Report No. 09-01588-92 March 4, 2010

VA Office of Inspector General 

Washington, DC 20420 

Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Hospitalized Community-Dwelling 

Elderly Veterans: Cognitive and 

Functional Assessments and 

 Follow-up after Discharge 
To Report Suspected Wrongdoing in VA Programs and Operations: 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov

(Hotline Information: http://www4.va.gov/oig/contacts/hotline.asp) 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

Executive Summary 

The VA Office of Inspector General, Office of Healthcare Inspections evaluated the 

extent to which Veterans Health Administration (VHA) clinicians conduct recommended 

assessments of elderly patients during hospitalization and ensure post-discharge followup care. 

We identified patients discharged from VA acute care hospitals during 

October 1–December 31, 2008, who were age ≥ 75 at the time of admission and who 

were discharged to a community setting. A random sample of these patients was selected 

for comprehensive medical record review. Reviewers evaluated records for the presence 

of functional and cognitive assessments. Completion of these assessments is widely 

accepted as a basic level of care for vulnerable elders, such that non-compliance indicates 

that care is likely of poor quality. 

During the study period, 15,456 veterans who were age ≥ 75 at the time of admission 

were discharged to a community setting from 142 VA acute care hospitals. The analysis 

of post-discharge care used data for all 13,913 patients with lengths-of-stay greater than 

one day, excluding those who died or were re-admitted on the day of discharge. 

We found that assessments of functional status were completed for more than 97 percent 

of the hospitalized elders whose medical records we examined. Likewise, most elder 

veterans (94 percent) had some evidence of care in the six weeks after hospital discharge. 

In contrast, less than 40 percent of patients had evidence of any cognitive assessment 

during their hospitalization or in the six months prior to admission. Hospitals with and 

without geriatrics academic programs did not differ substantially in these aspects of 

performance. 

We recommended that the Under Secretary for Health develop and implement a plan to 

ensure that vulnerable elderly veterans admitted to VA hospitals have a documented 

assessment of cognitive functioning. 

VA Office of Inspector General i 
VA Office of Inspector General 1 

DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Under Secretary for Health 

SUBJECT: Healthcare Inspection – Hospitalized Community-Dwelling Elderly 

Veterans: Cognitive and Functional Assessments and Follow-up after 

Discharge 

Purpose 

To evaluate the extent to which Veterans Health Administration (VHA) clinicians 

conducted recommended assessments of elderly patients during hospitalization and 

ensured post-discharge follow-up care. 

Background 

Aging of the U.S. population is nowhere more evident than among veterans. While 

nearly 40 percent of veterans were 65 years old or older in 2007, more than 46 percent 

are projected to be in that age group by 2015.1

 Further, hospitalized veterans are known 

to have multiple coexisting medical illnesses and poor functional status,2

 and 

hospitalization is well-described as a risk factor for early deterioration.3

 Hospitalized 

elderly veterans can be readily identified as a group for which specific interventions 

should be considered, and intensive follow-up can improve quality of life4

 and prevent 

readmission.4,5

As the goal of medical care for the elderly has progressed beyond survival to maximizing 

quality of life, attention has focused on the overall quality of medical care that the elderly 

 

1

 VA Office of Policy and Planning. 

2

 Weinberger M, Oddone EZ, Henderson WH. Does increased access to primary care reduce hospital readmissions? 

N Engl J Med. 1996;334:1441–7. 

3 Schonberg MA, et al. Index to Predict 5-Year Mortality of Community-Dwelling Adults Aged 65 and Older Using 

Data from the National Health Interview Survey. J Gen Intern Med. 2009;24:1115–22. 4

 Naylor MD, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. 

J Am Geriatr Soc. 2004;52:675–684. 

5

 Rich MW, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive 

heart failure. N Engl J Med. 1995; 333:1190–5. 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

VA Office of Inspector General 2 

 receive. RAND Corporation’s Assessing Care of Vulnerable Elders (ACOVE) project 

developed a set of quality indicators for the care of the vulnerable elderly.6

 Vulnerable 

elders are defined as elderly patients at increased risk for death or severe disability within 

the next 2 years. Based on comprehensive literature reviews and structured expert 

meetings, these guidelines established a basic level of care for the vulnerable elderly, 

such that non-compliance indicates that care is likely of poor quality. 

