Report to Congressional Requesters 

United States General Accounting Office

GAO

May 2003 VA LONG-TERM 

CARE 

Service Gaps and 

Facility Restrictions 

Limit Veterans’ Access 

to Noninstitutional 

Care 

GAO-03-487 
Veterans’ access to the six noninstitutional services we reviewed is limited 

by service gaps and facility restrictions. Of VA’s 139 facilities, 126 do not 

offer all six of these servicesadult day health care, geriatric evaluation, 

respite care, home-based primary care, homemaker/home health aide, and 

skilled home health care. Veterans have the least access to respite care, 

which is not offered at 106 facilities. By contrast, skilled home health care is 

not offered at 7 facilities. Veterans’ access is more limited than these 

numbers suggest, however, because even when facilities offer these services 

they often do so in only part of the geographic area they serve. In fact, for 

four of the six services the majority of facilities either do not offer the 

service or do not provide access to all veterans living in their geographic 

service area. Veterans’ access may be further limited by restrictions that 

individual facilities set for use of services they offer. For example, at least 9 

facilities limit veterans’ eligibility to receive noninstitutional services based 

on their level of disability related to military service, which conflicts with 

VA’s eligibility standards. Further, restrictions placed by many facilities on 

the number of veterans who can receive noninstitutional services have 

resulted in veterans at 57 of VA’s 139 facilities being placed on waiting lists 

for noninstitutional services. 

Noninstitutional Long-Term Care Services Not Available to All Veterans, Based on 

Geographic Areas, at VA’s 139 Facilities as of Fall 2002 

VA’s lack of emphasis on increasing access to noninstitutional long-term 

care services has contributed to service gaps and individual facility 

restrictions that limit access to care. Without emphasis from VA 

headquarters on the provision of noninstitutional services, field officials 

faced with competing priorities have chosen to use available resources to 

address other priorities. While VA has implemented a performance measure 

for fiscal year 2003 that encourages networks to increase veterans’ use of 

five of the six noninstitutional services, it does not require networks to 

ensure that all facilities provide veterans access to noninstitutional services. 

With the aging of the veteran 

population, the Department of 

Veterans Affairs (VA) is likely to 

see a significant increase in 

demand for long-term care. In 

response to recent GAO findings 

that variation exists in availability 

of noninstitutional services across 

VA, GAO was asked to update and 

expand its previous work to 

determine (1) whether veterans’ 

access to six noninstitutional 

services is limited by service 

availability and restrictions on use 

and (2) if access is limited, what 

factors contribute to limited 

access. GAO surveyed VA’s 139 

medical facilities, visited 4 of them 

and updated information collected 

from a fifth facility visited during 

earlier work, and interviewed 

headquarters and field officials. 

GAO is recommending that VA: 

• ensure that facilities follow VA’s 

eligibility standards when 

determining veteran eligibility for 

noninstitutional long-term care 

services, and 

• refine current performance 

measures to help ensure that all VA 

facilities provide veterans with 

access to required noninstitutional 

services. 

VA concurred with the 

recommendations. 

www.gao.gov/cgi-bin/getrpt?GAO-03-487.

To view the full report, including the scope 

and methodology, click on the link above. 

For more information, contact Cynthia A. 

Bascetta at (202) 512-7101. 

Highlights of GAO-03-487, a report to 

Congressional Requesters 

May 2003 

VA LONG-TERM CARE 

Service Gaps and Facility Restrictions 

Limit Veterans’ Access to 

Noninstitutional Care 
Page i GAO-03-487 VA Noninstitutional Long-Term Care 

Letter 1

Results in Brief 3

Background 4

Veterans’ Access Is Limited by Gaps in Service Availability and 

Facility Restrictions on Service Use 7

Lack of Emphasis, Inadequate Guidance, and Other Factors 

Contribute to Limited Access 12

Conclusions 16

Recommendations for Executive Action 16

Agency Comments 17

Appendix I VA Noninstitutional Long-Term Care Services in 

Our Review 18 

Appendix II Scope and Methodology 19 

Appendix III Availability and Utilization of Six Noninstitutional 

Long-Term Care Services by VA Medical Facility or 

Health Care System 22 

Appendix IV Comments From the Department of Veterans Affairs 27 

Appendix V GAO Contact and Staff Acknowledgments 28 

GAO Contact 28

Acknowledgments 28

Related GAO Products 29 

Tables 

Table 1: VA Long-Term Care Workload and Expenditures, by Care 

Setting, Fiscal Year 2002 6

Contents 
Page ii GAO-03-487 VA Noninstitutional Long-Term Care 

Table 2: Noninstitutional Services in Our Review Offered by the 

Five VA Facilities We Visited 20

Table 3: Availability and Utilization of Six Noninstitutional LongTerm Care Services at VA Medical Facilities (July 2002) 22

Figures 

Figure 1: Noninstitutional Long-Term Care Services at VA’s 139 

Medical Facilities 8

Figure 2: Noninstitutional Long-Term Care Services, Based on 

Geographic Areas, at VA’s 139 Medical Facilities 9

Abbreviations 

HCS health care system 

VA Department of Veterans Affairs 

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Page 1 GAO-03-487 VA Noninstitutional Long-Term Care 

May 9, 2003 

The Honorable Bob Graham 

Ranking Minority Member 

Committee on Veterans’ Affairs 

United States Senate 

The Honorable Lane Evans 

Ranking Minority Member 

Committee on Veterans’ Affairs 

House of Representatives 

The Honorable John D. Rockefeller IV 

United States Senate 

The Department of Veterans Affairs (VA) spent about $23 billion on health 

care in fiscal year 2002, including about $3.3 billion on long-term care. 

Demand for VA long-term care is likely to increase significantly during the 

next decade. Because of the aging of the veteran population, VA estimates 

that the number of veterans age 85 and older—those most in need of longterm care—will more than double, from about 640,000 currently to about 

1.3 million in 2012. Due to changes in VA’s eligibility standards more older 

veterans will be eligible to receive VA health care, including long-term care 

services. 

In recent years, VA has increased the proportion of its long-term care 

spending on care in noninstitutional settings, such as veterans’ own 

homes. This is consistent with the preference of many veterans and others 

to receive care in their homes or in other settings, such as adult day health 

care centers, that are less restrictive than institutions. For example, some 

veterans receive assistance in their homes with bathing and dressing 

provided by home health aides. However, VA has traditionally provided 

the bulk of veterans’ long-term care in institutional settings, such as 

nursing homes, which is reflected in VA’s spending for long-term care 

services. In fiscal year 2001, more than 90 percent of VA’s long-term care 

spending was for institutional long-term care. 

