[Senate Hearing 107-778]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 107-778
 
             OPTIONS TO NURSING HOME CARE--IS VA PREPARED?
=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION




                               __________

                             APRIL 25, 2002

                               __________

      Printed for the use of the Committee on Veterans' Affairs 








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                     COMMITTEE ON VETERANS' AFFAIRS

            JOHN D. ROCKEFELLER IV, West Virginia, Chairman

BOB GRAHAM, Florida                  ARLEN SPECTER, Pennsylvania
JAMES M. JEFFORDS (I), Vermont       STROM THURMOND, South Carolina
DANIEL K. AKAKA, Hawaii              FRANK H. MURKOWSKI, Alaska
PAUL WELLSTONE, Minnesota            BEN NIGHTHORSE CAMPBELL, Colorado
PATTY MURRAY, Washington             LARRY E. CRAIG, Idaho
ZELL MILLER, Georgia                 TIM HUTCHINSON, Arkansas
E. BENJAMIN NELSON, Nebraska         KAY BAILEY HUTCHISON, Texas

                     William E. Brew, Chief Counsel

      William F. Tuerk, Minority Chief Counsel and Staff Director

                                  (ii)






                            C O N T E N T S

                              ----------                              

                             April 25, 2002

                                SENATORS

                                                                   Page
Murray, Hon. Patty, U.S. Senator from Washington, prepared 
  statement......................................................    73
Rockefeller, Hon. John D. IV, U.S. Senator from West Virginia, 
  prepared statement.............................................     4
Specter, Hon. Arlen, U.S. Senator from Pennsylvania, prepared 
  statement......................................................     5

                               WITNESSES

Bascetta, Cynthia A., Director, Health Care, Veterans' Health and 
  Benefits Issues, United States General Accounting Office.......     6
    Prepared statement...........................................     8
Dickerson, Gladys, R.N., Home-Based Primary Care Coordinator, 
  Dallas VA Medical Center.......................................    37
    Prepared statement...........................................    38
Hemmings, Paula, R.N., Department of Veterans Affairs' Veterans 
  Integrated Service Network No. 2, Geriatrics and Extended Care 
  Line Manager, representing the Alzheimer's Association.........    42
    Prepared statement...........................................    44
McClure, Thomas, LCSW, Coordinator, VA Medical Foster Home 
  Program, Little Rock VA Medical Center.........................    39
    Prepared statement...........................................    40
Moye, Jennifer, Ph.D., Director of the Geriatric Mental Health/
  UPBEAT, Brockton VA Medical Center, and Associate Professor of 
  Psychology, Department of Psychiatry, Harvard Medical School...    48
    Prepared statement...........................................    50
Roswell, Robert H., M.D., Under Secretary for Health, Department 
  of Veterans Affairs............................................    58
    Prepared statement...........................................    59
    Response to written questions submitted by Hon. Patty Murray 
      to Robert Roswell..........................................    64

                                APPENDIX

Alzheimer's Association, prepared statement......................    75
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, 
  prepared statement.............................................    75
Davidson, Arlene, Vice President, Planning and Development, 
  Evercare, a Unitedhealth Group Affiliate, prepared statement...    80
Fischl, James R., Director, National Veterans Affairs and 
  Rehabilitation Commission, The American Legion, prepared 
  statement......................................................    79

                                 (iii)


             OPTIONS TO NURSING HOME CARE--IS VA PREPARED?

                              ----------                              


                        THURSDAY, APRIL 25, 2002

                                       U.S. Senate,
                             Committee on Veterans Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:25 a.m., in 
room SR-418, Russell Senate Office Building, Hon. John D. 
Rockefeller IV, chairman of the committee, presiding.
    Present: Senators Rockefeller, Graham, Wellstone, Specter, 
and Hutchinson.
    Chairman Rockefeller. The hearing will come to order, and I 
will forego my opening statement for the moment and yield with 
the permission of Senator Hutchinson to Senator Wellstone who 
has another pressing engagement.
    Senator Wellstone. Thank you so much for your graciousness, 
and then I really guess that what I want to say today, and I am 
going to try to be back for more of the committee hearing, Mr. 
Chairman and Senator Hutchinson, is that I was excited when 
this Millennium bill based in 1999 and would thank you for your 
leadership.
    I mean having had two parents with Parkinson's and kind of 
going through this ourselves about what do you do. People get 
elderly and struggle with these illnesses. How do you help them 
stay at home, live at home in as near normal circumstances with 
dignity, or if they need to go in a nursing home, how do we 
make sure that we--or we need respite care and all the rest. I 
thought that we in passing this legislation made a really 
significant commitment, and I guess my message for the VA today 
is you all have got to follow through. We are not doing this.
    I mean we did not pass a law just for symbolic reasons. We 
passed this law to make this happen, and it is not happening, 
and either the VA is going to have to sort of reorder its 
priorities and figure out how with its staff and its resources 
it, in fact, lives up to this mandate or to this vision or to 
this mission. You know it's noble.
    Or if the VA needs more resources, then, you know, we need 
to know how much more and why and what we need to do. I just 
put it in the context of--I said to Secretary Principi, whom I 
think is one the nicest, best people in government service, 
when he came here, you are great and people love you in 
Minnesota, but this budget is a straightjacket. And we got long 
waits and people are not getting access to specialty care in 
Minnesota now, and we are not having any more outreach 
community clinics.
    This is a horrible budget, and I am getting increasingly 
impatient that the VA is not, in fact, making this piece of 
legislation a reality in terms of actually providing help for a 
lot of our veterans who are now senior citizens and need the 
help.
    So there is a big missing piece here somewhere and this 
hearing therefore is extremely important. I thank you. I am 
going to try to come back, too.
    Chairman Rockefeller. Thank you, Senator Wellstone. I now 
want to introduce Senator Hutchinson for the purpose of making 
an introduction not on the first but on the second panel.
    Senator Hutchinson. Mr. Chairman, I thank you for your 
willingness to allow me to do this, because our schedules are 
so crazy up here, and I am afraid I will not be here when Tom 
testifies, and I did want to take the opportunity to say a word 
of welcome to one of my constituents who will be testifying on 
the second panel, and, Mr. Chairman, I also want to thank you 
for calling the hearing today. I think this is a very, very 
important topic, and the GAO study is going to be, I think, 
revealing, and this is a timely hearing, and I thank you for 
doing that.
    But it is my great privilege to welcome one of my 
constituents, Tom McClure, from Hot Springs, AR. Tom has 
dedicated his entire professional life to helping others, 
particularly veterans. He has served in the VA for 27 years. In 
January of 2000, he was appointed as the coordinator for the VA 
Medical Care Foster Home Program in central Arkansas.
    The Foster Home Program that Tom oversees is really, I 
think, a model, and it is also very much a win-win for the 
veterans and the Veterans Administration because the program 
offers the veteran a loving, caring home to reside in at no 
cost to the Veterans Administration.
    The program maintains a comprehensive medical plan by a 
multidisciplinary team of care providers and increases 
customers' satisfaction for the VA. Initially it was just a 
pilot program, but it was so successful that the Arkansas VA 
continued to fund the Foster Home Program out of their own 
operating funds.
    So, Tom, we thank you for your work and the committee is 
pleased to have you with us today. We look forward to your 
testimony. Thank you, Mr. Chairman.
    Chairman Rockefeller. Thank you, Senator Hutchinson, very 
much. We appreciate your being here and making that 
introduction. I think I can probably go ahead as chairman and 
give my opening statement.
    So I will. And it basically is what Paul was saying and 
what Tim was saying. In my mind, it is about the eighth hearing 
we have had on this subject, and the Millennium bill passed in 
1999. I remember every single second of the conference 
committee. I was surprised that the House went along with it to 
the extent that they did, but they did.
    It was the first time that long-term care coverage has 
happened in public policy since Medicaid. It was an extremely 
exciting concept that we could actually do some long-term care 
on a non-institutional basis and absolutely nothing has 
happened.
    That was in 1999, so it was 1999, 2000, 2001, 2002. I call 
this an embarrassment because ignoring the single-most 
important demand for long-term care will only intensify. And so 
we have hearings, and we ask why, and we get answers that are 
not satisfactory--OMB rules and regulations, this and that.
    But it always occurs to me that the Department of Veterans 
Affairs is the second largest organization outside of the 
Department of Defense in all of government, 220,000 people, led 
by a very able administrator and health deputy, and it seems to 
me that 220,000 people collectively would be able to find a way 
to take a law that was passed over 3 years ago, which addresses 
the primary concerns of veterans, and put it into practice, and 
this particular senator is now past the point of impatience.
    I am very angry about it. Therefore, this hearing is being 
set up in a very different way. We are having people who are 
making this work. We are having a GAO report, and then we are 
having the VA as the last panel so that the head of the health 
administration can hear and be told about what others before 
him said, because there are people who out there on their own 
are deciding to make this work.
    When Secretary Principi, who as Paul indicated is a 
wonderful person and really is, and is beloved by veterans and 
by this chairman, when he was up for his confirmation, I said, 
you know, I said the only question that is worth asking you 
really, because I know you and you have been here before, is 
are you willing to go face to face with the President of the 
United States, much less OMB, on budget issues, and he said, 
yes, I will.
    And I think the answer is no, he has not. And that is very 
clear or else it seems to me that this, the most important 
issue of long-term care, the one thing other than death and 
taxes that we all absolutely are going to face at some point, 
either in the comfort of home, as is contemplated here, or in a 
nursing home. For the first time in many years a government 
action relating to long-term care has been enacted, and then VA 
says, oh, by the way, we are hung up on rules and regulations.
    I do not buy that. I do not care if it is President 
Clinton. I do not care if it is President Bush. I do not care 
who it is. It is inexcusable. It is absolutely inexcusable, and 
so this hearing is for the purpose of either embarrassing or 
humiliating the VA into doing something. It is therefore what I 
would call a constructive hearing because its purpose is to get 
something going which is already in law.
    If there is a Federal law, we try to follow it. So I am 
ready to hear about the lack of guidance from central offices 
and OMB and regulations going back and forth, but they carry 
no--they create not a ripple of interest on my part anymore. I 
am only interested in a result, and I do not know, I am not 
seeking to do retribution here, but I am getting very close to 
it. I am getting very close to it because this is something 
that was not only really important to me. I happened to 
negotiate this personally, and as I say, it is the one thing 
everybody needs.
    I had a mother who died from Alzheimer's. That took 10 
years. It was not pleasant. I am not poor, so we were able to 
afford to give her what she needed, but she needed a whole lot. 
And so do veterans and many are poor and they cannot do it on 
their own. So we have a law which is being ignored and excuses 
do not work anymore.
    So we have people who are doing things. You know it is not 
like this cannot be done, because that is why we are going to 
have some witnesses from some VA places who are going ahead 
with this on their own. I do not know if they are in violation 
of VA rules or not, but to me they are heroes, and we are going 
to hear from them.
    There are more veterans today than ever seeking 
alternatives to nursing homes--what is known as non-
institutional care. They want to remain in the community. They 
want to remain in their home. My mother wanted to spend her 
last period of time in her home listening to the music that she 
loved, and I mean that is human nature. She was beyond the 
point of knowing where she was at that point, but it was 
incredibly important to those who cared about her. The 
Department of Veterans Affairs cares about veterans, and they 
have to show that through what they do.
    So 35 percent of the veteran population is 65 years or 
older. The law and the demand gave VA a very clear mandate for 
action. It was not--this would be a nice thing for you to 
consider. It is something you are going to do. Mandate is a 
strong word, not beloved by the American people, but beloved by 
people who pass laws and want to see them enacted.
    So the VA has been excruciatingly slow. Today we are going 
to try to get some answers about why this has happened and more 
importantly what the VA is going to do to change their ways, 
and I do not want to hear a lot about OMB because there are 
people here who evidently are not worried about OMB and who are 
doing things on their own.
    Dr. Roswell, for whom I have enormous respect--his new job 
is Under Secretary--needs to know and does, I am sure, the time 
for action is immediate. So there are clinicians here who have 
gone ahead. I am always gratified when you see people who work 
in large organizations who go against the grain and do things 
because they believe it. I want them to be applauded and 
showcased here and for us to learn from them.
    So I am not only no longer interested in dilatory tactics, 
but I am going to find ways to get very difficult about this, 
and I suspect that my good friend from Pennsylvania will join 
me in that effort. I yield to him at this point.
    [The prepared statement of Senator Rockefeller follows:]

 Prepared Statement of Hon. John D. Rockefeller IV, U.S. Senator From 
                             West Virginia

    I called today's hearing to focus on VA's inaction in 
making long-term care services available to veterans--
especially those who can and wish to reside in the community. 
This inaction is a terrible failure, to be sure. Veterans need 
these services, Congress was clear in demanding that they be 
provided, and for a variety of reasons, VA has chosen to both 
ignore the mandate and failed to meet veterans' needs.
    There is another side to this story: despite a dearth of 
guidance from Central Office, there are places on the VA 
landscape where some truly wonderful things are happening to 
keep veterans well cared for and in the setting of their 
choice. Good programs must be fostered, but in the VA 
environment, long-term care services are frequently starved.
    Today, more and more veterans are seeking alternatives to 
nursing homes. They want to remain in the community and, with 
the right kind of support and care from VA, are able to do so--
even with chronic and debilitating conditions.
    In 1999, Congress spoke clearly about the need for VA to 
step up its long-term care effort, not because we had issues 
about quality, but because of the high demand for care. The 
numbers bear repeating: About 35 percent of the veteran 
population is 65 years or older--it is the single largest 
segment of today's veteran population--and many need long-term 
care services. While the law and the demand gave VA a clear 
mandate for action, VA has moved excruciatingly slow. Today we 
will try to get some answers about why that has happened and, 
more importantly, about what VA will do to correct the 
situation. With Dr. Roswell new in his job as Under Secretary, 
the time is ripe for action.
    As I noted, there are VA clinicians who, in grappling with 
the demand, have not waited but have found some innovative 
solutions. I am always deeply gratified by the level of 
dedication and innovation of VA employees, and I applaud those 
who have moved forward.
    While the focus of this hearing is on options to nursing 
homes, I note the need for VA nursing home beds. For many 
veterans, non-institutional options will not work, and because 
of this Congress is on record stating that VA must have 
sufficient nursing home capacity. I am concerned, however, that 
the quest to maintain and fill nursing home beds not overshadow 
the need for other options. I know that VA is concerned about 
this as well, and is requesting some relief.
    It is vital that VA's role as a model for long-term care be 
recognized and rewarded, because we will have enormous problems 
with demand for this care in the years ahead. The only entity 
of any scope, size, or capacity that is dealing with how to 
meet the needs of an older population--albeit at a slower pace 
than I'd like--is VA. This role of VA must be highlighted and 
supported. I am here to do just that.

    Senator Specter. Thank you very much, Mr. Chairman. I would 
ask unanimous consent that my written statement be included in 
the record.
    Chairman Rockefeller. Absolutely.
    Senator Specter. I do not want to speak too long because I 
am anxious to hear how nasty you are going to be. [Laughter.]
    As I said to Senator Rockefeller on the floor a few minutes 
ago, it is time to get tough about this. I will support strong 
action by the chairman. We passed this legislation over a lot 
of objections in the House and the Senate, and we meant it. We 
want it to be carried out. And I commend you, Mr. Chairman, for 
having convened this oversight hearing.
    I regret being a little late arriving. We had a markup in 
the Environment and Public Works Committee and Judiciary 
Committee has scheduled an executive meeting later this 
morning, so I may have to excuse myself. But I will stay as 
long as I can, and I will review the record. I think this is a 
very, very important session, and I have never seen you nasty, 
so I am looking forward to that. [Laughter.]
    [The prepared statement of Senator Specter follows:]

      Prepared Statement of Hon. Arlen Specter, U.S. Senator From 
                              Pennsylvania

    Thank you, Mr. Chairman, for convening this hearing on the 
important issue of long-term care for our Nation's veterans. I 
know you and I both agree this is a critical service for 
America's veterans, their families, and for the Nation as a 
whole.
    Mr. Chairman, in 1999, you and I worked together diligently 
here in the Senate, and in Conference with the House of 
Representatives, to ensure that our veterans would have 
universal access to noninstitutional long-term care provided by 
the Department of Veterans Affairs. At that time, our proposal 
was met with great hostility by the some Members of the House. 
However, we prevailed in our efforts to make these services 
available to all of our aging veterans. Unfortunately, the VA 
has failed to abide by the law.
    As the testimony by our GAO witness will demonstrate, more 
than two and one half years after the passage of the Veterans 
Millennium Health Care and Benefits Act of 1999, VA is still 
not providing access to these crucial services for all of our 
veterans in need of this care.
    Fortunately, the need for these services has not gone 
unnoticed on the front lines of some VA hospitals throughout 
the nation. As the testimony of the members of our second panel 
show, innovation and compassion for our veteran patients is 
alive and well in VA hospitals. Unique programs, such as foster 
care for elderly veterans in Arkansas and vigorous case 
management of dementia patients in New York is showing 
Congress, and more importantly, the leadership of VA Central 
Office, that if the resources are available to assist in the 
creation of special programs, we can do wonders for thousands 
of sick and elderly veterans.
    Mr. Chairman, I sincerely expect that this hearing will 
light a fire in VA Central Office at the highest levels, 
including the Secretary's Office. VA must know that when 
Congress passes a law, we expect--and we demand--that it be 
carried out. Institutional and noninstitutional long-term care 
services are vital for our aging veteran population. Congress 
has said so in statute. Now VA must say so in action.
    Thank you very much Mr. Chairman for holding this hearing. 
I look forward to receiving the testimony of the witnesses.

    Chairman Rockefeller. So we are going to go right to our 
first panel. And I would ask them to come to the table. They 
are representatives of the General Accounting Office, and they 
are going to report on VA's response to the long-term care 
provisions of the Millennium Act. I welcome Cindy Bascetta, who 
is the Director of Veterans' Health Care Issues at GAO. I am 
comforted by that position, just knowing that it is there, 
Cynthia, so I am already happy about you.
    And also Jim Musselwhite, who is Assistant Director for 
Health Care. Ms. Bascetta, why do you not go ahead? Now we have 
a 5-minute rule.
    Ms. Bascetta. Right.
    Chairman Rockefeller. I am sure you have been warned about 
that.
    Ms. Bascetta. Absolutely.
    Chairman Rockefeller. Nobody has ever disobeyed that. 
[Laughter.]
    Ms. Bascetta. And I do not intend to.

   STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR, HEALTH CARE, 
  VETERANS' HEALTH AND BENEFITS ISSUES, UNITED STATES GENERAL 
 ACCOUNTING OFFICE, ACCOMPANIED BY JIM MUSSELWHITE, ASSISTANT 
                   DIRECTOR, HEALTH CARE, GAO

    Ms. Bascetta. Mr. Chairman, Senator Specter, thank you for 
inviting me here today to discuss our work on VA's non-
institutional long-term care services. It is no surprise, as 
you have pointed out, that demographic pressures will increase 
the demand for long-term care. The number of veterans aged 85 
and older, those most at risk of needing long-term care, is 
expected to triple over the next decade. While not all of their 
needs can be met in non-institutional settings, aging veterans 
are likely to be no different from other elderly Americans in 
preferring care that allows them to remain in their homes or in 
other settings that are less restrictive than nursing homes.
    As you know, although VA has been providing long-term care 
including non-institutional care on a discretionary basis, the 
Millennium Act requires adult day health care, geriatric 
evaluation, and respite care for all eligible veterans.
    Today, I would like to discuss our findings about VA's 
efforts to expand these services and highlight our early work 
on the availability of non-institutional services in general 
across the VA system.
    Mr. Chairman, as you have pointed out, more than 2 years 
after enactment, VA has not completed its response to the 
Millennium Act. VA has issued proposed regulations that would 
make the three services available in non-institutional 
settings, and we understand that final regulations will be 
issued next week.
    In the interim, however, I would like to point out that VA 
did issue a policy directive in October 2001 requiring that all 
eligible veterans have access to these services outside of 
institutions. Nevertheless, none of the three are universally 
available. In a survey we conducted of all 139 medical 
facilities, 99 reported offering adult day health care, 74 
offered non-institutional geriatric evaluation, and 29 offered 
non-institutional respite care.
    According to VA, central monitoring of medical facilities 
to ensure that they provide non-institutional access to all 
three services will begin soon.
    Our survey also showed that the six other non-institutional 
services offered by VA also vary in their availability from 
network to network. Most commonly offered by more than 120 
medical facilities are homemaker and home health aide services 
as well as skilled home health care. In contrast, non-
institutional clinics for Alzheimer's and dementia care are 
available at fewer facilities with only 32 reporting such care.
    In addition, we found that several facilities reported 
offering at least eight of the nine non-institutional long-term 
care services, but some offered only one non-institutional 
service or none at all. The results of our survey are similar 
to the distribution of services noted almost 4 years ago by the 
Advisory Committee on the Future of VA Long-Term Care. In its 
report, called ``VA Long-Term Care at the Crossroads,'' the 
committee stated that despite a continuum of offerings, VA 
services were not universally available and access was often 
restricted.
    VA headquarter's officials agree today that non-
institutional services are not yet equally accessible across 
the country. Despite this picture, VA has roughly doubled the 
proportion of long-term care provided outside of institutions 
over the past decade. Nonetheless, like Medicaid, the largest 
payer of long-term care, VA costs for non-institutional care 
remain dwarfed by its costs for nursing home and other 
institutional care.
    Over the next 10 years, the nation's health system as well 
as VA will face significant aging of the population 
particularly for those 85 years or older. Nearly 20 percent of 
individuals in this group report a disability compared to about 
5 percent between the ages of 65 and 84.
    Like its non-VA counterparts, VA needs to prepare for these 
demographic challenges. The task force and the Millennium Act 
reflect the importance of providing a continuum of non-
institutional services more evenly throughout the country to 
help meet this challenge.
    Our ongoing review, conducted at your request, will assess 
the reasons for the current unevenness in non-institutional 
long-term care services across the networks. Providing more 
universal access to non-institutional care could help VA meet 
the growth in demand and at the same time offer veterans more 
options from which to choose. This concludes my prepared 
statement, and I would be happy to answer any questions.
    [The prepared statement of Ms. Bascetta follows:]
   Prepared Statement of Cynthia A. Bascetta, Director, Health Care, 
Veterans' Health and Benefits Issues, United States General Accounting 
                                 Office
    Mr. Chairman and Members of the Committee:
    I am pleased to be here today to discuss noninstitutional long-term 
care services offered by the Department of Veterans Affairs (VA). These 
services, such as homemaker services and adult day health care, are 
delivered to veterans in their own homes and other locations in the 
community. VA will see increasing demand for long-term care in the 
coming years as the veteran population ages. Of particular significance 
is the expected tripling of the number of veterans age 85 and older--
the group most in need of long-term care. Although not all veterans' 
care needs can be met in noninstitutional settings, veterans may prefer 
such care because it allows them to remain in their homes or in other 
settings that are less restrictive than institutions.
    VA generally provided or paid for long-term care on a discretionary 
basis until passage of the Veterans Millennium Health Care and Benefits 
Act in November 1999.\1\ The Millennium Act required VA to offer 
certain long-term care services to eligible veterans, including 
services provided in noninstitutional settings. In particular, adult 
day health care, geriatric evaluation, and respite care are to be made 
available to eligible veterans.
---------------------------------------------------------------------------
    \1\ Pub. L. No. 106-117, 113 Stat. 1545 (1999).
---------------------------------------------------------------------------
    As part of our ongoing work addressing the availability of 
noninstitutional long-term care in VA, you asked us to provide 
information on (1) VA's efforts to expand noninstitutional long-term 
care in response to the Millennium Act's requirements,\2\ and (2) the 
noninstitutional long-term care services that VA's medical facilities 
offer. My statement focuses on the information we provided in a letter 
on VA's noninstitutional long-term care services,\3\ which is being 
released today. That letter is based on data from a survey of all 139 
VA medical facilities,\4\ interviews with officials in VA's Geriatrics 
and Extended Care Strategic Healthcare Group, and interviews with VA 
field officials responsible for long-term care services. To determine 
which noninstitutional long-term care services to include in our 
survey, we compiled a list of the services as identified by VA 
officials and in VA documents. (Descriptions of these noninstitutional 
services are provided in appendix I.)
---------------------------------------------------------------------------
    \2\ Although nursing home care and domiciliary care are also 
required by the act, we do not address these requirements.
    \3\ VA Long-Term Care: Implementation of Certain Millennium Act 
Provisions Is Incomplete, and Availability of Noninstitutional Services 
Is Uneven (GAO-02-510R, March 29, 2002).
    \4\ Although VA has 172 medical centers, in some instances 2 or 
more medical centers have consolidated into health care systems. 
Counting health care systems and individual medical centers that are 
not part of a health care system as single facilities, VA has 139 
facilities.
---------------------------------------------------------------------------
    In summary, more than 2 years after the act's passage VA has not 
completed its response to the act's requirement that eligible veterans 
be offered adult day health care, geriatric evaluation, and respite 
care. Although VA published proposed regulations that would make these 
three services available in noninstitutional settings to eligible 
veterans,\5\ the regulations had not been made final as of April 17, 
2002. To be responsive to the act's requirements before its draft 
regulations were made final, VA issued a policy directive requiring 
that these three services be available in noninstitutional settings. VA 
also offers other noninstitutional services. At the time of our review, 
however, both the services required as a result of the act and VA's 
other noninstitutional services were unevenly available across the VA 
system.
---------------------------------------------------------------------------
    \5\ 66 Fed. Reg. 50,594 (2001).
---------------------------------------------------------------------------
                               background
    VA served about one-third of its fiscal year 2001 long-term care 
workload, or average daily census, in noninstitutional settings (see 
table 1). Noninstitutional care accounted for about 8 percent of VA's 
long-term care costs during the same year.

