VA Long-Term Care: Oversight of Nursing Home Program Impeded by Data Gaps
Released: 2004-11-10T00:00:00

Letter

Background

VA operates its nursing homes in 132 locations, which are located throughout VA’s 21 health care networks. Almost all of these nursing homes are attached or in close proximity to a VA medical center. According to VA policy, VA staff at these facilities determine whether the veteran has a clinical need for nursing home care based on a comprehensive interdisciplinary clinical assessment. The interdisciplinary teams determining clinical need for nursing home care could include personnel such as the nursing home director, a social worker, nurse, physical therapist, and gerontologist. The care provided to veterans at a VA nursing home could include a range of services, including short-term postacute care needed to recover from a condition such as a stroke to longer-term care required by veterans who cannot be cared for at home because of severe, chronic physical or mental limitations.

VA may also refer patients to receive nursing home care under contract from non-VA nursing homes located in the community—referred to as community nursing homes. In fiscal year 2003, VA purchased care from community nursing homes in one of two ways. VA contracted with most nursing homes through the local VA medical center. In addition, VA also contracted with some community nursing homes under its Regional Community Nursing Home initiative, in which nursing home chains in single or multiple states contract directly with VA headquarters for services at their nursing homes. In fiscal year 2003, VA contracted with 1,723 nursing homes through its medical centers and with 508 more nursing homes under its Regional Community Nursing Home initiative.

Veterans may also choose to seek care in state veterans’ nursing homes. In fiscal year 2003, 109 state veterans’ nursing homes located in 44 states and Puerto Rico received VA payment to provide care. VA may refer patients to these nursing homes for care, but does not control the admission process. Veterans are admitted based on eligibility criteria established by the states. For state veterans’ nursing homes to participate in VA’s program, however, VA requires that at least 75 percent of the residents be veterans in most cases. State veterans’ nursing homes may also provide nursing home care to certain nonveterans, such as spouses of residents who are veterans. VA is authorized to pay for about two-thirds of the costs of construction of state veterans’ nursing homes and pays about a third of the costs per day to provide care to veterans in these homes. In fiscal year 2003, VA paid $56.24 per day for veterans in these state veterans’ nursing homes and awarded $174 million in grants to 16 states for renovations of existing facilities or construction of new state veterans’ homes.

Veterans can also receive nursing home care financed by sources other than VA, including Medicaid and Medicare, private health or long-term care insurance, or self-financed. States design and administer Medicaid programs that include coverage for long-term nursing home care to assist with daily activities such as eating and bathing. Medicare primarily covers acute care health costs and therefore limits its nursing home coverage to short stays requiring skilled nursing home care following hospitalization. State Medicaid programs are the principal funders of nursing homes, besides patients self-financing their care. Private health insurance pays for about 11 percent of nursing home and home health care expenditures.

VA Spent Almost Three-Quarters of Its Nursing Home Resources on Care for Veterans in VA Nursing Homes, but Expenditures Varied Widely by Network

VA nursing homes accounted for almost three-quarters of VA’s overall nursing home expenditures, or about $1.7 billion, in fiscal year 2003. Care in state veterans’ nursing homes accounted for 15 percent of nursing home expenditures, or about $352 million. Care in community nursing homes accounted for the lowest percentage of overall nursing home expenditures at 12 percent, or about $272 million. Overall, VA spent approximately $2.3 billion to provide or pay for nursing home care in VA nursing homes, community nursing homes, and state veterans’ nursing homes in fiscal year 2003.

In contrast to fiscal year 1998, in fiscal year 2003 the percentage of expenditures from community nursing homes declined, whereas the percentage of expenditures for care in VA nursing homes and state veterans’ nursing homes increased. (See fig. 1.) For example, 70 percent of nursing home expenditures were accounted for by VA nursing homes in fiscal year 1998 as compared to 73 percent in 2003. Moreover, the percentage of community nursing home expenditures was 17 percent in 1998 as compared to 12 percent in 2003. During the same years, VA’s overall nursing home expenditures increased by about a third, growing from about $1.7 billion to approximately $2.3 billion.

The percentage of nursing home expenditures for care in each nursing home setting varied widely by network in fiscal year 2003. (See fig. 2.) All networks spent the largest percentage of their resources on VA nursing homes. The percentage of expenditures for VA nursing homes ranged from a low of 47 percent in Network 19 (Denver) to a high of 88 percent in Network 6 (Durham). Further, the percentage of overall nursing home expenditures accounted for by community and state veterans’ nursing homes also varied widely across the networks. For example, the percentage of expenditures for community nursing homes ranged from a low of 2 percent in Network 3 (Bronx) to a high of 28 percent in Network 20 (Portland).

A comparison of how networks’ percentage of expenditures on each nursing home setting changed in fiscal year 2003 as compared to fiscal year 1998 showed that networks’ changes were consistent with the VA- wide changes. In fiscal year 2003, the percentage of expenditures for VA nursing homes increased in 15 of the 21 health care networks as compared to fiscal year 1998. Similar to the overall trend, the percentage of expenditures for state veterans’ nursing homes increased in 17 of 21 networks, whereas the percentage of expenditures for community nursing homes decreased in 17 of 21 networks. The largest shift in the percentage of expenditures for the three settings occurred in Network 19 (Denver). In this network, the percentage of expenditures for VA nursing homes declined from 75 to 47 percent because of a nursing home closure during this period. For more detailed information on the percent change in nursing home expenditures for each setting and network in fiscal years 1998 and 2003, see appendix II.

State Veterans’ Nursing Homes Provided Half of VA’s Overall Nursing Home Workload, but Networks’ Use of Nursing Home Care Setting Varied

State veterans’ nursing homes accounted for half of VA’s overall nursing home workload—measured by average daily census—in fiscal year 2003, even though they accounted for only 15 percent of expenditures. In large part this is because VA pays a per-diem rate for care in state veterans’ nursing homes that, on average, accounts for about one-third of the cost to provide veterans nursing home care in this setting. The remaining payments made to state veterans’ nursing homes come from a number of other sources including Medicaid, Medicare, private health insurance, and patients self-financing their care. VA nursing homes provided the next largest percentage of nursing home workload, 37 percent in fiscal year 2003. Community nursing homes provided 13 percent of overall nursing home workload. Overall, VA provided or paid for 33,214 patients to receive nursing home care daily in VA nursing homes, community nursing homes, and state veterans’ nursing homes in fiscal year 2003.

Since fiscal year 1998, VA has increased its use of state veterans’ nursing homes and decreased the use of VA nursing homes and community nursing homes. Overall, workload in VA’s nursing home program was 33,214 in fiscal year 2003, about 1 percent below its fiscal year 1998 workload. The percentage of nursing home workload provided in state veterans’ nursing homes increased from 43 to 50 percent. In contrast, the percentage of workload provided in VA nursing homes and community nursing homes declined. (See fig. 3.)

The increase in the percentage of nursing home workload provided in state veterans’ nursing homes resulted from a number of factors. States, with the assistance of construction grants from VA, built 17 new state veterans’ nursing homes, increasing the number of beds available during this period. The increasing percentage of state veterans’ nursing home workload also occurred as a result of declines in workload in VA nursing homes and community nursing homes due to changes in VA’s use of these settings. In VA nursing homes, VA officials attributed some of the decreases in nursing home workload to an increased emphasis on postacute patients with short lengths of stay. Moreover, VA officials told us that they are providing contract community nursing home care to fewer veterans and paying for shorter contracts than in the past. The number of patients VA served in this setting declined from 28,893 to 14,032 during this period. Network officials also told us that contracts for community nursing home care are often now 30 days or less and are used primarily to transition veterans to nursing home care, which is paid for by other payers such as Medicaid.