In November 1999, the Congress passed the Veterans Millennium Health 

Care and Benefits Act (Millennium Act),1

 which required that VA provide 

 1

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

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-03-487 VA Noninstitutional Long-Term Care 

veterans access to three servicesadult day health care, geriatric 

evaluation, and respite care. VA chose to meet the Millennium Act 

requirements by issuing a directive in October 2001 requiring that facilities 

provide adult day health care, noninstitutional geriatric evaluation, and 

noninstitutional respite care to veterans in need of such services.2

In April 2002, at the request of the Senate Committee on Veterans’ Affairs, 

we testified on variation in the availability of VA’s noninstitutional longterm care services.3

 Your offices expressed concern that this variation 

could mean that some veterans did not have access to noninstitutional 

services because of gaps in service availability and because of the 

restrictions that some facilities might place on veterans’ use of these 

services, such as limiting the amount of service a veteran may receive. To 

address these concerns, you asked us to update and expand our previous 

work4

 to determine (1) whether veterans’ access to six noninstitutional 

services is limited by service availability and restrictions on use and (2) if 

access is limited, what factors contribute to limited access. The six 

noninstitutional services you asked us to examine are the three that VA 

requires as a result of the Millennium Act adult day health care, geriatric 

evaluation, and respite careand three additional noninstitutional 

services—home-based primary care, skilled home health care, and 

homemaker/home health aide. See appendix I for information on these six 

noninstitutional long-term care services. 

To do our work, we surveyed each of VA’s 139 medical facilities to obtain 

data on the types of services offered and the number of veterans receiving 

the six noninstitutional long-term care services,5

 and where access to 

services was limited, we identified the reasons why services were limited. 

We compared these survey data to the data we obtained in our fall 2001 

survey of VA long-term care services to determine the extent to which 

 2

The act requires that VA provide noninstitutional extended care services to enrolled 

veterans until December 31, 2003. 

3

U.S. General Accounting Office, VA Long-Term Care: The Availability of Noninstitutional 

Services Is Uneven, GAO-02-652T (Washington, D.C.: Apr. 25, 2002). 

4

U.S. General Accounting Office, 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.: Mar. 29, 2002). 

5

Although VA has 172 medical centers, in some instances 2 or more medical centers have 

consolidated into health care systems. Counting health care systems and individual medical 

centers that are not part of a health care system as single facilities, VA has 139 facilities. 
Page 3 GAO-03-487 VA Noninstitutional Long-Term Care 

availability had changed since that survey. To gain an understanding of 

facilities’ noninstitutional long-term care operations we also interviewed 

VA officials in headquarters and in each of VA’s 21 network offices,6 visited 

4 VA medical facilities—located in Memphis, Tennessee; Richmond, 

Virginia; Tucson, Arizona; and Walla Walla, Washingtonand updated 

information collected from a fifth facility in Albany, New York, which we 

visited for our previous report on noninstitutional services. These five 

facilities were chosen based on variation in both the number and type of 

noninstitutional services they offered. In addition, we evaluated directives 

and regulations and other guidance related to these six noninstitutional 

services issued by VA headquarters, networks, and individual facilities. 

For a complete description of our scope and methodology, see appendix 

II. Our work was conducted from June 2002 through April 2003 in 

accordance with generally accepted government auditing standards. 

Veterans’ access to the six noninstitutional long-term care services in our 

study is limited by the lack of service availability and restrictions on their 

use. Of VA’s 139 facilities, 126 do not offer all six of the services. Veterans 

have the least access to noninstitutional respite care, which is not offered 

by 106 VA facilities. By contrast, skilled home health care is not offered at 

7 facilities. Furthermore, veterans’ access to care is more limited than 

these numbers suggest, because even when facilities offer these services 

they often do so in only parts of the geographic area they serve. In fact, for 

four of the six servicesnoninstitutional respite care, home-based 

primary care, adult day health care, and noninstitutional geriatric 

evaluationthe majority of facilities either do not offer the service or do 

not offer the service in the entire geographic area they serve. Veterans’

access may be further limited by restrictions that individual facilities set 

for use of services they offer. For example, 9 facilities, in conflict with 

VA’s eligibility standards, limited veterans’ access to noninstitutional 

services based on their level of disability related to military service. 

Further, restrictions placed by many facilities on the number of veterans 

who can receive noninstitutional services have resulted in veterans at 57 

of VA’s 139 facilities being placed on waiting lists for noninstitutional 

services. 

 6

VA originally created 22 networks, but in January 2002 VA merged 2 networks into a single 

network, leaving the agency with 21 networks. 

Results in Brief 
Page 4 GAO-03-487 VA Noninstitutional Long-Term Care 

VA’s lack of emphasis on increasing access to noninstitutional long-term 

care services and a lack of guidance on the provision of these services 

have contributed to service gaps and individual facility restrictions. VA 

headquarters has not emphasized increasing access to these services by 

establishing measurable performance goals as it has for other priorities 

such as maintaining workloads in VA nursing homes. Without such 

performance measures, field officials faced with competing priorities have 

chosen to use available resources to address other priorities. VA has 

implemented a performance measure for fiscal year 2003 that encourages 

networks to increase veterans’ use of five of the six noninstitutional 

services, but it does not require networks to ensure that all network 

facilities provide veterans access to noninstitutional services. Moreover, 

VA has not provided facilities with adequate guidance on the provision of 

noninstitutional respite care, even though most have had little experience 

in providing the service. Some networks and facilities are confused about 

how to provide the service and as a result some are not providing the 

service. VA has also not provided adequate guidance on which 

noninstitutional services are required. In particular, VA has not specified 

whether the home health services requirement includes one, all, or some 

combination of home-based primary care, homemaker/home health aide, 

and skilled home health care. In the absence of VA headquarters guidance 

on what home health services are required, VA facilities vary in their 

interpretations of what services they must provide. 

To help ensure that veterans have access to noninstitutional long-term 

care services and that such services are offered uniformly throughout VA, 

we are recommending that VA take actions to increase emphasis on 

provision of these services, provide adequate guidance on their provision, 

and ensure that VA’s eligibility standards are used to determine eligibility. 

VA concurred with our recommendations, discussed preliminary actions it 

plans to take, and stated that it will provide a detailed action plan to 

implement our recommendations after this report is issued. 

Changes in VA’s eligibility standards have resulted in an increase in the 

number of veterans who are eligible to receive VA health care, including 

noninstitutional long-term care services. The Veterans’ Health Care 

Eligibility Reform Act of 19967

 authorized VA to provide health care 

services not previously available to veterans without service-connected 

 7

Pub. L. No. 104-262 §§ 101, 104, 110 Stat. 3178-79, 3182-83 (1996). 