 Table 1: VA Long-Term Care Workload and Costs, by Care Setting, Fiscal
                                Year 2001
------------------------------------------------------------------------
                                      Average daily
      Long-term care setting             census a          Total cost
------------------------------------------------------------------------
Institutional b...................             45,033     $2,888,659,000
Noninstitutional..................             23,205        239,939,000
                                   -------------------------------------
    Total.........................             68,238     $3,128,598,000
------------------------------------------------------------------------
Source: VA.
 
a The average daily census represents the total number of days of
  inpatient care for institutional care and the total number of
  outpatient encounters for noninstitutional care, each divided by the
  number of days in the year. These figures may overstate the number of
  veterans receiving noninstitutional services because some veterans may
  receive more than one noninstitutional service on a particular day.
b Institutional long-term care includes care that VA provides or pays
  for in nursing homes and other residential settings.

    The proportion of VA's long-term care costs for noninstitutional 
care has doubled over the past decade, as shown in figure 1. This has 
occurred as part of a larger trend within VA toward reducing its heavy 
reliance on inpatient care. Nevertheless, VA's costs for 
noninstitutional long-term care remain small relative to its costs for 
institutional long-term care.

  Figure 1: VA Long-Term Care Costs, By Care Setting, Fiscal Year 1991-
                            Fiscal Year 2001
------------------------------------------------------------------------
                                                          1991     2002
------------------------------------------------------------------------
Noninstitutional long-term care.......................       4%       8%
Institutional long-term care..........................      96%      92%
------------------------------------------------------------------------
Source: VA.

    Medicaid--the nation's largest purchaser of long-term care--has 
seen a similar increase in the proportion of its long-term care costs 
for noninstitutional services. As in VA, the proportion of Medicaid's 
long-term care costs for this purpose has doubled, from 13 percent in 
1990 to 27 percent in 2000. However, similar to VA, the bulk of 
Medicaid's long-term care costs are still for institutional care.
    VA is one of several federal agencies attempting to emphasize 
noninstitutional long-term care. Executive Order 13217,\6\ signed in 
June 2001, directs six federal agencies to evaluate their policies, 
programs, statutes, and regulations to determine whether any should be 
revised or modified to improve the availability of noninstitutional 
services for qualified individuals with disabilities.\7\ Although VA 
was not among the agencies named in the order, VA joined the effort on 
a voluntary basis and subsequently reported that it will evaluate its 
noninstitutional long-term care services to determine whether any could 
be expanded or modified to further promote noninstitutional services to 
veterans with disabilities.
---------------------------------------------------------------------------
    \6\ 66 Fed. Reg. 33,155 (June 18, 2001).
    \7\ The agencies were the Departments of Education, Health and 
Human Services, Housing and Urban Development, Justice, and Labor, and 
the Social Security Administration.
---------------------------------------------------------------------------
    VA will face increasing demand for long-term care as our nation's 
veteran population ages. VA statistics show that, although the total 
number of veterans will decline in the next 10 years, the number of 
veterans age 85 and older will triple during that time. This will 
significantly increase the need for VA's long-term care resources 
because although a chronic physical or mental disability may occur at 
any age, the older an individual becomes, the more likely it is that a 
disability will develop or worsen. Indeed, while about 4.8 percent of 
persons age 65-84 report a disability, the proportion nearly quadruples 
to 18.1 percent among those 85 and older.\8\
---------------------------------------------------------------------------
    \8\ These data represent individuals reporting a problem with two 
or more of the following six activities of daily living: bathing, 
dressing, eating, transferring between bed and chair, toileting, and 
getting around inside the home. Data are from the Department of Health 
and Human Services' 1994-95 National Health Interview Survey on 
Disability.
---------------------------------------------------------------------------
    As a result of this demographic pressure, concerns have been raised 
for some time about VA's ability to meet the expected rise in demand 
for long-term care services. In 1997 VA established a Federal Advisory 
Committee on the Future of VA Long-Term Care composed of national 
leaders in long-term care, and charged it with evaluating VA long-term 
care services and developing a strategy for meeting future needs. In 
its June 1998 report,\9\ the committee stated that VA long-term care 
was unevenly funded and recommended that VA expand noninstitutional 
long-term care services and emphasize these services, when clinically 
appropriate, for veterans needing long-term care.
---------------------------------------------------------------------------
    \9\ Department of Veterans Affairs, VA Long-Term Care At The 
Crossroads: Report of the Federal Advisory Committee on the Future of 
VA Long-Term Care (Washington, D.C.: June 1998).
---------------------------------------------------------------------------
          va's response to the millennium act is not complete
    The Millennium Act requires VA to provide adult day health care--
noninstitutional care in which health maintenance and rehabilitative 
services are provided to frail elderly veterans in an outpatient day 
setting. The act also requires that VA provide two additional services, 
geriatric evaluation and respite care,\10\ but does not specify whether 
these services must be provided in institutional or noninstitutional 
settings.
---------------------------------------------------------------------------
    \10\ Geriatric evaluation involves evaluation of veterans with 
particular geriatric needs and is generally provided by VA through one 
of two services, geriatric evaluation and management or geriatric 
primary care. Respite care is a program in which brief periods of care 
are provided to veterans in order to give veterans' regular caregivers 
a period of respite.
---------------------------------------------------------------------------
    More than 2 years after the act's passage, however, VA has not 
completed its response to the act's requirement that all eligible 
veterans be offered these three services. In October 2001, VA published 
proposed regulations to add the three required services in 
noninstitutional settings to its medical benefits package, the standard 
health plan available to all veterans enrolled in VA's health care 
system. As of April 17, 2002, final regulations had not been published, 
although VA officials told us that VA sent draft final regulations to 
the Office of Management and Budget for approval on March 14, 2002.
    To be responsive to the act's requirements before its draft 
regulations were finalized, however, VA issued a policy directive in 
October 2001 requiring that its medical facilities ensure that veterans 
have access to adult day health care, geriatric evaluation, and respite 
care in noninstitutional settings. A VA headquarters official told us 
that VA headquarters will soon begin monitoring medical facilities to 
ensure that they provide access to these three services in 
noninstitutional settings.
    Both VA's directive and its proposed regulations specify that 
geriatric evaluation and respite care be provided in noninstitutional 
settings even though the act does not state whether they must be 
provided in institutional or noninstitutional settings. (Adult day 
health care is by definition a noninstitutional service.) VA officials 
told us that VA chose to make clear its intent to have these services 
provided in noninstitutional settings because they were already widely 
offered in institutional settings. In fact, prior to the act VA was not 
authorized to provide noninstitutional respite care--until then, VA 
could provide respite care only in institutional settings. In contrast, 
prior to the act VA provided both adult day health care and 
noninstitutional geriatric evaluation; VA headquarters encouraged 
facilities to offer these services and provided guidance for facilities 
to use when doing so.
    When VA issued its policy directive in October 2001, it was far 
from its goal of universal access to these three noninstitutional 
services, as shown in figure 2. Among the three services, adult day 
health care was most widely available, followed by geriatric evaluation 
and respite care. VA officials told us that noninstitutional respite 
care is not widely offered because until the Millennium Act VA was not 
authorized to provide respite care in noninstitutional settings.
 figure 2: number of 139 va facilities offering certain long-term care 
       services required by the millennium act and available in 
                 noninstitutional settings, fall 2001 



 
 
Source: GAO survey of VA facilities; VA headquarters data.
Note: Responses to our survey were submitted in September and October
  2001.
 
a ``Geriatric evaluation'' encompasses facilities reporting geriatric
  evaluation and management services in our survey and additional
  facilities reported by VA headquarters as offering geriatric primary
  care.

     availability of other noninstitutional services is also uneven
    Uneven availability of noninstitutional services is not limited to 
the three services that VA requires its facilities to offer in response 
to the Millennium Act. Although at least nine different 
noninstitutional long-term care services are provided or contracted for 
by VA (including the three services that VA requires as a result of the 
act), considerable unevenness exists in what services are offered by 
individual facilities. For example, 123 VA facilities reported offering 
skilled home health care,\11\ while about half as many facilities--63--
reported offering community residential care. Figure 3 shows the number 
of VA's 139 facilities at which these nine noninstitutional long-term 
care services are offered.
---------------------------------------------------------------------------
    \11\ Skilled home health care consists of professional home health 
care services, mostly nursing services, purchased by VA and delivered 
by non-VA health care providers.
---------------------------------------------------------------------------
 figure 3: number of 139 va facilities at which noninstitutional long-
        term care services are offered, by service (fall 2001) 



 
 
Source: GAO survey of VA facilities; VA headquarters data.
Note: Responses to our survey were submitted in September and October
  2001.
 
a Includes facilities reporting geriatric evaluation and management
  services in our survey and additional facilities reported by VA
  headquarters as offering geriatric primary care.

    Similar variation exists in the number of services offered by 
individual facilities. For example, while several facilities reported 
offering at least eight of the nine noninstitutional long-term care 
services we identified, one facility reported offering only one 
noninstitutional service, and two more facilities reported offering 
none at all.
    These results are similar to the distribution of services noted by 
the 1998 Advisory Committee on the Future of VA Long-Term Care, which 
stated that VA long-term care--institutional as well as 
noninstitutional--was not available universally and that access to 
long-term care was often restricted. Similarly, a VA headquarters 
official we spoke with noted that VA's noninstitutional long-term care 
services are not equally accessible across the country.
                        concluding observations
    As the veteran population ages, VA will face increasing demand for 
long-term care services. Providing more even access to noninstitutional 
long-term care services across VA facilities, including those services 
now required as a result of the Veterans Millennium Health Care and 
Benefits Act, could help VA meet this demand while at the same time 
offering veterans more options from which to choose.
          * * * * *
    Mr. Chairman, this concludes my prepared statement. I will be happy 
to answer any questions you or the other committee members may have.
                      contacts and acknowledgments
    For more information regarding this testimony, please contact me or 
James Musselwhite. Joe Buschy and Steve Gaty also made key 
contributions to this statement.
   appendix i: noninstitutional long-term care services offered by va
     Adult day health care: health maintenance and 
rehabilitative services provided to frail elderly veterans in an 
outpatient day setting.
     Alzheimer's/dementia care: specialized outpatient services 
such as behavioral and medical management provided to veterans with 
Alzheimer's disease or related dementias.
     Community residential care: a service in which veterans 
who do not require hospital or nursing home care--but who (because of 
medical or psychosocial health conditions) are unable to live 
independently--live in VA-approved community residential care 
facilities; VA pays administrative costs only.
     Geriatric evaluation: evaluation of veterans with 
particular geriatric needs, generally provided by VA through one of two 
services: (1) geriatric evaluation and management (GEM), in which 
interdisciplinary health care teams of geriatric specialists evaluate 
and manage frail elderly veterans, and (2) geriatric primary care, in 
which outpatient primary care, including medical and nursing services, 
preventive health care services, health education, and specialty 
referral, is provided to geriatric veterans.
     Home-based primary care: primary medical care provided in 
the home by VA physicians, nurses, and other VA healthcare 
professionals to severely disabled, chronically ill veterans whose 
conditions make them unsuitable for management in outpatient clinics.
     Homemaker/home health aide: home health aide and homemaker 
services, such as grooming, housekeeping, and meal preparation 
services.
     Home respite care: home-based services provided to 
veterans on a short-term basis to give veterans' caregivers a period of 
relief or respite.
     Hospice care: home-based palliative and supportive 
services for veterans in the last phases of incurable disease so that 
they may live as fully and as comfortably as possible.
     Skilled home health care: medical services provided to 
veterans at home by non-VA health care providers.
                                 ______
                                 
           United States General Accounting Office,
                                            Washington, DC,
                                                    March 29, 2002.
Hon. John D. Rockefeller IV,
Chairman, Committee on Veterans' Affairs,
U.S. Senate.

Hon. Lane Evans,
Ranking Democratic Member,
Committee on Veterans' Affairs,
House of Representatives

 Subject: VA Long-Term Care: Implementation of Certain Millennium Act 
Provisions Is Incomplete, and Availability of Noninstitutional Services 
           Is Uneven [GAO-02-510R VA Long-Term Care Services]

    The Department of Veterans Affairs (VA) spent about $3.1 billion on 
long-term care in fiscal year 2001, an amount that is likely to 
increase in the coming years as the veteran population ages. VA 
provides or pays for long-term care in institutional settings such as 
nursing homes and through noninstitutional care in veterans' own homes 
and other locations in the community. VA generally provided or 
contracted for long-term care on a discretionary basis until passage of 
the Veterans Millennium Health Care and Benefits Act in November 
1999.\1\ The Millennium Act required VA to offer certain long-term care 
services to eligible veterans, including care in noninstitutional 
settings. As part of our ongoing work addressing the availability of 
noninstitutional long-term care in VA, you asked us to provide the 
information we have obtained to date on (1) VA's efforts to expand 
noninstitutional long-term care in response to the act's requirements 
and (2) the noninstitutional long-term care services that VA's medical 
facilities offer. As agreed with your offices, we are also providing 
data on the number of institutional services offered by VA's 
facilities, and their utilization, to place the noninstitutional 
services in perspective.
---------------------------------------------------------------------------
    \1\ Pub. L. No. 106-117, 113 Stat. 1545 (1999).
---------------------------------------------------------------------------
    In summary, more than 2 years after the act's passage VA has not 
completely implemented its response to the act's requirement that all 
eligible veterans be offered adult day health care, respite care, and 
geriatric evaluation. Although VA published draft regulations that 
would make these three services available in noninstitutional settings 
to eligible veterans, the regulations had not been made final as of 
March 19, 2002. To be responsive to the act's requirements before its 
draft regulations were finalized, VA issued a policy directive 
requiring that these three services be available in noninstitutional 
settings. At the time of our review, however, access to these services 
was far from universal in VA. More generally, the availability of all 
VA noninstitutional long-term care services, including the newly 
required services, is uneven across the VA system. In commenting on a 
draft of this letter, VA officials generally agreed with our 
assessment.
    To determine the status of VA's efforts to expand noninstitutional 
long-term care in response to the Millennium Act's requirements, we 
interviewed officials in VA's Geriatrics and Extended Care Strategic 
Healthcare Group and evaluated directives, regulations, and other 
guidance that had been prepared in response to the act. To determine 
which long-term care services are offered by each of VA's 139 
facilities,\2\ we compiled a list of the services as identified by VA 
officials and in VA documents. We subsequently used a survey instrument 
to collect data on the types of services offered at each of VA's 139 
facilities and the utilization of these services. In constructing this 
survey, we consulted with VA headquarters officials and pretested it 
with VA field staff to ensure that it would be clear to the 
respondents. We received responses for all 139 VA facilities. However, 
we did not conduct site visits or otherwise attempt to verify any of 
the data provided to us in the surveys. Our work was conducted from 
September 2001 through March 2002 in accordance with generally accepted 
government auditing standards.
---------------------------------------------------------------------------
    \2\ Although VA has 172 medical centers, in some instances two or 
more medical centers have consolidated into health care systems. 
Counting health care systems and individual medical centers that are 
not part of a health care system as single facilities, VA has 139 
facilities.
---------------------------------------------------------------------------
                               background
    VA served about one-third of its fiscal year 2001 long-term care 
workload, or average daily census, in noninstitutional settings (see 
table 1). Noninstitutional care accounted for about 8 percent of VA's 
long-term care costs during the same year.

 Table 1: VA Long-Term Care Workload and Costs, by Care Setting, Fiscal
                                Year 2001
------------------------------------------------------------------------
                                      Average daily
      Long-term care setting             census a          Total cost
------------------------------------------------------------------------
Institutional b...................             45,033     $2,888,659,000
Noninstitutional..................             23,205        239,939,000
                                   -------------------------------------
    Total.........................             68,238     $3,128,598,000
------------------------------------------------------------------------
Source: VA.
 
a The average daily census represents the total number of days of
  inpatient care for institutional care and the total number of
  outpatient encounters for noninstitutional care, each divided by the
  number of days in the year. These figures may overstate the number of
  veterans receiving noninstitutional services because some veterans may
  receive more than one noninstitutional service on a particular day.
b Institutional long-term care includes care that VA provides or pays
  for in nursing homes and other residential settings.

    VA is not alone among federal agencies in spending a relatively 
small percentage of its long-term care dollars in noninstitutional 
settings. Noninstitutional care also accounts for a relatively small 
percentage of long-term care expenditures under Medicaid, the nation's 
largest purchaser of long-term care. In 2000, for example, about 27 
percent of Medicaid's long-term care spending was devoted to 
noninstitutional care.
      va's response to the millennium act is not fully implemented
    The Millennium Act requires VA to provide adult day health care--
health maintenance and rehabilitative services provided to frail 
elderly veterans in an outpatient day setting. The act also requires 
that VA provide two additional services--geriatric evaluation 
(evaluation of veterans with particular geriatric needs, generally 
provided by VA through one of two services, geriatric evaluation and 
management or geriatric primary care) and respite care (brief periods 
of care provided to veterans in order to give veterans' regular 
caregivers a period of respite)--but does not specify whether these 
services must be provided in institutional or noninstitutional 
settings.\3\ (Descriptions of these and other VA long-term care 
services are provided in enclosure I.) The Millennium Act's long-term 
care provisions were written partly in response to the 1998 report of 
the Federal Advisory Committee on the Future of VA Long-Term Care.\4\ 
The committee's report stated that VA long-term care was ``marginalized 
and unevenly funded'' and recommended that noninstitutional long-term 
care become the preferred option, when clinically appropriate, for 
veterans needing long-term care.
---------------------------------------------------------------------------
    \3\ Although nursing home care and domiciliary care are also 
required by the act, we do not address these requirements.
    \4\ Department of Veterans Affairs, VA Long-Term Care At The 
Crossroads: Report of the Federal Advisory Committee on the Future of 
VA Long-Term Care (Washington, D.C.: June 1998).
---------------------------------------------------------------------------
    More than 2 years after the act's passage, however, VA has not 
completely implemented its response to the act's requirement that all 
eligible veterans be offered adult day health care, respite care, and 
geriatric evaluation. In October 2001, VA published draft regulations 
to add the three required services in noninstitutional settings to its 
medical benefits package, the standard health plan available to all 
veterans enrolled in VA's health care system. As of March 19, 2002, 
final regulations had not been published, although VA officials told us 
that VA sent the regulations to the Office of Management and Budget for 
approval on March 14, 2002.
    To be responsive to the act's requirements before its draft 
regulations were finalized, however, VA issued a policy directive in 
October 2001 requiring medical facilities to ensure that veterans have 
access to adult day health care, respite care, and geriatric 
evaluations in noninstitutional settings. VA's directive--as well as 
its draft regulations--specifies that respite care and geriatric 
evaluation be provided in noninstitutional settings even though the act 
does not state whether these two services must be provided in 
institutional or noninstitutional settings. (Adult day health care is 
by definition a noninstitutional service.) VA officials told us that VA 
made this decision because respite care and geriatric evaluation were 
already widely offered in institutional settings. A VA headquarters 
official told us that VA headquarters will soon begin monitoring field 
facilities to ensure that they provide access to these three services 
in noninstitutional settings.
    When VA issued its policy directive in October 2001, it was far 
from its goal of universal access to these three noninstitutional 
services, as shown in figure 1. Among the three services, respite care 
was most widely available, although at most facilities this care was 
still offered only in institutional settings. According to VA 
officials, noninstitutional respite care is not widely offered because 
until the Millennium Act VA was not authorized to provide respite care 
in noninstitutional settings. Second to respite care in availability 
was adult day health care, followed by geriatric evaluation.
 figure 1: number of 139 va facilities offering certain long-term care 
       services required by the millennium act and available in 
     noninstitutional settings, during september and october 2001 



 
 
Source: GAO survey of VA facilities; VA headquarters data.
 
a Includes facilities reporting geriatric evaluation and management
  services in our survey and additional facilities reported by VA
  headquarters as offering geriatric primary care.