Although state veterans’ nursing homes predominate overall, networks vary widely in the percentage of workload met in different nursing home settings. For example, networks varied in their use of state veterans’ nursing homes ranging from a low of 22 percent in Network 8 (Bay Pines) to a high of 71 percent in Network 15 (Kansas City). (See fig. 4.) This variation is due, in part, to the available bed capacity of state veterans’ nursing homes in these networks. In 2003, Network 15 (Kansas City) had 1,509 state veterans’ nursing home beds compared to 420 beds in Network 8 (Bay Pines). However, wide network variation also existed in the percentage of networks’ workloads accounted for by VA nursing homes and community nursing homes.

Changes in networks’ delivery of nursing home care among the three nursing home settings were consistent with VA-wide changes between fiscal year 1998 and 2003. The percentage of workload provided in state veterans’ nursing homes increased in 19 of VA’s 21 health care networks. Similar to the overall trend, the percentage of workload met in community nursing homes declined in 17 networks and declined in 13 networks for VA nursing homes. The largest shift in the percentage of workload for the three settings occurred in Network 17 (Dallas). In this network, the percentage of workload for state veterans’ nursing homes increased from 0 to 30 percent because Texas opened up four state veterans’ nursing homes during this period. For more detailed information on the percent change in nursing home workload for each setting and network in fiscal years 1998 and 2003, see appendix III.

About One-Third of VA Nursing Home Care Is Long Stay, but VA Lacks Comparable Information for Other Nursing Home Settings

About one-third of the care VA provided in VA nursing homes was long stay in fiscal year 2003. The use of long-stay nursing home care (90 days or more) includes services needed when a person has a physical or mental disability that cannot be cared for at home. For example, veterans needing long-stay care may have difficulty performing some activities of daily living without assistance, such as bathing, dressing, toileting, eating, and moving from one location to another. They may have mental impairments, such as Alzheimer’s disease or dementia, that necessitate supervision to avoid harm to themselves or others or require assistance with tasks such as taking medications. The remainder, or two-thirds of VA nursing home care, was short-stay care (less than 90 days) in this setting. VA’s use of short- stay care includes nursing home services such as postacute care required for recuperation from a stroke or hip replacement. VA officials also told us that this care could include a number of other services such as the delivery of complex medical services such as chemotherapy, the treatment of wounds such as pressure ulcers, and end-of-life care. VA’s use of short- stay care is similar to services provided by Medicare, which provides short-term coverage, whereas VA’s use of long-stay care is similar to services provided by Medicaid, which provides long-term coverage for nursing home care.

Since fiscal year 1998, VA has decreased its use of long-stay care and increased its use of short-stay nursing home care. Specifically, the percentage of nursing home care that was long stay has declined from 43 to 34 percent between fiscal years 1998 and 2003. (See fig. 5.) In contrast, the percentage of short stays provided in this setting increased from 57 to 66 percent during the same period. This shift in the amount of short-stay care is consistent with VA’s policy on nursing home eligibility that sets a higher priority on serving veterans who require short-stay postacute care.

Short stay (less than 90 days)

Long stay (90 days or more)

Networks vary widely, however, in the percentage of VA nursing home care that is long stay. The percentage of long stays in VA nursing homes ranged from a low of 17 percent in Network 20 (Portland) to a high of 55 percent in Network 7 (Atlanta). (See fig. 6.) Network 20 (Portland) officials told us that the focus of their VA nursing homes has changed from long-stay care to short-stay transitional and rehabilitative care and as a result they are serving more veterans with shorter lengths of stay. By contrast, Network 7 (Atlanta) officials told us that several of their nursing homes provide services that are consistent with long-stay nursing home care such as providing assistance to veterans who have difficulty performing some activities of daily living such as the inability to independently eat.

VA lacks information on the amount of long- and short-stay nursing home care veterans receive in community and state veterans’ nursing homes preventing it from strategically planning how best to use these nursing home settings at the national and network levels to enhance access to nursing home services. VA officials told us that while some of these data may be available at certain facilities because the facilities collect them for their own purposes, VA does not require state veterans’ nursing homes and community nursing homes to provide billing or other information that identifies individual veterans on which length of stay could be calculated. VA collects information on the payments made to community nursing homes and state veterans’ nursing homes, but does not collect the days of care a veteran receives or other individual information. VA officials told us that they receive and pay individual claims for some veterans in community nursing homes, but that in other cases VA pays for care provided by community nursing homes based on invoices, which aggregate information on the number of patients being treated by a nursing home.

VA officials told us that they are in the initial planning stages of redesigning a payment system to collect information by individual veteran in community nursing homes, but that the implementation of such a system could take several years. Once completed, VA officials expect the new system to collect and report data on the total number of days individual veterans receive in community nursing homes. VA does not currently have plans to collect such data for state veterans’ nursing homes, but is exploring doing so.

About One-Fourth of Veterans Who Received Care in VA Nursing Homes Are Required to Be Served by the Millennium Act or VA Policy, but VA Lacks Comparable Information for Other Settings

In fiscal year 2003, about 26 percent of veterans who received care in VA nursing homes are required to be served by the Millennium Act or VA’s policy on nursing home eligibility. Of these veterans, about 21 percent are being treated under the Millennium Act because they have a service- connected disability rating of 70 percent or greater. The act also required that VA continue to treat veterans who had been receiving nursing home care in VA facilities at the time the law was enacted about 4 percent of the veterans receiving care in fiscal year 2003 fell into this category. Further, 1 percent of veterans in VA nursing homes are required to be served based solely on VA’s policy on nursing home eligibility that extended required coverage to veterans with a 60 percent service- connected disability rating who also met other criteria.

However, the vast majority of veterans—about 74 percent in fiscal year 2003—received VA nursing home care as a discretionary benefit based on available budgetary resources. VA’s policy on nursing home eligibility directs that for these veterans VA nursing homes admit, as a priority, patients who meet certain clinical and programmatic criteria: patients requiring nursing home care after a hospital episode, patients who VA determines cannot be adequately cared for in community nursing homes or home- and community-based care, and those patients who can be cared for more efficiently in VA nursing homes.

The percentage of veterans receiving VA nursing home care as required by the Millennium Act or VA’s policy on nursing home eligibility varied widely across networks in fiscal year 2003. The percentage of veterans receiving this care ranged from a low of 20 percent in Network 15 (Kansas City) and Network 11 (Ann Arbor) to a high of 39 percent in Network 1 (Boston). (See fig. 7.) However, most networks were grouped closer to the lower range. Fifteen of VA’s 21 health care networks had percentages of 26 percent or less. According to VA officials, the percentage of veterans that are required to be treated may be lower in some networks because networks may choose to pay for these veterans to receive care in community nursing homes. In contrast, some networks may prefer to treat these patients in VA nursing homes. For example, officials from Network 3 (Bronx), a network with the second highest percentage at 37 percent, told us that they prefer to treat these types of veterans in VA nursing homes because they have sufficient bed capacity.

VA lacks comparable information for community nursing homes or state veterans’ nursing homes on the percentage of veterans that are required to be served based on the Millennium Act or VA’s policy on nursing home eligibility even though these settings combined accounted for 63 percent of VA’s overall nursing home workload. The lack of such data prevents VA from strategically planning how best to use these nursing home settings at the national and network levels to enhance access to nursing home services. VA officials told us that while some of these data on eligibility status may be available at certain facilities because the facilities collect them for their own purposes, VA does not require that this information be collected and reported to headquarters. VA does not collect information by individual on all payments made to community nursing homes and state veterans’ nursing homes. As a result, VA cannot match individual veterans’ data from their payment system with data it currently collects on eligibility to determine the eligibility status of all veterans receiving contract care in community nursing homes and state veterans’ nursing homes. VA officials told us this type of analysis could be done if a new information system for collecting contract payments is designed and implemented to collect and report such information.