Background 
Page 5 GAO-03-487 VA Noninstitutional Long-Term Care 

disabilities or low incomes.8 As required by the act and due to an 

anticipated increase in demand for VA health care from these changes in 

eligibility, VA established an enrollment system to manage veterans’

access to care. This system includes eight priority categories for 

enrollment, with higher priority given to veterans with service-connected 

disabilities, lower incomes, or other recognized statuses such as former 

prisoners of war. If sufficient resources are not available to provide care 

that is timely and acceptable in quality for all priority groups, the act 

requires VA to limit enrollment nationally, consistent with the eight 

priority groups. If needed, enrollment restrictions would begin with the 

lowest priority category. On January 17, 2003, VA announced that it would 

no longer enroll priority 8 veterans, those in the lowest priority category, 

for the duration of the year.9

VA long-term care includes a continuum of services for the delivery of care 

to veterans needing assistance due to chronic illness or physical or mental 

disability. Assistance with veterans’ needs takes many forms and is 

provided in varied settings, including institutional care in nursing homes 

or in noninstitutional settings preferred by many veterans, including inhome care services and community-based services such as adult day 

health care centers. Long-term care also includes respite care services that 

temporarily relieve a veteran’s caregiver from the burden of caring for a 

chronically ill and disabled veteran in the home. VA offers long-term care 

services directly or through other providers with which VA contracts. 

VA provides most of its long-term care to veterans in institutional settings, 

such as VA nursing homes or state-owned veterans’ homes rather than in 

noninstitutional settings. In fiscal year 2002, VA served about 36 percent of 

its long-term care workload, or average daily census, in noninstitutional 

settings (see table 1). That same year noninstitutional care accounted for 9 

percent of VA’s long-term care expenditures. In contrast, noninstitutional 

 8

A service-connected disability is an injury or disease that was incurred or aggravated while 

on active military duty. VA classifies veterans with service-connected disabilities according 

to the extent of their disability. These classifications are expressed in terms of 

percentages—for example, the most severely disabled such veteran would be classified as 

having a service-connected disability of 100 percent. Percentages are assigned in 

increments of 10 percent. 

9

Priority 8 veterans are primarily veterans with no service-connected disabilities who have 

incomes above established limits for geographic regions set by the U.S. Department of 

Housing and Urban Development to reflect regional costs of living. Priority 8 veterans 

enrolled prior to January 17, 2003, remain enrolled to receive VA health care benefits. 
Page 6 GAO-03-487 VA Noninstitutional Long-Term Care 

care accounted for about 29 percent of Medicaid’s long-term care 

expenditures in fiscal year 2001, the most recent year for which data are 

available.10

Table 1: VA Long-Term Care Workload and Expenditures, by Care Setting, Fiscal 

Year 2002 

Long-term care setting Average daily censusa

 Total expenditures 

Institutional 43,363 $2,979,156,000 

Noninstitutional 24,126 283,098,000 

Total 67,489 $3,262,254,000 

Source: VA. 

a

The average daily census represents the total number of days of inpatient care for institutional care 

and the total number of outpatient encounters for noninstitutional care, each divided by the number of 

days in the year. Thus, the figures represent VA’s workload during the year and not an unduplicated 

count of veterans in these settings because some veterans receive more than one service. 

VA has delegated decision making regarding financing and service delivery 

for long-term care and other health care services to its 21 health care 

networks. VA allocates resources for health care to each of the 21 

networks primarily through the Veterans Equitable Resource Allocation 

system, in which networks are funded through a formula reflecting the 

number and types of veterans receiving care in the network, including 

those receiving long-term care.11 In turn, VA’s networks have budget and 

management responsibilities that include allocating resources received 

from headquarters to facilities within their networks—including resources 

used to provide long-term care services. 

 10Medicaid, the joint federal-state health-financing program for low-income individuals, is 

the nation’s largest funding source for long-term care. In fiscal year 2001, Medicaid 

expenditures on long-term care totaled $75.3 billion. 

11For more information on VA’s resource allocation system see U.S. General Accounting 

Office, VA Health Care: Allocation Changes Would Better Align Resources with Workload, 

GAO-02-338 (Washington, D.C.: Feb. 28, 2002). 
Page 7 GAO-03-487 VA Noninstitutional Long-Term Care 

Veterans’ access to the six noninstitutional services in our reviewadult 

day health care, geriatric evaluation, respite care, home-based primary 

care, homemaker/home health aide, and skilled home health care—is 

limited due to gaps in availability and facility restrictions on use of the 

services. Of VA’s 139 facilities, 126 do not offer all six noninstitutional 

services. Facilities that do offer a service do not always offer the service to 

veterans in the entire geographic area the facility serves. Further, veterans’

access to the six noninstitutional services may be limited by restrictions 

that individual VA facilities place on service use. Some of these facility 

restrictions conflict with VA eligibility standards which state that most 

services are to be available to all enrolled veterans regardless of priority 

group. The restrictions include providing services only to certain veterans 

or limiting the number of veterans who can use services at any one time. 

Access to care is limited because many VA facilities do not offer the six 

noninstitutional services in our review. Of VA’s 139 facilities, 126 did not 

offer all of the six noninstitutional services in fall 2002, a pattern similar to 

that in fall 2001. (See fig. 1.) The least commonly available service of the 

six we reviewed in 2001 and 2002 was noninstitutional respite care. This 

service was not available at 110 of VA’s 139 facilities in fall 2001, and as of 

fall 2002, noninstitutional respite care was not available at 106 of VA’s 139 

facilities. In contrast, the most widely available service we reviewed was 

skilled home health care, which was offered at all but 7 facilities. For a 

complete list of the services each VA facility reported offering, see 

appendix III. 

Veterans’ Access Is 

Limited by Gaps in 

Service Availability 

and Facility 

Restrictions on 

Service Use 

Access to Care Is Limited 

by Service Gaps Across VA 
Page 8 GAO-03-487 VA Noninstitutional Long-Term Care 

Figure 1: Noninstitutional Long-Term Care Services at VA’s 139 Medical Facilities 

Note: Includes services provided directly by facilities or through contracts with other providers as of 

fall 2001 and fall 2002. 

Veterans’ access to these services is further limited because among 

facilities that offer services, many do so in only parts of the geographic 

area they serve. Our fall 2002 survey showed that for four of the six 

services noninstitutional respite care, home-based primary care, adult 

day health care, and noninstitutional geriatric evaluationthe majority of 

the facilities either did not offer the service or did not offer the service in 

the entire geographic area they serve. As shown in figure 2, 42 facilities did 

not offer adult day health care and an additional 76 facilities did not offer 

it in their entire geographic service area. As a result, where veterans live in 

a facility’s geographic service area sometimes determines whether they 

can access the services offered by the facility. The remaining 21 facilities 

reported that they offered adult day health care in all parts of their 

geographic service areas. 

Offered

Not offered 

Homemaker/

home health 

aide 

Respite care Home-based 

primary care

Geriatric

evaluation

Adult day

health care

Skilled home

health care

0

20

40

60

80

100

120

140

Source: GAO.

VA facilities

2001 2002 2001 2002 2001 2002 2001 2002 2001 2002 2001 2002
Page 9 GAO-03-487 VA Noninstitutional Long-Term Care 

Figure 2: Noninstitutional Long-Term Care Services, Based on Geographic Areas, at 

VA’s 139 Medical Facilities 

Note: Includes services provided directly by facilities or through contracts with other providers as of 

fall 2002. 

VA may also arrange for veterans to access three noninstitutional longterm care services from non-VA sources even though VA does not pay for 

these services. The Millennium Act and VA policy allow facilities to make 

available to veterans the services required as a result of the Millennium 

Actadult day health care, noninstitutional respite care, and 

noninstitutional geriatric evaluationthrough other providers or payers 

while still overseeing the care delivered using a case management 

approach.12 However, VA headquarters has neither issued guidance on the 

use of case management to meet this requirement under the Millennium 

Act nor has it monitored the extent to which facilities use this option. 

Further, the use of case management by VA to make these three services 

 12Case management includes assessment of the veteran’s care needs, care planning and 

implementation, referral coordination, monitoring, and periodic reassessment of the 

veteran’s care needs. 

0

20

40

60

80

100

120

140

Homemaker/

home health aide 

Respite care Home-based 

primary care

Geriatric

evaluation

Adult day

health care

Skilled home

health care

Offered in entire geographic area

VA facilities

Source: GAO.

Offered but not in entire geographic area

Not offered
Page 10 GAO-03-487 VA Noninstitutional Long-Term Care 

available to veterans is limited by the eligibility of veterans for these other 

sources of care. That is, if veterans are not eligible for other sources of 

care, such as Medicaid and Medicare, and VA does not provide the service, 

then veterans will likely not have access to the three services. 

Access to care is further limited by the restrictions that some facilities 

place on the six noninstitutional services in our review. These restrictions 

include (1) limiting services to veterans with certain levels of serviceconnected disability, (2) limiting the amount of service that veterans can 

receive, and (3) establishing a maximum number of veterans who can 

receive a service at any time. 

We found that nine VA facilities imposed their own eligibility restrictions 

on access to noninstitutional services based on veterans’ serviceconnected disabilities. We identified five of these nine facilities through 

comments facilities made in our survey, although we did not 

systematically ask facilities this question in our survey. Because we did 

not systematically ask in our survey, it is possible that additional facilities 

may impose similar eligibility restrictions. Other VA facilities may have 

also instituted similar restrictions on access. These restrictions conflict 

with VA eligibility standards and result in inequitable access for veterans 

enrolled at these facilities. VA’s eligibility standards state that most 

services are to be available to all enrolled veterans, regardless of priority 

group.13

In our survey of VA’s 139 facilities, 5 facilities provided additional 

comments indicating that they limit certain services—including adult day 

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

respite care—to veterans with service-connected disabilities. Four of the 

5 facilities limit services to veterans with service-connected disabilities of 

70 percent or greater. In addition, one of the facilities we visited provides 

homemaker/home health aide services to veterans with service-connected 

disabilities of 70 percent or greater. Another facility we visited provides 

the service primarily to veterans with service-connected disabilities of 70 

percent or greater or veterans with service-connected disabilities of at 

least 60 percent for a single condition; other veterans may receive the 

 13Although VA issued a regulation on September 17, 2002, granting priority for 

appointments to veterans with service-connected disabilities of at least 50 percent and 

veterans needing care for a service-connected disability, the regulation does not change 

other veterans’ eligibility to receive services. 

Veterans’ Access to Care Is 

Further Limited by 

Individual Facility 

Restrictions 

Some Facilities Limit Access to 

Services Based on Veterans’

Service-Connected Disability 

Levels 
Page 11 GAO-03-487 VA Noninstitutional Long-Term Care 

service, but only for 6 months. In addition, one network official told us 

that 2 facilities in his network limit homemaker/home health aide services 

to veterans with service-connected disabilities of 70 percent or greater 

because under the Millennium Act VA must pay for nursing home care 

when such veterans need it.14 According to this official, because 

homemaker/home health aide services can keep veterans in their own 

homes rather than in nursing homes, providing the service to such 

veterans can delay the need for nursing home care and the resultant 

financial obligation for the facilities. 

The amount of service veterans receive may depend on which facility 

provides their care. Facilities vary in the limits they set. Some facilities 

restrict the amount of a noninstitutional service a veteran can receive once 

the veteran has been authorized to receive care. For example, a network 

official told us that one network facility offers veterans up to 24 hours per 

week of homemaker/home health aide services while a facility official in 

another network told us their facility provides no more than 10 hours per 

week. A facility we visited in another network does not place any 

restrictions on the amount of homemaker/home health aide services 

provided. 

Facility officials noted that they can serve more veterans if they limit the 

amount of service provided to each veteran. One facility we contacted 

provided veterans no more than 2 days per week of adult day health care. 

Because of this restriction, veterans whose medical needs require more 

adult day health care pay for the service themselves, find another payer 

such as Medicaid, or forego the additional service. At another facility we 

visited, veterans without service-connected disabilities were limited to 2 

full days or 3 half days per week regardless of medical need. In 1998, this 

facility also reduced the number of homemaker/home health aide hours 

provided each week from 21 to 8 in order to increase the number of 

veterans who could be provided the service. At both facilities, officials 

emphasized that the purpose of limits on the amount of service provided 

was to increase the number of veterans who could receive at least some of 

the service. 

 14The Millennium Act requires that VA provide nursing home care to any veteran who needs 

such care and who has a service-connected disability of 70 percent or greater, or to any 

veteran needing such care specifically for a service-connected disability, even if the 

disability is less than 70 percent. 

Access Is also Limited by 

Restrictions on the Amount of 

Services Provided 
Page 12 GAO-03-487 VA Noninstitutional Long-Term Care 

In our survey of VA facilities, 57 of 139 facilities reported maintaining a list 

of veterans waiting for at least one of the services in our review. These 

facilities told us in effect that they are not meeting all their veterans’ needs 

for noninstitutional services. Many facilities place limits on the total 

number of veterans they serve by establishing a budget cap—the 

maximum number of veterans who can receive a particular service at any 

time. For three of the six services in our study—home-based primary care, 

homemaker/home health aide, and noninstitutional geriatric evaluation—

most facilities reported in our survey that despite offering the service, they 

were currently unable to provide services to additional veterans within 

their budget caps. Additional veterans needing services would have to wait 

until space or resources became available. 

A lack of VA emphasis on increasing access to noninstitutional long-term 

care services, inadequate VA guidance on providing these services, and 

other factors have contributed to limited access for veterans. VA had not 

provided measurable standards for the provision of these services until 

fiscal year 2003 or oversight to monitor their provision as it has for highpriority services. VA guidance on the provision of noninstitutional longterm care services has left unclear to some facilities how one service is to 

be defined and provided and whether some of the services in our review 

are a part of what VA requires be made available to veterans who need 

them. Other factors, such as availability of contractors to provide a 

service, also contribute to the lack of access for specific services. 