ACOVE quality indicators have been the basis for specific measures incorporated into the 

National Committee for Quality Assurance’s widely-used Healthcare Effectiveness Data 

and Information Set (HEDIS). HEDIS includes 71 measures across 8 domains of care 

and is used by more than 90 percent of U.S. health plans.7

VHA has long been a leader in geriatrics research, education, and clinical care. Twenty 

“centers of geriatric excellence” focus on various aspects of the quality of life and care of 

aging veterans. These centers serve as resources for other VA facilities.8

 The VHA 

Dementia Steering Committee has developed recommendations on specific aspects of 

dementia care,9

 but the extent to which accepted healthcare services are provided for 

elderly veterans across the system is unclear. This review evaluated ACOVE quality 

indicators in the care of hospitalized veteran elderly, focusing on in-hospital patient 

assessments and follow-up care after discharge. 

Scope and Methodology 

Population and Hospitals 

We identified patients discharged from VHA acute care hospitals during 

October 1–December 31, 2008, who were age ≥ 75 at the time of admission and who 

were discharged to a community setting.10 Because advanced age is associated with an 

increased risk of functional decline, we excluded patients younger than 75 years old. We 

also excluded patients admitted to “Observation” status. For patients with multiple 

hospitalizations during the study period we analyzed only the most recent. 

We identified hospitals with academic geriatrics programs based on affiliations with one 

of VHA’s Geriatric Research, Education and Clinical Centers (GRECCs)11 and on 

 

6

 Wenger NS, Shekelle PG, and the ACOVE Investigators. Assessing Care of Vulnerable Elders: ACOVE Project 

Overview. Ann Intern Med. 2001;135:642–6. 

7 http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2010/2010_Measures.pdf. 8 http://www.patientcare.va.gov/Geriatrics.asp 9 Shay K, Burris JF, State of the Art Planning Committee. Setting the stage for a new strategic plan for geriatrics 

and extended care in the Veterans Health Administration: summary of the 2008 VA State of the Art Conference, 

"The changing faces of geriatrics and extended care: meeting the needs of veterans in the next decade." J Am Geriatr 

Soc. 2008;56:2330–9. 10 VHA Patient Treatment File, a national inpatient data extract. See Appendix A for included and excluded 

discharge locations. 

11 http://www.patientcare.va.gov/Geriatrics.asp. Because some of the 20 GRECCs are shared between facilities, 

25 Hospitals have the GRECC designation. 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

VA Office of Inspector General 3 

approved positions for geriatrics fellowship training.12 Twenty-one hospitals designated 

as GRECCs also had geriatrics training programs and were considered geriatrics 

academic hospitals for the purpose of comparisons with hospitals having neither a 

GRECC affiliation nor a geriatrics training program (non-geriatrics academic hospitals). 

Patient Selection and Medical Record Review 

We selected a random sample of 300 patients from the study population for 

comprehensive medical record review. We subsequently excluded 74 patients with 

hospitalizations of one day or less because admission assessments may be completed 

after the first hospital day and because detailed assessments may not be feasible during 

these brief hospitalizations. 

Medical records were examined using an algorithm developed with a test sample. 

Reviewers used VHA’s electronic medical record system to evaluate medical records for 

the presence of functional and cognitive assessments during each patient’s 

hospitalization. 

Our evaluation of functional and cognitive assessments was based on the following 

ACOVE Quality Indicator: 

IF a vulnerable elder is admitted to a hospital or is new to a physician practice, 

THEN multidimensional assessment of cognitive ability and assessment of 

functional status should be documented BECAUSE screening for dementia can 

lead to early detection and initiation of treatment that may delay further 

progression.13

This recommendation is supported by the observation that screening can detect dementia 

which is frequently not apparent to patients or caregivers and by multiple published 

guidelines advocating assessments on admission to a nursing home, hospital, or physician 

practice.13 

For this review, adequate assessment of cognitive function was considered to be any 

explicit mention of an assessment of short-term memory14 or visuospatial/executive 

functioning. No particular measurement tool was required and any instrument 

incorporating either of these elements was accepted. In particular, the mini-mental state 

exam (MMSE) and related tests were accepted.15 If no cognitive assessment was found 

 

12 VHA Office of Academic Affiliations. Fifty-six hospitals had at least one approved position for geriatrics trainees 

during the study period. 

13 Chow TW, MacLean CH. Quality indicators for dementia in vulnerable community-dwelling and hospitalized 

elders. Ann Intern Med. 2001;135–668. 