       availability of other noninstitutional services is uneven
    Uneven availability of noninstitutional services is not limited to 
the three services that VA requires its facilities to offer in response 
to the Millennium Act. Although at least nine different 
noninstitutional long-term care services are provided or paid for by VA 
(including the three services that VA requires as a result of the act), 
considerable unevenness exists in the number of these services offered 
by individual facilities and their utilization. For example, 123 VA 
facilities reported offering skilled home health care,\5\ while about 
half as many facilities--63--reported offering community residential 
care. These results are similar to the distribution of services noted 
by the 1998 Advisory Committee on the Future of VA Long-Term Care, 
which stated that VA long-term care--institutional as well as 
noninstitutional--was not available universally and that access to 
long-term care was often restricted. Similarly, a VA headquarters 
official we spoke with noted that VA's noninstitutional long-term care 
services are not equally accessible across the country. The services 
offered by each VA facility during the September and October 2001 
period, along with the number of veterans served in each, are shown in 
enclosure II.
---------------------------------------------------------------------------
    \5\ Skilled home health care consists of professional home health 
care services, mostly nursing services, purchased by VA and delivered 
by non-VA health care providers.
---------------------------------------------------------------------------
                            agency comments
    We provided a draft of this letter to VA officials for comment and 
received oral comments on March 19, 2002. In providing comments, VA's 
acting chief consultant, Geriatrics and Extended Care Strategic 
Healthcare Group, stated that VA agrees that its efforts to provide 
certain noninstitutional long-term care services in response to the 
Millennium Act's requirements are not complete, and that the 
availability of noninstitutional services is uneven. The acting chief 
consultant also noted that VA's home health care programs are widely 
available as shown in our survey results. This official also provided 
technical comments that we have incorporated as appropriate.
    As arranged with your offices, unless you publicly announce this 
letter's contents earlier we will make no further distribution until 30 
days after its date. At that time, we will send copies to the secretary 
of veterans affairs and interested congressional committees. The letter 
will also be available on GAO's home page at http://www.gao.gov. If you 
have questions, please contact me or James Musselwhite. Joe Buschy, 
Steve Gaty, and Stefanie Weldon also made key contributions to this 
letter.
                                       Cynthia A. Bascetta,
        Director, Health Care--Veterans' Health and Benefits Issues
                Enclosure I--VA Long-Term Care Services
                       noninstitutional services
     Adult day health care: health maintenance and 
rehabilitative services provided to frail elderly veterans in an 
outpatient day setting.
     Alzheimer's/dementia care: specialized outpatient services 
such as behavioral and medical management provided to veterans with 
Alzheimer's disease or related dementias.
     Community residential care: a service in which veterans 
who do not require hospital or nursing home care--but who (because of 
medical or psychosocial health conditions) are unable to live 
independently--live in VA-approved community residential care 
facilities; VA pays administrative costs only.
     Geriatric evaluation: evaluation of veterans with 
particular geriatric needs, generally provided by VA through one of two 
services: (1) geriatric evaluation and management (GEM), in which 
interdisciplinary health care teams of geriatric specialists evaluate 
and manage frail elderly veterans, and (2) geriatric primary care, in 
which outpatient primary care, including medical and nursing services, 
preventive health care services, health education, and specialty 
referral, is provided to geriatric veterans.\6\
---------------------------------------------------------------------------
    \6\ Geriatric primary care was not among the services included in 
our survey of VA facilities.
---------------------------------------------------------------------------
     Home-based primary care: primary medical care provided in 
the home by VA physicians, nurses, and other VA healthcare 
professionals to severely disabled, chronically ill veterans whose 
conditions make them unsuitable for management in outpatient clinics.
     Homemaker/home health aide: home health aide and homemaker 
services, such as grooming, housekeeping, and meal preparation 
services.
     Home respite care: home-based services provided to 
veterans on a short-term basis to give veterans' caregivers a period of 
relief or respite.
     Hospice care: home-based palliative and supportive 
services for veterans in the last phases of incurable disease so that 
they may live as fully and as comfortably as possible.
     Skilled home health care: medical services provided to 
veterans at home by non-VA health care providers.
                         institutional services
     Alzheimer's/dementia care: specialized inpatient services 
such as behavioral and medical management provided to veterans with 
Alzheimer's disease or related dementias.
     Community nursing home care: nursing home care provided to 
veterans in community nursing facilities.
     Domiciliary care: residential rehabilitation and health 
maintenance services provided to veterans who do not require hospital 
or nursing home care but are unable to live independently because of 
medical or psychiatric disabilities; may be provided in VA 
domiciliaries or in state-owned and operated veterans' 
domiciliaries.\7\
---------------------------------------------------------------------------
    \7\ Because VA does not actively place veterans in state veterans' 
domiciliaries or state veterans' nursing homes (rather, veterans must 
apply to the facilities for admission, and admission requirements vary 
by state), state veterans' domiciliary and state veterans' nursing home 
services were not included in our survey of VA facilities.
---------------------------------------------------------------------------
     Geriatric evaluation and management (GEM): evaluation and 
management of frail elderly veterans by interdisciplinary health care 
teams of geriatric specialists; may be provided in a distinct GEM unit 
or in existing nursing home or hospital beds.
     Hospice care: palliative and supportive inpatient services 
for veterans in the last phases of incurable disease so that they may 
live as fully and as comfortably as possible; may be provided in a 
distinct hospice unit or in existing nursing home or hospital beds.
     Respite care: hospital or nursing home care provided to 
veterans on a short-term basis to give veterans' caregivers a period of 
relief or respite; may be provided in a distinct respite unit or in 
existing nursing home or hospital beds and may be provided in VA 
hospitals, VA nursing homes, or community nursing homes.
     State veterans' nursing home care: nursing home care 
provided to veterans in state-owned and operated veterans' nursing 
homes, for which VA pays a portion of daily costs.
     VA nursing home care: nonacute nursing care services, 
variously referred to as subacute, skilled, intermediate, or custodial 
nursing care, provided to veterans in a VA facility's nursing home care 
unit.
        Enclosure II--VA Long-Term Care Services by VA Facility
    This enclosure provides information on the types and utilization of 
long-term care services, both institutional and noninstitutional, that 
VA's 139 facilities reported as of the September and October 2001 time 
frame. Each table contains service utilization data for all VA 
facilities in one of the 22 VA health care networks existing at the 
time of our survey.\8\ Following are the key methods we used to collect 
and present the data. Because of differences in the way utilization is 
calculated, the numbers in this enclosure should not be compared to 
those presented in table 1.
---------------------------------------------------------------------------
    \8\ In 1995, VA created 22 Veterans Integrated Service Networks, a 
new management structure to coordinate the activities of and allocate 
funds to VA hospitals, outpatient clinics, nursing homes, and other 
facilities in each region. In January 2002, VA announced the merger of 
networks 13 and 14 into a single organization known as network 23. In 
this enclosure, we report on these two networks separately because at 
the time of our survey they were operating as individual networks.
---------------------------------------------------------------------------
     We obtained data on the number of veterans receiving or 
authorized to receive services from each VA facility on the day the 
survey was completed.\9\ For example, if a veteran was receiving 
homemaker/home health aide services 3 days per week at the time of our 
survey, that veteran would have been counted in the utilization total 
even if the veteran was not receiving services on the particular day 
the survey was filled out. As a result, the utilization we report may 
exceed the average daily census for individual services, particularly 
in noninstitutional services, because on a given day the number of 
veterans authorized to receive services may be greater than the number 
who actually receive services.
---------------------------------------------------------------------------
    \9\ Although the surveys were sent out simultaneously, surveys for 
each facility were not completed on the same day.
---------------------------------------------------------------------------
     Several facilities indicated they had ``other'' services--
that is, services other than those we specifically asked about in our 
survey. In instances in which facilities reported ``other'' services 
with utilization of greater than 1,000 veterans, we note the types of 
``other'' services these facilities reported.

                            Table 2: Long-Term Care Services Offered by VA Facilities in Network 1, Boston, Mass. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               Number of veterans in each service, by facility or health care system (HCS)
                                                         ---------------------------------------------------------------------------------------
                       VA service                                                                                                        White   Total a
                                                          Bedford   Boston  Connecticut  Manchester  Northampton  Providence   Togus     River
                                                                     HCS        HCS                                                    Junction
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care.................................       68       80         49           13          19            4                  48      281
  Alzheimer's/dementia care.............................      200                                                                 125                325
  Community residential care............................      202                                           85                     75                362
  Geriatric evaluation and management...................       25                   0                                              28        94      147
  Home-based primary care...............................       15                 132    ..........                      63                          210
  Homemaker/home health aide............................       45      235         52           28         115           12        42        13      542
  Home respite care.....................................
  Hospice care..........................................                                                                      .......            .......
  Skilled home health care..............................        1       68         29    ..........         40           30        90        37      295
  Other noninstitutional................................                          368                                               0                368
Institutional long-term care services:
  Alzheimer's/dementia care.............................      110                                                                  50                160
  Community nursing home care...........................       32       95         62           15          34           53        23        11      325
  Domiciliary care......................................       42                                                                                     42
  Geriatric evaluation and management...................       24                  13                                     0         4                 41
  Hospice care..........................................        2        5          3           10           1            1         6         2       30
  Respite care..........................................      122        9          3           40           0            3         2        46      225
  VA nursing home care..................................      152      146          9           70          59                     38                474
  Other institutional...................................
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
  but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
  service. Some veterans may thus appear in several services at one facility.


        Table 3: Long-Term Care Services Offered by VA Facilities in Network 2, Albany, N.Y. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                                        Number of veterans in each service, by facility
                                                                  or health care system (HCS)
                                                      --------------------------------------------------
                      VA service                                                                Western  Total a
                                                                                                  New
                                                        Albany    Bath   Canandaigua  Syracuse    York
                                                                                                  HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care..............................      123       10         29         107       80      349
  Alzheimer's/dementia care..........................      100                  49         318      222      689
  Community residential care.........................        0       68  ...........  ........                68
  Geriatric evaluation and management................                    ...........                 62       62
  Home-based primary care............................      140      160        109         762      259    1,430
  Homemaker/home health aide.........................       60      104        211         129      261      765
  Home respite care..................................
  Hospice care.......................................                            1           1                 2
  Skilled home health care...........................       21                   0           5      168      194
  Other noninstitutional.............................        2                                       13       15
Institutional long-term care services:
  Alzheimer's/dementia care..........................                           24                            24
  Community nursing home care........................       50        5          8          32       25      120
  Domiciliary care...................................               203                                      203
  Geriatric evaluation and management................
  Hospice care.......................................        2        7          0           3        3       15
  Respite care.......................................        1        4          1           4        6       16
  VA nursing home care...............................       28      147         80          30      111      396
  Other institutional................................
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


         Table 4: Long-Term Care Services Offered by VA Facilities in Network 3, Bronx, N.Y. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                                              Number of veterans in each service, by
                                                               facility or health care system (HCS)
                                                         -----------------------------------------------
                       VA service                                                                 New    Total a
                                                                    Hudson    New                 York
                                                           Bronx    Valley   Jersey  Northport   Harbor
                                                                     HCS      HCS                 HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care.................................                 3        4        34        67      108
  Alzheimer's/dementia care.............................                        321                  29      350
  Community residential care............................               272      230       215                717
  Geriatric evaluation and management...................
  Home-based primary care...............................      107       65      143        45       137      497
  Homemaker/home health aide............................                35      196       159       127      517
  Home respite care.....................................
  Hospice care..........................................
  Skilled home health care..............................       22        6       38        35        19      120
  Other noninstitutional................................                                  241                241
Institutional long-term care services:
  Alzheimer's/dementia care.............................                                             14       14
  Community nursing home care...........................                19       36        47         4      106
  Domiciliary care......................................               133      165                  50      348
  Geriatric evaluation and management...................        2                           2         3        7
  Hospice care..........................................        7        2        4         7         5       25
  Respite care..........................................        2        3        2         1         6       14
  VA nursing home care..................................       69      180      260       101       153      763
  Other institutional...................................                                   11                 11
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


                           Table 5: Long-Term Care Services Offered by VA Facilities in Network 4, Pittsburgh, Pa. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                     Number of veterans in each service, by facility or health care system (HCS)
                                    ------------------------------------------------------------------------------------------------------------ Total a
             VA service                                                                                         Pittsburgh  Wilkes-
                                     Altoona   Butler  Clarksburg  Coatesville    Erie   Lebanon  Philadelphia      HCS      Barre   Wilmington
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care............                26          6          46          1                                44         2          0       125
  Alzheimer's/dementia care........                                      200                                                                         200
  Community residential care.......        0                  32         115                 181  ............                   91          4       423
  Geriatric evaluation and                                                                                             24         5        925       954
   management......................
  Home-based primary care..........                31                                          0          56          123                            210
  Homemaker/home health aide.......                78        139          94         82        7          30          113        39         13       595
  Home respite care................           .......          0                                                                                       0
  Hospice care.....................                                                   0                                           1  ..........        1
  Skilled home health care.........        7       15         37           3         15        5          76           28        16         22       224
  Other noninstitutional...........                50                                 2        0                       26         1                   79
Institutional long-term care
 services:
  Alzheimer's/dementia care........                                       36                  17                       50                            103
  Community nursing home care......       10        6         29           1          3       13          12           97         6          6       183
  Domiciliary care.................                47                    229                                           74                            350
  Geriatric evaluation and                                                                     6                                                       6
   management......................
  Hospice care.....................        0                   1                      6       20                        6         7          4        44
  Respite care.....................        1        4          0           3          1       40           4            8        60          2       123
  VA nursing home care.............       40       70                    217         32       74         208          336         0         56     1,033
  Other institutional..............                                                           38          12                      0                   50
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
  but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
  service. Some veterans may thus appear in several services at one facility.


       Table 6: Long-Term Care Services Offered by VA Facilities in Network 5, Baltimore, Md. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                                                         Number of veterans in each
                                                                       service, by facility or health
                                                                              care system (HCS)          Total a
                             VA service                             ------------------------------------
                                                                                  Maryland  Washington,
                                                                     Martinsburg     HCS        D.C.
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care............................................          7         198         81        286
  Alzheimer's/dementia care........................................                    148                   148
  Community residential care.......................................                      0         50         50
  Geriatric evaluation and management..............................                      0      1,150      1,150
  Home-based primary care..........................................                    180        109        289
  Homemaker/home health aide.......................................         18         252        117        387
  Home respite care................................................                      0                     0
  Hospice care.....................................................                     10                    10
  Skilled home health care.........................................                    180          5        185
  Other noninstitutional...........................................                     42          3         45
Institutional long-term care services:
  Alzheimer's/dementia care........................................                      0                     0
  Community nursing home care......................................         22          26         65        113
  Domiciliary care.................................................        281          50                   331
  Geriatric evaluation and management..............................                     24                    24
  Hospice care.....................................................                     23         16         39
  Respite care.....................................................          2          10          4         16
  VA nursing home care.............................................        166         200         90        456
  Other institutional..............................................                    101                   101
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


                            Table 7: Long-Term Care Services Offered by VA Facilities in Network 6, Durham, N.C. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                  Number of veterans in each service, by facility or health care system (HCS)
                                                              ---------------------------------------------------------------------------------- Total a
                          VA service                                                        Fayetteville
                                                               Asheville  Beckley   Durham     (N.C.)     Hampton  Richmond   Salem   Salisbury
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care......................................        61                             16         18                 70        14       179
  Alzheimer's/dementia care..................................       150                                        38                125                 313
  Community residential care.................................                  21                              30                200                 251
  Geriatric evaluation and management........................                          374                                                           374
  Home-based primary care....................................        33                 36                                                            69
  Homemaker/home health aide.................................        76                 33           0         60                 40        43       252
  Home respite care..........................................
  Hospice care...............................................         4         1                    2    .......                  5                  12
  Skilled home health care...................................        94         8                   70         21                 65  .........      258
  Other noninstitutional.....................................  .........                                                                         .......
Institutional long-term care services:
  Alzheimer's/dementia care..................................
  Community nursing home care................................         7        11       22          33         26         9        5        41       154
  Domiciliary care...........................................                                                 151                                    151
  Geriatric evaluation and management........................                            3  ............  .......        13       10                  26
  Hospice care...............................................         5         3       10           5          4        10        2         8        47
  Respite care...............................................         2         2        4           4          0                  5         4        21
  VA nursing home care.......................................        98        36       98          37         72        71       80       204       696
  Other institutional........................................                                                                               18        18
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
  but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
  service. Some veterans may thus appear in several services at one facility.


                            Table 8: Long-Term Care Services Offered by VA Facilities in Network 7, Atlanta, Ga. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                  Number of veterans in each service, by facility or health care system (HCS)
                                                              ----------------------------------------------------------------------------------
                          VA service                                                         Central                                             Total a
                                                               Atlanta  Augusta  Birmingham  Alabama  Charleston  Columbia   Dublin  Tuscaloosa
                                                                                               HCS                 (S.C.)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care......................................       19        0          8                   10         29                            66
  Alzheimer's/dementia care..................................                 5                                                                        5
  Community residential care.................................       31      174                  124                    30                           359
  Geriatric evaluation and management........................                                               250          0                           250
  Home-based primary care....................................       87       47         90       130         95         63                           512
  Homemaker/home health aide.................................       67      149         24        46         50         62       78        104       580
  Home respite care..........................................                 0                                          0                             0
  Hospice care...............................................        6                             0          8          5                            19
  Skilled home health care...................................       62       83                   21         75         60                  35       336
  Other noninstitutional.....................................       10      144               1,139b         18         13                         1,324
Institutional long-term care services:
  Alzheimer's/dementia care..................................                72                   40                                        53       165
  Community nursing home care................................       71       53         23         4         12         51       27          5       246
  Domiciliary care...........................................                60                                                                       60
  Geriatric evaluation and management........................                 2                              10          0                            12
  Hospice care...............................................                 7                   11                     8  .......          4        30
  Respite care...............................................        0        0                    4                     5  .......          1        10
  VA nursing home care.......................................      100       53                   80         28         81      115        116       573
  Other institutional........................................        0                                            ........                  20        20
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
  but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
  service. Some veterans may thus appear in several services at one facility.
b Geriatric primary care.


       Table 9: Long-Term Care Services Offered by VA Facilities in Network 8, Bay Pines, Fla. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                                    Number of veterans in each service, by facility or
                                                                 health care system (HCS)
                                                 -------------------------------------------------------
                                                                      North                              Total a
                   VA service                                       Florida/                      West
                                                    Bay     Miami     South     San     Tampa     Palm
                                                   Pines             Georgia    Juan             Beach
                                                                       HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care.........................                43        29                         13       85
  Alzheimer's/dementia care.....................
  Community residential care....................                                   90               165      255
  Geriatric evaluation and management...........       30                         300                        330
  Home-based primary care.......................      100      150       195       82      143               670
  Homemaker/home health aide....................      100       75       280       19       45       50      569
  Home respite care.............................                                             4                 4
  Hospice care..................................                                             0                 0
  Skilled home health care......................      154       18        35        5      180        4      396
  Other noninstitutional........................            1,528b    2,239c      373                      4,140
Institutional long-term care services:
  Alzheimer's/dementia care.....................                          29                61                90
  Community nursing home care...................       92       24       195        3       51       12      377
  Domiciliary care..............................      104                                   17               121
  Geriatric evaluation and management...........        8        5        20                          0       33
  Hospice care..................................       10       15         9        5       20       10       69
  Respite care..................................        8        4         7        5       11        3       38
  VA nursing home care..........................      102      127       116      116      161       98      720
  Other institutional...........................       24                          27                17       68
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.
b Geriatric primary care and geriatric psychiatry care.
c Geriatric primary care.


      Table 10: Long-Term Care Services Offered by VA Facilities in Network 9, Nashville, Tenn. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                        Number of veterans in each service, by facility or health care
                                                                 system (HCS)
                                      -----------------------------------------------------------------
              VA service                                                                     Tennessee  Total a
                                       Huntington  Lexington  Louisville  Memphis  Mountain    Valley
                                                                                     Home       HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care..............                                                    18        12         30
  Alzheimer's/dementia care..........                   259                                       100        359
  Community residential care.........         42         96                              90       213        441
  Geriatric evaluation and management                   338                                        84        422
  Home-based primary care............                                          95                             95
  Homemaker/home health aide.........         36         31          27        59       162       194        509
  Home respite care..................
  Hospice care.......................                     4           1                                        5
  Skilled home health care...........         28         65         325       214                 178        810
  Other noninstitutional.............                                           3       180       100        283
Institutional long-term care
 services:
  Alzheimer's/dementia care..........                    34                                                   34
  Community nursing home care........         53         33          36        40        49        43        254
  Domiciliary care...................                                                   330                  330
  Geriatric evaluation and management                                                    20         4         24
  Hospice care.......................  ..........         2           2                  16        10         30
  Respite care.......................          4          4           2         0         5         3         18
  VA nursing home care...............                    18                              63       110        191
  Other institutional................                                                              43         43
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


     Table 11: Long-Term Care Services Offered by VA Facilities in Network 10, Cincinnati, Ohio (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                                    Number of veterans in each service, by facility or
                                                                 health care system (HCS)                Total a
                    VA service                    ------------------------------------------------------
                                                   Chillicothe  Cincinnati  Cleveland  Columbus  Dayton
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care..........................          2          85          13        26       29      155
  Alzheimer's/dementia care......................
  Community residential care.....................        267          22         278        19       63      649
  Geriatric evaluation and management............         80         201         691                197    1,169
  Home-based primary care........................                                190                 45      235
  Homemaker/home health aide.....................        230          37         380        44      171      862
  Home respite care..............................
  Hospice care...................................                                  1   ........       3        4
  Skilled home health care.......................        235         167         175       697      180    1,454
  Other noninstitutional.........................
Institutional long-term care services:
  Alzheimer's/dementia care......................                                                    24       24
  Community nursing home care....................         30          13          41        16       39      139
  Domiciliary care...............................         42          66          92                100      300
  Geriatric evaluation and management............                                126                 30      156
  Hospice care...................................          7    ..........        14                 22       43
  Respite care...................................          5           2           2                  3       12
  VA nursing home care...........................         91          51         137                146      425
  Other institutional............................
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


     Table 12: Long-Term Care Services Offered by VA Facilities in Network 11, Ann Arbor, Mich. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                      Number of veterans in each service, by facility or health care
                                                               system (HCS)
                                  ---------------------------------------------------------------------- Total a
            VA service                                                                Northern
                                     Ann     Battle  Danville  Detroit  Indianapolis   Indiana  Saginaw
                                    Arbor    Creek                                       HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care..........        0       16        57        5          26           4        0      108
  Alzheimer's/dementia care......
  Community residential care.....        0        0       137        0          45          96        0      278
  Geriatric evaluation and                                                      28                            28
   management....................
  Home-based primary care........                12        21        1          19           2                55
  Homemaker/home health aide.....       43       79        66                   48           7               243
  Home respite care..............        0        0         0        0           0           0        0        0
  Hospice care...................                                                3           4                 7
  Skilled home health care.......        1        2         6        6          17          22        1       55
  Other noninstitutional.........
Institutional long-term care
 services:
  Alzheimer's/dementia care......                          23                                                 23
  Community nursing home care....       19       17        34       15          54          35        5      179
  Domiciliary care...............
  Geriatric evaluation and              16                                                                    16
   management....................
  Hospice care...................                11        42        2                       1                56
  Respite care...................        2        3         1        2  ............         1        2       11
  VA nursing home care...........       15       86       125       62                     125       70      483
  Other institutional............
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


       Table 13: Long-Term Care Services Offered by VA Facilities in Network 12, Chicago, Ill. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                        Number of veterans in each service, by facility or health care
                                                                 system (HCS)
              VA service              ------------------------------------------------------------------ Total a
                                       Chicago             Iron                         North
                                         HCS     Hines   Mountain  Madison  Milwaukee  Chicago   Tomah
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care..............       29       60         1        5        73        28      125      321
  Alzheimer's/dementia care..........                                             73                          73
  Community residential care.........                20                                               0       20
  Geriatric evaluation and management      440      805                300       106                       1,651
  Home-based primary care............       92      219                          115       115               541
  Homemaker/home health aide.........       49       73        14       14        34         2        3      189
  Home respite care..................
  Hospice care.......................                           1        6         5                          12
  Skilled home health care...........       48       87        15                 37                  2      189
  Other noninstitutional.............               180                 38                                   218
Institutional long-term care
 services:
  Alzheimer's/dementia care..........                                                       27                27
  Community nursing home care........      102       78         5       12        43        92       10      342
  Domiciliary care...................                                            167       159               326
  Geriatric evaluation and management      120        9                  4        10   .......               143
  Hospice care.......................                15         5                 30         7        4       61
  Respite care.......................       12        6         2        0         4         0        2       26
  VA nursing home care...............                75        33                 93       157      200      558
  Other institutional................                33                     .........                         33
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


    Table 14: Long-Term Care Services Offered by VA Facilities in Network 13, Minneapolis, Minn. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                                               Number of veterans in each service, by
                                                                facility or health care system (HCS)
                                                           --------------------------------------------- Total a
                        VA service                           Black
                                                             Hills   Fargo  Minneapolis   Sioux    St.
                                                              HCS                         Falls   Cloud
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care...................................               2         95         6      58      161
  Alzheimer's/dementia care...............................       1  ......         14                         15
  Community residential care..............................                                   30               30
  Geriatric evaluation and management.....................                                    5      10       15
  Home-based primary care.................................                         25                         25
  Homemaker/home health aide..............................      35      49        195         5      51      335
  Home respite care.......................................       0          ...........       1       0        1
  Hospice care............................................       4       1         12         2       0       19
  Skilled home health care................................      49      48        229        23      94      443
  Other noninstitutional..................................
Institutional long-term care services:
  Alzheimer's/dementia care...............................
  Community nursing home care.............................      11      16         84        10      11      132
  Domiciliary care........................................     132                                  105      237
  Geriatric evaluation and management.....................                                    1                1
  Hospice care............................................      15       2         10         4       3       34
  Respite care............................................       4       1          4         3       6       18
  VA nursing home care....................................      63      31         76        30     215      415
  Other institutional.....................................                                           41       41
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: In January 2002, VA announced the merger of networks 13 and 14 into a single organization known as
  network 23. In this enclosure we report on these networks separately because at the time of our survey they
  were operating as individual networks.
Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


  Table 15: Long-Term Care Services Offered by VA Facilities in Network
                      14, Lincoln, Neb. (Fall 2001)
------------------------------------------------------------------------
                                     Number of veterans in each
                                       service, by facility or
                                      health care system (HCS)
             VA service             ---------------------------- Total a
                                     Central          Nebraska/
                                       Iowa    Iowa    Western
                                       HCS     City    Iowa HCS
------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care............        4      53         2        59
  Alzheimer's/dementia care........
  Community residential care.......        0                           0
  Geriatric evaluation and                        21        12        33
   management......................
  Home-based primary care..........       33                          33
  Homemaker/home health aide.......        8      81        32       121
  Home respite care................           ......         2         2
  Hospice care.....................        0       6         3         9
  Skilled home health care.........       25     243        17       285
  Other noninstitutional...........
Institutional long-term care
 services:
  Alzheimer's/dementia care........
  Community nursing home care......       25      17        58       100
  Domiciliary care.................       68                14        82
  Geriatric evaluation and                 1                           1
   management......................
  Hospice care.....................       13       3         3        19
  Respite care.....................        1       0         2         3
  VA nursing home care.............      179                54       233
  Other institutional..............       14                          14
------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: In January 2002, VA announced the merger of networks 13 and 14
  into a single organization known as network 23. In this enclosure we
  report on these networks separately because at the time of our survey
  they were operating as individual networks.
Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service
  at the time of our survey. Dashes indicate that a facility reported
  the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services
  at each facility because veterans may be authorized to receive more
  than one service. Some veterans may thus appear in several services at
  one facility.


     Table 16: Long-Term Care Services Offered by VA Facilities in Network 15, Kansas City, Mo. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                         Number of veterans in each service, by facility or health care
                                                                  system (HCS)
                                        ---------------------------------------------------------------- Total a
               VA service                          Eastern
                                         Columbia   Kansas   Kansas   Marion   Poplar     St    Wichita
                                           (Mo.)     HCS      City    (Ill.)   Bluff    Louis
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care................         1        7        7                         13        6       34
  Alzheimer's/dementia care............
  Community residential care...........                                            10      172               182
  Geriatric evaluation and management..                                                  1,779             1,779
  Home-based primary care..............       104                                          114               218
  Homemaker/home health aide...........        57       99       65       32  .......      101       19      373
  Home respite care....................                                                      0  .......        0
  Hospice care.........................                  0                 3        2        0  .......        5
  Skilled home health care.............                137       16      144        8       83  .......      388
  Other noninstitutional...............                384                                      .......      384
Institutional long-term care services:
  Alzheimer's/dementia care............
  Community nursing home care..........  ........       42       50       26       12       36       11      177
  Domiciliary care.....................                176                                  36               212
  Geriatric evaluation and management..        12                                            8                20
  Hospice care.........................         4        4                 1                 1        0       10
  Respite care.........................         1        1        1        2       22        9        0       36
  VA nursing home care.................        25      139                35       39       23  .......      261
  Other institutional..................                  0                20                 5                25
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


                          Table 17: Long-Term Care Services Offered by VA Facilities in Network 16, Jackson, Miss. (Fall 2001)
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                      Number of veterans in each service, by facility or health care system (HCS)
                                       --------------------------------------------------------------------------------------------------------
              VA service                             Central                  Gulf                                                              Total a
                                        Alexandria  Arkansas  Fayetteville   Coast   Houston  Jackson  Muskogee    New    Oklahoma  Shreveport
                                                       HCS       (Ark.)       HCS                                Orleans    City
--------------------------------------------------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care...............         14         75                              11       18        43       43         7                   211
  Alzheimer's/dementia care...........                                                                                         261                   261
  Community residential care..........                    62                             217        0                  9                   11        299
  Geriatric evaluation and management.
  Home-based primary care.............                   185                     53      150                          82        40         65        575
  Homemaker/home health aide..........         20        179                .......       50  .......                           27         28        304
  Home respite care...................                                                                           .......                        ........
  Hospice care........................                                                        .......                  0  ........                     0
  Skilled home health care............         16         76                      6      111  .......        56        9        38         73        385
  Other noninstitutional..............                                                     0                                   236                   236
Institutional long-term care services:
  Alzheimer's/dementia care...........         16         32                     44                                                                   92
  Community nursing home care.........         52         44          17         17       27       22        34       17        24         25        279
  Domiciliary care....................              ........                     66                                                                   66
  Geriatric evaluation and management.          1         18                              10                           0         0                    29
  Hospice care........................                        ............        8        5                  0        1                              14
  Respite care........................          1          8           1          2        5       57         0        0         1          1         76
  VA nursing home care................        130        110                     65      110      114                 53        21                   603
  Other institutional.................                                                     0        0                                                  0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes indicate that a facility reported the service
  but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be authorized to receive more than one
  service. Some veterans may thus appear in several services at one facility.


  Table 18: Long-Term Care Services Offered by VA Facilities in Network
                      17, Dallas, Tex. (Fall 2001)
------------------------------------------------------------------------
                                         Number of veterans in
                                            each service, by
                                        facility or health care
                                              system (HCS)       Total a
              VA service               -------------------------
                                        Central   North   South
                                         Texas    Texas   Texas
                                          HCS      HCS     HCS
------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care...............        1      11      40       52
  Alzheimer's/dementia care...........                      100      100
  Community residential care..........               67       0       67
  Geriatric evaluation and management.               60   2,000    2,060
  Home-based primary care.............              161     168      329
  Homemaker/home health aide..........      104      77      95      276
  Home respite care...................        0      20               20
  Hospice care........................                8       0        8
  Skilled home health care............               48      65      113
  Other noninstitutional..............       12             230      242
Institutional long-term care services:
  Alzheimer's/dementia care...........        4      15      58       77
  Community nursing home care.........      102      59      90      251
  Domiciliary care....................        0     264              264
  Geriatric evaluation and management.       10       8               18
  Hospice care........................        0      17      20       37
  Respite care........................        0      10      10       20
  VA nursing home care................      379     210     214      803
  Other institutional.................      124                      124
------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October
  2001.
Empty cells indicate that a facility did not report offering the service
  at the time of our survey. Dashes indicate that a facility reported
  the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services
  at each facility because veterans may be authorized to receive more
  than one service. Some veterans may thus appear in several services at
  one facility.


      Table 19: Long-Term Care Services Offered by VA Facilities in Network 18, Phoenix, Ariz. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                       Number of veterans in each service, by facility or health care
                                                                system (HCS)
            VA service             --------------------------------------------------------------------- Total a
                                                             Big
                                    Albuquerque  Amarillo   Spring  El Paso  Phoenix  Prescott   Tucson
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care...........          5                                     42        37       25      109
  Alzheimer's/dementia care.......        141           0                                            10      151
  Community residential care......                                       19       22                          41
  Geriatric evaluation and                111                            40                177      114      442
   management.....................
  Home-based primary care.........        124                    0                84                203      411
  Homemaker/home health aide......        174    ........                         57         2      138      371
  Home respite care...............                                                                    6        6
  Hospice care....................                                                15                 31       46
  Skilled home health care........          5           5        0       12      200        74      138      434
  Other noninstitutional..........                                                          16                16
Institutional long-term care
 services:
  Alzheimer's/dementia care.......                                                          16        7       23
  Community nursing home care.....         70           4        4                64        16       56      214
  Domiciliary care................                                                         120               120
  Geriatric evaluation and                       ........                                    3       28       31
   management.....................
  Hospice care....................         11           3        0                14        10       17       55
  Respite care....................          9           0        0                 4         0        6       19
  VA nursing home care............          3         117       40                46        57        1      264
  Other institutional.............                                                           4       16       20
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


       Table 20: Long-Term Care Services Offered by VA Facilities in Network 19, Denver, Colo. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                        Number of veterans in each service, by facility or health care
                                                                 system (HCS)
                                      ------------------------------------------------------------------ Total a
              VA service                                                                Salt
                                       Cheyenne   Denver    Fort     Grand   Montana    Lake   Sheridan
                                                            Lyon   Junction    HCS      City
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care..............                 15                                              3       18
  Alzheimer's/dementia care..........
  Community residential care.........                132  .......                                            132
  Geriatric evaluation and management                150                                                     150
  Home-based primary care............                 72           ........               120                192
  Homemaker/home health aide.........        82      116        0                  8       60        22      288
  Home respite care..................                           0                           0                  0
  Hospice care.......................                     .......                  3        2                  5
  Skilled home health care...........         3       65      172        20       11       40        26      337
  Other noninstitutional.............                     .......                                        .......
Institutional long-term care
 services:
  Alzheimer's/dementia care..........                           8                                              8
  Community nursing home care........         2       57  .......         7       33       28         2      129
  Domiciliary care...................
  Geriatric evaluation and management                  4  .......            .......                           4
  Hospice care.......................         5       10  .......  ........        3        1         1       20
  Respite care.......................         0        3        0  ........        3        0         1        7
  VA nursing home care...............        37       43       27        30  .......                 50      187
  Other institutional................                           0                           0                  0
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


      Table 21: Long-Term Care Services Offered by VA Facilities in Network 20, Portland, Oreg. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                 Number of veterans in each service, by facility or health care system
                                                                 (HCS)
                              -------------------------------------------------------------------------- Total a
          VA service                                        Puget
                                Alaska   Boise   Portland   Sound   Roseburg  Spokane   Walla    White
                                 HCS                         HCS                        Walla     City
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term
 care services:
  Adult day health care......                                   40                 15                 2       57
  Alzheimer's/dementia care..                         125      410                                           535
  Community residential care.
  Geriatric evaluation and                            175           ........                                 175
   management................
  Home-based primary care....                         116      137                                           253
  Homemaker/home health aide.       23       52        21       95  ........       25        8       31      255
  Home respite care..........                                                      20                         20
  Hospice care...............        1        1        46        8                  3  .......                59
  Skilled home health care...       77       60       188  .......                  4        3               332
  Other noninstitutional.....                          99   3,127b                                         3,226
Institutional long-term care
 services:
  Alzheimer's/dementia care..                                   18        14                                  32
  Community nursing home care       11       17        51      150        20       40        7        9      305
  Domiciliary care...........                         192                                           658      850
  Geriatric evaluation and                    4                  8         0                                  12
   management................
  Hospice care...............                 6         7        6         3        4  .......                26
  Respite care...............        0       49        41       16         2      100  .......               208
  VA nursing home care.......                15       270      105        32       28       21               471
  Other institutional........       33                              ........                                  33
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.
b Geriatric primary care, geriatric memory disorder care, and other services.


   Table 22: Long-Term Care Services Offered by VA Facilities in Network 21, San Francisco, Calif. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                            Number of veterans in each service, by facility or health
                                                                care system (HCS)
                                         --------------------------------------------------------------- Total a
               VA service                   Central              Northern
                                          California  Honolulu  California    Palo     Reno      San
                                              HCS                   HCS       Alto            Francisco
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care
 services:
  Adult day health care.................                     2          6        20        6         6        40
  Alzheimer's/dementia care.............  ..........                            100                130       230
  Community residential care............
  Geriatric evaluation and management...        300        423                  100                          823
  Home-based primary care...............         39         61        117        35        7        75       334
  Homemaker/home health aide............          6         11         67        20       45        70       219
  Home respite care.....................
  Hospice care..........................          2                     0         5                  5        12
  Skilled home health care..............                     6         20        15        3        25        69
  Other noninstitutional................  ..........                             50                           50
Institutional long-term care services:
  Alzheimer's/dementia care.............                                         50                           50
  Community nursing home care...........         10          3         80        50        8        32       183
  Domiciliary care......................                                        100                          100
  Geriatric evaluation and management...          2                               0                            2
  Hospice care..........................         10          3         11        25        4         5        58
  Respite care..........................        300          4          5       200        3         3       515
  VA nursing home care..................         43         41         62       343       50        75       614
  Other institutional...................                               27                            0        27
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.


    Table 23: Long-Term Care Services Offered by VA Facilities in Network 22, Long Beach, Calif. (Fall 2001)
----------------------------------------------------------------------------------------------------------------
                                                                Number of veterans in each service, by
                                                                 facility or health care system (HCS)
                                                             -------------------------------------------
                         VA service                           Greater                                    Total a
                                                                Los     Loma    Long   Southern    San
                                                              Angeles   Linda   Beach   Nevada    Diego
                                                                HCS                       HCS
----------------------------------------------------------------------------------------------------------------
Noninstitutional long-term care services:
  Adult day health care.....................................  .......      38                        61       99
  Alzheimer's/dementia care.................................              220     225                        445
  Community residential care................................               44       0                         44
  Geriatric evaluation and management.......................      350             300       53               703
  Home-based primary care...................................  .......              72                70      142
  Homemaker/home health aide................................               56                        34       90
  Home respite care.........................................               20                                 20
  Hospice care..............................................               59       0                         59
  Skilled home health care..................................  .......     602       0      211               813
  Other noninstitutional....................................  .......                                    .......
Institutional long-term care services:
  Alzheimer's/dementia care.................................               28                                 28
  Community nursing home care...............................       64     178      48       20       73      383
  Domiciliary care..........................................      247                                        247
  Geriatric evaluation and management.......................        7               3                         10
  Hospice care..............................................               10      14                 6       30
  Respite care..............................................       10      54       3                 3       70
  VA nursing home care......................................      240      89      76                25      430
  Other institutional.......................................  .......               4                          4
----------------------------------------------------------------------------------------------------------------
Source: GAO survey of VA facilities.
Notes: Responses to our survey were submitted in September and October 2001.
Empty cells indicate that a facility did not report offering the service at the time of our survey. Dashes
  indicate that a facility reported the service but did not report the service's utilization.
 
a We did not calculate the total number of veterans receiving services at each facility because veterans may be
  authorized to receive more than one service. Some veterans may thus appear in several services at one
  facility.

    Chairman Rockefeller. Thank you very much. Jim Musselwhite.
    Mr. Musselwhite. I am available to answer questions.
    Chairman Rockefeller. You indicated that OMB is going to 
send over rules and regulations in a week. That does not mean 
that they are not going to be sent back for further revision. 
Why do you think really it has taken this long?
    Ms. Bascetta. It is difficult for me to answer that 
question. The focus of our work was on what was available and 
the condition of universality of these services across the 
networks and we spent less time in trying to figure out why the 
agency had taken so long to actually promulgate regs. Our 
understanding is that many of the issues they found to be 
understandably complex, perhaps particularly issues related to 
copayments, but we do not have the details of what went on 
between OMB and the department.
    I would also point that even if there had not been issues 
with OMB, the rest of the Nation is also facing a pretty 
significant challenge in trying to figure out how to provide 
these services, so in other words, notwithstanding the 
interactions in Washington, I think the decisions about how 
best to provide care in the field are also difficult ones that 
need to be made.
    Chairman Rockefeller. But it is true, is it not, that the 
Department of Veterans Affairs is meant to be the best in terms 
of dealing with aging? In other words, that is why 50 percent 
of all medical students do their training at VA hospitals 
because that is where they get geriatric training. I mean VA is 
meant to be good at this. This is not meant to be a discovery 
process on their part.
    Ms. Bascetta. That is correct. Certainly in geriatric 
evaluation and geriatric medicine, the VA is perceived as a 
leader. In terms of their provision of care in non-
institutional settings, we have done less to have an opinion 
about how they stack up compared to other health care systems, 
but I can tell you that the task force found that they were 
pretty typical of the rest of the Nation, that the Nation is 
not doing as well as it could be in recrafting how to shift 
from institutional to non-institutional settings.
    The task force also suggested that VA might want to look to 
some states that are farther ahead in providing non-
institutional care.
    Chairman Rockefeller. Well, we are going to hear from 
those, and they obviously----
    Ms. Bascetta. Right.
    Chairman Rockefeller [continuing]. Were not bottled up by 
the inertia----
    Ms. Bascetta. That is correct.
    Chairman Rockefeller [continuing]. That was taking place in 
this and the past administration, and I am interested, if you 
know about those, and why it is that some are willing to move 
ahead irrespective of whatever consequences there might be and 
could not care less because they know what their mission is.
    Veterans are much older than the general population. Here 
we have a really important medical mission, and all of a sudden 
everybody freezes up except a few people from whom we will 
hear.
    Ms. Bascetta. Right. You are right that there is this 
tremendous variability. We are hoping that in the study that we 
are conducting for you now, we will better understand what the 
reasons are for some of this unevenness, but clearly we have 
seen in the VA area as well as in some states that where there 
is a commitment it seems to unleash a great deal of creativity 
in being able to provide non-institutional services in a very 
cost effective way, but we are hoping to understand that much 
better over the next few months.
    Chairman Rockefeller. I will stop here, but I understand 
when you say there are many technical problems and the Nation 
is trying to figure out all of these things, but where there is 
a clear direction, where there is a clear sort of triumphantly 
conceived policy which speaks to such direct needs of veterans, 
it just does not occur to me that sort of the technical problem 
between OMB and VA or whoever is botching this thing up is a 
particularly compelling excuse.
    Ms. Bascetta. I agree.
    Chairman Rockefeller. I mean if you are talking about the 
Nation trying to figure it out, that is one thing. If you are 
talking about VA trying to figure it out, that strikes me as 
quite another.
    Ms. Bascetta. I agree, and as you point out, others have 
been able to proceed despite those kinds of problems.
    Chairman Rockefeller. Thank you. Senator Specter.
    Senator Specter. Thank you very much, Mr. Chairman. Ms. 
Bascetta, how long have these regulations been languishing 
awaiting OMB approval?
    Ms. Bascetta. I am not sure I have the exact date. Do you 
know, Jim?
    Mr. Musselwhite. No, I do not.
    Senator Specter. About 2\1/2\ years?
    Ms. Bascetta. I think that is probably about right.
    Senator Specter. Why?
    Ms. Bascetta. As I said, I wish I had the details. I do not 
know.
    Senator Specter. I am not asking you for details. I am 
asking you why 2\1/2\ years have elapsed and you still do not 
have OMB approval of these regulations. You are silent. Let the 
record show you are nodding. What action did the VA take to try 
to get the regulations promulgated?
    Ms. Bascetta. Dr. Roswell would be in a better position to 
answer that. I do not know how much interaction there was 
between OMB or VA. I do not know what their response is, what 
OMB's response would have been to the draft regulations, or 
whether they asked them to make revisions or the basis of those 
kinds of revisions.
    Senator Specter. Well, what is the view of VA generally 
when Congress, by legislation, mandates--that word means 
requires--that VA do certain things? Maintain nursing home care 
capacity at 1998 levels, provide outpatient based long-term 
geriatric care services, adult day care, adult day health care, 
respite care, geriatric evaluations, to all VA patients in need 
of such care. Does the Veterans Administration--this may seem 
like an easy question--but does the Veterans Administration 
take seriously a congressional mandate?
    Ms. Bascetta. I certainly hope so.
    Senator Specter. Well, then why is nothing done?
    Ms. Bascetta. Well, they do need to promulgate regulations 
and those do go through the Office of Management and Budget.
    Senator Specter. Well, do you think the VA has some duty of 
diligence----
    Ms. Bascetta. Absolutely.
    Senator Specter [continuing]. To push whoever is not 
promulgating regulations to do that?
    Ms. Bascetta. Yes, I do.
    Senator Specter. I understand the VA has a series of 
excuses that might be called reasons, but was any effort made 
to come back to the Congress--to the relevant committees--to 
say these are our problems?
    Ms. Bascetta. Well, that is a good point, and I was going 
to say that if there were problems, it would have at least been 
beneficial certainly to us and to you to have an understanding 
of what those problems might have been.
    Senator Specter. Well, we have a very important piece of 
legislation. We have a very strong stand taken by the Congress, 
and we have inertia, inaction, indolence, and disregard by the 
administration. What do you suggest that we do about it, Ms. 
Bascetta? Go to court, get a contempt citation, put somebody in 
jail?
    Ms. Bascetta. Having this hearing I think is an important, 
a very important signal, and the tone that Senator Rockefeller 
set in laying out these very clear expectations, which should 
have been clear all along, is certainly an important step in 
moving this process along.
    Senator Specter. How many hearings have we had on this 
subject, Ms. Bascetta?
    Ms. Bascetta. That I am not sure.
    Senator Specter. Several. Well, we hope this hearing does 
some good, but there has been certain turnover in the VA, and 
it is easy to find excuses, but there are a lot of veterans out 
there who are not getting the services which Congress has 
decided, as a matter of public policy, ought to be given.
    Ms. Bascetta. That is correct.
    Senator Specter. Thank you, Mr. Chairman.
    Chairman Rockefeller. Thank you, Senator Specter. Senator 
Graham, we welcome you. There is kind of a somber mood around 
here if you care to add to it. [Laughter.]
    Senator Graham. I think that, Mr. Chairman, you and Senator 
Specter have properly set the mood, and it is not necessary for 
me to contribute to that level of seriousness. Obviously 
representing a state with a very large population of veterans 
and an especially large population of older veterans, these 
issues of long-term care are extremely important, and I 
appreciate your holding this hearing and giving us an 
opportunity to both hear on the record what the status of 
implementation of the 1999 legislation is to date and to hear 
the recommendations such as those that Senator Specter just 
propounded as to what alternatives are before us.
    Senator Specter. Mr. Chairman, Senator Graham may want to 
use our protocol when he convenes hearings on CIA failures.
    Senator Graham. No comment.
    Senator Specter. It is too late now, Bob.
    Chairman Rockefeller. I just want to ask a question, and 
then, Senator Graham, if you want to do so. You know I think in 
your report, you say that 8 percent of dollars spent on VA 
long-term care were in non-nursing home settings. So people say 
resources are the excuse. My answer to that would be there may 
be some increase in workload on the part of an incredibly loyal 
work force in the VA, but you certainly cannot use cost as a 
reason, because non-institutional care is going to be a lot 
less expensive. Would you not agree?
    Ms. Bascetta. On a per person basis, yes, that is correct, 
it should be less expensive.
    Chairman Rockefeller. So any time I hear resources used as 
an excuse today, I am going to bear that very much in mind.
    Ms. Bascetta. Right.
    Chairman Rockefeller. Now, we do not wish to be--Senator 
Graham, did you have any questions?
    Senator Graham. No.
    Chairman Rockefeller. OK. We do not wish to be short with 
you in terms of time, but we want to move to some of these 
folks who are making this thing work, so we thank you very much 
for doing the work. I am extremely glad that you are both 
there, and I thank you for coming.
    Ms. Bascetta. Thank you.
    Mr. Musselwhite. Thank you.
    Chairman Rockefeller. OK. Panel two is our innovators 
panel, and they have programs that are already at work. So 
Gladys Dickerson, who runs a home-based program geared toward 
those with dementia, will be one of our witnesses.
    Tom McClure and his Medical Foster Care Program will be 
another. Paula Hemmings, Network Number 2's geriatric and 
extended care service line manager, but with us today 
representing the Alzheimer's Association. And finally, Jennifer 
Moye. Who is a researcher and a psychologist with a great story 
to tell about what can be done in terms of geriatric mental 
health. We are so glad you are here. Right now you are not 
giving special time to your patients because you are away from 
them, and I apologize for that, but I think that you understand 
that we are talking here about the greater good. So I am very 
grateful that you are here, and why do we not start, Ms. 
Dickerson, with you on home-based dementia.

