Long-Term Care Services for Veterans
Released: 2017-02-14T00:00:00

Summary:
The Veterans Health Administration (VHA), an operating unit of the Department of Veterans Affairs (VA), is a direct service provider of health care, similar in many ways to a large private sector health care system. In addition to providing inpatient, outpatient, and a range of other medical care services, the VHA provides and purchases long-term care services. The VA is one of two federal payers of long-term care services (the other being Medicaid).
Since the 1960s, the VA has been authorized to provide nursing home care to eligible veterans in various settings, including VA facilities, private nursing facilities contracted by the VA, and state veterans homes (P.L. 88-450). These nursing home benefits were further expanded in subsequent legislation (P.L. 91-101 and P.L. 93-82). In 1999, the Veterans Millennium Health Care and Benefits Act (P.L. 106-117) required the VA to provide such benefits to veterans needing nursing home care due to one of their service-connected conditions, as well as veterans who overall have a service-connected disability rating of 70% or more, who need the care for any condition, service-connected or not. In addition, the law required the VA to maintain staffing and level of services for institutional care not less than the FY1998 level; the law also required non-institutional long-term care services as part of the VA medical benefits package.
About 9.1 million veterans (43% of all veterans) were estimated to be enrolled in the VHA in FY2016. Although the overall number of veterans in the United States has declined since FY2000, the number of veterans enrolled in the VHA has increased significantly in that same time period. In FY2000, just over 4.9 million veterans were enrolled in the VHA; by FY2016 that number was estimated to have increased 86%, to 9.1 million enrollees. This increase is due, in part, to the growing number of veterans with service-connected disabilities, as well as more liberal enrollment policies. Among veterans with a service-connected disability, the proportion who have a disability rated as 70% or more service-connected (and therefore eligible for VA paid nursing home care) has also increased.
VA long-term care programs are administered at the VA facility level, with some variability in how programs are administered. Each VA facility offers certain mandatory programs and may offer several optional programs as well. Eligibility for VA long-term care programs depends on eligibility for VA health care, which is based primarily on "veteran status" resulting from military service. Once enrolled, veterans' eligibility for long-term care services depends on several factors, including veterans' need for the service (as determined by the VA), whether the service is institutional or non-institutional, and (for certain programs), veterans' service-connected status.
Institutional settings may include both inpatient acute care and nursing home care. However, the majority of VA long-term care provided in institutional settings occurs in nursing home facilities, such as VA Community Living Centers (CLCs), community nursing homes, and state veterans homes. Non-institutional care includes outpatient and ambulatory care settings, as well as care that occurs in the home or another community-based setting. Non-institutional services include
home-based primary care, community residential care, geriatric evaluation, palliative care, adult day health care, homemaker/home health aide care, respite care, home skilled care, home hospice, and veteran-directed home and community-based services and medical foster homes (at some facilities).
Some long-term care services are provided directly by VA staff, whereas others are purchased from providers outside of the VA. Long-term care expenditures are a small but not insignificant part of the VHA total medical care budget, at just over one-tenth of the VHA's budget. In FY2015, the VHA spent $7.4 billion (13% of its total appropriated funding for medical care, which was $55.8 billion) for veterans' long-term care. Institutional care accounted for almost $5.3 billion, or 71% of VA's total long-term care spending, while non-institutional care accounted for $2.1 billion, or 29%. The majority of VHA institutional care spending (64%) was for VA Community Living Centers (CLCs), nursing facilities owned and operated by the VA.
This report provides an overview of VA long-term care services, including legislative highlights, eligibility, organizational structure, descriptions of services (both institutional and non-institutional care), and expenditures. The report also describes three key issues for Congress when considering the VA and its long-term care financing and delivery system:
1. Veterans' access to long-term care services. 2. Settings where services are provided and the appropriate balance between institutional and non-institutional care. 3. Veteran's health coverage options and federal coordination.

subsections: section_title: Introduction
paragraphs: The United States has a long history of providing benefits to those who have served in the defense of the nation. What began as a disability compensation and pension program for veterans during the early years of the republic has grown into a comprehensive veteran benefits and services system. The federal responsibility of managing this system has been entrusted by Congress primarily to the Department of Veterans Affairs (VA). The VA carries out its veterans programs nationwide through the following three administrations and an appeals board:
The Veterans Health Administration (VHA) is responsible for veteran health care programs. The Veterans Benefits Administration (VBA) is responsible for disability compensation, pension, vocational rehabilitation, education assistance, home loan guaranty, and insurance, among other benefits. The National Cemetery Administration (NCA) is responsible for providing burial space and maintaining national cemeteries, among other responsibilities. The Board of Veterans Appeals (BVA) renders final decisions on appeals regarding veteran benefits claims.
The VHA, the largest and most visible operating unit, is predominantly a direct service provider of primary and specialty care, similar in many ways to a large private sector health care system. However, some aspects of the VHA are very different from a private health care system. Not only does the VHA employ health professionals to provide health care services directly, but the VHA also purchases care for certain veterans from community health providers. Further, the VHA provides social services and other supportive services—such as housing assistance, home health aide services, and adult day health care—that are rarely tied to private sector health care providers or financed by private health insurance or Medicare. Beyond the provision of health care and other support services to veterans and eligible family members, the VHA is statutorily required to conduct medical research into the special health care needs of veterans, to train health care professionals, to serve as a contingency back up to the Department of Defense (DOD) medical system during a national security emergency, and to provide support to the National Disaster Medical System and the Department of Health and Human Services (HHS) as necessary.
In addition to providing inpatient, outpatient, and a range of other medical care services, the VHA has been authorized by Congress since the 1960s to provide nursing home care to eligible veterans in VA facilities, private nursing facilities contracted by the VA, and state veterans homes. Although the VHA initially provided only institutional-based long-term care, VA long-term care services have expanded to include a full range of long-term services and supports (LTSS)—both institutional and non-institutional. These services include programs of care directly provided by the VA, such as home-based primary care and geriatric evaluation, as well as services purchased by the VA, such as home health aide and home respite care. The VA typically refers to programs under this broad umbrella as Geriatrics and Extended Care (GEC) Programs (see Figure 1 and text box for terminology used in this report). These programs share a primary goal: to support veterans to remain safe in the least restrictive environment.
This report provides an overview of the long-term care services offered by the VA, whether directly provided or purchased from the community. It first provides a brief history of legislation relevant to VA long-term care services. Next, it provides information on veteran eligibility for care and enrollment, to give a picture of who these programs serve. It then provides an overview of the structure of the VHA to explain how care is administered, followed by a description of the various long-term care programs that the VA offers. Finally, the report discusses potential issues of interest for Congress.
section_title: Brief Legislative History
subsections: section_title: 1960s-1970s
paragraphs: Prior to the enactment of P.L. 88-450 in 1964, the VA did not have explicit statutory authority to provide nursing home care to veterans in VA facilities; however, the VA did provide a limited form of institutional care in its domiciliaries for those who no longer needed hospitalization. Toward the end of FY1964, within the scope of existing statutory authority, the VA began making plans to implement a nursing home care program with 2,000 beds in VA hospitals "for those veterans who have obtained maximum hospital benefits, [but] are too physically disabled for domiciliary care, and still have a need for nursing care which for various reasons cannot be provided in the community." In August 1964, P.L. 88-450 authorized, among other things, 4,000 beds for nursing home care. It further authorized care in private or public nursing homes for no more than six months at VA expense for VA patients who had received maximum hospital benefits but who still needed long-term nursing home care. If the veteran needed permanent nursing home care for more than six months, the veteran would be placed in a VA nursing home rather than a private nursing home. P.L. 88-450 also authorized the VA to make per diem payments to state veterans' nursing homes for the care of eligible veterans. In enacting P.L.88-450, Congress recognized the growing need for nursing home care for World War II veterans in future years, and at the same time recognized the need for VA to move patients from expensive hospitals settings (when they no longer needed hospitalization) to less expensive nursing home settings for longer-term convalescence.
P.L. 91-101, enacted in 1969, amended P.L. 88-450 and eliminated the six-month limitation on care at a contracted community nursing home for veterans who were previously hospitalized in a VA hospital for a service-connected disability. For all other veterans, the six-month limitation applied, but the VA was authorized to extend the time period at its discretion. The Veterans Health Care Expansion Act of 1973 ( P.L. 93-82 ) further liberalized eligibility for contracted community nursing home care for veterans with service-connected conditions and authorized the VA to provide nursing home care to veterans in contracted community nursing homes without having to be admitted to a VA hospital first. 
section_title: 1980s-1990s
paragraphs: In 1998, a Federal Advisory Committee on the Future of VA Long-Term Care found that 
VA's long-term care system developed incrementally in the 1970s and early 1980s. Nursing home care remains its primary emphasis, while home and community based care is underdeveloped. In addition, long-term care programs are not fully integrated into the healthcare system at many VA facilities. Despite a continuum of offerings, services are not available universally and access often is restricted. Many facilities do not have mechanisms for coordinating long-term care services, relying on episodic admissions to individual programs. Long-term care is largely viewed as an adjunct rather than an integral part of the healthcare system, VA long-term care services must be remodeled to effectively deliver needed services.
Based on recommendations of the Federal Advisory Committee on the Future of VA Long-Term Care, Congress began to examine the VA's long-term care programs, which led to the enactment of the Veterans Millennium Health Care and Benefits Act ( P.L. 106-117 ) in November 1999. This act, among other things, mandated nursing home care for veterans with a service-connected condition in need of such care and for veterans with nonservice-connected conditions who are 70% or more service-connected disabled. Among other things, it also required the VA to provide non-institutional care, such as home-based care and adult day health care, to all enrolled veterans. In his signing statement, President Clinton stated:
This bill is especially significant for its approach in the provision of enhanced extended care services to veterans. It firmly establishes that the Department of Veterans Affairs (VA) should accord the highest priority for nursing home care to the most severely disabled veterans and those needing care for service-connected disabilities. It will also ensure that veterans enrolled in the VA health care system receive noninstitutional, extended-care services, including geriatric evaluations and adult day health care.
section_title: VHA Eligibility, Enrollment, and Long-Term Care
paragraphs: In general, eligibility for VA long-term care services depends on several factors, including veterans' need for the service, as determined by the VA; whether the service is institutional or non-institutional; and, for certain programs, veterans' service-connected status. However, to understand eligibility for VA long-term care services, it is important to understand eligibility for VA health care in general, the VA's enrollment process, and its enrollment priority groups. Unlike Medicare or Medicaid, VA medical care is not an entitlement program. Contrary to numerous claims made concerning promises of "free health care for life," not every veteran is automatically entitled to health care from the VA.
subsections: section_title: Overview of VHA Eligibility
paragraphs: Eligibility for VA health care is based primarily on "veteran status" resulting from military service. In general, veteran status is established by active-duty status in the military, naval, or air service and a discharge or release from active military service under "other than dishonorable" conditions (e.g., general, honorable, under honorable conditions). After veteran status has been established, the VA next places an applicant into one of two categories. 
The first category comprises veterans with service-connected disabilities or with incomes below an established threshold. Service-connected disability means that such disability was incurred or aggravated in the line of duty in active service. Veterans with service-connected disability or income below the threshold are regarded by the VA as "high priority" veterans and are enrolled in Priority Groups 1-6 (see Figure B-1 ). The second category of veterans comprises those who do not fall into one of the first six priority groups—primarily veterans with nonservice-connected medical conditions and with incomes above the VA-established threshold. These veterans are enrolled in Priority Group 7 or 8.
As shown in Table 1 , the majority of VA-enrolled veterans (77%) fall into Priority Groups 1-6, with 23% of veterans in Priority Group 1 (those with 50% or more service-connected disability or determined by VA to be unemployable due to service-connected conditions) and 22% of veterans in Priority Group 5 (those with incomes below the threshold, receiving VA pensions, or receiving Medicaid). Once veterans are enrolled in the VA health care system, they remain in the system and do not have to reapply for enrollment annually, unless they wish to disenroll formally.
section_title: VHA Enrollment
paragraphs: The size and scope of the VA health care system are influenced by several factors, including the size of the veteran population, the number of veterans eligible for VA health care, veterans' decisions about whether to enroll, and once enrolled, whether to utilize VA health care services, including long-term care services. An estimated 9.1 million veterans (43% of all veterans) were enrolled in the VA health care system in FY2016. Those not enrolled are either ineligible to enroll or eligible but choose not to enroll. In addition, some veterans may be eligible but unaware of their eligibility status. While overall the number of veterans in the United States has declined since FY2000, the number of veterans enrolled in the VA health care system has increased significantly.
The Veterans' Health Care Eligibility Reform Act of 1996 ( P.L. 104-262 ) required the establishment of a national enrollment system to manage the delivery of inpatient and outpatient medical care. The VHA began formally enrolling veterans for the first time in FY1999. As shown in Figure 2 , just over 4.9 million veterans (19% of all veterans) were enrolled in the VHA in FY2000; by FY2016, that number was estimated to have increased 86%, to 9.1 million enrollees. This increase is due, in part, to factors such as enrollment in newer veterans from Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND), a larger number of female veterans, and economic conditions, among other factors. The number of veterans receiving VA health care services is projected to level off over the next 10 years.
section_title: Veterans and Long-Term Care
paragraphs: VHA enrollees are a clinically complex population with significant health care needs. VHA enrollees are more likely than nonveterans to be diagnosed with chronic health conditions, including those linked to their military service. For example, conditions such as PTSD are more prevalent in veterans compared with nonveterans, as are conditions such as cancer and diabetes. This likelihood is due, in part, to VHA eligibility policies based on service-connected conditions. Moreover, VHA policies regarding mental health screening, for example, lead to higher rates of diagnosis. In addition, veterans who access the VHA also tend to be older, less socioeconomically well off, and less healthy than veterans who do not rely on the VA for care.
The VA health care system faces the challenge of providing care to those aging with disability as well as those aging into disability. Veterans of all ages may need long-term care, both younger veterans with disabilities and aging veterans. Moreover, the number of veterans with a service-connected disability, defined as a disability caused by injury or disease incurred or aggravated during active military service, is increasing. The VA determines whether veterans have service-connected disabilities, and for those with such disabilities, assigns ratings from 0% to 100% (in increments of 10%) based on the severity of the disability. As shown in Figure 3 , nearly 2.5 million veterans had a service-connected disability in FY2003; by FY2013, that number had increased to over 3.7 million. Moreover, the number of veterans who are rated in the highest disability rating group (i.e., veterans with 70% to 100% service-connected disabilities) has increased. Among those veterans with service-connected conditions, about 2 in 10 veterans (18%) were rated as having 70% to 100% service-connected disabilities in FY2003, compared with 3 in 10 veterans (30%) in FY2013. As the number of veterans with a service-connected disability increases, the demand for VA long-term care services over a veteran's lifespan will likely increase.
The need for long-term care typically increases with age. In the general population, it is estimated that about half (52%) of individuals turning age 65 will develop a disability serious enough to need long-term care. Most will need care for two years, on average. However, one in seven is expected to have care needs for five years or more. Because the veteran population is older than the general population, long-term care services are an important part of VA's health benefits package. In 2016, 48% of all veterans enrolled in the VHA were aged 65 and over, compared with 15% of the general population (as of 2015). The majority of older veterans (85%) are aged 65 to 84. Vietnam-era veterans are the largest cohort of veterans and the cohort now reaching advanced age.
section_title: VHA Organization and Long-Term Care
subsections: section_title: Overview of VHA Organization
paragraphs: The VHA is the largest integrated health care system in the United States, with over 1,700 sites of care, including medical centers, nursing facilities, clinics, and vet centers. To administer this large system, the VHA has divided the country into Veterans Integrated Service Networks (VISN), based on geography (see Figure 5 ). There are currently 18 VISNs, which vary regarding the number of sites of care, the types and number of facilities, and the geographic size of the network's region. Each VISN has a VISN Director, who has oversight of the VA facilities within that VISN and directly supervises the facility director at each facility. 
For example, VISN 10 has oversight of VA facilities in Indiana, the lower peninsula of Michigan, and Ohio, including 10 medical centers (VAMCs) and one outpatient health care center (HCC). Each of these main facilities has associated community based outpatient clinics (CBOCs) under its purview; for example,
Cleveland, OH VAMC has 12 CBOCs in outlying areas, such as Akron and Canton. The Columbus, OH, HCC has four CBOCs, including Zanesville and Marion.
