In 1944, President Franklin D. Roosevelt made a commitment that no servicemen blinded in combat in World War II would be returned to their homes without adequate training to meet the problems imposed by their blindness, according to VA. From 1944 to 1947, the Army and Navy provided this rehabilitation training. In 1947, responsibility for this training was transferred to VA, and in 1948, VA opened its first BRC to provide comprehensive inpatient care to legally blind veterans. In 1956, blind rehabilitation services were expanded to include veterans whose legal blindness was not service-connected. Because of this expansion, the demographics of VA’s blind veteran population shifted toward predominately older veterans whose legal blindness was caused by age-related eye diseases. Expanded eligibility also caused an increase in demand for services. VA responded to this demand by opening 9 additional BRCs in the United States and Puerto Rico for a total of 10 facilities with 241 authorized beds. (See table 1.) As of May 5 2004, VA reported that there were 2,127 legally blind veterans waiting for admission to BRCs. In fiscal year 2003, VA estimated that about 157,000 veterans were legally blind, with more than 60 percent age 75 or older. About 44,000 legally blind veterans were enrolled in VA health care. VA estimated that through 2022, the number of legally blind veterans would remain stable. (See fig. 1.) The National Institutes of Health (NIH) considers the increase in age- related eye diseases to be an emerging major public health problem. According to NIH, the four leading diseases that cause age-related legal blindness are cataract, glaucoma, macular degeneration, and diabetic retinopathy, each affecting vision differently. (See fig. 2 for illustrations of how each disease affects vision.) Cataract is a clouding of the eye’s normally clear lens. Most cataracts appear with advancing age, and by age 80, more than half of all Americans develop them. Glaucoma causes gradual damage to the optic nerve—the nerve to the eye—that results in decreasing peripheral vision. It is estimated that as many as 4 million Americans have glaucoma. Macular degeneration results in the loss of central visual clarity and contrast sensitivity. It is the most common cause of legal blindness in older Americans and rarely affects those under the age of 60. Diabetic retinopathy is a common complication of diabetes impairing vision over time. It results in the loss of visual clarity, peripheral vision, and color and contrast sensitivity. It also increases the eye’s sensitivity to glare. Nearly half of all diabetics will develop some degree of diabetic retinopathy, and the risk increases with veterans’ age and the length of time they have had diabetes. To assist legally blind veterans, VA established Visual Impairment Services Team (VIST) coordinators who act as case managers and are responsible for coordinating all medical services for these veterans, including obtaining medical examinations and arranging for blind rehabilitation services. There are about 170 VIST coordinators, who are located at VA medical centers that have at least 100 enrolled legally blind veterans. VIST coordinators are also responsible for certain administrative services such as reviewing the veteran’s compensation and pension benefits. Almost all of VA’s blind rehabilitation services for veterans are provided through comprehensive inpatient care at BRCs, where veterans are trained to use their remaining vision and other senses, as well as adaptive devices such as canes, to help compensate for impaired vision. VA offers both basic and computer training. (See table 2 for examples of the types of skills taught during basic and computer training.) In fiscal years 2002 and 2003, VA spent over $56 million each year for inpatient training at BRCs. During this same time period, VA spent less than $5 million each year to provide outpatient rehabilitation training for legally blind veterans. VA offers three types of blind rehabilitation outpatient services to legally blind veterans, but these services are available in few VA locations. The three types of services include Visual Impairment Services Outpatient Rehabilitation (VISOR), Visual Impairment Center to Optimize Remaining Sight (VICTORS), and Blind Rehabilitation Outpatient Specialists (BROS). The services range from short-term outpatient programs provided in VA facilities to home-based services. Figure 3 identifies the locations throughout the United States and Puerto Rico where these services are offered. VISOR is a 10-day outpatient program located at the VA medical center in Lebanon, Pennsylvania, that offers training in the use of low vision equipment, basic orientation and mobility, and living skills. Serving veterans in the surrounding 13-county area, it is primarily for veterans who can independently perform activities of daily living and who require only limited training in visual skills and orientation and mobility, such as traveling within and outside their homes. According to a VISOR official, the program is meant to provide training to veterans while they wait for admission to a BRC or to veterans who do not want to attend a BRC. Veterans who participate in this program are housed in hoptel beds within the medical facility. In fiscal year 