 STATEMENT OF GLADYS DICKERSON, R.N., HOME-BASED PRIMARY CARE 
             COORDINATOR, DALLAS VA MEDICAL CENTER

    Ms. Dickerson. Mr. Chairman and members of the committee, I 
appreciate this opportunity to speak before you today regarding 
alternatives to institutionalization for long-term care.
    Hospital-based and Home-Based Primary Care--HBPC as it is 
referred to--and other programs associated with HBPC ensures 
that the right care at the right time in the right setting is 
available to veterans all over the nation. Programs such as 
HBPC, adult day care, telemedicine, advances in home-based 
primary care for end of life in advancing dementia, which is 
referred to as the AHEAD program, the senior companion program, 
in-home respite and assisted living ensures that veterans 
receive alternatives to institutional care.
    These services can be provided at a much reduced cost to 
the VA system and keep the patients out of acute care beds and 
at home where they prefer. The number of veterans with long-
term care needs is increasing as the population ages. 
Currently, we have an estimated 600,000 individuals with 
dementia alone within the veteran population. Dementia and 
similar diseases are progressive.
    The victims are vulnerable to accidents, injuries which 
ultimately make them completely dependent in all aspects of 
their daily living. These diseases are projected to triple in 
the veteran population over the age of 65. The incurable nature 
of these diseases and long-term conditions, the suffering that 
they cause the patient and their families, and the cost of 
care, of managing diseases such as dementia, makes it a 
priority to find alternatives to institutionalization.
    Home and community-based care allows the veteran to live at 
home rather than in an institution, making it a win-win 
situation for such programs as the HBPC program and the AHEAD 
project. Families are able to participate in quality of life 
issues with the veterans in the home environment and the cost 
of care is usually lower than the cost of skilled care nursing 
facilities.
    Across VHA, the data indicates that families prefer to keep 
veterans at home, but they are unable to as the veteran becomes 
more impaired. The AHEAD project through HBPC focuses on the 
dementia patient's problems. Focus areas include earlier 
identification, caregiver support, completion of advanced 
directives and symptom management.
    The project allows the veteran to receive appropriate care 
in the location they prefer and help sustain caregivers in 
their vital roles. The AHEAD project took 20 VA facilities 
across the country and we completed a 9-month collaboration 
committed to improve the care of veterans with dementia who 
prefer to live at home.
    These teams demonstrated notable success in early 
identification of dementia, symptom management, caregiver 
support and staff education. Home-based primary care is the 
most cost effective way to deliver interdisciplinary home care.
    The HBPC program offers long-term patients the kind of 
alternative to nursing home placement. It minimizes the amount 
of followup that they have to go through in the ambulatory care 
clinic. It prevents premature admissions to the hospital by 
early identification and premature admission to long-term care 
facility. It also allows the patient the option of dying in the 
home rather than in an institution.
    The purpose of the Community Adult Day Care Program is to 
establish functional impaired individuals with a supportive 
professional environment so that they can be nurtured; to 
facilitate the return of the older veteran to his home and to 
coordinate their long-term care; to maintain the older veteran 
at the highest level of function possible both physically, 
socially, and medically; and to provide the family and 
caregiver with professional support, enabling them to maintain 
the disabled veteran in the community.
    The Senior Companion Program often makes the difference 
between living at home and in an institution. This translates 
into major health cost savings for the senior, their family, 
and the taxpayers. Nursing home costs is an average of $38,000 
annually per patient per year. However, the cost of supporting 
one senior companion for an entire year is $3,850. Telemedicine 
technology also allows us to reduce costs, time, and efficiency 
and eliminates distance.
    In conclusion, funding an expansion of HBPC programs will 
enable alternatives to institutionalization of long-term care 
veterans, which we need expanded programs, innovative 
approaches to long-term care, and this would mean a cost 
savings to the VA. HBPC keeps families together and this 
concludes my remarks, and I will be happy to answer any 
questions.
    Chairman Rockefeller. Thank you very, very much. Tom 
McClure.
    [The prepared statement of Ms. Dickerson follows:]
 Prepared Statement of Gladys Dickerson, R.N., Home-Based Primary Care 
                 Coordinator, Dallas VA Medical Center
    Mr. Chairman and Members of the Committee:
    I appreciate the opportunity to speak before you today regarding 
alternatives to Institutionalization in Long Term Care. Home Based 
Primary Care (HBPC) and those programs associated with HBPC; ensure 
that the right care, at the right time, in the right setting is 
available to veterans all over the nation. Programs such as HBPC, Adult 
Day Care, Telemedicine, Advances in Home Based Primary Care for End of 
Life in Advancing Dementia (AHEAD), Senior Companion, In-Home Respite, 
and Assisted Living ensure veterans receive alternatives to 
institutional care. These services can be provided at a much-reduced 
cost to the VA system and keep the patient out of an acute care bed and 
at home, where they prefer to remain.
            non-institutional alternatives to long-term care
    The number of veterans with long-term health care needs is 
increasing as the population ages. Currently, there are an estimated 
600,000 individuals with dementia within the veteran population.
    Dementia and similar diseases are progressive. Their victims are 
vulnerable to accidents and injuries that ultimately make them 
completely dependent in all aspects of daily living. These diseases are 
projected to triple in the veteran population over age 65. The 
incurable nature of most long-term conditions, the suffering it causes 
patients and their families, and the cost of care make managing 
diseases such as dementia and others a priority to promote non-
institutional care for VA.
    Veterans who receive the home and community based care that allows 
them to live at home rather than in an institution, makes this a ``win-
win'' situation for such programs as the HBPC and AHEAD Project. The 
family is able to participate in quality of life issues with the 
veteran in their home environment. The cost of care is usually lower 
than care provided in a skilled care facility.
    Across the VHA, data indicates many families prefer to keep the 
veteran at home but they are unable to, as the veteran becomes more 
impaired. The AHEAD project through HBPC focuses on the dementia 
patient's problems. Focus areas are, early identification, caregiver 
support, completion of Advance Directives, and symptom management. The 
project allows veterans to receive appropriate care in a location they 
prefer and helps sustain caregivers in their vital role.
    In the AHEAD Project, 20 VA facilities around the country completed 
a nine-month collaboration, committed to improving care of veterans 
with dementia who prefer to live at home. These teams demonstrated 
notable success in early identification of dementia, symptom 
management, caregiver support, and staff education. It has been shown 
that the best place for veterans with long-term problems is in the HBPC 
Programs across the country. Home Based Primary Care is the most cost 
effective way to deliver interdisciplinary health care. This care is 
defined as accessible, comprehensive, coordinated, continual, 
accountable and acceptable.
    The HBPC Program offers long-term patients this kind of care.
     An alternative to nursing home placement.
     Minimizes the amount of follow up in an Ambulatory Care 
Clinic.
     Prevents premature admissions to long-term care 
institutions.
     Maintains optimal physical, cognitive, and psychosocial 
functioning.
     Allows the patient the option of dying at home rather than 
in an institution.
    The purposes of the Community Adult Day Care facilities are:
     To enable functionally impaired individuals to reside in a 
supportive home environment rather than nursing home care facilities.
     To facilitate the return of older veterans to their homes 
and to coordinate their long-term care.
     To maintain the older veteran at the highest level of 
functioning possible (physical, social and medical).
     To provide the family and caregivers with professional 
support, enabling them to maintain disabled veterans in the community.
    The Senior Companion Program often makes the difference between 
living at home or in an institutional setting. This translates into 
major health care savings for seniors, their families, and taxpayers. 
Nursing home care costs an average of $38,000 annually per person. 
However, the cost of supporting one Senior Companion for an entire year 
is $3,850.
    Telemedicine technology allows us to reduce travel time and costs, 
improves efficiency and provides better quality care.
    In conclusion, funding and expansion of all HBPC Programs can 
ensure alternatives to institutionalization for the long-term veteran 
patient. With these expanded programs, innovative approaches to long-
term care can be established with a cost saving to VHA, patients and 
their caregivers. HBPC keeps families together.
    This concludes my remarks. I will be happy to respond to any 
questions you may have.

  STATEMENT OF THOMAS McCLURE, LCSW, COORDINATOR, VA MEDICAL 
       FOSTER HOME PROGRAM, LITTLE ROCK VA MEDICAL CENTER

    Mr. McClure. I appreciate the strong language from this 
committee because I think we need action, and I think I have 
some good news. I am here to tell you about a unique and 
exciting program that actually changes lives. The VA hospital 
in Little Rock has taken the Medical Foster Home Program and 
the HBPC programs and formed a partnership that provides an 
extremely personal and comprehensive service that benefits not 
only our disabled veterans, but it benefits our communities and 
the VA hospital at a low cost.
    This program has an excellent record of satisfaction among 
the veterans and their families. The secret, these homes 
provide a permanent home with private rooms. They provide 24 
hour supervision, home cooked meals, a safeguard against abuse 
and neglect. We have never had a case of abuse in our program. 
We take sick, depressed veterans and turn them into grandpas, 
father figures. We turn them into family members.
    We fatten them up and make them laugh. They bring their 
pets to these foster homes. They are allowed flexibility in 
their routine. They are treated with dignity and respect, 
because those are our standards. The Medical Foster Home 
Program also provides a valuable service to our community, and 
that is in the form of jobs and income. Also an opportunity to 
work at home.
    But the reason I am successful at recruiting good homes is 
because this program provides a meaning and a purpose in these 
caregivers' lives. Our community, the everyday people, have 
defended our nation in war, they have run our factories, and 
they have built our homes. These people can also care for our 
frail elderly population if we support them. They can do it 
better and they can do it with less cost than any other 
alternative.
    The program also provides a service to our VA hospital by 
giving the discharge planners an alternative to nursing home 
placement. Already, 50 percent of my referrals come from the VA 
hospital, and that is growing. 25 percent come from the 
community just by word of mouth. If I advertise this program, I 
would be overwhelmed.
    Eight of our 44 veterans living in foster homes are 100 
percent service connected. They or their family choose to spend 
their own money to live in a foster home rather than have VA 
pay for their care in a nursing home. The cost of these two 
programs, HBPC and the Medical Foster Home, in partnership is 
$37 per day per patient. That is compared with $155 per day for 
nursing home care. I got that in the April issue of the AARP 
national average.
    The foster home staff consists of myself, a part-time 
secretary, one vehicle, one cell phone at $8 per day. I travel 
15 to 2,200 miles per month. I am on call 24 hours a day, 7 
days a week. But I have reached my limit. And we need action. I 
have added 44 patients to the HBPC case load, and now they have 
reached their limit. This is a win-win situation, and this is a 
solution. This concludes my statement but not my ideas.
    [The prepared statement of Mr. McClure follows:]

  Prepared Statement of Thomas McClure, LCSW, Coordinator, VA Medical 
           Foster Home Program, Little Rock VA Medical Center

    Mr. Chairman and members of the Committee:
    My name is Tom McClure and I am a VA social worker at the 
Central Arkansas Veterans Healthcare System. I am honored to be 
here today because one of your staff, Kim Lipsky, heard me and 
a colleague present our Medical Care Foster Home Project at a 
recent national conference, and she thought you would be 
interested. We recently finished a pilot, funded by VA, and we 
are now disseminating our findings.
    For 23 years I have been working in our Home Based Primary 
Care Program. I saw firsthand how hard veterans worked to stay 
in their own homes even though they had severe chronic 
illnesses and disabilities, unsuitable housing, and poor social 
supports. I often witnessed how difficult it was for elderly 
spouses to continue to care for their very disabled husbands. 
Time and time again I observed the unwillingness of veterans 
and their families to consider placement in a nursing home.
    We wanted to try to find ways for these patients to 
continue to stay in the community and still get the care they 
needed. A few times I helped our patients make informal 
community arrangements to live in the home of a hired 
caretaker. These situations worked out well for the veterans. 
The Home-Based Primary Care (HBPC) team managed the medical 
care. Then we heard about our Central Office's ``New Clinical 
Initiative Funding.'' We asked for and were given the resources 
to develop Medical Care Foster Homes for our veterans--$95,000 
for each of 2 years. This money paid my salary so I could 
develop foster homes full time. It also paid for my half time 
assistant, travel costs and cell phone costs. We set about to 
recruit caring families and individuals in the communities 
served by our large HBPC program.
    Now, 2 years later, we now have 35 foster homes and 45 
patients. Our outside funding has ended, but the Medical Center 
chose to continue at the same level of funding. Eight of our 
Foster Care patients are 100 percent service connected; some of 
them came directly from a community nursing home to our foster 
home at their own expense.
    Here is how our program works. When I recruit a foster 
home, I assess their motivation, attitude, life experience, and 
I explain the general needs of our disabled veterans. I check 
their references and do a criminal background check. Our safety 
engineer inspects the home environment. If everything checks 
out, we approve the home and can begin to match the home with 
patients who are interested in family living. We involve any 
family or friends of the veteran in the process of selecting a 
foster home. I encourage them to visit a few homes. I serve as 
an intermediary between the veteran and the foster home 
sponsors in agreeing on the monthly fee. This fee ranges from 
$1000 to $1800 per month depending on the care needs of the 
veteran. For this fee the veteran gets a private room, personal 
care, 24-hour supervision, meals, laundry, and activities. This 
is a permanent home. We do not uproot these veterans when they 
become terminally ill and place them in a nursing home. They 
remain in the foster home. It is understood that the VA will 
provide medications, supplies, and health care. All the 
veteran's needs are met.
    The veterans pay for their Medical Foster Care with no 
funding from VA. They use their Social Security, private 
pensions, and VA pensions or service-connected disability 
compensation. Most have spending money in reserve. The veterans 
who qualify for non-service-connected pensions can have their 
pensions increased to cover the costs of the Medical Foster 
Care. We have a liaison in the Little Rock VA Regional Office 
that assists us in processing claims in a timely manner, but 
sometimes it does take several months.
    Once in Medical Foster Care, the patients are visited 
regularly by the HBPC team members, who conduct an 
interdisciplinary geriatric assessment, develop a treatment 
plan, provide medications and medical equipment, and educate 
the foster family in the care of the veteran. Because of the 
close partnership between our Foster Care Program and HBPC, we 
safeguard against abuse.
    So far we have recruited our Medical Care Foster Homes from 
persons in the community who are experienced in caring for the 
elderly, either former health care workers or those with 
experience caring for family members. Even though the income is 
important to foster home sponsors, we feel the most important 
factor is that the program instills meaning and purpose to 
their lives. This is why we can recruit good people. Also we 
help our Foster Home Sponsors. They have 24-hour access to us. 
We also offer respite 2-4 times a year so they can rest and 
reduce stress levels.
    We believe Medical Foster Care/HBPC is humane care and 
affordable for VA and the Veteran. At our facility, with a 
census of 45 patients in foster care, the VA direct care costs 
are $29 per day for the HBPC portion of the care, plus $8 per 
day for the Foster Home Program, for a total of $37 per day.
    The Central Arkansas Veterans Healthcare System has formed 
a partnership with the Medical Foster Care Program and the HBPC 
Program, permitting us to provide this unique care environment. 
Many states have adult foster care. But this program is just 
for veterans and VA healthcare providers are actively involved 
in caring for the patients and overseeing the homes. The most 
important feature of this program is that it improves the 
quality of life for our frail, disabled veterans in a family 
atmosphere. We take sick, depressed veterans from our wards, 
place them in a family environment and they become grandfather, 
uncles, and father role models.
    Here at Little Rock, we are at capacity for the number of 
homes and patients can be managed with existing staff. HBPC's 
census of 180 is now 25 percent Foster Care patients and 
growing. With this program in its infancy, we are unable at 
this time to predict the limits of its growth.
    I believe VA Medical Centers could develop Medical Care 
Foster Homes in conjunction with existing Home Based Primary 
Care Programs. It is not easy work, but it is important and 
gratifying work that would give our aging veterans a true 
alternative to institutional care.
    This concludes my statement. I will be happy to respond to 
the Committee's questions.

    Chairman Rockefeller. Or the obvious and clear emotion just 
one inch below your words. You commitment is enormous.
    Ms. Hemmings.

   STATEMENT OF PAULA HEMMINGS, R.N., DEPARTMENT OF VETERANS 
AFFAIRS' VETERANS INTEGRATED SERVICE NETWORK NO. 2, GERIATRICS 
 AND EXTENDED CARE LINE MANAGER, REPRESENTING THE ALZHEIMER'S 
                          ASSOCIATION

    Ms. Hemmings. Mr. Chairman and members of the committee, 
thank you very much for giving me the opportunity to testify at 
this important hearing. I am the Director of Geriatrics and 
Extended Care Line for the Upstate New York Integrated Service 
Network. However, I am here this morning on behalf of the 
Alzheimer's Association and the views expressed do not 
necessarily reflect the views of the Department of Veterans 
Affairs.
    The purpose of my appearance today is to explain how the 
VISN 2 located in upstate New York was able to implement the 
Chronic Care Networks for Alzheimer's disease project fully 
utilizing the continuum of VA institutional and non-
institutional long-term care programs that are variable to the 
veterans.
    In 1996, VISN 2 was the only VA network that was a member 
of the National Chronic Care Consortium. Membership in this 
organization reflects commitment on the part of VA Central 
Office as well as the executive support in VISN 2.
    As members of the NCCC, the Alzheimer's Association and 
VISN 2 leadership made a commitment to partner in the CCN/AD 
project because of our strong belief that chronic care takes 
many resources to work.
    In upstate New York, the partners recognized that they had 
a common goal. They also served the same target population, 
individuals with dementia and their caregivers and families. 
This recognition of commonality promoted pooling of experience, 
experience and resources. Both agencies also recognized that no 
one organization, no matter how complete its array of services 
and programs, is sufficient to successfully manage the chronic 
and progressive illness of dementia throughout its course.
    VISN 2 is strongly motivated to partner with the community 
organization to better serve an aging veteran population with 
the prevalence of chronic illness. Nationally, the rate at 
which a veteran population is aging surpasses the general 
population. The 20 percent reduction in the overall veteran 
population is offset by the significant growth of very elderly 
veterans, thereby maintaining significant demand from health 
care services in the next 10 years.
    The CCN/AD's primary project goals are: identification of 
individuals in the early stages of the condition; 
implementation of state-of-the-art comprehensive care 
guidelines; creation of a dual track to support both a person 
with dementia and the family caregivers over time and across a 
continuum of needed services; and modification of the care for 
coexisting conditions with recognition of the underlying 
dementia and its effects.
    As a selected CCN/AD site, VISN 2 is active in the 
development, piloting and demonstration of the model. Chapter 
and VA partners quickly identified training as a major 
component of the intervention. Primary care clinicians were 
targeted for initial and ongoing training. Staff of both 
partnering organizations was educated about the goals, 
protocols and their role in addition to dementia topics.
    Once the initial piece of the project was accomplished, the 
role of the Dementia Care Manager became more important. This 
is a staff role unique both to this project and within the VA. 
These staff serve as a variety of diverse functions all 
designed to advance the goals of the CCN/AD initiative.
    The dementia care managers work diligently to ensure that 
all veterans continue to have access to VHA resources and 
services when they need it. This is a good illustration of a 
model that strategically places VHA resources alongside 
numerous community partners to work in concert in meeting the 
needs of the chronically ill veterans.
    Treatment and management of chronic illnesses such as 
dementia fundamentally challenge the way health care service 
delivery systems are currently delivered. Typically care 
delivery centers around brief episodic office visits with the 
primary care provider. The nature of the visit commonly focuses 
on the medical aspects of presenting problems. Chronic care 
management, however, presents fundamentally a different 
reality.
    Chronic progressive illness, such as Alzheimer's, needs to 
be addressed over time and it must include the patient's family 
and caregivers. Plans often need to include access to a full 
range of non-institutional resources such as home-based primary 
care, the homemaker home health aide, adult day health care, 
and respite care, all service that the VA provides and 
coordinates.
    Planning has to include caregivers who oftentimes are as 
old and as sick as the identified patients they care for, and 
yet they are so crucial to the success or failure of the 
management of the disease. Planning with them is important. VA 
chose to use a CCN/AD program as a springboard to help 
influence its medical model and culture of primary care to 
better accommodate the needs of veterans and patients with 
chronic illness.
    It has expanded the provider's appreciation to where care 
is actually delivered. It is delivered in the home. It 
contributed to the provider's understanding that successful 
management of our patients with dementia care means addressing 
the needs of the family and patient as well. This project has 
taught us that we must reach out to our partners in the 
community who have common missions and work with them to offer 
our veterans and their family caregivers what they need, not 
just what we have. Thank you.
    [The prepared statement of Ms. Hemmings follows:]
  Prepared Statement of Paula Hemmings, R.N., Department of Veterans 
  Affairs' Veterans Integrated Service Network No. 2, Geriatrics and 
  Extended Care Line Manager, Representing the Alzheimer's Association
    Mr. Chairman and members of the Committee, thank you very much for 
giving me the opportunity to testify at this important hearing.
    In my professional life I am the Director of the Geriatrics and 
Extended Care Line for the upstate New York Veterans Integrated 
Services Network (VISN 2). However, I am here this morning on behalf of 
the Alzheimer's Association and the views that I express do not 
necessarily reflect the views of the Department of Veterans Affairs.
    The purpose of my appearance today is to explain how Veterans 
Integrated Service Network (VISN 2), located in upstate New York, was 
able to implement the Chronic Care Networks for Alzheimer's Disease 
(CCN/AD) project fully utilizing the continuum of VA institutional and 
non-institutional long-term care programs that are available to the 
Veterans.
    In 1996, VISN 2 was the only VA Network that was a member of the 
National Chronic Care Consortium (NCCC). Membership in this 
organization reflects commitment on the part of VHA Central Office as 
well as executive support in VISN 2. As members of the NCCC, the 
Alzheimer's Association and VISN 2 leadership made a commitment to 
partner in the CCN/AD project because of our strong belief that chronic 
care takes many resources to work. There were seven sites selected from 
the NCCC applicants. VISN 2 and the upstate New York chapters of the 
Alzheimer's Association were among those selected. The importance of 
this project was recognized by the Robert Wood Johnson Foundation who 
heavily underwrote the evaluation component of the VISN 2/upstate New 
York Alzheimer's Association chapters site.
                      background on ccn/ad project
    The following is a detailed description of the CCN/AD initiative 
and VISN 2 and the upstate Alzheimer's Association chapters 
participation. VISN 2 and the four upstate New York chapters of the 
Alzheimer's Association formed a community partnership to participate 
in the CCN/AD initiative, a national demonstration project. In Upstate 
New York the partners recognized that they had a common goal. They also 
served the same target population, individuals with dementia and their 
caregivers and families. The partners strove to provide their clients 
with the best quality care their agency resources allowed. This 
recognition of commonality promoted pooling of experience, expertise 
and resources. The Alzheimer's Association chapters have a history and 
extensive experience providing support and education to diagnosed 
individuals, their caregivers and families. The VA brought to the 
partnership their clinical experience and expertise in the provision of 
an enviable continuum of chronic care services. Both agencies have much 
to offer individuals with dementia and their caregivers. Both agencies 
also recognize, that no one organization, no matter how complete its 
array of services and programs, is sufficient to successfully manage 
the chronic and progressive illness of dementia throughout its course. 
Partnership is essential. Partnering in CCN/AD meant that both 
organizations could provide better access for their clients to a wider 
arrangement of services. Also as important, the partnership in the CCN/
AD initiative would establish the foundation for development of a 
disease management model of care in VISN 2. This model serves as a 
guide for providing services and support throughout the course of the 
disease at all care sites within the Network.
                     demographic profile of visn 2
    VISN 2 is an integrated health care delivery system composed of 
inpatient facilities, nursing homes, community clinics, non-
institutional care programs provided through contracts, and community 
agency referrals. VISN 2 provides acute inpatient and nursing home care 
services at five locations: Albany, Western New York, Syracuse, Bath 
and Canandaigua, provides primary care at twenty-nine community-based 
clinics that are located throughout the region. The VISN serves an area 
of 42,925 square miles encompassing 47 counties in New York State as 
well as two in northern Pennsylvania, with an estimated 573,546 
veterans (17.7% of those veterans were treated in FY 2000).\1\ This is 
approximately the same area (minus counties in northern Pennsylvania) 
served by four Alzheimer's Association chapters. The chapters and VA 
Medical Centers formed the partnerships based upon shared service 
areas.
---------------------------------------------------------------------------
    \1\ ``Veteran Demographics''. Department of Veterans Affairs Web 
site. Available at: www.va.gov/visns/visn02/. Accessed December 6, 
2001.
---------------------------------------------------------------------------
    VISN 2 was strongly motivated to partner with a community 
organization, such as the Alzheimer's Association, to better serve an 
aging veteran population with a prevalence of chronic illness. 
Nationally, the rate at which the veteran population is aging surpasses 
the general population.
    Highlights of veteran demographics for upstate NY:
     Over 52% of veterans treated in FY 2001 were 65 years of 
age or older, with nearly one-quarter over age 75.
     Perhaps equally significant is that while our total 
veteran population decreases, the number of veterans over age 85 will 
nearly double in the same five-year period.
    While veterans over age 65 historically use health care services at 
a higher rate than younger veterans, greater demand is profoundly more 
significant among those 85 and over, in all major care settings-acute 
inpatient, ambulatory and nursing home care. The 20% reduction in the 
overall veteran population is offset by the significant growth of very 
elderly veterans, thereby maintaining significant demand for health 
care services over the next ten years.\2\
---------------------------------------------------------------------------
    \2\ Ibid.
---------------------------------------------------------------------------
    These demographic data provided VISN 2 an incentive to participate 
in the CCN/AD initiative addressing Alzheimer's disease, a chronic 
illness whose prevalence increases with age. A disease which if left 
undiagnosed could interfere with the management of their medical care 
and cause them to be labeled as non compliant patients, possibly 
leading to their death because they were not taking their medications 
as prescribed.
    In addition to the demographic challenges presented to us, VISN 2 
was impelled by fiscal and budget realities to make effective changes, 
rapidly, and to look outside itself for agencies with whom to 
collaborate.
    In VISN 2, Care Lines are structured along major program emphases. 
In my case, the major program emphasis is Geriatrics and Extended Care 
(GEC). In VISN 2, the Care Line Directors are given budgetary and 
operating authority over all relevant programs in this new 
organizational structure. Decisions about program operations are 
matrixed with the Directors of the major Medical Centers in upstate New 
York. This structure allows us to rapidly deploy and standardize the 
best, efficient and effective practices across all sites of care 
delivery within our Network. The Care Line organizational structure 
lets administrators in our Network focus and concentrate on all the 
pertinent issues and requirements relevant to aligning resources for 
efficient and effective service delivery. It also impacts the speed of 
implementation, in that, I can influence deployment across the entire 
Network catchment area, and not just at one Medical Center at a time. 
This structure allowed me to institute the CCN/AD initiative rapidly 
throughout all of upstate NY and hire and put in place Dementia Care 
Managers at each major site which I will talk about later.
                          ccn/ad project goals
    The CCN/AD project's primary goals are: identification of 
individuals in early stages of the condition, implementation of state 
of the art comprehensive care guidelines, creation of a dual track to 
support both the person with dementia and the family caregivers, over 
time and across the continuum of needed services, and modification of 
the care for coexisting conditions with recognition of the underlying 
dementia and its affect. As a selected CCN/AD site, VISN 2 was active 
in the development, piloting and demonstration of the CCN/AD model.
    Chapters and VA partners quickly identified training as a major 
component of the intervention. Primary care clinicians were targeted 
for initial and ongoing training. Other staff in both partnering 
organizations, were also trained in sessions specifically designed to 
meet their needs. A site wide curriculum was developed that outlined a 
basic introductory presentation with CME credit that the VA clinical 
director of the Initiative delivered at each sub site. The purpose was 
to assure that each location started with the same basic information. 
During the clinical director's travels to the sub sites he met with key 
personnel and along with dementia care managers recruited physician 
``champions'' who would participate in or support future sessions.
                 the role of the dementia care manager
    Recognizing the varied resources and needs of each sub site, 
Dementia Care Managers and chapter coordinators determine future 
educational needs for the staff at their facilities using the 
curriculum as a guideline to identify target audiences and use a 
variety of methods. Faculty was recruited from within the VA and more 
frequently from universities, Alzheimer's Disease Centers and 
Alzheimer's Disease Assistance Centers. Staff at both partnering 
organizations were educated about the goals, protocols and their role 
in addition to dementia topics. A milestone occurred when demands for 
training came from numerous diverse staff themselves after hearing 
about or experiencing the quality of Alzheimer's Association chapter 
training sessions for direct care staff. Eventually, this led to use of 
Alzheimer's Association chapters for train-the-trainer programs and 
development of a plan to use those newly trained as instructors and 
dementia resource individuals in their unit. The implementation of that 
plan was the culmination of efforts to reach our goal to train the full 
range of staff at VA facilities.
    Once the initial piece of the project was accomplished, the role of 
the Dementia Care Manager became more important. This is a unique staff 
role; unique both for this project and within the VA. These staff serve 
a variety of diverse functions all designed to advance the goals of the 
CCN/AD initiative. The Dementia Care Manager is there to respond to 
questions related to the tools after the education sessions and to 
collect the necessary data for the project. The other responsibility of 
the Dementia Care Manager is to work with the primary care provider to 
establish the psychosocial support system for the Alzheimer's patient 
in the community. Further these staff work with the family and the 
Alzheimer's Association to provide family/caregiver support.
    The Dementia Care Managers like the other VISN 2 Geriatrics and 
Extended Care staff work diligently to insure that all veterans 
continue to have access to VHA resources and services when they need 
it. VISN 2 is one of the Networks nationally that met veteran resource, 
use reliance target levels for both our institutional Nursing Home 
programs as well as our non-institutional home care programs and 
services. But the needs, both in nature and kind of need, of patients 
with chronic illnesses and their families will always exceed the VHA's 
ability to directly provide for them.
              partnership with the alzheimer's association
    Faced then with increasing numbers of aging veterans in the upstate 
New York area and the competing healthcare budget needs previously 
mentioned, geriatric and extended care program planners in our Network 
factored in access to Alzheimer's Association community resources, as a 
necessary component to compliment services for veterans with dementia 
and their families. It is a good illustration of a model that 
strategically places VHA resources along side numerous community 
partners to work in concert to meeting the needs of chronically ill 
veterans.
                       the chronic care challenge
    Treatment and management of chronic illnesses, such as dementia, 
fundamentally challenge the way healthcare service delivery systems are 
currently configured.
    Medical care delivery within VHA, as is the case with most medical 
care systems, is well designed to manage health care problems of the 
general population. Typically care delivery centers around brief, 
episodic office visits with the primary care provider. The nature of 
the visit commonly focuses on the medical aspects of presenting 
problems. Patients are given prescriptions, advice on life style 
changes and follow up appointments if necessary to track progress of 
the condition for which they are being treated. At times, referrals may 
be made to specialty clinics and if warranted to treat acute illness, 
hospitalization. In addition, providers in these settings are busy. 
They have high patient volume and are daily pressed to complete their 
scheduled visits. As would be expected, resources in most health care 
systems are aligned to meet this mission and model of healthcare 
delivery.
    Chronic care management, however, presents a fundamentally 
different reality. Chronic progressive illness, such as Alzheimer's, 
needs to be addressed in clinic, over time rather than episodically. 
Also managing these patients, who are typically frail and elderly, 
takes time. Time to plan access to a full range of non-institutional 
resources such as Home Based Primary Care, Homemaker Home Health Aide, 
Adult Day Health Care and Respite Care, all services that the VA 
provides and/or coordinates. Providers are trained and trained well to 
assess and treat on the medical level and patients with chronic illness 
need this care. But often simultaneously, these patients and families 
need assessment and care on several other non-medical dimensions as 
well. These other domains that require attention and often intervention 
and care planning include functional, social, financial, psychological, 
behavioral and environmental dimensions. Further adding to the 
complexity is the work that needs to be done with the family 
caregivers. Caregivers often times are as old and sick as the 
identified patients they care for, yet they are so crucial to the 
success or failure of the management of the disease. Their needs must 
be accounted for in care planning. Finally, the nature of chronic 
progressive illness is such that it evolves, develops, and eventually 
deteriorates over time. Changes in condition and circumstance must not 
only be monitored but must be prepared for proactively. Patient's 
changes in physical, behavioral and functional needs require different 
mixes of supports, services and settings. Their caregivers' skills, 
aptitudes, as well as their own family and agency supports available to 
assist them need to be looked at as they progress through role changes 
and the changing demands that their loved ones chronic illness places 
on them. This is where the Dementia Care Managers come in and provide 
invaluable assessment, coordination and support.
    To successfully address chronic illness management, the mindset, 
both clinically and in resource planning and deployment, needs to be 
fundamentally different than an uncritical reliance on a system of 
delivery designed to serve needs of a general population. The 
consequences of dependence on episodic care delivery as it's currently 
organized or premature reliance on costly institutional care for 
management of chronic illness is to squander precious resources that 
are and will be needed to treat the ever growing population of veterans 
with chronic illness.
                   replication of the ccn/ad project
    Given the complexity of what is described above, it is impractical 
to think that any one agency, no matter how vast its resources, can 
unilaterally provide all the care patients and their families with 
chronic progressive illness will need. To begin to think like this, and 
coordinate with community partners and monitor care over time outside 
of the clinic encounter, is nothing short of a cultural change in 
healthcare delivery. To actively change medical care delivery culture, 
the endorsement and commitment from top leadership is required. VISN 2 
chose to use the CCN/AD model as the springboard to help change it's 
medical model and culture of primary care and to influence it over time 
to better accommodate the needs of patients with chronic illnesses and 
their families. Over a five year period, the VISN deployed dedicated 
Dementia Care Managers to cover all the medical centers and major care 
sites within the VISN. These staff are able to take the time medical 
providers don't have to do detailed assessment of both patient and 
caregiver needs. They also are a direct contact point and portal of 
entry into the VA system and continuum of services. They are easily 
reached by their partners at the Alzheimer's Association and help 
sustain this inter-agency relationship. They collaborate with both VHA 
providers and Chapter staff and work to integrate into care planning 
relevant data about both patient and caregiver's current functioning.
                              conclusions
    CCN/AD created in VISN 2, over time, the reality of viable 
partnerships with community agencies such as the Alzheimer's 
Association. It imparted to our providers the importance of addressing 
caregiver needs and supporting them as they struggled to cope with 
their loved ones illness on a day to day basis. It reaffirmed that 
chronic care had to be managed across settings and over time. It 
expanded the providers' appreciation as to where care was actually 
delivered in the majority of instances. It contributed to the 
provider's understanding that successful management of our patients 
with dementia means addressing the needs of the patient's family 
caregivers as well.
    Our veteran patients, whom we correctly refer to as our nation's 
heroes, who now come to us with dementia, along with their family 
caregivers, who are quiet, unsung heroes in their own right, continue 
to teach us. They teach us that to be true to our mission and 
obligation to ``serve him who has borne the battle and his widow and 
orphan'', we must continue to maximize our resources to serve the 
extended care needs of our veterans as they age, become frail and more 
heavily rely upon us. They teach us that to be successful in our 
mission we cannot be solely focused on our identified patient, the 
veteran. We must also focus on those in our veterans' lives who are 
most intimately caught up in the provision of their extended care 
needs. And finally, they teach us not to come to rely solely on VHA 
resources to achieve our mission. They have taught us that we must 
reach out to our partners in the community, who have common missions, 
and work with them to offer our veterans and their family caregivers 
what they need, not just what we have.

    Chairman Rockefeller. Thank you very much, Ms. Hemmings. 
Dr. Moye. And this will be geriatric mental health and your 
study about that.

 STATEMENT OF JENNIFER MOYE, PH.D., DIRECTOR, GERIATRIC MENTAL 
HEALTH CLINIC/UPBEAT, BROCKTON VA MEDICAL CENTER, AND ASSOCIATE 
  PROFESSOR OF PSYCHOLOGY, DEPARTMENT OF PSYCHIATRY, HARVARD 
                         MEDICAL SCHOOL

    Ms. Moye. Right. Mr. Chairman and Senator Graham, my name 
is Jennifer Moye. I am the Director of the Geriatric Mental 
Health UPBEAT Clinic at the Boston VA Brockton Campus, and I am 
an Assistant Professor of Psychology in the Department of 
Psychiatry at Harvard Medical School.
    I am pleased to testify today on the Unified 
Psychogeriatric Biopsychosocial Evaluation and Treatment, or 
UPBEAT program.
    I have worked as a psychologist with medically and 
neurologically frail older veterans with late onset mental 
health concerns for the past 10 years, and I speak today as a 
clinician. Our clinic was founded in 1995 as part of a 5-year, 
nine-site clinical demonstration project that evaluated the 
effectiveness of outpatient case management combined with 
mental health treatment for elderly veterans who have 
previously undiagnosed mental health problems in the context of 
serious medical illness.
    This program is based on two research findings, one, mental 
health problems are underdiagnosed and inadequately treated in 
the elderly. These are fellows who are not going to say to 
their doctor, ``gee, I have been feeling sad, could I talk to a 
psychologist?'' They are more likely to sort of buck up and 
suffer, unfortunately.
    And also, the second finding, elderly who have depression 
or other mental health problems have more complex medical 
management, have a more complicated recovery from illness, and 
are more expensive for our health care system.
    In the UPBEAT program, patients 60 years or older admitted 
to medical or surgical inpatient services were screened for 
depression, anxiety or alcohol use. 1,687 veterans with these 
problems were randomly assigned to either a treatment group or 
a usual care group.
    In the treatment group, those fellows got an intensive 
interdisciplinary assessment, followed by outpatient case 
management combined with mental health treatment.
    In the year following enrollment, veterans in the treatment 
group had higher utilization of outpatient care, especially 
mental health and telephone encounters, costing 1,171 more 
dollars per patient per year than the usual care group.
    However, that expanded outpatient cost was more than made 
up for by savings in inpatient costs of $3,027, resulting in a 
net savings on average of $1,856 per patient per year, or a 
total savings for all patients enrolled in the treatment group 
of approximately $1.5 million.
    The savings were chiefly attributable to reduced length of 
stay when those veterans were rehospitalized. We are starting 
to look at other subgroups, and it looks like in specifically 
targeted subgroups, such as patients with circulatory 
conditions or more significant depressions, the savings may be 
even greater, up to $5,000 per patient per year.
    Let me share with you an example to illustrate the program. 
One veteran in the UPBEAT program was enrolled at our site when 
he was surgically hospitalized and he screened positive for 
depression. The depression was triggered in part because the 
current surgery he was having was reminiscent of the eight 
surgeries he received in 1945 after he was injured by shrapnel.
    This patient participated in six combat jumps in Africa, 
Italy, France and Germany, including the Battle of the Bulge 
and the Anzio and Normandy invasions for which he received the 
Bronze Star for heroism.
    Late in life when confronted with illness and 
vulnerability, he became overwhelmed with depression, to the 
point where he would retreat from everyone and stay in bed and 
then that would compromise his health.
    He entered our program at the age of 75 participating at 
first very reluctantly, but eventually enthusiastically with 
the case management as well as the psychotherapy, and in this 
case some psychopharmacology to help him sleep. He was still 
having nightmares of the war.
    With that treatment, he was able to manage his mood better 
when medically ill, and he successfully underwent a subsequent 
surgery without that excess disability caused by depression. 
Furthermore, as a result of speaking in psychotherapy about his 
war experiences for the first time ever, he began to also share 
these with his family.
    None of his family members were previously aware of any of 
the details of his military service, and this newfound capacity 
for communication was tremendously appreciated by both the 
veteran and the family.
    What does the success of the UPBEAT program tell us about 
outpatient case management programs? UPBEAT is a non-
institutional program that reduces institutional care and 
reduces total cost of care. These findings are similar to other 
studies that find case management of these high risk geriatric 
patients can forestall a nursing home admission or other 
institutional care use and be cost effective.
    Key elements of successful programs are: interdisciplinary 
teams, readily accessible primary care, home-based care, adult 
day health care, the things my panel members have described, 
integration of mental health treatment, case management to 
coordinate that optimal utilization of the health care system, 
and careful targeting of the patients to identify those most at 
risk for institutional care and most likely to benefit from 
such programming.
    Patients with dementia require additional services 
including travel and caregiver support. The ultimate success of 
these programs will rely on appropriate case loads for 
clinicians and case managers, and I really want to second Tom's 
noting on how large the case loads are getting for the 
clinicians these days, and clear program goals and performance 
measures for clinicians and administrators.
    In closing, I have felt very blessed to work with elderly 
veterans and very grateful for that opportunity. I am also 
grateful for the opportunity to speak with you today. Thank 
you.
    [The prepared statement of Ms. Moye follows:]
 Prepared Statement of Jennifer Moye, Ph.D., Director of the Geriatric 
    Mental Health/UPBEAT, Brockton VA Medical Center, and Associate 
  Professor of Psychology, Department of Psychiatry, Harvard Medical 
                                 School
    Mr. Chairman and Members of the Committee:
    My name is Jennifer Moye. I am the Director of the Geriatric Mental 
Health/UPBEAT clinic at the Boston VA, Brockton Campus, and an 
Assistant Professor of Psychology in the Department of Psychiatry at 
Harvard Medical School. I am pleased to testify today on the Unified 
Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) 
program.
                         review of upbeat model
    I have worked as a psychologist with medically and neurologically 
frail older veterans with late onset mental health concerns for the 
past ten years, and I speak today as a clinician. Our clinic was 
founded in 1995 as part of a nine site clinical demonstration project 
that evaluated the effectiveness of intensive outpatient case 
management and mental health treatment for elderly veterans with 
previously undiagnosed mental health problems in the context of serious 
medical illness. The program is based on previous research 
demonstrating: 1) mental health problems are under diagnosed and 
inadequately treated in the elderly; 2) elderly who have depression or 
other mental health problems have more complex medical management, a 
more complicated recovery from illness, and are more expensive for the 
health care system.
                          upbeat cost savings
    In the UPBEAT program, patients 60 years and older admitted to 
medical or surgical inpatient services were screened for depression, 
anxiety, or alcohol abuse. 1,687 veterans with these problems were 
randomly assigned to a treatment versus usual care group. The treatment 
group received interdisciplinary assessment followed by outpatient care 
coordination and mental health intervention. In the year following 
enrollment, veterans in the treatment group had higher utilization of 
outpatient care, especially mental health and telephone encounters, 
costing $1,171 more per patient per year, than the usual care group. 
However this expanded outpatient cost was more than made up for by 
savings in inpatient costs of $3,027, resulting in a net savings of 
$1,856 per patient per year, or a total savings for all patients 
enrolled in the treatment group of approximately $1.5 million dollars. 
Savings were attributable to a reduced length of stay when re-
hospitalized. Savings were even greater in targeted subgroups, such as 
those with circulatory diseases or more significant depression, 
estimated at $5,000 per patient per year. Additional analyses are 
ongoing.
                        upbeat clinical example
    One veteran in the UPBEAT program was enrolled at our site when he 
was surgically hospitalized and screened positive for depression. The 
depression was triggered in part because the current surgery was 
reminiscent of the eight surgeries he received in 1945 after being 
injured by shrapnel in World War II. This veteran participated in six 
combat jumps as a paratrooper in Africa, Italy, France, and Germany, 
including the Battle of the Bulge, and the Anzio and Normandy invasions 
during which time he received the Bronze Star. Late in life when 
confronted with illness and vulnerability, he became overwhelmed with 
depression, to the point of remaining in bed constantly, compromising 
his health. He entered our program at the age of 75, participating at 
first reluctantly, then enthusiastically in case management and 
individual psychotherapy with psychopharmacology. With treatment he was 
able to manage his mood better when medically ill, and he successfully 
underwent a subsequent surgery without the excess disability caused by 
depression. Furthermore, as a result of speaking about his war 
experiences for the first time in psychotherapy, he began to also share 
these with his family. None of his family members were previously aware 
of any details of his military service. This newly found capacity for 
such communication was tremendously appreciated by both the veteran and 
his family.
           essentials of case management for at-risk veterans
    What does the success of the UPBEAT program tell us about 
outpatient based case management programs? UPBEAT is a non-
institutional program that reduces institutional care and reduces total 
cost of care. These findings are similar to other studies that find 
case management of at-risk geriatric patients can forestall nursing 
home admission. Key elements of these programs are:
          1) interdisciplinary teams;
          2) readily accessible primary medical care;
          3) home based care and support when indicated;
          4) integration of mental health treatment;
          5) case management to coordinate optimal utilization of the 
        health care system; and
          6) careful targeting of patients and interventions to 
        identify those patients most at-risk for institutional care and 
        most likely to benefit from such programming.
    Patients with dementia require additional services including 
travel, caregiver support such as respite care, and adult day health 
care. The ultimate success of such programs will rely on appropriate 
caseloads for primary care clinicians and case managers, clear program 
goals, and performance measures for clinicians and administrators.
    In closing, I have been most grateful to work with our elderly 
veterans, and I thank you for the opportunity to speak before you 
today.
                               attachment
    Kominski, G., et al (2001). UPBEAT: The impact of a psychogeriatric 
intervention at VA Medical Centers. Medical Care, 39, 500-512.*
---------------------------------------------------------------------------
    [* The information referred to has been retained in the committee's 
files.]

    Chairman Rockefeller. Thank you, Dr. Moye. A little off-
the-wall question here. None of you have particularly talked 
about--you, I think, Ms. Dickerson talked about savings--none 
of you have talked about the problem of resources that I assume 
VA would care to bring forward, and I am wondering if that has 
anything to do with the fact that some of you were told not to 
bring up the subject of resources by the VA?
    Ms. Dickerson. Particularly in my case, resources are 
readily available. Alan Harper in North Texas Health Care 
System is a very believer of HBPC, and he has seen the things 
that we have done. So we have been able to get the resources. 
What we did was that he transferred a lot of the nursing staff 
from the inpatient to the outpatient.
    Chairman Rockefeller. You found a way?
    Ms. Dickerson. Yes, we found a way.
    Chairman Rockefeller. And you found a way without 
fundamentally compromising the health care of others?
    Ms. Dickerson. Yes.
    Chairman Rockefeller. Because you cared to take the 
initiative?
    Ms. Dickerson. Yes. So we have transferred from inpatient 
occupational therapists, physical therapists, dieticians, 
social workers and nurses. We even have a physician and a 
physician's assistant that was transferred from other places in 
the hospital.
    Chairman Rockefeller. But it would be easy, it seems to me, 
for VA to come forward and say, well, we cannot do this because 
we do not have the budget that we have. I mean that is what 
Senator Graham and I say every year, and that is what VA says 
every year, and we are all right every year, and so they could 
come forward and say that.
    And what you are saying is, yes, they can come forward and 
say that, but you, Ms. Dickerson, were able to undertake 
something without compromising the health care and other 
critical areas for the same population of veterans that we are 
all talking about and do just exactly what the long-term care 
law required.
    Ms. Dickerson. That is exactly right. We also maintained a 
$22 per day per patient for the last 5 years, so the cost has 
not increased.
    Chairman Rockefeller. And you also, as I think you 
indicated, know that as time goes on, you will be saving more 
money?
    Ms. Dickerson. Yes. We have also increased our patient load 
to over 200 patients.
    Chairman Rockefeller. So the patient load has gone up, the 
money can be handled, and the resources are not an excuse?
    Ms. Dickerson. Yes.
    Chairman Rockefeller. Anybody else wish to comment?
    Ms. Moye. I just wanted to comment on the issue I want 
people to appreciate the complexity of the older patients. As 
the GAO reported, we are seeing this tripling in the over 85-
year-old veteran, and these are veterans who are already 
expensive to the health care system, and we are saying let us 
spend more money on them, so I cannot speak to fiscal issues. I 
am a clinician, but I want to emphasize how very, very complex 
these patients are, how they require more time to work in a 
preventative fashion.
    Our primary care clinicians currently have case loads of 
1,200 patients. We have a waiting list of about 500 patients. I 
know you have heard these things. That may be appropriate if 
you are working in an HMO setting and you have lots of young 
adults who you see once a year, but when you have very 
complicated 85-year old patients, we really need to look at the 
issue of directing resources to those needs.
    Chairman Rockefeller. And I do understand that, but Ms. 
Hemmings, who looks like she wants to say something, I want to 
say to you that one of the things I certainly remember about my 
mother in talking about complexities with older people is that 
particularly in Alzheimer's you go through stages where there 
is an enormous amount of violence, an enormous amount of just 
sort of following people around houses or outdoors or down 
streets. You are not quite sure where they are going to go.
    They hit, they throw food, they scratch at certain points 
and they stop, and they will take it up again. Often a single 
caregiver if the person is larger in size cannot transport that 
person to a bathroom, for example, or to a tub, and so what Dr. 
Moye says becomes even more true, and that is that it is indeed 
very complex, and in your field and in others manifestly 
complex and yet you have handled it?
    Ms. Hemmings. Well, I think the way it is handled, too, is 
that we all talked about having some form of case management, 
and I think that is really one of the real issues that we have 
used. The nurse or the social worker, depending on what site 
she is at, works with whatever level that patient is at. The 
issue is to try and identify it early and through some of the 
other medications and also give us a time to educate the family 
how to deal with some of these behaviors.
    If you learn how to do some diversional therapy and some of 
the other things that are going to be coming up, you can also 
handle the patient better at home, but it also gives us much 
more time to work with the Alzheimer's Association to set up 
support systems for the family. The caregiver really needs a 
lot of support, and so while we are supporting the medical 
needs of the veteran, the Alzheimer's Association provides 
support from the community in terms of helping the caregiver, 
who is usually a wife, cope with these things that are going 
on, learn more skills and then we from the VA will offer, 
respite care will offer homemaker home health aide.
    So you are really combining the best of both worlds, 
because a veteran is not just a veteran. He is a member of a 
community, and his family is part of the community. So there is 
a lot of other community services that can be called upon to 
help with this relief and the support when it occurs. But I 
think the initial part of helping to educate--that is why it is 
so important to identify it early--helps the family then cope 
when it becomes more difficult. But then rely on things like 
home-based primary care when it becomes more difficult for the 
family, and eventually sometimes the patients are not able to 
stay at home anymore.
    And then we use our VA nursing home, but in the meantime we 
have kept them out in the community with their loved ones as 
long as we possibly can and I think that is what really makes a 
big difference is that partnering.
    Chairman Rockefeller. If Senator Graham will forgive me, I 
just want to ask one more question to Tom McClure feeding off 
of what Dr. Moye said, and that is that the amazing complexity 
as people get to be 85 or older, and sometimes younger than 
that, and that is, you know, that is like saying that rain is 
wet. I mean that is inevitable.
    I am not trying to play doctor here, but that is the fact, 
when you get to be that age, because there is an enormous range 
of things that work together and then some manifest themselves 
more than others. Some fit under the category of Parkinson's, 
Alzheimer's, dementias, mental depression, schizophrenia, 
stroke. But, I accept what you say, but that is manifestly true 
across all fields of medicine, I would think.
    And so I would like to get your response, Tom McClure, to 
this general situation of resources and we just do not have the 
money to do this.
    Mr. McClure. Well, those eight service connected veterans 
that are 70 percent and above that are on my program, that is 
saving our hospital director about $320,000 a year. My budget 
is $95,000. That is not to speak of the VERA allocation on 
managing the medically complex patient of about 40 patients. I 
know that is not generating actual revenue, but it is bringing 
revenue into the VISN. But that is another good point about 
this, and we are managing medically complex patients.
    Chairman Rockefeller. And saving money?
    Mr. McClure. And I think the other thing to look at in a 
global view. Instead of just looking at the VA budget, if we 
can take veterans and place them in foster homes with that 
partnership, rather than into a nursing home, you know we are 
saving our national budget by managing them with a cost-
effective program, not to speak of the VA budget. And I think 
we must look at the entire budget of this nation in planning 
these.
    Chairman Rockefeller. Thank you, sir. Senator Graham.
    Senator Graham. Thank you, Mr. Chairman. Again, thank you 
for holding this hearing. One of the observations that has been 
made about these long-term care services, particularly the non-
institutional services, is that they are uneven across the VA 
system.
    Ms. Dickerson, you just gave a very persuasive statement 
about what you are doing in the Dallas area, as have each of 
you in your own particular VA centers. Why is not what you just 
described in Dallas or in Little Rock or among the Alzheimer's 
patients or among the geriatric mental health, why is that not 
the norm in VA as opposed to the exception?
    Ms. Hemmings. I can answer in terms of the Alzheimer's 
project. I think we were the pilot for the VA, and so we have 
given this information in the beginning to everyone in long-
term care via teleconference, and when the project is----
    Senator Graham. When did you provide that information?
    Ms. Hemmings. Well, we told them we started the project 
when we did in like 1997. We are having an evaluation finishing 
up this year, and then we will go back to everyone with the 
results of the project. We are in the middle of something, so 
you kind of do not say it is successful until you finish it, 
but I think we are always trying to keep people informed of 
what we are doing. So some of this might be related to the fact 
that you are in the middle of doing a project.
    Ms. Dickerson. In my case, I do believe that these types of 
programs will be successful all over the Nation once they 
realize that the resources, you do not have to hire a lot of 
people to do this, you just need to transfer around, move 
people around from the inpatient to outpatient if that is 
possible in other facilities as it was in our facility, because 
that is simply what we did.
    Senator Graham. You say whether it is possible to move from 
inpatient institutional care to at-home community care. Is that 
a constraint of physical facilities of people or what are the 
limitations on making that transition?
    Ms. Dickerson. There should not be any. There should not be 
any limitations on moving people around where they are needed 
and what is most cost effective and what is better for patient 
care.
    Senator Graham. Mr. McClure, what about in the area of 
foster care?
    Mr. McClure. Foster care, of course, I placed my first 
veteran in a foster home in 1987 on an informal basis because I 
did not have alternatives. But the VA in which I work for the 
central office funded this program in the year of 2000 as a 
pilot project and we just completed that. Our director, as I 
said, has already put it in his budget, and I think now it is 
time to act, and this is my own personal opinion and not that 
of the VA, but this program should go nationwide and 
immediately.
    Senator Graham. Well, I agree with you, not only because it 
is humane, but also you made the case that it is cost 
effective, but even more fundamentally the people who are our 
particular concerns, the veterans of America, they did not 
defend Little Rock, they defended the United States of America, 
and there ought to be an expectation of an evenness of service 
whether you live in the far Northwest or the far Southeast of 
the United States. We have a national system, and it ought to 
be a national system in terms of benefits readily available.
    Mr. McClure. And I do expect that.
    Senator Graham. Dr. Moye, as you were describing your 
program, I was struck with the fact that while you have been 
conducting you say nine areas that you have centers that you 
have been doing your pilot work?
    Ms. Moye. It was at nine VA medical centers, yes.
    Senator Graham. That this is not an issue that is peculiar 
to America's veteran population. If you saw the front page of 
today's Washington Post, there is an article that the President 
has indicated that next week he is going to make an 
announcement in support of parity for mental health treatment.
    To what degree is the information that you have gathered in 
your research applicable to the general American older 
population, and to what degree is it peculiarly relevant to the 
veteran population?
    Ms. Moye. That is a wonderful question. We know that mental 
health problems are underdiagnosed and undertreated in the 
current cohort of all older adults. For the reason I just 
suggested, I think there are stigma issues, there is lack of 
familiarity with, ``OK, this is what depression looks like, and 
when I have it I need to share it with my physician, I need to 
get some treatment for it.''
    However, I think the problem may be somewhat worse in the 
veteran population. I think we do a good job of identifying and 
treating serious mental illness such as schizophrenia, but not 
these sort of low level, but clinically significant, 
depression, anxiety, oftentimes related to war experiences. We 
did a survey in our outpatient clinics. We interviewed veterans 
waiting to see their doctors who were not in mental health 
treatment. 40 percent had a combat trauma history; 15 percent 
were to this day having problems with intrusive memories and 
nightmares.
    So I think when those things are also lurking and coming 
into the picture and then suddenly you are having illness and 
vulnerability and maybe a heart bypass surgery, that strains 
your coping resources and may make it more likely that you have 
some mental health issues arise.
    Senator Graham. Thank you, Mr. Chairman.
    Chairman Rockefeller. Senator Wellstone.
    Senator Wellstone. Thank you, Mr. Chairman, and I 
apologize. I had to go back and forth, and I missed your 
testimony, and Perry Lange was just giving me a summary of some 
of what you said, I think, and then I just was hearing Senator 
Graham's question of mental health.
    First of all, I want to thank you. I think really, you 
know, you kind of light a candle and you show what we can do at 
the community level, and I guess the only obvious question, and 
I gather you maybe touched on some of this, is whether or not 
you have received the kind of support that you would like to 
have from the existing VA system, and if not, where do we need 
to fill the gaps here, and if so, in what ways? That is, I 
think, my only question, you know, asking for as honest an 
answer as possible.
    I mean you should know what can be done. The question is 
are you getting the support from the existing VA system as is 
or not, and if not, you know, we do not have to get into 
acrimony, but where are the gaps? What do we need to start 
doing to make this happen throughout the VA system in the 
United States of America?
    Ms. Hemmings. Well, related to the Alzheimer's project, we 
received support by having us join the National Chronic Care 
Consortium, so we have been under support all along for this 
project, and then with our contacts with headquarters, when 
this is done, we will use that support to roll it out. So I 
think from that perspective, we have always had the support of 
headquarters in this project, because it has been something 
that we have identified as a real population need in our 
veteran population. And then the programs already exist in the 
VA. So that supported the types of home care that we needed.
    Ms. Dickerson. I feel in Dallas we have received the kind 
of support that we needed. When we wanted to start a Senior 
Companion Program, we were given the go-ahead to start a Senior 
Companion Program. We have 33 senior companions that, you know, 
this gives the seniors an opportunity to do a great service to 
stay with the veteran while the wife has a little respite.
    We have also been able to start many other programs. The 
telemedicine program, we received the support to start that, 
and that just broke through all distances. We can go 100 miles 
or 10 miles.
    Senator Wellstone. What are the critical elements of the 
support so that we can try to make these models be more and 
kind of apply system wide?
    Ms. Dickerson. I think system wide, the most important 
thing was you needed nursing service support. If you do not 
have the nurses who are the case managers, then your program 
cannot grow. So we had tremendous nursing service support. They 
closed beds in the hospital that were being underutilized and 
moved those resources to outpatient facilities, and then, of 
course, the director has to support what the nursing service 
chief wants, but I think the nursing service support was one of 
the biggest things that we had in Dallas.
    Mr. McClure. I would like to add to that I worked for 9 
years as a social worker with the HBPC program. I used every 
resource I could find to keep them at home, and there is a 
point in time when these veterans have to be removed. We can at 
least keep them in a family setting-HBPC and foster care. Our 
caregivers are ill and exhausted, and I feel like we need at 
least to attach a foster home program to each one of our HBPC 
programs in the Nation.
    Mrs. Dickerson, it is a wonderful program, they keep 
veterans at home as long as possible, but you can hire all the 
aides, have all the nurses that you can get, but there is a 
period of time where our veterans require 24-hour supervision. 
In Little Rock, I am taking those patients when HBPC cannot 
maintain them any longer, placing them in a capable foster home 
with the VA support, and we are managing them until they die.
    Ms. Moye. I spoke in my testimony about performance 
measures for clinicians, and one of the things that has been 
concerning for me is sort of, if I can come back to case load, 
sort of a blunt instrument about case loads, that we are under 
tremendous pressures to see as many patients as possible. And 
folks look at just absolute number of patients, and I wonder if 
it might be possible to develop some sophistication in this 
such as is done in chronic psychiatry where patients are 
described as maybe sustaining, moderate, intense and end of 
life, and if you are working in the intense or end of life 
area, then your case load expectation would be lower to 
accommodate that, because we know it would pay off in the end, 
and it would be what the veterans want.
    But it is hard to do that when the main pressure you are 
getting is see more people more quickly, you know, the absolute 
number of patients you see is the performance measure by which 
I am judged.
    Ms. Hemmings. Can I just make one other comment? It is not 
related to VA support, but I think as a part of what 
realistically what is happening and why some things cannot be 
done. I run the total geriatric program in upstate New York, 
and from that perspective, sometimes it is not just what is 
available in the community, and the other piece in terms of 
trying to do some of these programs is the issue of getting 
health care workers.
    It is not the money from the VA. It is what is available 
out in the community, and I think most of us that are in health 
care today are finding it more difficult to find the health 
care workers and the support that we need because people are 
not going into health care. So sometimes you cannot implement 
something you really want to implement just because the 
resources in the community are not there in which to pull from, 
and that is becoming extremely difficult for everyone in health 
care these days.
    I think that is another piece of it that has to be looked 
at, because we are part of the community and we buy some of our 
services from the community, and it is very difficult. People 
want to do everything else but be a health care worker these 
days.
    Senator Wellstone. Thank you.
    Chairman Rockefeller. Thank you, Senator Wellstone. I have 
other questions I want to ask, but I think in view of time 
constraints that I cannot or at least, I will not. And I want 
to point out that each of the four of you have made an enormous 
contribution. You have come from various distances, and you 
have made a great contribution to this, and you have raised the 
bar, I think, for our next witness, and for all of us.
    Ingenuity is what has always separated invention, the 
willingness to not fear that if you try to do something which 
is new, and you work for some government bureaucracy, that you 
are not going to be retaliated upon.
    And, fortunately, there are people who exercise that sense 
of ingenuity and risk taking. You might call it a model. You 
might call it a pilot or whatever. Nevertheless, you all are 
doing extraordinary things and helping people and loving it, 
and wanting to see it done for everybody. So I thank you all 
very, very much for taking your time to come.
    Ms. Hemmings. Thank you.
    Chairman Rockefeller. Our final panel today includes Dr. 
Robert Roswell, who is the newly, and I need to say that, the 
newly confirmed Under Secretary for Health. He is accompanied 
by Marsha Goodwin, who is the Acting Chief Consultant for VA 
Geriatrics.
    As I indicated earlier in the hearing, I broke with the 
usual protocol, to have Dr. Roswell not be the first but the 
last witness, and I wanted him to be able to listen to the 
testimony, both positive and less than positive, so that we can 
talk about VA and what is the most vulnerable veteran segment 
in the future. So, Dr. Roswell, welcome back. I am very glad 
you are here, and we look forward to your statement.