14 Chodosh J, Edelen MO, Buchanan JL, et al. Nursing home assessment of cognitive impairment: development and 

testing of a brief instrument of mental status. J Am Geriatr Soc. 2008;56:2069–75. 

15 Deputy Under Secretary for Health for Operations and Management Memorandum, “Brief Mental status 

Measures – Alternatives to Mini Mental State Exam (MMSE),” June 13, 2007. 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

VA Office of Inspector General 4 

during the index hospitalization, the review was extended to include the 6-month period 

prior to admission. Examination of medical records was supplemented by text word 

searches using the terms memory, cognitive, and MMSE.

An adequate functional assessment required a description of the patient in any two of the 

following areas: dressing, eating, ambulating, toileting, hygiene, preparing meals, 

managing money, shopping for groceries or personal items, performing light or heavy 

housework, and using a telephone. No particular measurement tool was required and any 

instrument incorporating these elements was accepted.16 If assessments were absent, 

records were examined by a second reviewer. 

Post-Discharge Care 

For the analysis of post-discharge care, we excluded patients with a length-of-stay of 

1 day or less and those who died or were readmitted on the day of discharge. 

We based our evaluation of post-discharge care on the following ACOVE Quality 

Indicator in the “continuity and coordination of care” topic area. 

IF a vulnerable elder is discharged from a hospital to home and survives at least 

4 weeks after discharge, THEN he or she should have a follow-up visit or 

documented telephone contact within 6 weeks of discharge AND the physician’s 

medical record documentation should acknowledge the recent hospitalization 

BECAUSE follow-up with a health provider after hospital discharge is needed for 

management of the disease process that prompted the hospitalization and for 

review of medications, treatment modalities, and pending test results.17

An episode of care was defined as any inpatient or outpatient encounter, with a 

corresponding Current Procedural Terminology code.18 To count as post-discharge care, 

the encounter must have occurred at least one day after the index discharge date. Only 

care rendered within the first 50 days after discharge was included in the analysis. 

We accounted for patient deaths by matching the study population with the Social 

Security Administration’s Death Master File. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency. 

 

16 Acceptable instruments included but were not limited to the following: Barthel Index of Activities of Daily 

Living, Katz Index of Independence in Activities of Daily Living, Instrumental Activities of Daily Living Scale, and 

the Geriatric Health Questionnaire. 

17 Wenger NS, Young R. Quality Indicators of Continuity and Coordination of Care for Vulnerable Elder Persons. 

RAND Corporation Working Paper WR-176, August 2004. See also ACOVE Project. Ann Intern Med. 

2001;135–653.

18 VHA Patient Treatment File and National Patient Care Database. 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

Data Analysis 

Differences in completion of assessments based on the presence of academic geriatrics 

programs were evaluated using the chi-square test. Confidence intervals were calculated 

using a normal approximation to the binomial distribution. The Kaplan-Meier method 

was used for graphical presentation of events from time of hospital discharge, with 

censoring of patients at time of death, and upon receipt of post-discharge care. Trends in 

the provision of post-discharge care between geriatrics academic hospitals and nongeriatric academic hospitals were compared using the log-rank test. 

Results 

During October 1–December 31, 2008, 15,456 veterans who were age ≥ 75 at the time of 

admission were identified as having been discharged from 142 VHA acute care hospitals 

to community settings. After the initial selection of 300 patients from this population, 

74 patients were excluded because they had been hospitalized for less than one day and 

14 were excluded because they had been miscoded and in fact were discharged to nursing 

homes. The median age of the remaining 212 patients was 82 years (range 75-100), 

1.4 percent were female, and 49.5 percent were married. The median length of stay was 

4 days (range 2–53) (see Table 1). 

Table 1. Characteristics of Selected Veterans Admitted to VHA Acute Care 

Hospitals October 1–December 31, 2008, and Discharged to Community Settings.

Total Number of Patients in Review Population 15,456 

Randomly Selected Sample 300 

Patients with length-of-stay >1 day and confirmed to 

 have been discharged to community settings 212 

Age, median years 

 (range) 

82 

(75–100) 

Sex, percent female 1.4 

Marital status, percent married 49.5 

Length of stay, (median days) 

 (range) 

4 

(2–53) 

Cognitive and Functional Assessments 

Among the 212 evaluated patients, 56 (26.4 percent) had evidence of a cognitive 

assessment during the inpatient visit and 28 (13.2 percent) had no cognitive assessment 

during the hospital stay but did have an assessment during the prior 6 months. Taken 

together, 84 patients (39.6 percent; 95 percent confidence interval, 33.0–46.5) had a 

recent cognitive assessment. Functional assessment during hospitalization was 

VA Office of Inspector General 5 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

documented for 207 (97.6 percent) patients (Tables 2 and 3). Most functional 

assessments were documented by nursing staff using standardized admission templates. 