Many facilities also have a Community Living Center (CLC), which is a nursing facility owned and operated by the VA. The CLC may be located within the same physical structure as the VA hospital, or it may be a separate structure at a nearby location; regardless, the CLC is considered a part of the parent VAMC and is under the direction of that facility's director. Alternatively, VISN 1 covers more states (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) and has 11 VAMCs. In contrast, VISN 21 covers a large geographical area and has nine VAMCs in three states (Northern California, Hawaii, and Nevada) and covers U.S. territories such as Guam, which has one CBOC and one Vet Center under the purview of the VAMC in Honolulu, HI. Table 2 shows national numbers of different types of facilities as of December 2015.
section_title: VA Long-Term Care Organization
paragraphs: VA LTC programs are administrated at the VAMC/HCC level. Each VAMC/HCC offers certain mandatory programs and may offer several optional programs as well. The VISN Director offers some oversight into programming, but each facility has latitude to administer the various programs, within the parameters of national handbooks and directives, resulting in variability from facility to facility even within the same VISN. For example, in VISN 17, which primarily encompasses the state of Texas, all but two of the VAMCs offer the Medical Foster Home Program (MFH). MFH is a VA-approved adult foster care setting and is not currently mandated nationally. The Waco and Harlington, TX, VAMCs do not offer MFH—a local facility decision that may be based on factors such as lack of patient demand, staffing, budget, and availability of interested caregivers. Another example of program variability is Veteran Directed Home and Community Based Services (VD-HCBS), a collaborative program of the VA and the Administration for Community Living (ACL) that provides veterans with a budget to direct their own home care services. Sixty-eight VAMCs (out of 168) offered this program, as of October 2016; veterans served by other VA facilities do not have access to VD-HCBS. Nationally, the VHA Office of Geriatrics and Extended Care (GEC) provides guidance and oversight for these programs, including performance metrics, policy, auditing, and staff training.
At the facility level, LTC programs may be organized in one Geriatrics Department (often called a "Service" or "Care Line") or housed in one of several different departments (such as Social Work Service, Nursing Service, or Primary Care). Geriatrics Departments may be led by an Associate Chief of Staff for Geriatrics, or equivalent position, who is responsible at the facility level for the administration of LTC programs and reports to the facility chief of staff. From facility to facility, there is variability in program organization and management.
section_title: VHA Long-Term Care Services
paragraphs: The VA offers long-term care in both institutional and non-institutional settings. Institutional settings may include both inpatient acute care and nursing home care, although the majority of long-term care the VA provides in institutional settings occurs in a nursing home setting, which is the primary focus in this report. Non-institutional care includes outpatient or ambulatory care settings, as well as care that occurs in the home or another community-based setting. These services cover a full spectrum of care needs, spanning veterans who are largely independent, to those who require significant assistance with basic daily activities, to those who are near the end of life. Some long-term care services are provided directly by VA staff, while other services are purchased from providers outside the VA. The subsection below describes non-institutional services provided and purchased by the VA. The next subsection provides information about long-term care provided in institutional settings. 
subsections: section_title: Non-Institutional Care
paragraphs: The VA provides home and community-based care to eligible veterans enrolled in the VHA who meet certain clinical criteria (see Table 3 ). A primary goal of these programs is to support veterans in remaining safely in their home settings, with optimum health and wellness as they age. The VA is statutorily required to provide two non-institutional long-term care services: adult health care and respite care. VA's other non-institutional long-term care services are provided as part of the health care benefits package. Although the VA provides many of these services directly, it also purchases certain services from community providers and then pays those providers, similar to other federal payers such as Medicare. These programs are described below.
subsections: section_title: VA Provided Care
paragraphs: The Home Based Primary Care (HBPC) program provides long-term, comprehensive primary care services to eligible veterans. Such services are coordinated by an interdisciplinary team that makes home visits. Generally, veterans who have difficulty getting around outside the home due to a chronic health condition or other long-term care need are eligible for HBPC. The HBPC team comprises VA staff, including physicians, nurse practitioners or physician's assistants, nurses, social workers, dietitians, physical or occupational therapists, psychologists, and pharmacists. Team members make separate home visits, form a medical care plan, and provide comprehensive case management for veterans. Primary goals of the program include maintaining veterans safely in their home, reducing hospitalizations and emergency department visits, and managing complex chronic illnesses to help increase veterans' quality of life. HBPC programs are accredited by the Joint Commission on the Accreditation of Health Care Organizations (Joint Commission) under home care standards and are surveyed every three years by the Joint Commission.
The Community Residential Care (CRC) program is a supported housing program where veterans reside in a VA-approved group home. VA staff provide case management services to the veteran and monitor the care provided by the group home staff. The CRC program is designed for veterans who do not need a nursing home level of care, but do need support with their daily living skills, such as household tasks, meal preparation, and transportation. The veteran pays the CRC home out-of-pocket for room and board, which varies depending on geographic cost of living and amount of care provided. The VA staff make regular visits to see the veteran and inspect the home initially and annually. In addition, VA staff offer ongoing education and training to the CRC caregivers on topics such as infection control, working with challenging behaviors, and falls prevention.
For veterans who need more assistance than a CRC home can provide, the Medical Foster Home (MFH) program may be an option available at some VAs. MFH is a subset of the CRC program providing a higher level of care to eligible veterans. The veteran resides in a VA-approved adult foster care setting, with caregivers providing supervision 24 hour per day. Caregivers are private individuals, many of whom have nursing or nursing aide backgrounds, who choose to open up their home to veterans. The caregiver must also live in the home and may accept no more than three veterans as residents at a time. The MFH program is designed for veterans who would need nursing home level of care if not for significant in-home supports. The MFH caregiver provides assistance with personal care, supervision, and management of household tasks for the veteran. The veteran pays the MFH caregiver out-of-pocket for room and board, with these costs varying by the amount of care needed and geographic cost of living. All MFH veterans are also enrolled in a home visiting VA program, such as HBPC, which provides case management and oversight of the veteran's care. In addition, the VA MFH Coordinator arranges the placement of the veteran, monitors the care, organizes education and training for the caregivers similar to the CRC trainings, and arranges for initial and annual inspections of the homes that are conducted by VA staff, which typically includes the coordinator, a life safety expert, dietitian, and nurse.
In addition to programs offered in the home setting, the VA offers several outpatient clinic-based services. For example, as required under current law, VA offers geriatric evaluation in many settings, including outpatient, inpatient, and long-term care settings. Although VA is required to provide geriatric evaluation to eligible veterans it may not be provided at all VA facilities. In part, this is due to facilities not having a geriatrician, another provider with geriatric expertise, or the necessary interdisciplinary expertise. The key component of geriatric evaluation is a comprehensive, interdisciplinary assessment, with team members including, but not limited to, a physician and at least two of the following disciplines: nurse, social worker, occupational or physical therapist, dietitian, or pharmacist. Veterans are referred from primary care or other specialties seeking input related to issues, such as
increasing functional deficits; behavioral issues related to dementia; complicated psychosocial situations related to aging; polypharmacy (i.e., aging veterans who are taking medications that may cause side effects, and who could benefit from a simplified medication regimen); and frequent hospitalizations. 
The team forms a recommended treatment plan and then either manages the implementation of that plan or makes recommendations back to the primary care team for how to best manage the veteran's care.
Another clinic-based option available to veterans is outpatient palliative care. The outpatient Palliative Care Clinic focuses on comfort care and symptom management for veterans with chronic illnesses helping to increase veterans' quality of life. Veterans may be seen in a Palliative Care Clinic even while continuing to receive curative treatment. Generally, veterans may have a prognosis of two years or less to live. Palliative care may also be appropriate earlier, when a veteran's goals are primarily related to symptom management and quality of life. The Palliative Care Team includes a medical provider, social worker, nurse, chaplain, and may include a psychologist and dietitian. Hospice, a specific form of palliative care for veterans with six months or less to live, is provided in home or inpatient settings.
A limited number of VA facilities offer onsite Adult Day Health Care (ADHC) . ADHC is an outpatient day program that provides activities, socialization, supervision, and meals in a congregant setting. This program is targeted toward veterans who would need nursing home care if not for such assistance, including veterans who need assistance with personal care and daily living skills, as well as veterans with cognitive impairments that need supervision. ADHC programs generally offer structured activities such as restorative exercises and social activities (e.g., music, crafts, and outings), personal care, me dication management, and meals.
section_title: VA-Purchased Care
paragraphs: Adult Day Health Care , as described above, is also purchased by the VA from community agencies. In this situation, the VA has agreements with local community agencies that provide ADHC services. The VA refers veterans to those ADHC sites, authorizes how many days per week the veteran may attend based on clinical need, and monitors the care provided via onsite visits made by VA clinical staff at least quarterly. In addition, the VA staff conducts an annual inspection of the ADHC site. The VA pays an agreed-upon daily or hourly rate to the ADHC sites, similar to state Medicaid programs.
Homemaker/Home Health Aide (H/HHA) services are another service that the VA purchases from community agencies. Clinical eligibility for H/HHA services is the same as for the ADHC program; veterans who are clinically eligible for nursing home level of care may receive home health aide services in their home, with the goal of keeping the veterans in their home rather than in a nursing facility. A VA provider assesses the need for care and places an order. Next, a VA coordinator contacts the veteran to discuss his or her needs, determines amount of care to be provided based on clinical need, and makes a referral to a community home health agency. The VA reassesses the veteran's need for care at least annually and assesses the agency's quality annually.
Respite services are also purchased by the VA and provided either in the home by a home health agency or in an ADHC setting. Respite services are intended to be short term and are generally limited to thirty days per calendar year per veteran; respite is meant to give the family caregiver a break from caring for the veteran. Clinical eligibility is the same as for ADHC or home health aide services.
The VA also purchases skilled home care , which is provided by qualified personnel for a limited time with the goal of rehabilitation or restoring health status. Skilled home care includes but is not limited to home physical, occupational, or speech therapy; wound care; and intravenous (IV) care. A VA physician determines that a veteran needs the skilled care and then orders the skilled care and VA coordinators contact the veteran and arrange the care. In general, the VA purchases skilled home care from Medicare-certified home care agencies. The VA monitors the agencies' quality measures at least annually.
Another service that the VA purchases from community agencies is home hospice . As mentioned previously, hospice is a type of palliative care or comfort care. To be eligible for hospice, a veteran must have a life-limiting diagnosis and a physician must determine that a veteran has a life expectancy of six months or less. The VA hospice coordinator then contacts the veteran and family to provide further education regarding hospice and makes a referral to a community hospice agency. The hospice agency provides an interdisciplinary care team, which manages the symptoms of the life-limiting diagnosis, works with the veteran on goals for care, and seeks to improve quality of life. The team generally consists of a physician, nurses, a social worker, aides, and a chaplain. If the veteran's needs cannot be met in the home, the VA may pay for a general inpatient hospice stay or an inpatient respite stay in a community facility. Or the VA may transfer the veteran to a VA Community Living Center (CLC) to receive inpatient hospice services in a VA facility.
Finally, a limited number of VA facilities offer Veteran-Directed Home and Community- Based Services (VD-HCBS) . Clinical eligibility is the same as for ADHC or H/HHA services (see Table 3 ). VD-HCBS provides veterans with a budget for services, and the veteran determines how to use that budget to hire home health aides or arrange other supportive services to help the veteran live independently. The goals of the program are to provide the veteran more control and choices related to his or her care and to keep the veteran safely in his or her home. The veteran may use the funds to pay a family member or private citizen to provide aide services. The VA has agreements with local Area Agencies on Aging (AAA) to administer the program, including providing case management services and oversight of budget.
section_title: Institutional Care
paragraphs: As the VA works to support veterans in their home environment, some veterans may have long-term care needs that can be served in institutional settings (see Table 4 ). The VA is mandated to provide nursing home care to certain service - connected veterans . As previously mentioned, the Veterans Millennium Health Care and Benefits Act ( P.L. 106-117 ) requires the VA to provide nursing home care to the following veterans: 
any veteran in need of such care for a service-connected disability; or to any veteran who is in need of such care and who has a service-connected disability rating of 70% or more; or any veteran who has a service-connected disability rated 60% or more and unemployable; or any veteran who has a service-connected disability rated 60% or more and who has been rated permanently and totally disabled. 
Depending on available resources, the VA may also provide nursing home care to nonservice-connected veterans who are clinically in need of institutional care. This care may be provided in a VA Community Living Center (CLC), a Community Nursing Home (CNH), or a State Veteran's Home.
The VA has 135 Community Living Centers (CLC) associated with VAMCs across the country that provide nursing home level of care. CLCs are staffed by VA employees and may provide rehabilitation, custodial, and hospice care to veterans. Some CLCs may offer specialty services, such as a specialized dementia unit. In the mid-2000s, this program underwent a change in the model of care, renaming the facilities from Nursing Home Care Units to Community Living Centers to evoke a more homelike atmosphere and acknowledge that CLCs are the veterans' home. In addition to the name change, the VA launched a system-wide program to promote cultural transformation, including a more person-centered approach, more homelike interior design, and more resident choice related to daily schedule of meals, sleep and wake times, and bathing. CLCs are inspected by the VA's Office of the Inspector General and the Long-Term Care Institute.
While not all VAMCs have CLCs, all are required to operate a Community Nursing Home (CNH) program. Under this model, the VA has contracts with community nursing facilities to provide care to veterans. The VA inspects the nursing facility initially and then reviews quality annually, and VA clinical staff make monthly visits to each nursing facility where veterans have been placed to monitor the care being provided. The VA Community Nursing Home Coordinator makes arrangements for placement of eligible veterans and acts as a liaison for the nursing facility.
The third setting for VA nursing home care is in a State Veterans Home (SVH) . SVHs are owned and operated by the state in which they reside, and eligibility requirements are determined by the state of jurisdiction. The state may apply for grants from the VA to cover some of the cost of infrastructure, and the SVH may receive a per diem that covers approximately one-third of the cost of the veteran's care. The VA also surveys the SVH annually. Each state operates SVHs differently, but may offer various levels of care in addition to nursing home, such as domiciliary (independent living), assisted living, and adult day health care.
In addition to providing long-term care in these settings, VA facilities may choose to provide respite, hospice, and palliative care, as well as geriatric evaluation programs, to eligible veterans in an institutional setting. As previously mentioned, veterans are eligible for 30 days of respite care per calendar year, in general; if needed, this care may be provided in an institutional setting (such as CLC or CNH), depending on resource availability, to give the family caregiver a break from caregiving. The clinical criteria for veterans receiving institutional respite care is the same as for home respite; however, this program may be limited in certain VA facilities   depending on resource or bed availability. In addition, hospice care may be provided to veterans in an institutional setting. For example, veterans receiving home hospice whose care needs can no longer be managed at home may move into a VA CLC to receive hospice care for a short time, while their symptoms are managed, or while they are actively dying. In some cases, the VA may also pay for inpatient hospice care in other institutional settings, such as community inpatient hospice facilities. Also, palliative care may be offered in institutional settings; some CLCs may have palliative care units, or a VA may have a palliative care team that consults at the bedside of veterans in a hospital intensive care unit. Similarly, geriatric evaluation teams may consult with veterans residing in acute inpatient settings. Although the provision of these programs varies across VA facilities, the programs should be available to eligible veterans residing in institutional settings.
section_title: VHA Long-Term Care Expenditures
paragraphs: Long-term care expenditures are a small but not insignificant part of the VHA medical care budget, at just over one-tenth of the VHA's total medical care budget. In FY2015, the VHA spent $7.4 billion, just over 13% of its total medical care spending ($55.8 billion), for veteran's long-term care (see Table 5 ). Institutional care accounted for almost $5.3 billion, or 71% of VA's total long-term care spending, while non-institutional care accounted for $2.1 billion, or 29%. While total appropriated funding for VHA medical care has increased 25% (in nominal dollars) since FY2010, the proportion of total appropriations spent on long-term care has remained relatively unchanged. However, non-institutional long-term care expenditures doubled from FY2010 to FY2015 (non-inflation adjusted dollars). As a proportion of total VA long-term care spending, non-institutional care increased from 19% to 29% from FY2010 to FY2015. As Table 5 shows, the percentage of total VHA medical care spent on long-term care ranged from approximately 12% to 13% from FY2010 to FY2015.
subsections: section_title: Institutional Care
paragraphs: The majority of VHA institutional care spending (64%) is for VA Community Living Centers (CLCs), which are nursing facilities owned and operated by the VHA (see Table 6 ). For FY2015, just over 9,000 veterans received care in CLCs. However, the majority of the "workload"—defined as the average number of veterans receiving nursing home care per day (or the average daily census)—was provided by state veterans' nursing homes, which are owned and operated by states. Over half (53%) of the workload for FY2015 was accounted for by state veterans nursing homes. It is important to note that total medical care obligations for state nursing homes identified in Table 6 , as well as per diem costs, account only for VA's portion of the total cost of care in state homes. States and veterans are also responsible for a share of the total costs of care in these settings.
Moreover, most VHA institutional spending pays for long-stay care. Across all institutional settings, 88% of residents were long-stay residents (defined as veterans residing in a setting for 91 days or more). Compared with other VA institutional settings, CLCs have higher per diem costs, on average, but also have a greater proportion of short-stay residents. Short-stay residents are more likely to need post-acute or rehabilitative care, which is often more resource-intensive than custodial nursing care provided to long-stay residents. Table 6 compares FY2015 short-stay versus long-stay per diem costs by institutional setting. As shown in the table, average per diem rates for CLC short-stay in 2015 were greater than their average long-stay rates. According to the VA, CLCs may provide specialized care for veterans with mental or behavioral health conditions, as well as certain programs for those with dementia or spinal cord injuries. In addition, CLC per diem costs account for other direct and indirect VA expenditures such as physician and other skilled medical staff, medical education and research, and overhead expenditures related to VA national programs. These types of costs are not included in per diem costs for CNHs and state nursing homes.
section_title: Non-Institutional Care
paragraphs: In FY2015, almost 70% of expenditures for long-term care provided in non-institutional settings were for either home-based primary care or homemaker/home health aide programs (see Table 7 ). The program that received the most visits or encounters (referred to as clinic stops/procedures in the table) was homemaker/home health aide programs. Services through homemaker/home health aide programs are provided more frequently, often several times a week, if not daily, to veterans who need ongoing assistance with personal care needs.
section_title: Issues for Congress
paragraphs: Three broad issues emerge for Congress when considering VA long-term care eligibility, financing, and delivery. The first issue is veterans' access to care, specifically access to long-term care services. The second issue is the setting where long-term care services are provided and the appropriate balance between home and community-based versus institutional services. The third issue involves veteran's health coverage options and federal coordination of financing and health care delivery within the VA health care system and across federal programs. 
subsections: section_title: Access to Care
paragraphs: The veteran population, on average, is older than the general population. Further, the number of veterans who have disabilities that are rated as 70% or more service-connected, and therefore are eligible for VA-paid nursing home care, has increased. This growth may lead to more veterans needing access to long-term care services in order to remain in the community, as well as a greater number of veterans eligible for nursing home care at VA's expense. However, the current policy discussion has primarily focused on reforming access to care within the VA health care system, particularly in relation to primary and specialty care. The Veterans Access, Choice, and Accountability Act of 2014 ( P.L. 113-146 ), as amended, required two different external assessments of the VA. The first was an independent assessment of the VA offering multiple broad recommendations for next steps for the VA. The second assessment, conducted by the Commission on Care, made various recommendations regarding the future of the VA in a report published in July 2016. Both sets of recommendations acknowledge the challenges associated with an increasing number of aging and disabled veterans, but they were largely silent on how such demographic implications will affect the demand for VA long-term care services. The VA's capacity to meet the needs of aged and disabled veterans over time depends on its ability to provide that care directly, but also to purchase care from the community. 
This challenge raises several questions for policymakers: In the context of VA health system reform, are there access issues to be considered for long-term care as well as for specialty and primary care areas? How can the VA maximize quality and efficiency, recognizing that access to long-term care services and care coordination across acute and long-term care may prevent the frequency or need for more expensive care, such as acute inpatient stays or emergency department visits? Does the VA have the right size and mix of geriatric and extended care health professionals to meet the demands of the disabled and aging veteran population both now and in the future? Does the VA have the flexibility it needs to negotiate with community partners who provide much of VA's home and community-based care? 
section_title: Institutional vs. Home and Community-Based Services
paragraphs: Over the past two decades, federal financing and delivery of long-term care, particularly for the largest federal payer of LTSS (Medicaid) has shifted toward the provision of care in home and community-based settings rather than institutional care. In FY1995, the proportion of Medicaid LTSS spending on institutional care was 82%, with 18% spent on home and community-based services (HCBS). Almost 20 years later, the proportion of Medicaid LTSS spending on institutional care has decreased to 47%, with more than half of spending (53%) on HCBS (data for FY2014). Medicaid's shift toward more HCBS occurred with various administrative efforts and activities, as well as financial incentives and broader statutory authority from Congress for states to provide such services. In part, Medicaid HCBS expansion was prompted by the U.S. Supreme Court decision in Olmstead v. L.C. , which held that the institutionalization of people who could be cared for in community settings was a violation of Title II of the Americans with Disabilities Act (ADA). The movement to expand HCBS has occurred alongside the shift to more patient-centered and consumer-driven models of care, which seek to honor the preferences of the individual. Most individuals express a strong preference for remaining in their homes and communities rather than in institutions.
Similarly, the VA has expressed a desire to move toward "a more balanced offering of home and community-based services." However, in FY2015, 29% of VA long-term care spending was on non-institutional care versus 71% of spending on institutional care. One issue that may affect the balance of long-term care services offered is VA's statutory requirement to provide nursing home care to veterans with 70% or more service-connected disability, as well as the requirement to provide nursing home care to veterans who are service-connected and need care for their service-connected disability. Thus, similar to federal Medicaid statute, which requires states to provide nursing home care to certain eligible beneficiaries, the VA operates under a mandate to provide such care to certain veterans.
Moreover, the current design of the State Veterans Home (SVH) program generally favors institutional care over HCBS. As stated previously, under this federal-state partnership, the VA provides grants to states to build, modify, or acquire nursing home, domiciliary, and adult day health care facilities—a federal grant to the state may not exceed 65% of the total project cost. In addition to providing grants to states for facility construction, the VA provides a fixed per diem to states for each veteran who receives care in a state veteran's home. Thus, under the current program design, states generally have an incentive to continue to maintain long-term and extended care facilities rather than explore non-institutional alternatives. 
According to the VA, HCBS is less costly than facility-based options and growth in LTSS expenditures can be moderated by moving toward the provision of more HCBS. However, in the aggregate LTSS spending can be moderated only if HCBS spending increases as institutional spending decreases. VA's requirement to maintain a specific level of long-term care beds and staffing, as well as the mandate to provide institutional care to certain veterans, may create barriers to shifting care to HCBS. To efficiently use the institutional resources it has, the VA must keep the institutional beds occupied. Further, whether beds are occupied or not, the cost to maintain the physical infrastructure of facilities owned and operated by the VA is a consideration. Current contracting requirements may limit the VA's ability to purchase institutional care in the community, thereby offsetting the need for institutional settings owned and operated by the VA. Such requirements may also limit the VA's capacity to provide care to veterans in their communities. Unless VA institutional spending can be reduced, spending on more HCBS may be an additional cost to the VA rather than a shift in cost.
This issue raises several questions for policymakers: What is the right proportion of VA LTSS spending on institutional versus non-institutional care? Does the VA have the appropriate number of CLC beds offering the right types of care? Does the VA have the ability and flexibility needed to partner with community long-term care facilities to provide care to veterans in their communities and potentially reduce demand for VA-owned and operated CLCs? Should Congress review the VA's long-term care infrastructure, comparing projected demand against capacity? And, finally, how might Congress compel the VA to shift care from institutions to home and community-based settings?
section_title: Coverage Options and Federal Coordination
paragraphs: Not all veterans rely on the VA exclusively for their health care. Many veterans access care through other sources of health coverage, and most enrolled veterans have more than one source of coverage. According to the 2015 VHA Survey of Enrollees, approximately 78% of veterans enrolled in the VHA have some type of public or private health care coverage in addition to VA health care. For example, 51% of veterans reported they were enrolled in Medicare, 7% had Medicaid, 19% had TRICARE, and 28% had private insurance (note that individuals may have reported more than one source of coverage). Only 20% of veterans surveyed reported having no other health coverage.
Veterans with more than one coverage option may choose to access the VA instead of care covered under another health care program or insurer for a variety of reasons: personal preference, lower or no out-of-pocket costs (copayments) for certain services, or access to services that may not be available through traditional health insurance or Medicare. Veterans who have Medicare or private health insurance may seek services not covered by those plans from the VA, such as adult day health care or respite care. Although the VA offers some long-term care services similar to Medicaid (e.g., home health aides to assist with personal care), unlike Medicaid, the VA does not require veterans to spend down assets or meet strict income guidelines to receive long-term care. Conversely, some eligible veterans may elect other coverage options and choose to receive their health care in the community due to personal preference, proximity, or more timely access to a provider. Veterans' reliance on VA health care varies; some veterans rely solely on the VA, whereas others use the VA intermittently for certain health care services. This discrepancy presents a challenge for the VA in understanding current demand, and predicting future demand, for health care services. As veterans age, they may come to rely more on VA's long-term care services, which are not covered by Medicare or private health insurance. 
Veterans enrolled in the VHA are likely to receive health care in other settings and through other forms of coverage. Coordination across federally financed health care programs is important to ensure efficient, appropriate, and high-quality health care. It is also critical to avoiding service duplication and overutilization—aspects that may further constrain VA's health care system resources and capacity. This raises several questions for policymakers: Where are there inefficiencies or duplication that could be limited or coordination that could be enhanced? When, or for what services, should veterans access Medicaid, Medicare, and the VA? What do the VA and CMS know about veterans dually enrolled in Medicare or Medicaid and the VHA, or enrolled in all three programs, that could inform care coordination? How can the VA best plan for future demand when veterans have multiple care options and may ultimately seek none, some, or all of their care from the VA?
Appendix A. VHA Copayments for Long-Term Care Services
Veterans who are enrolled in the VA health care system do not pay any premiums; however, some veterans are required to pay copayments for certain services and outpatient medications related to the treatment of a nonservice-connected condition. Table A-1 summarizes which Priority Groups are charged copayments for long-term care services. Only veterans in Priority Group 1 (those who have been rated 50% or more service-connected) and veterans who are deemed catastrophically disabled by a VA provider are never charged a copayment, even for treatment of a nonservice-connected condition. For veterans required to pay long-term care copayments, these charges are based on three levels of nonservice-connected care, including copayments for inpatient, non-institutional, and adult day health care. However, actual copayments may vary depending on a veteran's financial situation. For example, P.L.114-315, the Jeff Miller and Richard Blumenthal Veterans Health Care and Benefits Improvement Act of 2016 exempted Medal of Honor recipients from paying LTC copayments for both service and nonservice connected LTC.
Certain VA long-term care programs have associated costs other than a VA copayment. For example, regardless of service-connected status, veterans residing in Medical Foster Home or Community Residential Care homes pay out of pocket for room and board. The out-of-pocket cost varies by geographical area and amount of care needed. There is no additional VA copayment. Similarly, veterans who reside in State Veterans Homes may have out-of-pocket costs; this varies from state to state and is often on a sliding fee scale. The payment is made to the State Veterans Home, and there is no additional VA copayment. Conversely, there is no copayment or cost to the veteran of any kind for VA hospice services, regardless of veterans' income or service-connected status.
Appendix B. Veterans Priority Groups
 Figure B-1 lists the Veterans Priority Groups 1 through 8 and their eligibility criteria.