Conclusions

Gaps in nursing home data impede VA’s ability to monitor and strategically plan for the nursing home care VA pays for nationally and at the network level. The workload in state veterans’ nursing homes and community nursing homes has grown to 63 percent of VA’s overall nursing home workload. However, VA does not have data on length of stay and the eligibility status of veterans receiving care in these settings as it has for VA nursing homes. As a result, VA cannot strategically plan how best to serve veterans it is required to serve, including those who have a 70 percent or greater service-connected disability rating, or other veterans receiving care on a discretionary basis; nor can VA strategically plan how best to use the nursing home settings to provide long- and short-stay nursing home care nationally or in individual networks. Equally important, the lack of such data and assessments hampers congressional oversight of strategic options available to VA in its nursing home care planning and its progress in meeting veterans’ needs.

Recommendations for Executive Action

To help ensure that VA can provide adequate program monitoring and planning for nursing home care and to improve the completeness of data needed for congressional oversight, we recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to take two actions: For community nursing homes and state veterans’ nursing homes, collect and report data on the number of veterans who have long and short stays, comparable to data VA currently collects on VA nursing homes.

For community nursing homes and state veterans’ nursing homes, collect and report data on the number of veterans in these homes that VA is required to serve based on the requirements of the Millennium Act or VA’s policy on nursing home eligibility, comparable to data VA currently collects on VA nursing homes.

Agency Comments and Our Evaluation

We provided a draft of this report to VA for comment. In commenting on the draft, VA stated that it concurred in principle with our recommendations. VA stated that it will continue its efforts to reduce data gaps in the community nursing home and state veterans home programs, but VA did not indicate specific plans to collect data on length of stay and eligibility for its long-term care planning process. Moreover, VA stated that data other than eligibility and length of stay, such as age and disability, are most crucial for its long-term care strategic planning and program oversight. We disagree with VA’s position that eligibility and length-of-stay data are not considered most crucial and are concerned about VA’s lack of specificity regarding its intent to utilize these data. While factors such as age and disability are generally recognized as important in projecting need for nursing home care, VA needs data on veterans’ eligibility status and length of stay to determine what portion of the overall veteran need for nursing home care VA will meet nationally and in individual communities. Because VA is required to serve veterans that meet the requirements of the Millennium Act or VA policy, VA needs to project the number of these veterans seeking nursing home care from VA and determine the number of other veterans it will also serve on a discretionary basis after meeting this need. To strategically plan and provide the type of service needed in the future, VA must also project what proportion of veterans with different eligibility statuses will need short-stay or long-stay nursing home care. VA needs to use this information to determine if the nursing home care it currently pays for in VA nursing homes, contract community nursing homes, and state veterans’ nursing homes is appropriately located and provides the type of nursing home care needed by veterans.

VA also noted that it is narrowing information gaps on both veterans’ eligibility status and length of stay for veterans in its community and state veterans’ nursing home programs by using data extracted from various sources to estimate these numbers. However, VA did not provide these data for our review. Given that the combined workload in these settings accounted for 63 percent of VA’s overall nursing home workload in fiscal year 2003, we believe that complete information on veterans’ eligibility status and length of stay for veterans in these settings is crucial for both strategic planning and program oversight.

VA noted that one of our statements—that about one-fourth of veterans receiving nursing home care are entitled to such care under the requirements of the Millennium Act—could be misinterpreted to imply that some of these “mandatory” veterans are being displaced by veterans receiving discretionary care. We did not imply this relationship, nor did our work examine this particular issue.

We are sending copies of this report to the Secretary of Veterans Affairs and appropriate congressional committees. The report is available at no charge on GAO’s Web site at http://www.gao.gov. We will also make copies available to others on request.

If you or your staff have any questions about this report, please call me at (202) 512-7101. Another contact and key contributors are listed in appendix V.

Appendix I: Objectives, Scope, and Methodology

We reviewed the Department of Veterans Affairs’ (VA) nursing home program for fiscal year 2003 for VA nursing homes, community nursing homes, and state veterans’ nursing homes to determine (1) VA spending to provide or pay for nursing home care, (2) VA workload provided or paid for, (3) the percentage of nursing home care that is long and short stay, and (4) the percentage of veterans receiving care that are required to be served by the Millennium Act or VA policy. To place this information in context, you asked us to supplement our findings with information for fiscal year 1998.

To address the first two objectives, we obtained data on nursing home workload and expenditures at the network level for fiscal years 1998 and 2003 from several VA headquarters offices. VA’s Geriatrics and Extended Care Strategic Healthcare Group provided us workload data for VA nursing homes and community nursing homes, as reported in VA’s Automated Management Information System. This group also gave us workload data from monthly reports completed by state veterans’ nursing homes that were maintained at the VA medical centers. These data are used by the Geriatrics and Extended Care office to provide per diem grants to state veterans’ homes. The Office of the Chief Financial Officer for the Veterans Health Administration (VHA) provided us expenditure data from VA’s Cost Distribution Report for the nursing home care provided or paid for by VA.

To do our analysis, we used average daily census as a measure of workload. Average daily census is the total number of days of nursing home care provided in a year divided by the number of days in the year. For VA nursing home expenditures, we included the direct costs used to provide nursing home care plus other facility costs associated with operating the nursing home. VA nursing home expenditures excluded depreciation as well as VA headquarters and network administrative costs. To calculate community nursing home expenditures, we included all contract payments made to community nursing homes plus additional facility expenditures required to directly support the program at the local VA medical center. To calculate state veterans’ home expenditures, we included per diem payments made to state veterans’ nursing homes plus additional facility expenditures required to directly support the program at local VA medical centers. Expenditures for state veterans’ homes did not include construction grants.

To determine the percentage of long and short stays in VA nursing homes in fiscal years 1998 and 2003, we obtained data on length of stay from VHA’s Extended Care Patient Treatment Files. The Patient Treatment Files include nursing home discharges for veterans who were discharged from a VA nursing home during a fiscal year, and current resident files for veterans who were not discharged by the end of a fiscal year. Using length of nursing home stay, we classified stays of 90 days or more as long stays and stays of less than 90 days as short stays. Length of stay is calculated as the number of days in a nursing home between the admission and discharge days and was given a minimum value of 1. The number of days absent from the nursing home, such as for a hospital stay, was subtracted from the length of stay. Because current residents were not discharged within the fiscal year, we calculated their lengths of stay by looking ahead into the next fiscal year. That is, we matched current residents with discharges in the next fiscal year to determine whether their stays were short or long. A current resident who was admitted on the last day of the fiscal year, for example, but was discharged after 90 days into the next fiscal year, was classified as having a long stay. If the same resident was discharged within 90 days of the next fiscal year, then the stay was classified as short. We classified nursing home stays as long for current residents who were not discharged in the next fiscal year. Our analysis for long- and short-stay care was based on nursing home stays rather than individual veterans because some veterans had multiple nursing home stays.

To determine the percentage of veterans in VA nursing homes receiving care that are required to be served by the Millennium Act or VA policy, we obtained individual data on eligibility for veterans enrolled in VA’s health care system. VHA’s Office of Policy and Planning provided us these data in an enrollment file for fiscal year 2003. We merged these data with the discharge and current resident files from VHA’s Extended Care Patient Treatment Files in order to calculate the percentage of veterans receiving nursing home care that are required to be served in fiscal year 2003. Our analyses on eligibility are based on individual veterans rather than nursing home stays; because some veterans had multiple nursing home stays in a given year, we retained veterans’ first nursing home stay and eliminated other stays in that year. We used a variable from VA’s enrollment file that measures service-connected disability rating. In addition, we used variables from the file that measure whether the veteran is unemployable and whether the veteran is considered permanent and total disabled, based on disabilities not related to military service.

We included the following categories of veterans in our calculation to determine the percentage of veterans receiving nursing home care required to be served by the Millennium Act or VA’s policy on nursing home eligibility: (1) veterans who had a service-connected disability rating of 70 percent or more; (2) veterans who were admitted to a VA nursing home on or before November 30, 1999; and (3) veterans who had a service- connected disability rating of 60 percent and who were also unemployable or permanent and total disabled. We did not include in our estimate veterans VA is required to serve who need nursing home care because of a service-connected disability, but who do not have a service-connected disability rating of 70 percent or more. VA did not have data on these veterans, but a VA official estimated that this group is very small based on conversations with facility staff.

To supplement our knowledge of the type of nursing home care provided in VA networks, we visited two networks and five nursing homes. In Network 5 (Baltimore) we visited Washington, D.C.; Martinsburg, West Virginia; and Baltimore, Maryland. In Network 23 (Minneapolis) we visited St. Cloud, Minnesota; and Minneapolis, Minnesota. We selected these two networks because they were in different geographic regions and had variation in the types of care offered in their facilities. Within each network, we chose one nursing home that provided more long-stay nursing home care and another that provided more short-stay care.

We assessed the reliability of workload and expenditure data in VA’s nursing home program, VHA’s enrollment data file, and VHA’s Extended Care Patient Treatment Files in several ways. First, we performed tests of data elements. For example, we examined the range of values for length of stay to determine whether these data were complete and reasonable. Second, we reviewed existing information about the data elements. For example, we obtained and reviewed information from VHA on data elements we used from VHA’s Extended Care Patient Treatment Files. Third, we interviewed agency officials knowledgeable about the data in our analyses and knowledgeable about VA’s nursing home program. For example, we sent network-specific nursing home workload and expenditure data provided to us by VA headquarters to each of VA’s 21 health care networks through electronic mail in December 2003. Network officials reported whether these data were accurate and indicated where they found discrepancies. Through discussions with VA headquarters and network officials we resolved the discrepancies. We determined that the data we used in our analyses were sufficiently reliable for the purposes of this report.

We performed our review from January 2003 to November 2004 in accordance with generally accepted government auditing standards.

Appendix II: Changes in Percentage of Nursing Home Expenditures by Setting and Network, Fiscal Years 1998 and 2003

Increase was less than 1 percent.

Decrease was less than 1 percent.

Fiscal year 2003 percentage of total

Appendix III: Changes in Percentage of Nursing Home Workload by Setting and Network, Fiscal Years 1998 and 2003

Decrease was less than 1 percent.

Increase was less than 1 percent.

Fiscal year 2003 percentage of total

Appendix IV: Comments from the Department of Veterans Affairs

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact

Acknowledgments

In addition to the contact named above, Cheryl A. Brand, Pamela A. Dooley, and Thomas A. Walke made key contributions to this report.

Related GAO Products

VA Long-Term Care: More Accurate Measure of Home-Based Primary Care Workload Is Needed. GAO-04-913. Washington, D.C.: September 8, 2004.

VA Long-Term Care: Changes in Service Delivery Raise Important Questions. GAO-04-425T. Washington, D.C.: January 28, 2004.

VA Long-Term Care: Veterans’ Access to Noninstitutional Care Is Limited by Service Gaps and Facility Restrictions. GAO-03-815T. Washington, D.C.: May 22, 2003.

VA Long-Term Care: Service Gaps and Facility Restrictions Limit Veterans’ Access to Noninstitutional Care. GAO-03-487. Washington, D.C.: May 9, 2003.

Department of Veterans Affairs: Key Management Challenges in Health and Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003.

VA Long-Term Care: The Availability of Noninstitutional Services Is Uneven. GAO-02-652T. Washington, D.C.: April 25, 2002.

VA Long-Term Care: Implementation of Certain Millennium Act Provisions Is Incomplete, and Availability of Noninstitutional Services Is Uneven. GAO-02-510R. Washington, D.C.: March 29, 2002.

VA Long-Term Care: Oversight of Community Nursing Homes Needs Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001.