Geriatrics academic hospitals and non-geriatrics academic hospitals did not differ 

significantly with respect to either assessment (p > 0.5 for all comparisons). 

Table 2. Medical Record Review: Cognitive Assessment. Geriatrics academic 

hospitals were defined as those affiliated with a GRECC and having a geriatrics 

fellowship training program. Non-geriatrics academic hospitals had neither GRECC 

affiliation nor fellowship training. For all comparisons between hospital types, p > 0.5. 

GRECC = Geriatric Research, Education and Clinical Center. 

Hospital Type 

Total 

(88 hospitals) 

Geriatrics 

Academic 

(16) 

Non-Geriatrics 

Academic 

(42) 

Other 

(30) 

Number of patients 212 41 78 93 

Assessment during 

hospitalization 

(percent) 

56 

(26.4) 

10 

(24.4) 

24 

(30.8) 

22 

(23.7) 

Assessment only 

during prior 

6 months (percent) 

28 

(13.2) 

5 

(12.2) 

9 

(11.5) 

14 

(15.1) 

ANY Assessment 

(percent) 

84 

(39.6) 

15 

(36.6) 

33 

(42.3) 

36 

(38.7) 

Table 3: Medical Record Review: Functional Assessment. See Table 2 for definitions.

Hospital Type 

Total 

(88 hospitals) 

Geriatrics 

Academic 

(16) 

Non-Geriatrics 

Academic 

(42) 

Other 

(30) 

Number of patients 212 41 78 93 

Assessment during 

hospitalization 

(percent) 

207 

(97.6) 

40 

(97.6) 

78 

(100) 

90 

(96.8) 

VA Office of Inspector General 6 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

Post-Discharge Care

The analysis of post-discharge care used data for all 13,913 patients with lengths-of-stay 

greater than 1 day and who did not die or require readmission on the day of discharge. 

Among 13,698 patients who were alive 4 weeks after discharge, 12,921 (94.3 percent) 

had documented VHA care within 6 weeks of discharge. Most patients received care 

within 10 days of discharge (Figure 1). 

Figure 1. Kaplan-Meier Estimate of the Probability of Post-Discharge VHA Care.

Comparison of post-discharge care for the 2,785 patients from the 21 hospitals with 

geriatrics academic programs and the 84 hospitals (5,371 patients) without such programs 

revealed that patients at hospitals with geriatric academic programs were more likely to 

receive care within 50 days of discharge (p = 0.0003). However, the difference in followup care based on hospital type was small, with Kaplan-Meier estimates differing by 

VA Office of Inspector General 7 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

4.3 percent at 10 days and by 1.2 percent at 6 weeks. More than 94 percent of patients in 

both groups had some evidence of care at 6 weeks post-discharge.

Discussion 

Assessments of functional status were recorded in almost all patients, in most cases as 

part of admission nursing documentation. Follow-up care was also evident for most 

discharged veterans, while cognitive assessments were accomplished for far fewer. 

Hospital status as a center for academic geriatrics had no substantial impact on findings. 

Our evaluation for the presence of cognitive and functional assessments required detailed 

medical review of a limited number of randomly selected records. However, the 

assessment of follow-up care utilized data for all patients during the study period. This 

approach allowed for a robust appraisal of follow-up care, but was limited by the data 

available. We counted as evidence of post-discharge care any progress note entry into 

the electronic medical record for which workload information was provided. These 

encounters therefore included notes describing coordination of care in the absence of any 

direct involvement with patients, possibly exaggerating the extent of meaningful followup care. At the same time, our estimate may have understated follow-up care by not 

accounting for care by private providers. 

An additional limitation of our review results from inclusion of unresponsive and 

uncooperative patients, for whom a cognitive assessment would not have been possible. 

We noted, however, that the mental status of patients often changed throughout 

hospitalizations and patients for whom an assessment was not possible on admission 

could often be examined at some point prior to discharge. Our reviews encompassed the 

entire hospital stay for all patients. Inclusion of patients who were persistently 

unresponsive or uncooperative could have understated the rate of appropriate completion 

of assessments. However, many of these patients would have been excluded from our 

review because they were discharged to nursing homes, and our review was limited to the 

care of patients discharged to community settings. 