2003, 54 veterans attended the VISOR program; about 20 to 30 percent of these veterans were legally blind. According to a VISOR official, there is no waiting list for this program and the local medical center provides the necessary funding for it. VICTORS is a 3- to 7-day outpatient program for veterans in good health whose vision loss affects their ability to perform activities of daily living, such as personal grooming and reading mail. The program provides the veterans with a specialized low vision eye examination, prescriptions for and training in the use of low vision equipment, and counseling. There are three VICTORS programs located in VA medical centers in Kansas City, Missouri; Chicago, Illinois; and Northport, New York. Veterans are housed in hoptel beds within the medical facility or in nearby hotels. In fiscal year 2003, VICTORS served over 900 veterans; about 25 to 30 percent of these veterans were legally blind. According to VICTORS officials, the wait time for admission to VICTORS varied from about 55 to about 170 days. The medical center where the program is located funds the services. BROS are blind rehabilitation outpatient instructors who provide a variety of short-term services to veterans in their homes and at VA facilities. BROS train veterans prior to and following their participation in BRC programs, as well as veterans who cannot or do not choose to attend a BRC. BROS training addresses veterans’ immediate needs, especially those involving safety issues such as reading prescriptions or simple cooking. There are 23 BROS throughout VA’s health care system, with 7 located in the VA network that covers Florida and Puerto Rico. In fiscal year 2003, BROS trained about 2,700 veterans, almost all of whom were legally blind. Wait time for BROS services varied from about 14 to 28 days according to the BROS we interviewed. BROS are funded by the medical centers where they are located. VA officials who provide services to legally blind veterans told us that some veterans could benefit from increased access to outpatient blind rehabilitation services. We obtained this information by asking VA to review all of the veterans who, as of March 31, 2004, were on the waiting lists for admission to the five BRCs we visited and to determine whether outpatient services could meet their needs. VA officials reported that 315 out of 1,501 of these veterans, or 21 percent, could potentially be better served through access to outpatient blind rehabilitation services, if such services were available. The types of veterans VA believes could potentially benefit from outpatient services include those who are very elderly or lack the physical stamina to participate in a comprehensive 28- to 42-day BRC program and those who have medical needs that cannot be provided by the BRC. For example, some BRCs are unable to accept patients requiring kidney dialysis. In addition, some veterans do not want to leave their families for long periods of time and some legally blind veterans are primary caretakers for their spouses and are unable to leave their homes. VA officials also told us that veterans in good health who can independently perform activities of daily living and require only limited or specialized training could also be served effectively on an outpatient basis. A VA study concluded that there is a need for increased outpatient services for legally blind veterans. In 1999, VA convened a Blind Rehabilitation Gold Ribbon Panel to study concerns about the growing number of legally blind veterans. The panel examined how VA historically provided blind rehabilitation services and recommended that VA transition from its primarily inpatient model of care to one that included both inpatient and outpatient services. In 2000, VA established the VIAB to implement the panel’s recommendations. The VIAB drafted guidance for a uniform standard of care policy for visually impaired veterans throughout VA’s health care system. This guidance outlined a continuum of care to provide a range of services from basic low vision to comprehensive inpatient rehabilitation training, including use of more outpatient services from both VA and non-VA sources. In January 2004, a final draft of the uniform standard of care policy was forwarded to VA’s Health Systems Committee for approval. The committee believed additional information was needed for its approval and requested additional analysis that compared currently available blind rehabilitation services with anticipated needs. VA plans to complete this analysis in the first quarter of fiscal year 2005 and then resubmit the uniform standard of care policy and the additional analysis to the Health Systems Committee. VA officials were unable to provide a timeframe for the Health Systems Committee’s approval. Some VIST coordinators have already provided outpatient services to legally blind veterans by referring them to state and private blind rehabilitation services. For example, in Florida a VIST coordinator referred veterans to the Lighthouse for the Blind for computer training at its outpatient facility if they did not live near and did not want to travel to the BRC. A VIST coordinator in Oklahoma arranged contractor-provided computer training in the veteran’s home for veterans with a 20 percent or more service-connected disability.