ill and in need of long-term care,

although some may be terminally ill or need short-term care following

hospitalization. In fiscal year 1994, half of the HBHC programs reported to

VA that their patients had an average age of 71 years or less. There is no

limit on how long veterans may stay in the program. During fiscal year

1994, half the questionnaire respondents that had an HBHC program

indicated that their patients stayed in the program an average of 7 months

or less. As of March 31, 1995, about 44 percent of the patients had been in

the program 1 year or longer.

In order to qualify for HBHC services, veterans

• must be homebound;

• should have a caregiver—such as a spouse, family member, significant

other, or friend—to assist with their care;

• must live within a defined geographic area—usually a 30-mile radius of the

hospital;

• must generally only need services Monday through Friday during normal

working hours; and

• must be entitled to VA medical care.

Under the HBHC program, an interdisciplinary team of VA hospital staff

delivers primary care services to veterans in their homes. A typical

program consists of several nurses, a social worker, a coordinator, a clerk,

and the part-time services of a physician and dietician. Some programs

also have a physical therapist, occupational therapist, or home health

technician.

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B-257587 

Skilled nursing is the predominant service of HBHC programs: 99 percent of

the HBHC programs report providing this service.2

 Skilled nursing includes

such activities as changing dressings, teaching patients how to manage

their medical problems, administering medications, and drawing blood

samples for laboratory analysis. Nursing services are provided in

accordance with the patient’s plan of care.

HBHC social workers provide psychosocial services, such as counseling and

resolution of social and emotional problems that affect treatment or

impede medical recovery. Ninety-six percent of the HBHC programs provide

these services to veterans in their homes, according to questionnaire

respondents from hospitals with HBHC programs.

HBHC physicians usually work in the programs on a part-time basis and

have primary medical responsibility for all HBHC patients. Their

responsibilities include identifying the patients’ medical problems,

defining the medical management of the problems, and determining

whether to admit HBHC patients to the medical center. Approximately

80 percent of the respondents said their HBHC program provides physician

services in veterans’ homes.

Dietician services are another important component of HBHC programs,

with almost 9 out of every 10 programs reporting that their dieticians make

home visits. HBHC dieticians assess patients’ nutritional needs over time in

relation to changes in their condition. They also teach patients and their

caregivers how to adapt and modify their food preparation practices.

Responses to our questionnaire showed that most HBHC programs in fiscal

year 1995 did not provide skilled physical, occupational, or speech

therapy; home health aide services; or pharmacy services to veterans in

their homes.

In fiscal year 1994, VA reported expenditures of $36.6 million on this

program.

2

We did not determine how frequently veterans used services provided under the home health care

approaches used by VA.

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Characteristics and

Services of the

Community-Based

Programs

Most veterans receive home health care services from community-based

providers through either VA’s fee-based program or Medicare’s home

health care benefit. These veterans tend to need short-term home health

care associated with an acute medical condition, although some have

longer-term needs. Many of the services commonly provided by the

fee-based program and Medicare are the same, but more types of services

are generally available to veterans covered by Medicare.

VA’s Fee-Based Program Nearly all VA hospitals used the fee-based program in fiscal year 1995 to

purchase skilled home health care services from community-based

providers. Most veterans in this program receive short-term home health

care services to address acute medical conditions, such as hip fractures or

surgical wounds. Some veterans, however, receive long-term home health

care services to address chronic conditions, as in the case of a patient with

Parkinson’s disease, for example, who has an ongoing need for skilled

services, such as intramuscular injections.

Half of our questionnaire respondents reported that their fee-based

patients in fiscal year 1994 had an average age of 61 years or less. VA will

authorize payment to community providers for a maximum of 12 months

following a veteran’s hospital discharge, and reauthorization can be

extended upon the approval of a VA physician. During fiscal year 1994, half

of our questionnaire respondents indicated that their fee-based patients

had an average length of stay in the program of 90 days or less.