Conclusions 

We found that assessments of functional status were completed for more than 97 percent 

of the hospitalized elderly veterans whose medical records were examined. Likewise, 

most elderly veterans (94 percent) had some evidence of care in the 6 weeks after 

hospital discharge. In contrast, less than 40 percent of patients’ medical records 

contained evidence of any cognitive assessment during their hospitalization or in the 

6 months prior to admission. Hospitals with and without geriatrics academic programs 

did not differ in these aspects of performance. 

VA Office of Inspector General 8 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

VA Office of Inspector General 9 

Recommendation 

We recommended that the Under Secretary for Health develop and implement a plan to 

ensure that vulnerable elders admitted to hospitals have a documented assessment of 

cognitive functioning. 

Comments 

Under Secretary for Health Comments 

The Under Secretary for Health agreed with the findings and conclusions (See Appendix 

B for the complete text of the Under Secretary’s comments). 

Assistant Inspector General for Healthcare Inspections Comments 

The Under Secretary for Health’s comments and implementation plan are responsive to 

the recommendation. We will continue to follow up until all actions are complete. 

The Under Secretary stated that “cognitive testing of individuals on the basis of age 

alone, absent signs or symptoms of cognitive change, is not justified in the face of 

potential adverse consequences of false positive findings.” 

The RAND Corporation’s Assessing Care of Vulnerable Elders (ACOVE) quality 

indicators were the basis of this review. In accordance with the relevant ACOVE quality 

indicators, we did not recommend cognitive testing of individuals on the basis of age 

alone. Hospitalization constitutes an important predictor of subsequent decline in elders, 

and hospitalized elders were the subject of this review. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

Appendix A 

VA Office of Inspector General 10 

Discharge Locations 

Included Discharge Locations (Discharged to Community) 

• Community/Independent. 

• Foster Home. 

• Halfway House. 

• Boarding House. 

• Residential Hotel or Care Facility. 

• Other Placement/Unknown. 

• VA-Paid Home/Community Health. 

• Home-Based Primary Care. 

• Medicare Home Health Care. 

• Other Home Health Care. 

Excluded Discharge Locations 

• VA Medical Center. 

• Military Hospital. 

• Other Federal Hospital. 

• Other Government Hospital at VA Expense. 

• Community Hospital. 

• VA NHCU. 

• CNH at VA Expense. 

• State Home-Nursing. 

• State Home-Domiciliary. 

• VA Domiciliary. 

• Penal Institution. 

• Spinal Cord Injury-VA Approved Program. 

• Respite. 

• Hospice. 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

Appendix B 

Under Secretary for Health Comments 

VA Office of Inspector General 11 

Department of 

Veterans Affairs Memorandum

Date: January 27, 2010 

From: Acting Under Secretary for Health (10) 

Subject: OIG Draft Report, Healthcare Inspection – Hospitalized 

Community-Dwelling Elderly Veterans: Cognitive and 

Functional Assessments and Follow-up after Discharge, 

(WebCIMS 447143) 

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed and I concur with the draft report and 

recommendation. I am pleased that assessments of functional status were 

found to be completed for over 97 percent of the medical records examined 

for hospitalized Veterans. The report highlights the need to care for frail 

and elderly Veterans, and presents the specific skills and principles 

necessary to give quality care for this vulnerable population. 

2. The Veterans Health Administration (VHA) has long recognized the 

uniquely complex and involved health care needs for hospitalized elderly 

Veterans. I chartered a Dementia Steering Committee (DSC) comprised of 

field and Department of Veterans Affairs Central Office subject matter 

experts. The DSC was charged with ongoing review of scientific evidence 

as the basis for developing guidance for VHA clinical operations involving 

elderly Veterans who are at heightened risk for cognitive decline due to 

progressive degenerative neurological disease. The DSC has closely 

examined the professional and scientific literature concerning cognitive 

screening, and repeatedly determined that cognitive testing of individuals 

on the basis of age alone, absent signs or symptoms of cognitive change, is 

not justified in the face of potential adverse consequences of false positive 

findings. This determination is consistent with the conclusions and 

recommendations of the United States Preventive Services Task Force. 