VA network and facility officials told us that VA headquarters has not 

emphasized increased access to noninstitutional long-term care services 

but emphasized other priorities. As a result, these officials said they use 

their resources for the priorities VA headquarters emphasizes rather than 

noninstitutional services. For example, officials in 9 of VA’s 21 networks 

told us that VA headquarters’ emphasis on the performance measure that 

requires networks to maintain workload in VA nursing homes has led them 

to devote resources to nursing home care that they might otherwise have 

used to provide noninstitutional services. One network director told us 

that the “pressure” from VA headquarters to maintain nursing home 

utilization is much greater than that to offer noninstitutional services. In 

another network, an official at a VA facility not offering three of the 

services in our study told us that these services were “victims of 

competition for resources.” In other words, the facility had not funded 

these three noninstitutional services because facility officials had chosen 

to devote resources to other services. Another network director told us 

Access at Many Facilities Is 

Restricted by Limits on the 

Number of Veterans Served 

Lack of Emphasis, 

Inadequate Guidance, 

and Other Factors 

Contribute to Limited 

Access 

VA Has Not Emphasized 

Increased Access to 

Noninstitutional LongTerm Care Services 
Page 13 GAO-03-487 VA Noninstitutional Long-Term Care 

that, if forced to choose between funding different services, the network 

would allocate resources to services included in a performance measure. 

One way VA emphasizes services is through performance measures, which 

VA establishes to monitor network officials’ progress toward meeting 

certain VA strategic goals, such as increasing veteran access to services. 

VA has demonstrated that requiring network officials to meet measurable 

performance standards can promote change. For example, since their 

inception in fiscal year 1996 VA performance measures have included a 

measure for providing immunizations to prevent pneumonia to veterans 

age 65 and older and those at high risk of the disease. VA increased the 

percentage of veterans in this population who received the immunization 

from 26 percent in fiscal year 1996 to 81 percent in fiscal year 2002. 

In October 2002, VA introduced a performance measure for 

noninstitutional long-term care which requires all networks to provide 

noninstitutional services to a portion of their enrolled veterans needing 

such services14.4 percent in fiscal year 2003 and 16 percent in fiscal 

year 2006.15 The fiscal year 2003 goal for this measure will require the 

majority of networks to increase utilization of their noninstitutional 

services. The performance measure includes five of the services in our 

review but does not include noninstitutional geriatric evaluation. 

However, the performance measure does not require networks to ensure 

that veterans can access noninstitutional long-term care services at all 

network facilities. Instead, network targets can be achieved in the current 

performance measure if networks increase utilization at facilities that 

already offer noninstitutional services. 

VA headquarters has provided inadequate guidance to networks and 

facilities on the provision of noninstitutional respite care to address 

confusion in the field about what this service is and how it should be 

provided. This confusion exists, in part, because VA has limited 

experience with noninstitutional respite care and VA traditionally 

provided respite care in institutions such as nursing homes. 

Noninstitutional respite care, by contrast, is provided only in 

noninstitutional settings, such as a veteran’s own home. 

 15According to VA, when it plans for noninstitutional services it assumes that the vast 

majority of veterans will choose to use their Medicare benefits for home health care. 

VA Has Provided 

Inadequate Guidance on 

the Provision of 

Noninstitutional Respite 

Care 
Page 14 GAO-03-487 VA Noninstitutional Long-Term Care 

Although noninstitutional respite care has been required by VA for over a 

year, VA has not issued adequate guidance on the provision of 

noninstitutional respite care and VA staff told us they were unsure how to 

develop a noninstitutional respite care service. VA issued a directive in 

October 2001 that requires all facilities to provide noninstitutional respite 

care to veterans in need of the service yet it inadequately defines 

noninstitutional respite care and does not provide facilities with 

information regarding how to provide the service. For example, the 

directive states that noninstitutional respite care may be provided in a 

home or other noninstitutional settings. However, it does not specify 

which noninstitutional settings may be used for the purpose of respite 

care. In fact, officials in 6 of the 21 networks we contacted indicated that 

there was confusion in their networks about how to establish 

noninstitutional respite care programs and 1 of these networks reported 

this was the reason facilities in the network were not providing the 

service. Further, in our survey, six facilities reported that they offer 

noninstitutional respite care in community nursing homes, which are 

institutional settings, thus not meeting the requirement for noninstitutional 

respite care. VA headquarters officials said they are developing a 

handbook that will define and provide guidance on the provision of 

noninstitutional respite care. 

VA requires that facilities offer a home health service benefit as part of 

VA’s medical benefits package.16 VA headquarters officials told us that the 

home services benefit includes home-based primary care, 

homemaker/home health aide, and skilled home health care. However, VA 

policy does not specify whether one, some combination, or all three home 

health services are required under the home health services benefit. 

Currently 138 out of VA’s 139 facilities offer at least one of these three 

home health services, 59 facilities offer two of the three services, and 66 

facilities offer all three. Without clear guidance to facilities on what 

services they must make available in order to fulfill the home health 

services benefit, facilities vary in their interpretation of what is included in 

the benefit and headquarters cannot ensure that veterans have access to 

the services to which they are entitled. 

Because facilities and networks vary in their interpretation of what is 

included in the home health services benefit, facilities do not uniformly 

 16The medical benefits package is the set of services to be available to all enrolled veterans. 

VA Guidance Does Not 

Specify Which Home 

Health Services Are 

Required 
Page 15 GAO-03-487 VA Noninstitutional Long-Term Care 

offer the same home health services. For example, at one facility we 

visited, an official told us that the facility interpreted the home health 

services benefit to mean that veterans must have access to skilled home 

health care—which the facility made available to all veterans. The facility 

restricted veterans’ access to its homemaker/home health aide and homebased primary care services because facility officials did not believe these 

services were required under the home health benefit. Similarly, in another 

network an official told us that the network interpreted the home health 

services benefit to include all three home care serviceshome-based 

primary care, homemaker/home health aide, and skilled home health care. 

As a result, access to these three services varies according to facility 

interpretation of what is required. Without clear guidance to facilities on 

what services they must make available in order to fulfill the home health 

care services requirement, headquarters cannot ensure that veterans have 

access to the home health services to which they are entitled and veterans 

are likely to experience variation in the benefits package. 

Other factors limiting access to services include lack of contractors, 

difficulty hiring needed staff, and limitations imposed due to distances VA 

staff can travel. The lack of contractors is particularly important in adult 

day health care, where 62 facilities that either did not provide adult day 

health care at all or only did so in parts of their geographic service areas 

reported that they experienced difficulty in finding local contractors to 

provide the service. In addition, 63 facilities cited insufficient facility staff 

as the reason for not offering geriatric evaluation or only offering it to a 

portion of their geographic service area. Officials in VA headquarters told 

us that many facilities have been unable to recruit clinically trained 

geriatric staff, such as geriatricians and geriatric nurse practitioners, 

needed to operate this service. 

For home-based primary care, 94 facilities that did not offer the service at 

all or did not do so in all parts of their geographic service area reported 

that they did not do so because many veterans live outside of the facility’s 

home-based primary care service area. VA guidance limits the service to 

veterans who live within a locally established radius of the facility because 

Other Factors Limit the 

Availability of 

Noninstitutional Services 
Page 16 GAO-03-487 VA Noninstitutional Long-Term Care 

home-based primary care staff travel from the facility to veterans’ homes 

to deliver care.17

Veterans’ access to the six noninstitutional long-term care services we 

reviewed is limited and highly variable across the country. Extensive gaps 

in services exist at many facilities either because they do not offer the 

services or do not offer it in all parts of their service areas. Moreover, 

individual facility restrictions on veterans’ use of services means that 

access may be further restricted. These include facility restrictions based 

on veterans’ levels of service-connected disability that are inconsistent 

with VA eligibility standards. Facility restrictions have resulted in waiting 

lists for services at many facilities. The end result is that veterans’ access 

to these services is often limited or nonexistent based on where they live. 

Shortfalls and unevenness in veterans’ access to noninstitutional long-term 

care services have resulted because VA headquarters has not provided 

adequate guidance and emphasis on making these services available. VA 

has not provided sufficient guidance to clear up confusion at facilities as 

to how noninstitutional respite care services are provided or to make clear 

which home health services facilities must provide. As a result, facilities 

vary in their interpretation of which services to provide, creating 

unevenness in their availability. Furthermore, VA has not sufficiently 

emphasized the importance of providing these services to encourage 

networks and facilities to make them a priority in their overall service 

continuum. In particular, VA has not developed a performance measure 

that would help ensure the provision of these services consistently across 

VA facilities. 

To increase access to noninstitutional long-term care services and make 

access more even across networks and facilities, we recommend that the 

Secretary of Veterans Affairs direct the Under Secretary for Health to: 

• ensure that facilities follow VA’s eligibility standards when determining 

veteran eligibility for noninstitutional long-term care services; 

• define and provide guidance on noninstitutional respite care; 

 17At two facilities we visited where home-based primary care is offered, officials told us 

that veterans would likely be provided home health care through a contract service if they 

lived outside of each facility’s home-based primary care service area. 

Conclusions 

Recommendations for 

Executive Action 
Page 17 GAO-03-487 VA Noninstitutional Long-Term Care 

• specify in VA policy whether home-based primary care, homemaker/home 

health aide, and skilled home health care are to be available to all enrolled 

veterans; and 

• refine current performance measures to help ensure that all VA facilities 

provide veterans with access to required noninstitutional services. 

In commenting on a draft of our report, VA agreed with our findings and 

conclusions and concurred with our recommendations. VA stated that it 

will add eligibility sections in each new directive and handbook it issues 

concerning noninstitutional long-term care programs and develop 

performance measures to underscore the importance VA places on its 

noninstitutional long-term care programs. VA, however, did not provide 

details on how it plans to address our recommendations, but instead 

stated that it will provide a detailed action plan to implement our 

recommendations in response to the issuance of this report. VA’s written 

comments are in appendix IV. 

As agreed with your office, unless you publicly announce its contents 

earlier, we will plan no further distribution of this report until 30 days after 

its date. At that time, we will send copies to interested congressional 

committees and other parties. We also will make copies available to others 

upon request. In addition, the report is available at no charge on the GAO 

Web site at http://www.gao.gov. If you or your staffs have any questions 

about this report, please call me at (202) 512-7101. Another contact and 

key contributors are listed in appendix V. 

Cynthia A. Bascetta 

Director, Health Care—Veterans’

 Health and Benefits Issues 

Agency Comments 
Appendix I: VA Noninstitutional Long-Term 

Care Services in Our Review 

Page 18 GAO-03-487 VA Noninstitutional Long-Term Care 

• Adult day health care: health maintenance and rehabilitative services 

provided to frail elderly veterans in an outpatient setting during part of the 

day. 

• Geriatric evaluation: evaluation of veterans with particular geriatric needs, 

generally provided by VA through one of two services: (1) geriatric 

evaluation and management, in which interdisciplinary health care teams 

of geriatric specialists evaluate and manage frail elderly veterans, and (2) 

geriatric primary care, in which outpatient primary care, including medical 

and nursing services, preventive health care services, health education, 

and specialty referral, is provided to geriatric veterans. 

• Home-based primary care: primary health care, delivered by a VA 

physician-directed interdisciplinary team of VA staff including nurses and 

other healthcare professionals to homebound (often bedbound) veterans 

for whom return to an outpatient clinic is not practical. 

• 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. It does not 

include skilled professional services. 

• Respite care: services provided to temporarily relieve the veteran’s 

caregiver from the burden of caring for a chronically ill and severely 

disabled veteran in the home. Noninstitutional settings for respite care 

include veterans’ own homes. 

• Skilled home health care: medical services provided to veterans at home 

by non-VA health care providers. 

Appendix I: VA Noninstitutional Long-Term 

Care Services in Our Review 
Appendix II: Scope and Methodology 

Page 19 GAO-03-487 VA Noninstitutional Long-Term Care 

We reviewed the Department of Veterans Affairs’ (VA) provision of six 

noninstitutional long-term care services in order to update and expand our 

previous work to determine (1) whether veterans’ access to six 

noninstitutional services is limited by service availability and restrictions 

on use and (2) if access is limited, what factors contribute to limited 

access. The six services we reviewed include the three services VA chose 

to require all facilities to provide to meet the Millennium Act 

requirements—adult day health care, noninstitutional geriatric evaluation, 

and noninstitutional respite care—and three additional noninstitutional 

services—home-based primary care, skilled home health care, and 

homemaker/home health aide. 

To determine if veterans’ access to the six noninstitutional long-term care 

services is limited and if it is limited, to what extent, we sent an electronic 

mail survey to VA’s 139 medical facilities in September 2002. We asked 

facilities to indicate which of the six services they offered and, for each 

service they offered, asked them to provide the number of veterans 

currently receiving or authorized to receive the service and the number of 

veterans who received the service during July 2002.1

 The month of July 

2002 was chosen because workload data were likely to be available at the 

time the survey was completed by VA staff. We also asked facilities to 

indicate whether each offered service was available to veterans living in all 

parts of their geographic service areas. We compared these survey data to 

the data we obtained in our fall 2001 survey of VA long-term care services 

to determine the extent to which availability had changed since that 

survey. We also compared our current survey results to information 

provided by VA headquarters, and where we noted differences we 

contacted facility officials to clarify their survey responses. 