To qualify for this program, veterans must be entitled to VA medical care.

Veterans are not required, however, as in the HBHC program, to have a

caregiver at home, live within a certain distance of the hospital, or

generally need services only during certain hours of the work week.

Skilled nursing is the predominant service covered by the fee-based

program. Nearly all respondents to our questionnaire said that they usually

purchase skilled nursing services for veterans.

Physical, occupational, and speech therapy services are each purchased

for patients in the fee-based program in over half of the medical centers,

according to questionnaire respondents. Physical therapists work with

patients to improve their capacity to perform simple daily activities, and

occupational therapists assess patients’ rehabilitation needs, develop plans

of care, and provide training. Speech therapists help patients such as

stroke victims improve their ability to communicate.

Page 6 GAO/HEHS-96-68 Veterans’ Home Health Care
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The fee-based program also covers the services of physicians and

psychologists. However, only about one-fifth or fewer of the respondents

said that they usually purchase these services under the fee-based

program.

Although VA cannot use fee-based program funds for home health aide

services, 22 percent of the respondents said they provide this service to

veterans in that program.3

 Medical centers can pay for these services

through VA’s Homemaker/Home Health Aide program.4

In fiscal year 1994, VA reported payments of $27.3 million on fee-based

home health care services.

Medicare’s Home Health

Care Benefit

Most respondents to our questionnaire indicated that they refer veterans

covered by Medicare’s home health care benefit to community-based

providers. Most people who receive Medicare home health care benefits

do so for services associated with an acute medical condition, often

following hospitalization. Since 1989, however, Medicare has been

providing more long-term home health care services to chronically

disabled elderly beneficiaries. VA officials told us that Medicare-eligible

veterans follow the same basic pattern, with most receiving short-term

home health care services around an acute medical condition requiring

hospitalization. We were unable to determine how long veterans referred

by VA hospitals received Medicare-funded home health care. However, in

1992, about three-quarters of the general Medicare population that used

the home health care benefit received services for fewer than 120 days; the

average duration of services for these beneficiaries was 42 days.

To qualify for Medicare home health care coverage, beneficiaries must be

eligible for Medicare (almost all elderly and some disabled people),

homebound, in need of skilled nursing or therapy services on a part-time

or intermittent basis, and under the care of a physician who prepares and

periodically reviews their care plan. The VA physician usually fulfills

Medicare’s physician requirement for veterans discharged from a VA

hospital. Unlike the HBHC program, Medicare does not require beneficiaries

3

Under its Spinal Cord Injury program, VA may pay for home health aides who provide bowel and

bladder care for quadriplegic veterans.

4

Through the Homemaker/Home Health Aide program, VA hospitals can spend up to 15 percent of their

Community Nursing Home program funds on homemakers and home health aides for veterans residing

at home. This includes veterans in the fee-based and HBHC programs. During fiscal year 1995, 122

medical centers participated in this program. Expenditures totaled approximately $15 million, or about

4 percent of the Community Nursing Home budget.

Page 7 GAO/HEHS-96-68 Veterans’ Home Health Care
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to have a caregiver at home or live within a certain radius of the hospital

that discharged them.

Skilled nursing and home health aide services—along with physical

therapy, occupational therapy, speech therapy, and medical social

services—are the home health care services that VA usually facilitates for

veterans covered by Medicare. Approximately 70 percent or more of the

respondents to our questionnaire indicated that they facilitate the delivery

of these services.

Physician, dietician, and pharmacy services are not covered under

Medicare’s home health care benefit. However, physician services are

covered by other parts of the Medicare program; pharmacy and dietician

services may be covered by Medicare under some circumstances.

Medicare, and not VA, pays for community-based providers to deliver home

health care services to veterans covered by Medicare’s home health care

benefit. VA incurs some administrative costs in referring patients to

Medicare, as well as the costs of VA physicians’ developing and reviewing

plans of care, but VA does not separately identify these costs.

Cost Data for VA’s

Home Health Care

Programs Portrayed

Differently

Data on the costs of VA’s home health care programs are reported

differently, both among HBHCs and between HBHCs and fee-based programs.

As a result, to the extent that VA administrators make decisions about

whether to have an HBHC program on the basis of the relative costs of

HBHCs and fee-based programs, they do so on the basis of their perceptions

of cost rather than comparable data.

HBHC program costs are based on data developed by the hospitals that

support the programs. VA Central Office officials told us that hospitals

have wide latitude in deciding which costs to charge to their HBHC

programs. This results in different cost charges among the 74 HBHC

programs. For example, some HBHC programs include costs of librarians or

chaplains, while others include costs of anesthesiologists or optometrists.

In addition, hospitals commonly charge costs to their HBHC programs for

certain administrative support functions, such as costs for a portion of one

full-time-equivalent staff person in the Office of the Chief of Staff. One

hospital, for example, charged $8,600 for support from the Chief of Staff’s

Office in fiscal year 1994. However, we found another case in which a

hospital charged $80,500 for approximately 2 full-time-equivalent staff

from the Chief of Staff’s Office. A VA Central Office official agreed that a

Page 8 GAO/HEHS-96-68 Veterans’ Home Health Care
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charge this high was an error. Central Office officials further stated that

they discuss questionable charges that appear in VA’s cost reports with

hospital staff but that it is up to the hospitals to appropriately allocate

costs.

VA’s reported costs of its fee-based program, on the other hand, represent

payments made to community-based providers but exclude costs such as

program administration and other indirect costs associated with caring for

veterans in this program. For example, costs for staff who administer the

program are included in the operating costs of the hospitals where the

staff work and are not identified as a cost of the fee-based program. In

addition, approximately 70 percent of our questionnaire respondents

stated that they case-manage fee-based patients, yet costs associated with

case management are not included in the fee-based program.

Since VA reports the costs of its programs differently, VA hospital officials

are left to make decisions on whether or not to have an HBHC program

based on their perceptions of the relative cost of HBHC and fee-based

programs. These perceptions vary widely. For example, about 3 years ago,

the Tampa HBHC program began treating patients who previously would

have received fee-based care. One reason for doing so was to reduce the

costly fee-based payments for nursing services. The Kansas City Missouri

hospital, on the other hand, terminated its HBHC program in 1994 and

referred some of its HBHC patients to community-based providers. A former

HBHC official told us that hospital administrators believed that it was less

costly to pay for community-based services than for an HBHC program.

Respondents to our questionnaire also expressed very different views

regarding costs and why they either have or do not have an HBHC program.

Over three-fourths of the questionnaire respondents with an HBHC program

stated that one reason their medical center has an HBHC program is that it

is less costly than purchasing fee-based services. Conversely,

approximately half of the respondents without an HBHC program said that

one reason they do not have an HBHC program is that it would be more

costly than community-based care purchased under the fee-based

program.

Respondents to our questionnaire also expressed very different views on

whether HBHC was more cost effective as compared with community-based

care. In this instance, cost-effectiveness refers not only to the actual costs

incurred in treating a veteran but also to the effectiveness of the care. For

example, who has fewer hospital admissions and shorter hospital stays:

Page 9 GAO/HEHS-96-68 Veterans’ Home Health Care
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HBHC patients receiving primary care services or patients receiving skilled

services from community-based providers? About 40 percent of our

respondents said they had no basis to judge whether HBHC was more or

less cost effective than community-based care. The remaining respondents

were evenly divided on which method of providing home health care to

veterans was the more cost effective.

Quality Assurance

Approaches for VA

Programs and

Medicare

VA monitors the quality of care provided by its home health care programs,

but it is more directly involved in monitoring the care its own employees

provide, through HBHC, than the care delivered by community-based

providers. Licensing and certification assessments of community-based

providers conducted by independent organizations provide VA some

assurance that veterans in the fee-based program and those covered by

Medicare’s home health care benefit receive care from qualified home

health care providers.5 HBHC programs are assessed by outside

organizations as well, but in addition, they use case management and

quality indicators to evaluate the care they deliver.6

 Medical centers are

less likely to use these additional means to monitor the quality of care

delivered by community-based providers.

Medicare has the primary responsibility for ensuring that quality care is

furnished under its home health care benefit. Medicare requires

community-based providers to have internal quality assurance programs.

Moreover, Medicare requires VA physicians referring patients to prepare

and review plans of care.

Assessment of HBHC and

Community-Based

Providers

All HBHC programs are accredited by the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO) and are subject to a

performance review every 3 years. JCAHO staff apply standards contained in

their Accreditation Manual for Home Care to evaluate how well the home

health care provider assessed the patient’s service needs, planned for the

patient’s care, and monitored the patient’s response to the care provided.

Before 1995, JCAHO’s reviews did not measure actual outcomes of care but

instead focused on processes and the capacity of a provider to deliver

quality care. JCAHO’s 1995 standards, however, place more emphasis on

outcomes of care.

5

We did not review individual state licensing requirements, which vary by state, or compare them with

Medicare’s certification requirements.

6

We did not determine the extent to which community-based providers case manage their patients or

use quality indicators to evaluate the care they deliver.

Page 10 GAO/HEHS-96-68 Veterans’ Home Health Care
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Community-based home health care providers that are certified to treat

Medicare beneficiaries are assessed at least once every 15 months by a

state survey agency (usually a component of the state health department),

by JCAHO, or by the National League for Nursing’s Community Health

Accreditation Program (CHAP). These surveys are intended to ensure that

Medicare beneficiaries receive care from qualified home health care

providers. State survey agencies, under contract with the Health Care

Financing Administration (HCFA), which administers Medicare, survey

community-based providers7

 to determine if they meet Medicare’s

conditions of participation. These conditions cover such topics as

acceptance of patients, medical supervision, and skilled nursing services.

Survey staff visit home health care providers and examine organizational,

functional, personnel, and patient records and visit with patients in their

homes to evaluate the quality and scope of services provided. Home health

care providers that meet JCAHO’s or CHAP’s standards are also deemed to

have met Medicare’s conditions of participation. Thus, veterans in HBHC

programs and those receiving home health care services covered by

Medicare are assured of receiving care from Medicare-certified providers.

Most, but not all, fee-based patients also receive care from

Medicare-certified providers. About 83 percent of the respondents to our

questionnaire said they purchase care from Medicare-certified providers

most, almost all, or all of the time for their fee-based patients. For

example, the three hospitals we visited use only Medicare-certified home

health care providers. These hospitals select the providers on the basis of

factors such as which providers serve the area where the veteran needing

home health care lives, whether the provider is Medicare-certified, and

whether the hospital’s past experience with the provider has been positive.

However, fee-based patients who are paralyzed do not always receive care

from Medicare-certified providers because the fee-based program allows

family members who have been trained and certified by VA to deliver

bowel and bladder care to quadriplegic veterans. Also, a VA Central Office

official told us that there are not enough Medicare-certified providers in

some areas of the country.

Case Management VA’s programs also employ case management to ensure quality care. Case

management, in general, involves coordinating the services needed by and

provided to a patient. Case management may address only a veteran’s

health needs or the total needs of a veteran and his or her family.

Similarly, case management may be limited to the process of arranging

7

At the end of 1994, the number of Medicare-certified home health care providers totaled 7,864.

Page 11 GAO/HEHS-96-68 Veterans’ Home Health Care
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initial services or may be an ongoing process for the duration of an illness.

Not everyone discharged to home health care from a hospital needs case

management; some veterans and their families may act as their own case

managers. When case management is appropriate, it is seen as important

to the adequacy of the home health care veterans receive: 68 percent of the

questionnaire respondents said that case management greatly improves

the adequacy of care patients receive.

The way in which a veteran’s care is managed by VA may differ somewhat

depending upon the program that is providing for the veteran’s services.

Nearly all (96 percent) of the respondents with HBHC programs said that

they typically case manage patients and that nurses are usually the

primary case managers. For veterans receiving fee-based services, most

respondents (73 percent) said the VA physician who orders the home

health care reviews the provider’s periodic reports on the patient’s health

status most, almost all, or all of the time, and 62 percent said someone

(most often a nurse) serves as a case manager for patients. For veterans

receiving care paid for by Medicare, about the same number of

respondents (72 percent) said the VA physician who orders the home

health care reviews the provider’s periodic reports most, almost all, or all

of the time, but fewer (49 percent) said that someone (usually a nurse)

case manages the patient’s care.

Respondents also described different primary functions of case managers

in the different programs, as shown in table 1. Nearly all respondents with

an HBHC program said that their case managers performed the primary

functions listed in the table, while respondents without an HBHC program

indicated that their case managers were much less likely to perform these

functions. The greatest difference among respondents was that evaluating

the patient’s home environment was much less likely to be a primary

function of the community-based program case manager than it was to be

a function of the HBHC case manager.

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Table 1: Primary Functions of VA Case

Managers in the HBHC and Fee-Based

Programs and Under the Medicare

Home Health Care Benefit

Percent of respondents who said

this was a “primary function” of

their case managers

Case management function

HBHC

program

Fee-based

program

Medicare

benefit

Participate with provider staff in initially

assessing needs of patients 90 46 44

Coordinate development, evaluation, and review

of patient care plans 94 53 43

Evaluate patient’s home environment 85 21 14

Evaluate ability of caregiver to meet the care

needs of the patient 90 39 34

Monitor and manage the overall delivery of care

to patient 92 43 32

Review and assess periodically the medical

condition of the patient with provider staff 92 54 41

The HBHC and community-based programs we visited replicated the

difference in primary case management functions described in the

questionnaires. Case management at the Boston and Tampa HBHC

programs involves each of the six functions cited in table 1. For example,

each program holds team meetings at least weekly to discuss veterans’

status and needs. The Boston, Tampa, and West Roxbury hospitals also

case manage patients in their community-based programs, but the

management is not as extensive as that conducted by HBHC programs. For

example, case management at West Roxbury is limited to defining a plan

of care and arranging for the veteran to receive it. At the Tampa hospital,

case managers participate with community provider staff in assessing the

care needs of patients, coordinate development of patient care plans, and

periodically review patients’ medical conditions with community provider

staff. However, case managers at Tampa do not have the primary functions

of directly monitoring and managing the overall delivery of home health

care services provided patients under the fee-based or Medicare programs

or, for those patients covered by Medicare, directly evaluating the patient’s

home environment and ability of the caregiver to meet the care needs of

patients.

Our discussions with medical center staff in the three locations we visited

suggest some additional reasons why the primary functions of case

management in the community-based programs may differ from those in

HBHC. First, case managers for veterans receiving community-based care

may also be responsible for a variety of other functions, leaving less time

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to devote to case management. For example, a Tampa medical center

nurse who manages veterans’ cases in the fee-based and Medicare

programs told us that she coordinates services for two other sets of

veterans as well: those that need hospice services and those that are in

contract nursing homes. None of the HBHC case managers we spoke to told

us that they had similar responsibilities for veterans outside of the HBHC

program. Second, medical center case managers may be responsible for

arranging home health care services for a large number of veterans as

compared with the number of veterans managed by HBHC case managers,

which would also leave them less time to devote to case management

functions. The two nurse case managers at the Boston medical center, for

example, referred 1,074 veterans to community providers in fiscal year

1994. In contrast, Boston’s three HBHC case managers were responsible for

case managing and providing care to 112 veterans that same year.

Quality Indicators Another way VA assesses veterans’ care is by monitoring performance

indicators that VA believes are related to the quality of care provided. For

example, if a provider frequently used by a VA hospital has high rates of

patient deaths or patients’ being readmitted to the hospital, visiting an

emergency room, falling, having impaired skin integrity, or getting an

infection, this may reflect a problem with the care being provided. Patient

satisfaction is also useful as a way of assessing the quality of care. For

example, one HBHC program we visited set a standard that at least

90 percent of its veterans would be satisfied with their care, as measured

by a patient satisfaction survey. In the fourth quarter of fiscal year 1994,

99.5 percent of the veterans surveyed said that they were satisfied with

their care. Indicators such as these are useful to assess performance,

identify problems, develop corrective actions, and monitor the

effectiveness of the changes made.

As table 2 shows, more medical centers track selected quality indicators

for their HBHC programs than for their community-based programs.8

 We did

not ask how often the community-based providers themselves track these

indicators for their patients.

8

The table lists only those indicators we included in our questionnaire; it does not provide a

comprehensive list of all indicators that might be used by a medical center.

Page 14 GAO/HEHS-96-68 Veterans’ Home Health Care
B-257587 

Table 2: Quality Indicators Used in

VA’s HBHC and Fee-Based Programs

and for Medicare’s Home Health Care

Benefit Quality indicator

Percentage of medical centers that

reported tracking each indicator

HBHC

program

Fee-based

program

Medicare

benefit

Patient deaths 70 31 29

Visits to the medical center’s emergency

department 52 22 18

Visits to other hospitals’ emergency departments 41 14 10

Hospital readmissions 66 36 31

Falls 89 15 14

Impaired skin integrity 70 22 24

Infection rates 93 17 13

Patient satisfaction 97 62 59

Although VA hospitals less often track these quality indicators for

community-based providers and patients receiving their care from those

providers, they do take other steps to ensure that veterans in

community-based programs receive quality care. Eighty percent of

questionnaire respondents stated that they have periodic telephone or

personal contacts with provider staff most, almost all, or all of the time to

discuss the health status of veterans in the fee-based program, and

65 percent said that they have similar contacts for veterans that are

covered by Medicare’s home health care benefit. About 80 percent said

that they require providers to submit periodic written reports regarding

the health status of veterans in the fee-based program most, almost all, or

all of the time, and about 70 percent said they ask for similar reports for

those veterans in the Medicare program. Further, VA officials told us that

hospitals evaluate patients’ medical conditions when they have an

inpatient or outpatient visit at the hospital.

Observations Because VA’s home health care programs provide different arrays of

services to veterans who generally have different home health care needs

and because consistent program cost data are not available, it is difficult

to compare the relative costs of VA’s methods of meeting veterans’ home

health care needs. And although VA itself more directly monitors care

provided under its HBHC program, the quality of care furnished by

community-based providers paid for by both VA and Medicare is evaluated

in other ways—including by HCFA as part of its responsibility for

administering the Medicare program.

Page 15 GAO/HEHS-96-68 Veterans’ Home Health Care
B-257587 

Agency Comments

and Our Evaluation

We obtained comments on a draft of this report from VA officials, including

the Deputy Under Secretary for Health. The officials noted that the lack of

consistent cost data, in this case for the various types of home health care

provided, is a problem not unique to VA and is a challenge for all health

care providers. They said that VA, in making improvements to its financial

management and information systems, is attempting to better identify

costs associated with all of its programs, including each component of its

home health care programs.

The officials also told us that VA is developing performance measures that

will allow managers at multiple levels to understand and identify desired

program outcomes. Once these outcomes are in place, managers will be

accountable for meeting them in the most cost-effective and efficient

manner. VA officials also said that they intend to do cost-benefit analyses

for home health care and other programs, once enough data are available.

The VA officials additionally suggested some technical changes, primarily

for clarification, which we incorporated as appropriate.

As arranged with your staff, unless you announce its contents earlier, we

plan no further distribution of this report for 7 days after its issue date. At

that time, we will send copies to the Secretary of Veterans Affairs, the

Senate and House Committees on Appropriations, and other interested

parties. We will also make copies available to others upon request.

This report was prepared under the direction of James Carlan, Assistant

Director, Health Care Delivery and Quality Issues. If you or your staff have

any questions concerning this report, please contact Robert Dee, the

evaluator-in-charge, at (617) 565-7470. Other staff contributing to this

report were Sally Coburn, Patricia Jones, Clarita Mrena, Joan Vogel, and

Leonard Hamilton.

Sincerely yours,

Carlotta C. Joyner

Associate Director, Health Care Delivery

 and Quality Issues

Page 16 GAO/HEHS-96-68 Veterans’ Home Health Care
Page 17 GAO/HEHS-96-68 Veterans’ Home Health Care
Contents

Letter 1

Appendix I 

Scope and

Methodology

20

Appendix II 

VA Medical Centers

With HBHC Programs

and Their Fiscal Year

1995 Staffing

Authorizations

22

Tables Table 1: Primary Functions of VA Case Managers in the HBHC

and Fee-Based Programs and Under the Medicare Home Health

Care Benefit

13

Table 2: Quality Indicators Used in VA’s HBHC and Fee-Based

Programs and for Medicare’s Home Health Care Benefit

15

Abbreviations

CHAP Community Health Accreditation Program

HBHC Hospital-Based Home Care

HCFA Health Care Financing Administration

JCAHO Joint Commission on Accreditation of Healthcare

Organizations

VA Department of Veterans Affairs

Page 18 GAO/HEHS-96-68 Veterans’ Home Health Care
Page 19 GAO/HEHS-96-68 Veterans’ Home Health Care
Appendix I 

Scope and Methodology

To develop our description of the ways VA provides home health care, we

obtained both nationally descriptive data and additional data at three

locations. Collecting these data required audit work at VA’s Central Office

as well as at the Boston, Massachusetts, and Tampa, Florida, medical

centers and at the West Roxbury division of the Brockton Medical Center

in Massachusetts. In addition, we reviewed VA’s policies and procedures

for operating its HBHC and fee-based programs as well as Medicare’s

regulations concerning its home health care benefit. We also obtained

various VA reports detailing operations of its HBHC and fee-based programs.

We selected the three hospitals we visited to give us examples of hospitals

that have an HBHC program (the medical centers in Boston, Massachusetts,

and Tampa, Florida) and one that does not (West Roxbury, a division of

the Brockton Medical Center). At these locations, we interviewed staff and

obtained documents about their programs. Additionally, we visited 30

veterans in their homes to understand better how their home health care

services were provided; 12 were receiving HBHC services, while 18 were

receiving community-based services. Of the 12 veterans receiving HBHC

services, 6 were cared for by the Boston HBHC program and 6 by Tampa’s

program. Of the 18 veterans receiving community-based care, we visited 6

discharged by each of the three VA hospitals. Seventeen of the 18 veterans

were covered by Medicare’s home health care benefit, and 1 was covered

by VA’s fee-based program. During our visits, a registered nurse on our

staff interviewed veterans and discussed their care and activities, observed

their medical conditions, and reviewed information from their medical

files. We then discussed our observations with appropriate officials at the

three medical centers.

To obtain nationally representative data about the three home health care

programs, we sent a detailed questionnaire to 158 VA medical center

directors and 7 other VA health care facilities. We asked respondents to

answer questions about their HBHC program, if they had one, and about

their community-based program for health care. The questions covered

general descriptive information, program staffing, patient admissions and

discharges, program services, case management, quality assurance

measures, reasons why they did or did not have an HBHC program, and

other issues. We pretested the questionnaire at three medical centers,

obtained comments from VA officials, and revised it accordingly. A total of

151 medical centers and 6 other VA health care facilities responded to the

questionnaire. We were unable to verify independently most of the

information provided through the questionnaire. However, questionnaire

responses from programs at the three hospitals we visited were consistent

Page 20 GAO/HEHS-96-68 Veterans’ Home Health Care
Appendix I 

Scope and Methodology

with the information we obtained at those locations. In addition,

questionnaire responses were consistent with selected aggregate

information provided by the VA Central Office.

Page 21 GAO/HEHS-96-68 Veterans’ Home Health Care
Appendix II 

VA Medical Centers With HBHC Programs

and Their Fiscal Year 1995 Staffing

Authorizations

Medical center location

Authorized FY 1995

full-time-equivalent

staffinga

Albany, NY 9.70

Albuquerque, NM 6.25

Allen Park, MI 9.40

Asheville, NC 5.00

Atlanta, GA 6.85

Baltimore, MD 11.00

Batavia, NY 7.15

Bay Pines, FL 7.20

Birmingham, AL 9.80

Boston, MA 8.20

Bronx, NY 7.00

Buffalo, NY 12.90

Brooklyn, NY b

Butler, PA 4.90

Castle Point, NY c

Charleston, SC 3.50

Chicago (Lake Side), IL 6.75

Chicago (West Side), IL 7.50

Cleveland, OH 7.20

Columbia, MO 6.50

Dallas, TX 8.00

Danville, IL 5.00

Dayton, OH 5.00

Denver, CO 7.65

Des Moines, IA 5.30

Durham, NC 8.00

East Orange, NJ 5.75

Ft. Wayne, IN 3.00

Fresno, CA 5.00

Gainesville, FL 7.80

Hines, IL 14.65

Honolulu, HI 5.00

Houston, TX 7.75

Indianapolis, IN 8.00

Iowa City, IA 6.13

Lexington, KY 7.75

(continued)

Page 22 GAO/HEHS-96-68 Veterans’ Home Health Care
Appendix II 

VA Medical Centers With HBHC Programs

and Their Fiscal Year 1995 Staffing

Authorizations

Medical center location

Authorized FY 1995

full-time-equivalent

staffinga

Little Rock, AR 13.50

Long Beach, CA 9.70

Madison, WI 7.55

Manchester, NH 5.50

Martinez, CA 8.95

Memphis, TN 9.00

Miami, FL 11.00

Milwaukee, WI 7.75

Minneapolis, MN 12.80

New Orleans, LA 11.00

New York, NY b

Newington, CT 4.88

North Chicago, IL 9.00

Northport, NY 7.90

Oklahoma City, OK 6.85

Palo Alto, CA 7.00

Philadelphia, PA b

Phoenix, AZ 9.60

Pittsburgh, PA 9.60

Portland, OR 8.00

Providence, RI 5.50

Salt Lake City, UT 7.73

San Antonio, TX 8.00

San Diego, CA 8.00

San Francisco, CA 5.75

San Juan, PR 6.30

Seattle, WA 8.25

Sepulveda, CA 10.00

Shreveport, LA 8.00

St. Louis, MO 6.80

Syracuse, NY 6.25

Tampa, FL 8.27

Tucson, AZ 8.00

Washington, DC 10.70

West Haven, CT 3.75

West Los Angeles, CA 4.50

(continued)

Page 23 GAO/HEHS-96-68 Veterans’ Home Health Care
Appendix II 

VA Medical Centers With HBHC Programs

and Their Fiscal Year 1995 Staffing

Authorizations

Medical center location

Authorized FY 1995

full-time-equivalent

staffinga

White River Junction, VT 3.90

Wilkes Barre, PA 4.50

aStaff size is based on the HBHC program’s full-time-equivalent employee authorization.

bThe medical center did not respond to our questionnaire.

cInformation was not provided on the questionnaire received from the medical center.

(101454) Page 24 GAO/HEHS-96-68 Veterans’ Home Health Care
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