Such guidance from the DSC may explain your finding of less than 

40 percent of a cognitive assessment during hospitalization or 6 months 

prior to admission. 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge

VA Office of Inspector General 12 

3. Nonetheless, VHA agrees that excellent care of hospitalized elderly 

Veterans warrants attention to cognitive function, and is making strides in 

ensuring that appropriate screening is completed. The Office of Geriatrics 

and Extended Care (GEC), within the Office of Patient Care Services, 

works with other program offices and with facility staff to provide expertise 

and leadership in the care of elderly Veterans. For over 2 years, GEC has 

been actively advised by a DSC. To ensure that appropriate cognitive 

assessment for a greater proportion of elderly hospitalized Veterans during 

hospitalization or prior to admission, GEC will collaborate with the Office 

of Nursing Services (ONS) to determine what aspect(s) of cognitive 

function: 1) are part of a customary, comprehensive nursing assessment of 

patients upon admission to hospital; 2) will be documented in an upcoming 

standardized admission template for nursing assessment; and 3) if any 

additional aspects of cognitive function should be included in the new 

standardized admission template. Further, GEC will obtain additional input 

from the VA National Center for Health Promotion and Disease Prevention 

and VHA to ensure consistency with related guidance that is currently 

being developed by those groups on related issues of dementia screening 

and use of dementia warning signs. Once the new, standardized nursing 

admission template is implemented, GEC and ONS will monitor data on 

documentation of cognitive function; and determine whether changes to the 

template, or other further action, is warranted. Any recommended changes 

in policy and practice will be provided to me for consideration. 

4. Thank you for the opportunity to review the report and provide 

comments. I would be pleased to discuss any concerns or comments you 

may have about this response. If you have any questions, please have a 

member of your staff contact Margaret Seleski, Director, Management 

Review Service (10B5) at (202) 461-7245. 

 (original signed by:) 

Gerald M. Cross, MD, FAAFP 

Attachment 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

VETERANS HEALTH ADMINISTRATION 

Additional Comments Related to Recommendations in OIG 

Draft Report, Healthcare Inspection, Hospitalized 

Community-Dwelling Elderly Veterans: Cognitive and Functional 

Assessments and Follow-up after Discharge, (WebCIMS447143)

Date of Report: December 17, 2009 

OIG Recommendation

We recommended that the Under Secretary for Health develop and 

implement a plan to ensure that vulnerable elders admitted to hospitals have 

a documented assessment of cognitive functioning. 

VHA Comments

Concur 

VHA’s Office of Geriatrics and Extended Care (GEC) will collaborate with 

the Office of Nursing Service (ONS) to determine the following: 

1. What aspect(s) of cognitive function are part of a customary, 

comprehensive nursing assessment of patients upon admission to 

hospital. 

2. What aspect(s) of cognitive function will be documented in the new, 

standardized admission template for nursing assessment that is currently 

being developed by ONS. 

3. Whether any additional aspect(s) of cognitive function should be 

included in the new, standardized nursing admission template as new 

scientific findings come to light. 

GEC will obtain additional input on the determination in “3.” above from 

the VA National Center for Health Promotion and Disease Prevention and 

the VHA Dementia Steering Committee, to ensure consistency with related 

guidance that is currently being developed by those groups on the related 

issues of dementia screening and use of dementia warning signs. 

Once the new, standardized nursing admission template is implemented, 

GEC and ONS will monitor data on documentation of cognitive function; 

will determine whether changes to the template or other further action is 

warranted; and will provide the Under Secretary for Health with any 

recommendation for change in policy and practice on this matter. 

VA Office of Inspector General 13 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge

VA Office of Inspector General 14 

The anticipated completion date for this action will depend on when the 

new nursing admission template is implemented. Review of local or 

national documentation data will occur by October 2010 if the national rollout and implementation of the Inpatient Assessment Template occurs in 

May 2010, as currently projected. However, if implementation of the 

Template is delayed, then data will be reviewed within 6 months of 

Template deployment. 

 In process October 2010 

Veterans Health Adminstration 

December 2009 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Audrey Collins-Mack, RN 

(404) 929-5944 

Acknowledgments Lisa Barnes, LMSW 

Jerome E. Herbers, Jr., MD 

Wilma Reyes, MD 

Prabu Selvam, MHS 

Kathleen Shimoda, RN 

Marilyn Walls, RN 

Susan Zarter, RN 

VA Office of Inspector General 15 
Hospitalized Community-Dwelling Elderly Veterans: Assessments and Follow-up after Discharge 

Appendix D 

VA Office of Inspector General 16 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp.