Nationwide, VA provides or pays for veterans’ nursing home care in three settings: CLCs, community nursing homes, and state veterans’ nursing homes.the cost of care that is covered for eligible veterans. These settings vary in terms of their characteristics, as well as VA provides nursing home care to veterans in 134 CLCs nationwide. CLCs are typically within or in close proximity to VA medical centers. VA requires CLCs to meet The Joint Commission’s long-term care standards. veterans in CLCs, while discretionary veterans may be required to pay a copayment depending on their income or other factors. See Veterans Health Administration Handbook 1142.01, Criteria and Standards for VA Community Living Centers (Aug. 13, 2008). The Joint Commission is an independent organization that accredits and certifies health care organizations and programs in the United States. Medicare is the federal health insurance program for people age 65 and older, individuals under age 65 with certain disabilities, and individuals diagnosed with end-stage renal disease. Medicaid is a federal-state program that provides health care coverage to certain categories of low-income individuals. pays for the full cost of care for mandatory veterans, while discretionary veterans may be subject to a similar copayment as in CLCs depending on their income or other factors. However, VA is generally restricted by law from paying for more than 6 months of care for discretionary veterans. These veterans must therefore have other sources of payment, and, according to VA officials, most long-stay residents may enroll in Medicaid, have private long-term care insurance, or pay for care through out-of- pocket spending. VA also pays for all or part of veterans’ care in 140 state veterans’ nursing homes nationwide. For state veterans’ nursing homes, VA pays at least a portion of the cost of providing nursing home care for eligible veterans in these homes, but does not control the admission process. Veterans are admitted based on eligibility criteria as established by state requirements. For state veterans’ nursing homes to participate in VA’s program, however, VA generally requires that at least 75 percent of the In addition, VA requires state veterans’ nursing residents be veterans. homes to be certified by VA annually, and ensures compliance with its standards through surveys and audits. Each fiscal year, VA establishes the per diem rates paid to state veterans’ nursing homes for care provided to veterans. For mandatory veterans, VA pays a higher per diem For discretionary that covers the full cost of care, including medications.veterans, VA pays the lesser of the basic per diem established by VA or one-half of the total daily cost of care.nursing homes, there is no restriction on the number of days for which VA may pay for care for discretionary veterans in state veterans’ nursing homes. As part of VA’s support and oversight of state veterans’ nursing homes, VA medical centers of jurisdiction process and approve per diem reimbursements for the state veterans’ nursing homes located in their geographic areas. In addition to paying some or all of the cost of providing nursing home care to veterans, VA supports state veterans’ nursing homes by awarding grants to states for construction or renovation of facilities. These grants are awarded following VA’s review and approval of proposals submitted by state officials. In addition to per diem payments and construction grants from VA, state veterans’ nursing homes may receive payments from a number of different sources, including Medicare and Medicaid. While veterans of all ages may need VA nursing home care, the need for such care increases with age because elderly veterans are more likely to have functional or cognitive limitations that indicate a need for nursing home care. in 2014 and decline thereafter (see fig. 1). However, the percentage of elderly veterans is expected to remain relatively unchanged due to a decline in the overall veteran population. Although the need for VA nursing home care remains, for over a decade VA has highlighted the potential benefits of providing veterans with alternative options for long- term care—specifically, less costly home and community-based care—in an effort to lessen the need for more costly nursing home care. For example, in its 2014 budget justification, VA proposed legislation that would authorize VA to pay for care in VA-approved medical foster homes for veterans who would otherwise need nursing home care. Functional limitations are physical problems that limit a person’s ability to perform routine daily activities, such as eating, bathing, dressing, paying bills, and preparing meals. Cognitive limitations are losses in mental acuity that may also restrict a person’s ability to perform such activities. Institutionalization in a nursing home is more common at older ages—in 2010, about 1 in 8 people age 85 or older resided in institutions, compared with 1 percent of people ages 65 to 74. See Congressional Budget Office: Rising Demand for Long-Term Services and Supports for Elderly People (Washington D.C.: June 2013). Decisions about the nursing home setting in which a veteran will receive care are decentralized to the local level because of several factors, including variability