To determine the factors that contribute to limited access to the six 

noninstitutional long-term care services we asked survey respondents to 

indicate the reasons why their facilities do not offer certain services and 

what factors influence the number of veterans using the services they do 

offer. We also conducted telephone interviews of officials in each of VA’s 

21 network offices to assess the role each network plays in deciding what 

noninstitutional services network facilities will offer and what criteria 

facilities will use in allocating services. 

 1

The utilization data provided by VA facilities does not represent an unduplicated count of 

veterans in these settings because some veterans may receive more than one 

noninstitutional service. 

Appendix II: Scope and Methodology 
Appendix II: Scope and Methodology 

Page 20 GAO-03-487 VA Noninstitutional Long-Term Care 

To augment information collected through our survey and telephone 

interviews, we visited four VA medical facilities to interview VA officials 

and clinicians on veteran demand for noninstitutional services and reasons 

for variation in access to the six noninstitutional services. We also updated 

information we collected from a site we visited during our earlier work on 

VA’s noninstitutional services.2

 As shown in table 2, the five facilities 

included in this report—Albany, New York; Memphis, Tennessee; 

Richmond, Virginia; Tucson, Arizona; and Walla Walla, 

Washingtonreflect differences in the number and type of 

noninstitutional long-term care services offered. 

Table 2: Noninstitutional Services in Our Review Offered by the Five VA Facilities We Visited 

VA facility 

Number of services 

in our review 

offered at the time 

of our visit 

Home-based 

primary care

Homemaker/

home health 

aide 

Skilled home 

health care 

Adult day 

health care 

Geriatric 

evaluation Respite care

Albany, New York 5 X X X X X 

Memphis, 

Tennessee 

4 X X X X 

Richmond, 

Virginia 

2 X X 

Tucson, Arizona 6 X X X X X X 

Walla Walla, 

Washington 

2 X X 

Source: GAO. 

We selected the Memphis and Tucson VA facilities to visit because each 

offered at least four of the six services and had similar numbers of 

veterans enrolled. However, the number of veterans using their services 

differed substantially, which allowed us to explore the reasons for 

observed differences in service utilization. The Albany facility offered five 

of the six services and is located in a network that has extensive 

noninstitutional service offerings. In contrast, the Richmond and Walla 

Walla facilities were selected because they each offered two services; 

further, we selected the Walla Walla facility because it is located in a 

sparsely populated area. 

We met with officials in VA’s Geriatrics and Extended Care Strategic 

Healthcare Group and obtained documents on VA’s noninstitutional longterm care services, including service descriptions, policies, guidance, and 

 2

GAO-02-652T. 
Appendix II: Scope and Methodology 

Page 21 GAO-03-487 VA Noninstitutional Long-Term Care 

other information. In addition, we interviewed the Deputy Under Secretary 

for Health for Operations and Management to determine the level of 

oversight that this office provides regarding the noninstitutional long-term 

care services offered by VA facilities, including the implementation and 

tracking of network performance measures related to noninstitutional 

care. 
Appendix III: Availability and Utilization of 

Six Noninstitutional Long-Term Care Services 

by VA Medical Facility or Health Care System 

Page 22 GAO-03-487 VA Noninstitutional Long-Term Care 

Table 3 provides information on the availability and utilization of the six 

noninstitutional long-term care services reported by VA’s 139 medical 

facilities and health care systems for the month of July 2002.1

Table 3: Availability and Utilization of Six Noninstitutional Long-Term Care Services at VA Medical Facilities (July 2002) 

 Number of veterans receiving servicea

VA medical facility or 

health care system (HCS) 

Home-based 

primary care

Homemaker/ 

home health aide 

Skilled home 

health care

Adult day 

health care 

Geriatric 

evaluation Respite care 

Network 1 (Boston) 

Bedford 13 35 — 27 22 

Boston HCS 107 65 96 20 

Connecticut HCS 132 53 77 22 115 

Manchester 44 19 26 7 

Northampton 101 48 26 

Providence 55 14 52 8 

Togus 86 500 1 6 

White River Junctionb

12 49 45 26 

Network 2 (Albany) 

Albany 159 62 22 107 613 

Bath 177 115 14 0 

Canandaigua 132 186 33 15 

Syracuse 273 147 37 45 216 

Western New York HCS 263 285 68 120 26 

Network 3 (Bronx) 

Bronx 120 15 21 93 

Hudson Valley HCS 71 48 6 3 

New Jersey HCS 132 262 45 6 

Northport 47 64 32 12 49 

New York Harbor HCS 210 219 16 156 1,136 

Network 4 (Pittsburgh) 

Altoonab

 12 

Butler 36 123 58 

Clarksburg 176 23 6 

Coatesville 80 0 24 

Erie 84 16 3 2 

Lebanon 2 7 67 

Philadelphia 16 17 905 

Pittsburgh HCS 133 129 87 51 16 

 1

Although VA has 172 medical centers, in some instances 2 or more medical centers have 

consolidated into health care systems. Counting health care systems and individual medical 

centers that are not part of a health care system as single facilities, VA has 139 facilities. 

Appendix III: Availability and Utilization of 

Six Noninstitutional Long-Term Care Services 

by VA Medical Facility or Health Care System 
Appendix III: Availability and Utilization of 

Six Noninstitutional Long-Term Care Services 

by VA Medical Facility or Health Care System 

Page 23 GAO-03-487 VA Noninstitutional Long-Term Care 

 Number of veterans receiving servicea

VA medical facility or 

health care system (HCS) 

Home-based 

primary care

Homemaker/ 

home health aide 

Skilled home 

health care

Adult day 

health care 

Geriatric 

evaluation Respite care 

Wilkes-Barre 30 99 1 76 

Wilmington 25 4 5 

Network 5 (Baltimore) 

Martinsburg 73 16 

Maryland HCS 220 273 52 287 12 3 

Washington, DC 125 120 6 85 292 

Network 6 (Durham) 

Asheville 35 90 22 61 26 61 

Beckley 10 

Durham 47 37 130 97 1 

Fayetteville (NC) 19 18 11 17 

Hampton 27 29 13 0 

Richmond 101 0 1,800 

Salem 40 13 71 3 

Salisbury 35 100 11 

Network 7 (Atlanta) 

Atlanta 90 51 52 7 550 7 

Augusta 53 195 88 2 56 

Birmingham 94 4 62 0 27 4 

Central Alabama HCS 135 57 48 257 

Charleston 96 57 92 6 169 10 

Columbia (SC) 35 53 82 20 

Dublin 68 127 

Tuscaloosa 94 15 

Network 8 (Bay Pines) 

Bay Pinesb

123 83 44 23 857 

Miamib

224 75 54 32 397

N. Florida/S. Georgia HCSb

248 270 30 9 647

San Juan 193 0 2 569 

Tampab

163 39 155 300 

West Palm Beach 42 23 2 

Network 9 (Nashville) 

Huntington 60 49

Lexington 23 32 53 52 1 

Louisville 29 469 46 

Memphisb

112 73 227 560

Mountain Home 158 42 14 15

Tennessee Valley HCS 216 129 13 —

Network 10 (Cincinnati) 

Chillicothe 186 102 3 

Cincinnati 22 60 71 26

Cleveland 249 378 26 9 288
Appendix III: Availability and Utilization of 

Six Noninstitutional Long-Term Care Services 

by VA Medical Facility or Health Care System 

Page 24 GAO-03-487 VA Noninstitutional Long-Term Care 

 Number of veterans receiving servicea

VA medical facility or 

health care system (HCS) 

Home-based 

primary care

Homemaker/ 

home health aide 

Skilled home 

health care

Adult day 

health care 

Geriatric 

evaluation Respite care 

Columbus 44 13 25 

Dayton 53 275 179 37 42

Network 11 (Ann Arbor) 

Ann Arbor 88 13 54 0 

Battle Creek 120 107 22 31 1 

Danville 96 117 — 40 0 

Detroit 100 29 100 1 5 

Indianapolis 111 109 49 20 48 0 

Northern Indiana HCS 96 180 87 1 4 

Saginaw 31 15 2 8 2 

Network 12 (Chicago) 

Chicago HCSb

94 30 52 36 12 

Hines 183 64 90 45 133

Iron Mountain 12 15 0 

Madison 21 — 5 18

Milwaukee 146 30 23 60 60

North Chicago 144 1 19 

Tomah 5 1 

Network 15 (Kansas City) 

Columbia (MO) 134 55 18 0 3 

Eastern Kansas HCS 61 54 6 18

Kansas City 64 16 3 

Marion 31 215 

Poplar Bluff 38 22

St. Louis 75 78 30 10 —

Wichitab

35 40 9 

Network 16 (Jackson) 

Alexandria 15 21 7 

Central Arkansas HCSb

187 145 31 73 719 

Fayetteville (AR) 3 

Gulf Coast HCS 75 51 134 195

Houston 92 36 60 6 333

Jackson 35 115 28 

Muskogeeb 8 38 

New Orleans 82 12 35 

Oklahoma City 32 34 160 11 — — 

Shreveport 64 33 80 

Network 17 (Dallas) 

Central Texas HCS 97 23 2 18 0 

North Texas HCSb

195 98 39 18 62 

South Texas HCS 189 128 57 44 418 
Appendix III: Availability and Utilization of 

Six Noninstitutional Long-Term Care Services 

by VA Medical Facility or Health Care System 

Page 25 GAO-03-487 VA Noninstitutional Long-Term Care 

 Number of veterans receiving servicea

VA medical facility or 

health care system (HCS) 

Home-based 

primary care

Homemaker/ 

home health aide 

Skilled home 

health care

Adult day 

health care 

Geriatric 

evaluation Respite care 

Network 18 (Phoenix) 

Albuquerqueb

96 168 3 135

Amarillob 82 

Big Spring 

El Pasob 3 1 

Phoenix 75 57 250 —

Prescott 6 72 38 —

Tucson 163 128 156 39 25 8 

Network 19 (Denver) 

Cheyenne 107 1 

Denver 76 134 66 61 122 14 

Fort Lyon 85 165 0 

Grand Junctionb 6

Montana HCS 

Salt Lake Cityb

127 115 98 83 

Sheridan 25 5 2 

Network 20 (Portland) 

Alaska HCS 15 87 

Boise 45 43 5

Portland 119 26 68 94

Puget Sound HCS 149 125 19 35 144 0 

Roseburg 25 17 

Spokane 28 11 12 10 

Walla Wallab 14 — 

White City Domiciliary 29 — 76 60 3 

Network 21 (San Francisco) 

Central California HCSb 52 18 19 38

Honolulub 65 11 4 2 75

Northern California HCS 185 78 69 6 

Palo Alto 115 29 48 15 90 10 

Reno 83 83 83 9 35 0 

San Francisco 99 69 40 8 80 

Network 22 (Long Beach) 

Greater Los Angeles HCS 245 95 12 57 123 

Loma Linda 90 210 25 

Long Beach 115 119 

Southern Nevada HCS 33 34 0 

San Diego 77 40 15 50 80 

Network 23 (Minneapolis)c 

Black Hills HCS 105 101 1 

Central Iowa HCS 49 17 66 

Fargo 69 240 2 
Appendix III: Availability and Utilization of 

Six Noninstitutional Long-Term Care Services 

by VA Medical Facility or Health Care System 

Page 26 GAO-03-487 VA Noninstitutional Long-Term Care 

 Number of veterans receiving servicea

VA medical facility or 

health care system (HCS) 

Home-based 

primary care

Homemaker/ 

home health aide 

Skilled home 

health care

Adult day 

health care 

Geriatric 

evaluation Respite care 

Iowa City 182 302 85 352 4 

Minneapolis 116 200 130 200 44 0 

Nebraska/Western Iowa 

HCS 94 82 7 36 1 

Sioux Falls 51 50 2 16 

St. Cloud 76 105 87 12 1 

Source: GAO. 

Notes: Responses to our surveys were submitted September through November 2002. 

Facility cells that are empty indicate that a facility did not report offering the service at the time of our 

survey. A dash indicates that a facility reported offering the service but did not report the service’s 

July 2002 utilization. 

a

Services include those provided directly by VA staff or through contracts. 

b

Facility reported using only a volunteer service to provide noninstitutional respite care to veterans. 

We did not include volunteer respite care services in our number of facilities offering noninstitutional 

respite care. 

c

Network 23 was created when Networks 13 and 14 were merged into a single network in January 

2002. VA currently has 21 networks. 
Appendix IV: Comments From the Department of Veterans Affairs 

Page 27 GAO-03-487 VA Noninstitutional Long-Term Care 

Appendix IV: Comments From the 

Department of Veterans Affairs 
Appendix V: GAO Contact and Staff 

Acknowledgments 

Page 28 GAO-03-487 VA Noninstitutional Long-Term Care 

James C. Musselwhite, (202) 512-7259 

 In addition to the contact named above Pamela Dooley, Steve Gaty, 

Marcia Mann, and Kristin Wilson made key contributions to this report. 

Appendix V: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Acknowledgments 
Related GAO Products 

Page 29 GAO-03-487 VA Noninstitutional Long-Term Care 

Long-Term Care: Availability of Medicaid Home and Community Services 

for Elderly Individuals Varies Considerably. GAO-02-1121. Washington, 

D.C.: September 26, 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. 

Veterans’ Affairs: Observations on Selected Features of the Proposed 

Veterans’ Millennium Health Care Act. GAO/T-HEHS-99-125. Washington, 

D.C.: May 19, 1999. 

Related GAO Products 

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