in the choice of available settings, the nursing home care services available, and admissions policies at each type of setting. In addition, veterans’ nursing home service needs, eligibility status, and preferences about the location of care are considered in deciding the setting to choose. VA program officials told us that the decisions as to which nursing home setting would be used are decentralized to the local level because they are dependent upon several factors including the type of setting available in each community, and availability varies considerably across locations. For example, veterans in need of nursing home care in Augusta, Maine who wish to stay within about a 50-mile radius may have the option of receiving care from several settings including 1 CLC, 12 community nursing homes and 2 state veterans’ nursing homes, assuming availability of beds and resources. However, veterans in Saginaw, Michigan wishing to stay within a similar radius may have the option of receiving care from 1 CLC and 3 community nursing homes, depending on the availability of beds and resources, since the only 2 state veterans’ nursing homes are over 100 miles away. In addition, VA officials told us that decisions about which setting is used are based upon veterans’ specific nursing home service needs, and settings varied in the type of specific services offered. For example, officials told us that in certain geographic areas CLCs provide certain services that are not available in the community, such as dementia care, behavioral health services, and care for ventilator-dependent residents. In other areas, however, officials told us that these specialized services might not be available in a CLC and instead might be available at a community nursing home. When an individual medical center has more than one CLC in its service area, each CLC may offer a unique set of services. Therefore, according to officials, the availability of different types of services in each nursing home setting depends largely on location. VA officials further told us that admissions policies are generally the same for all CLCs, but may vary for community nursing homes and state veterans’ nursing homes. CLCs are required to provide care based on agency-wide policies; therefore, eligibility criteria and admissions policies are generally uniform across the country. An interdisciplinary team— including personnel such as a registered nurse, social worker, recreation therapist, medical provider, dietitian, and any other discipline(s) directly involved in the care of the resident—at the VA medical center of jurisdiction determines whether the veteran has a clinical need for nursing home care. This determination is to be based on a comprehensive clinical assessment of medical, nursing and therapy needs; level of functional impairment; cognitive status; rehabilitation needs; and special emphasis care needs, such as spinal cord injury or end-of-life care. Each CLC is required to use a standardized instrument that is used by all Centers for Medicare & Medicaid Services-certified nursing homes for assessment, treatment planning, and documentation and evaluation of care and services. Three key factors are considered at the time of admission: (1) the specific services to be provided; (2) whether the stay is short or long; and (3) the setting to which the resident will be discharged. Admissions policies are generally standardized for community nursing homes, but may vary for state veterans’ nursing homes based on state requirements. Community nursing homes are required to be certified for participation in the Medicare and Medicaid programs, and use the same standardized instrument for assessment, evaluation and treatment planning as CLCs. VA officials told us that community nursing homes are required to accept all eligible veterans referred by VA, subject to availability of beds and required resources. State veterans’ nursing homes are not required to provide VA with documentation of their admissions policies. Since these homes are state-owned and operated entities they are subject to admissions and eligibility criteria that vary from state to state. For example, for admission, state veterans’ nursing homes in Alabama require the veteran to have 90 days of service, at least one day of which was wartime service. In contrast, state veterans’ nursing homes in New York require the veteran to have only 30 days of active service, while homes in Florida do not require any wartime service. In addition to the type of available settings, the nursing home care services available, and admissions policies at each type of setting, VA officials told us that veterans’ eligibility status, and preferences about remaining close to home and family or willingness to travel to a nursing home setting were important considerations. For example, a discretionary veteran with a preference for staying close to home might be a candidate for admission to a community nursing home or a state veterans’ nursing home if a CLC was too far away. However, officials told us that because of the veteran’s discretionary status, he or she would be informed of VA’s restriction of coverage to only the first 180 days of care in the community nursing home, and staff would assist the veteran in obtaining Medicaid coverage.