 STATEMENT OF ROBERT ROSWELL, M.D., UNDER SECRETARY OF HEALTH, 
   DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY MARSHA E. 
GOODWIN, R.N., M.S.N., ACTING CHIEF CONSULTANT, GERIATRICS AND 
EXTENDED CARE, AND DIRECTOR, GERIATRICS PROGRAM, DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Roswell. Well, thank you, Mr. Chairman. It is a 
privilege to appear before you as the Under Secretary for 
Health, and I appreciate your support in facilitating my 
confirmation. Mr. Chairman, Senator Wellstone, it is a pleasure 
to be here, and I want to thank both of you for calling 
attention to what I truly believe is a tremendous problem that 
we simply must do a better job in facing, and I salute you for 
your efforts in convening this hearing.
    You talked about deviations, and to allow a dialog I will 
not be making a formal statement, although I would ask that my 
statement by included in the record.
    Chairman Rockefeller. It will be done.
    Dr. Roswell. I have several concerns. You asked about OMB. 
The interim rules for the three services that were specified 
were actually published last year. The final rule will be 
published in the Federal Register next week, so admittedly this 
is too long, but those rules will be published very shortly, 
and we will have that implemented.
    I think this morning we have seen some truly wonderful 
examples, not only of compassion and commitment to the needs of 
veterans, but also in innovation in how we meet those needs. 
The four examples we have just heard are heart-wrenching really 
because there is such a great need, and there are many other 
examples as well throughout the country, tremendous innovation 
across our system.
    It is clear that we need a full continuum of services to 
meet the broad range of long-term care needs of America's 
veterans. Just as no two patients are alike, no two set of 
circumstances associated with long-term care are alike, and it 
is important that we maintain a full continuum of care, and 
nurture innovation in meeting and developing a full continuum 
of care.
    The cost of care per patient per year in long-term care 
services can vary from as much as $140,000 a year per patient 
in a VA staff nursing home bed to as little as $2,500 a year 
for home care programs using interactive technology.
    The Millennium Health Care bill focuses on our need to 
provide that long-term care, but with all due respect, Mr. 
Chairman, the one capacity that is measured is the most costly 
on that continuum, and that is the institutional long-term 
care, at an average cost of $140,000 per patient per year when 
the average cost of non-institutional care is only $10,000 per 
patient per year, meaning that we could serve 14 patients in a 
non-institutional setting for the cost of one patient in an 
institutional setting, and yet the Mil bill mandates that we 
maintain our 1998 VA staff nursing home capacity at historical 
levels.
    We have submitted from the department a request for 
legislation that would ask you to consider looking at the three 
levels of VA nursing home care--VA staffed nursing home care, 
state nursing home beds, and contract community nursing home 
beds--in meeting that obligation for commitment.
    I think that truly the most important part of this is 
making sure that we can deploy the resources in a way that 
meets the broad needs of our veterans. There are concerns now 
with tremendous growth in the users in our system, lengthy 
waiting times for access to care, and a statutory requirement 
which admittedly we have not yet complied with, but hope to 
comply with by 2004 to maintain the VA staff nursing home bed 
capacity.
    Those are the constraints that cause competition for the 
dollars. The 2003 budget request submitted earlier this year, 
however, would provide over $100 million for additional long-
term care services and would add staff to the 75 Home Based 
Primary Care Programs like the ones Gladys Dickerson spoke of 
throughout the country.
    It would also add 30 additional of those programs so we are 
committed to long-term care. We are committed to innovation. We 
are looking at ways to provide the needs in new and less costly 
ways, but more importantly that meet the needs of the veterans 
in a less restrictive environment that allow better quality of 
life and greater functional independence.
    I would be happy to answer any questions you might have.
    [The prepared statement of Dr. Roswell follows:]
  Prepared Statement of Robert H. Roswell, M.D., Under Secretary for 
                 Health, Department of Veterans Affairs
    Mr. Chairman and Members of the Committee:
    Thank you for inviting me to discuss non-institutional alternatives 
to long-term care provided by the Department of Veterans Affairs (VA).
    VA has a long history of providing high quality geriatric and 
extended care to chronically ill elderly veterans and is nationally 
recognized as a leader and innovator in the care of older persons. 
Today one of our greatest challenges is to find ways to meet the 
increasing demand for extended care services in the most appropriate 
settings and within available resources.
    As you know, veterans prefer to receive care in their homes and 
communities when it is possible to do so. These programs are highly 
cost effective in comparison to institutional care and allow VA to 
provide care to a greater number of veterans than would be possible 
through increased reliance on institutional programs. However, our 
ability to expand these programs may be impacted by the interaction 
between competing requirements.
            veterans millennium health care and benefits act
    Since Public Law 106-117, the Veterans Millennium Health Care and 
Benefits Act, became effective in November 1999, VA has focused on 
implementation of the extended care provisions of that law. To date, 
the following provisions have been implemented:
     Mandatory nursing home care for veterans rated 70% 
service-connected and above and for any service-connected veteran who 
needs nursing home care for a service-connected disability;
     Three pilot programs evaluating different models of all-
inclusive care for the elderly (VA as sole provider, at the Dayton 
VAMC; VA/community partnership, at the Denver VAMC; and VA as care 
coordinator, at the Columbia, SC, VAMC); and
     An assisted living pilot initiated in VISN 20 at all VA 
facilities in Alaska, Washington, Oregon, and Idaho.
    VA anticipates publication of final regulations on the medical 
benefits package and co-payments for extended care next week. The 
regulations--to be effective 30 days from the date of publication--add 
three non-institutional extended care services, outpatient geriatric 
evaluation, adult day health care, and respite care, to VA's standard 
benefits package. Other important extended care services, e.g., home 
care, hospice/palliative care, and inpatient respite care, were already 
in VA's standard benefits package. Also last October the Veterans 
Health Administration (VHA) issued a policy directive requiring 
provision of these non-institutional services. Access to these services 
is not currently uniform throughout the VA system, but work is ongoing 
to determine what barriers to access exist and to develop plans for 
addressing these barriers.
    The requirement to maintain staffing and level of extended care 
services in VA facilities no lower than the 1998 level is being met for 
non-institutional care (VA home-based primary care and VA adult day 
health care) but not for institutional care (VA nursing home care and 
VA domiciliary). Plans are in place to be in full compliance by 2004. 
The Administration has recently proposed legislation to implement the 
President's FY 2003 Budget that would revise the requirement for 
maintaining levels of extended-care services to veterans.
                       va long term care strategy
    As the VA health care system has redefined itself in the last six 
years as a ``health care'' system instead of a ``hospital'' system, 
VA's approach to extended care has further evolved from an 
institutionally-focused care model to one that includes a complete 
continuum of home and community-based extended care services in 
addition to nursing home care.
    In its 1998 report, VA Long Term Care at the Crossroads, the 
Federal Advisory Committee on the Future of Long-Term Care in VA, made 
20 recommendations and 4 related suggestions on the operation and 
future of VA long term care services. These recommendations served as 
the foundation for VHA's national strategy to re-vitalize and re-
engineer long term care services. One of the major recommendations of 
the Committee was that VA should expand home and community-based care 
while retaining its three nursing home programs (VA, contract 
community, and State home).
    VA is making progress on that strategy. Between 1997 and 2001, VHA 
average daily census (ADC) in home and community-based care increased 
from 11,500 to 16,150. VHA has a Budget Performance Measure calling for 
an ambitious 34 percent increase in the number of veterans receiving 
home and community-based care compared to FY 2001. We plan continued 
increases each year to achieve a level of 34,500 ADC in home and 
community-based programs in FY 2006. To achieve these goals, we will 
expand both the services VA provides directly and those we purchase 
from affiliates and community partners. We will meet most of the new 
need for long-term care through home health care, adult day health 
care, respite, and homemaker/home health aide services.
    The piloting and evaluation of new models of care will be 
important. One example you have heard about today is VA's Advances in 
Home-Based Primary Care for End of Life in Advancing Dementia (AHEAD) 
quality improvement project, which was initiated in 2001 with 20 VA 
teams from 15 networks. AHEAD II is now underway to include a wider 
variety of primary care settings that serve community-dwelling veterans 
with dementia.
    VA also must explore utilization of new technologies, such as 
telemedicine, to expand care of veterans in the home and other 
community settings. We have shown that by using interactive technology 
to coordinate care and monitor veterans in the home environment, we are 
able to significantly reduce hospitalizations, emergency room visits, 
and prescription drug requirements, while improving patient 
satisfaction with the care they receive. Use of technology not only 
reduces the need for institutional long-term care, but also provides 
veterans with a more rewarding quality of life and greater functional 
independence. For example, in FY 2000 VISN 8 developed an innovative 
alternative to institutional care known as the Community Care 
Coordination Service (CCCS). CCCS provides care coordination of groups 
of clinically complex, high cost, chronically ill patients. With the 
use of technology, CCCS has improved their quality of life and their 
perceived functional status, thus allowing them to remain both 
independent and at home. A recent survey of these patients showed that 
41 percent would be in a nursing home if not for enrollment in this 
program. An Odds Ratio Analysis has shown that these patients were 77.7 
percent less likely to be admitted to a nursing home than a similar 
group that did not participate in the program. The innovative use of 
technology has also improved communication and clinical relationships 
with the State veterans domiciliary in Lake City, FL, and has increased 
access to assisted living facilities. A care coordinator has become the 
primary communication link between the domiciliary and the local VA 
medical center. This enhanced communication has reduced unscheduled 
clinic visits by veterans in the State home by 29 percent.
    To the extent that we can do so within the existing programmatic 
resources, VA's plans for long-term care are as follows:
     achieve an integrated care management system that 
incorporates all of the patient's clinical care needs;
     provide more care in home and community-based settings as 
opposed to inpatient settings, when appropriate;
     achieve greater consistency in access to and quality of 
care provided in all settings;
     achieve greater consistency across the system in assessing 
patients for extended care and in managing care, including post 
institutional care;
     continue to emphasize VHA research and educational 
initiatives that will improve delivery of services and outcomes for 
VA's elderly veteran patients; and
     continue to develop new models of care for diseases and 
conditions that are prevalent among elderly veterans. You have heard 
testimony today about VISN 2's participation in one such initiative to 
find better ways of caring for veterans with severe dementia. To help 
find better ways of caring for these veterans, VHA is participating in 
a multi-site demonstration project on Alzheimer's disease and care 
management, which is co-sponsored by the Alzheimer's Association and 
the National Chronic Care Consortium (NCCC).
                               conclusion
    VA has made considerable progress toward organizing a geriatrics 
and LTC system that can respond to shifts in demand and to changes in 
local healthcare market characteristics, and provide seamless care. We 
have launched major national initiatives to improve end-of-life care 
and pain management for veteran patients. We are in the process of 
implementing an aggressive home- and community-based care strategy.
    Mr. Chairman, this concludes my prepared remarks. For information 
purposes, I have included two attachments to my statement. The first 
addresses veteran demographics and population projections; the second 
discusses VA's geriatric and extended care programs. I will now be 
happy to address any questions that you and other members of the 
Committee might have.
     Attachment A.--Veteran Demographics and Population Projections
    Between 2000 and 2010, the veteran population is currently 
projected to decline by 17.7 percent (from 24.3 to 20.0 million). 
However, this projection may change due to the current armed conflicts. 
Over the same time period, the percent of veterans over the age of 65 
will decline only by 9 percent (from 9.3 million to 8.5 million), while 
those 75 and older will increase 12 percent (from 4 to 4.5 million), 
and those over 85 will increase by 208 percent (from 422,000 to 1.3 
million). To continue to provide the appropriate and needed service to 
veterans, this ``demographic imperative'' must be addressed.
    At present, about 38 percent of the veteran population is over 65, 
compared to about 13 percent of the total U.S. population. Over 51 
percent of veterans who have service-connected disabilities or are poor 
are over 65. The number of veterans over age 65 peaked at 9.3 million 
in the year 2000, when 66 percent of all American males aged 65 and 
over were veterans. A second but smaller peak is expected to occur in 
2015, with the aging of Vietnam-era veterans. The projected peak in the 
number of elderly veterans during the first decade of the 21st century 
is well in advance of the general United States population (which is 
expected to peak in the year 2030). This is one of the driving forces 
behind VHA's current efforts to find high quality, affordable extended 
care solutions for meeting the needs and preferences of veterans.
    The most vulnerable of our older veteran population, those over 75 
and particularly those over 85, will continue to increase into the next 
decade. This is notable since these persons are especially likely to 
require institutional care and to need healthcare of all types. Also of 
importance is the fact that current VA patients, compared to the 
general population, are not only older, but they also generally have 
lower incomes and no health insurance, and they are much more likely to 
be disabled and unable to work. While it is important to maintain our 
nursing home capacity to serve the post-acute rehabilitation, respite, 
geriatric evaluation and hospice/palliative care needs of older, 
chronically disabled veterans, it is equally important to expand our 
home and community-based extended care options wherever possible and 
appropriate.
    Attachment B.--Current VHA Geriatric and Extended Care Programs
    Today, VHA provides a comprehensive array of long term care 
services that include direct VHA provided services, services purchased 
in the local community, and services supported through construction and 
per diem grants to states. VHA also assists veterans and families in 
obtaining services through other publicly funded healthcare programs 
such as Medicare and Medicaid, and provides assistance in obtaining 
services that are personally financed by the veteran. While the array 
of services provided by VHA is comprehensive, all services are not 
available in all VA locations, and access to care is currently not 
equitable across the system. The major long term care programs provided 
by VA are described below:
    State Veterans Homes. A significant part of VHA's long term care 
strategy is effected through one of the longest existing Federal-State 
partnerships, the State Home Grant program. Through this program, the 
Department provides grants to states for the construction and support 
of state veterans homes to provide long term care for frail, elderly 
veterans. The construction grant program provides up to 65% federal 
funding to states to assist in the cost of construction of new nursing 
home and domiciliary facilities, or expansion or remodeling of existing 
facilities. VA's per diem program, part of the Medical Care account, 
assists states in providing domiciliary and nursing home care for 
veterans through partial payment of per diem costs. Most recently, 
regulations have been published on per diem payments for provision of 
adult day health care in State homes. In FY 2001, over 16,000 veterans 
on any given day were provided nursing home care in state veterans 
homes. While this program dates back to the post-Civil War era, it has 
grown dramatically over the past 10 years. The state home program 
substantially augments VHA's capacity to provide a continuous residence 
for veterans in need of long term care, especially for veterans in 
rural areas.
    The Geriatric Evaluation and Management (GEM) and Geriatric Primary 
Care Programs. The majority of VA medical centers have GEM and/or 
geriatric primary care programs. The GEMs provide both primary and 
specialized care services to a targeted group of elderly patients on an 
inpatient unit or in outpatient settings. On the inpatient GEM units, 
an interdisciplinary team of geriatric experts performs comprehensive, 
multidimensional evaluations of frail, elderly patients. The goals of 
these intensive services are to improve functional status; to stabilize 
the acute and chronic medical conditions and/or psychosocial problems; 
and to discharge the patient to home, residential care, or to the least 
restrictive environment feasible.
    GEM clinics provide similar comprehensive care for geriatric 
patients on an outpatient basis in addition to providing primary care 
for frail, older patients to prevent unnecessary institutionalization. 
The geriatric staffs also are available for specialty consultation on 
elderly patients with complex problems being cared for by primary care 
and other specialty services.
    Geriatric primary care clinics have been expanding in VHA over the 
past few years with the move from inpatient to outpatient care and 
expansion of primary care throughout the system. These clinics provide 
geriatric evaluation services and on-going primary care for geriatric 
patients.
    Nursing Home Care Units (NHCUs). VA nursing homes provide skilled 
nursing and related medical services through an interdisciplinary 
approach to meeting the multiple physical, social, psychological and 
spiritual needs of patients. Most also provide sub-acute and post-acute 
care. In general, these units are co-located with or are an integral 
part of the VA medical center. In FY 2001, 41,934 veterans received 
care in VA's 135 NHCUs.
    Community Nursing Home Care. VHA contracts with approximately 2,800 
community nursing homes to provide nursing home care for veterans 
making a transition from the hospital to the community. Each community 
nursing home is evaluated and inspected by VHA staff prior to selection 
as a contract facility, and VHA staff provides follow-up visits to 
assess the progress of veterans admitted to the facility and to monitor 
the overall quality of care.
    In order to improve access to community nursing homes and reduce 
the administrative cost associated with maintaining hundreds of 
individual contracts, VHA has recently developed contracts with multi-
state nursing home providers. In 1996, six multi-state contracts and 
one single-state contract were awarded to corporations for quality 
community nursing home care in 1,053 facilities. These seven contracts 
together span 43 states and added nearly 600 nursing homes to VHA's 
existing contract community nursing home program. Since 2000, VA has 11 
Regional Contracts (replaced multi-state), which include 8,000 
facilities. In 2001, nearly 28,800 veterans were treated in community 
nursing homes at VA expense.
    Adult Day Health Care (ADHC). This therapeutically oriented program 
provides health maintenance and rehabilitation services to veterans in 
a congregate, outpatient setting. VHA operates 14 ADHC programs, which 
had an average daily attendance of 446 patients in FY 2001. VA also 
contracts with an estimated 480 non-VA agencies for ADHC, which 
provided services to an average of 804 veterans each day in FY 2001. 
The contract program has been established by 66 VA facilities.
    Alzheimer and Other Dementia Care Programs. Approximately 52 VA 
medical centers have developed specialized programs for the care of 
veterans with dementia. These programs include inpatient and outpatient 
dementia diagnostic programs, behavior management programs, adapted 
work therapy programs for patients with early to mid stage dementia, 
Alzheimer's special care units within VA nursing homes and transitional 
care units, and a model inpatient palliative care program for patients 
with late stage dementia. Programs for family caregivers of dementia 
patients include support groups and caregiver education, as well as 
respite and adult day health care services for the patient that allow 
``free time'' for the caregiver. Many of these specialized programs for 
patients with dementia have been developed by VHA's Geriatric Research, 
Education and Clinical Centers (GRECCs). Seven of the current 21 GRECCs 
have a primary or secondary focus on Alzheimer's disease and related 
dementias. These GRECCs have made significant contributions to both the 
scientific understanding of dementia and improved models of care for 
dementia patients.
    Home-Based Primary Care. This program is operated at 75 VA 
facilities across the country to provide in-home primary medical care 
to home-bound veterans with chronic diseases, as well as to patients 
with a terminal illness. The patient's family provides the necessary 
personal care under the coordinated supervision of an interdisciplinary 
treatment team based at the VA facility. The team plans and provides 
for the needed medical, nursing, social, rehabilitation, and dietetic 
regimens and trains family members and the patient in supportive care. 
In FY 2001, comprehensive primary care was provided in the home by VHA 
staff to an average of 7,803 patients on any given day.
    Contract Home Health Care. VHA also arranges with community home 
health agencies to provide skilled home care services for veterans. 
Under this program, VA pays a per-visit rate to the agency providing 
the service, similar to what is done under the Medicare program. In FY 
2001, 3,273 veterans were provided these services on any given day.
    Domiciliary Care. Domiciliary care is provided in VA domiciliaries, 
as well as State homes. VA domiciliaries provided care to 24,931 in FY 
2001. Nearly 5,000 of those veterans were homeless and admitted for 
specialized care. In addition to services for the homeless, the 
domiciliary provides other specialized programs to facilitate the 
rehabilitation of patients who suffer from head trauma, stroke, mental 
illness, alcoholism, early dementia, and a number of other disabling 
conditions. Although the average age of veterans overall in VA 
domiciliaries is 59 years (43 years for those in the homeless program), 
increased attention is being focused on older veterans who reside in VA 
domiciliaries. For example, elderly domiciliary patients are encouraged 
to become involved with programs in the community such as senior 
centers and Foster Grandparents. These activities have facilitated 
continued community involvement as well as reintegration into the 
community. Many of the domiciliaries in state veterans homes provide 
similar services, although patients in the state home domiciliaries 
tend to be older. In FY 2001, 47 State Veterans Home domiciliaries in 
33 states served more than 6,400 veterans.
    Community Residential Care/Assisted Living. This program provides 
room, board, personal care, and general health supervision for veterans 
who, because of health conditions, are not able to live independently 
and have no suitable family or social support system to provide needed 
care. A multidisciplinary team of VHA staff inspects private homes that 
provide residential care/assisted living services prior to including 
the home in VHA's program and annually thereafter. Payment for services 
provided in a residential care home is the responsibility of the 
individual veteran. In FY 2001, 7,055 veterans received residential 
care on a daily basis in homes approved and monitored by VHA.
    Homemaker/Home Health Aide (H/HHA). This program enables selected 
patients who meet the criteria for nursing home placement to remain at 
home through the provision of personal care services. The H/HHA 
services are purchased by VHA from public and private agencies in the 
community. Case management is provided directly by VHA staff. During FY 
2001, 120 VA facilities purchased these services for approximately 
3,824 veterans on any given day.
    Respite Care. Another program that enables the chronically ill, 
disabled veteran to live at home longer than would be otherwise 
possible is respite care. This program is available at nearly all VA 
facilities and is designed to reduce the caregiving burden from the 
spouse or other caregiver by admitting the veteran to a VA hospital or 
nursing home for planned, brief periods, totaling no more than 30 days 
per year. During the inpatient stay, patients are also provided with 
evaluative and treatment services needed to maintain or improve 
functional status, thus prolonging the veteran's capacity to remain at 
home. A formal evaluation of this program, concluded in 1995, found a 
high level of satisfaction among family caregivers and a high level of 
enthusiasm for the program by VHA staff delivering the care. In FY 
2001, nearly 700 veterans were receiving respite care on any given day. 
Home respite was authorized under P.L. 106-117 and programs have been 
initiated at a number of VA facilities, utilizing contract services and 
piloting the use of volunteers to provide the respite services.
    Hospice/Palliative Care. A number of VA medical centers have an 
interdisciplinary hospice/palliative care consultation team that is 
responsible for planning, developing and arranging for the local 
provision of hospice care, directly by VA or through contract or 
referral to community programs. Hospice/palliative care programs offer 
pain management, symptom control, and other medical services to 
terminally ill veterans or veterans in the late stages or chronic 
disease process, as well as bereavement counseling and respite care to 
their families. System-wide education and training was provided in the 
early 1990's to facilitate the incorporation of hospice/palliative care 
concepts into each VA facility's approach to the care of veterans at 
the end of their lives. New education programs are being planned to 
reinforce the concepts for current staff. Approximately 42 percent of 
VA facilities have inpatient hospice/palliative beds but nearly 38 
percent of facilities have neither inpatient beds nor consultative 
services. The majority of VA facilities refers or contracts for hospice 
services through community-based agencies. Hospice and palliative care 
initiatives are currently being intensified throughout VHA to improve 
end-of-life care for veterans. Specific strategies to increase the 
availability of these services to veteran patients are currently under 
development.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Patty Murray to Robert 
                              Roswell, MD
    Question 1. Do you believe the VA should work with private home 
health care providers to meet its obligations to provide veterans with 
long term care opportunities?
    Answer. Collaboration with private home health care agencies is 
integral to VA's success in meeting the home health and long-term care 
needs of veterans. Through the VA Community Health Nurse Coordinator 
program, VA works with private home health agencies in providing needed 
care to veterans. The majority of the effort in this program involves 
referrals by VA staff of those veterans who choose to use their 
Medicare eligibility to home health care (HHC) agencies. Additionally, 
VA maintains arrangements with over 500 HHC agencies for the provision 
of care at VA expense. In FY 2001, approximately 3,300 veterans were 
enrolled in skilled private HHC, and another 3,800 were enrolled in 
homemaker/home health aide services at VA expense on any given day.
    Question 2. Without Medicare reimbursement, home health agencies 
cannot survive, despite an infusion of VA funds. How can we address the 
inequities in funding that may force many home health care providers to 
leave?
    Answer. Home Care expenditures from all payers totaled $32 billion 
in FY 2000 (latest available data). In that year, private funds covered 
47.8 percent of all HHC spending ($15.5 billion), and public, non-VA 
funds (Medicare and Medicaid) covered 51.9 percent ($16.8 billion). 
VA's expenditures of $108 million for skilled HHC and home health aide 
services in FY 2000 represent only 0.3 percent of home care spending. 
VA's current and planned efforts for purchasing home care services do 
not indicate a major presence in the marketplace. This Department has 
no opinion on the larger issues of Medicare reimbursement.
    Question 3. Has the VA carefully considered access for all 
veterans, regardless of where they live, when developing options to 
nursing home care?
    Answer. VA's planning model for long-term care (LTC) services, both 
nursing home (NHC) and home and community based care (H&CBC), is based 
on the enrolled veteran population, rather than the total veteran 
population. To the extent that veterans who live at a distance from a 
VA Medical Center are enrolled in VA for their health care, then their 
needs for LTC are addressed. In this regard, nursing home care is 
mandated for veterans with a 70% or more service-connected disability. 
Veterans with less than a 70% service-connected disability receive care 
on a resource available basis.
    One of the advantages of contracting or purchasing home care is 
that VA can address veterans' HHC needs without attempting to provide 
it directly in geographic locations where demand for care could not 
justify an efficient VA-operated program. At the same time, VA has been 
successful in establishing Home Based Primary Care (HBPC) Programs at 
VA clinics located at a distance far from the host VA medical center. 
The HBPC Programs at Hot Springs, Arkansas and Joliet, Illinois are the 
best examples of VA-operated satellite home care efforts.
    Access to nursing home care for veterans is provided through VA's 
three programs: VA nursing home care units (NHCU); contract community 
nursing homes (CCNH); and State veteran nursing homes. There are 
currently 135 VA NHCUs, contracts with 2,800 CCNHs and 11 regional 
contracts, and 102 State nursing homes. Increased demand for nursing 
home care will primarily be met in CCINIH and State nursing homes. 
Construction of new State home beds, with VA providing up to 65 percent 
of the cost, is based on veteran population need in each geographic 
area.

    Chairman Rockefeller. OK. I want to just deal, Dr. Roswell, 
with your statement you have made. You are correct that 
Congress has said that VA must not reduce nursing home beds, 
and on the other, that VA must increase its efforts of non-
institutional long-term care. You would like to be relieved of 
one to do more of the other.
    Unfortunately, both are necessary elements to long-term 
care. So you are not going to get that wish under the laws of 
health care. Some people just do not stay in the community, 
cannot stay in the community, should not stay in the community. 
So you have asked for relief from VA staffed nursing home beds 
requirement.
    I am willing to entertain the possibility of some change. I 
think we must be assured that VA retains sufficient capacity to 
provide institutional long-term care for those who need such 
services, and I want you to talk about those who do need such 
services, and if you do not do it, then I will get Dr. Moye to 
come back to do it.
    So far, VA has not been able to do this in the area of 
specialized services, and so I do not know how I am meant to 
react to what you just said. In a sense you gave a reason why 
you cannot comply--because it costs $140,000 per patient for 
institutionalized care--knowing full well as you said that that 
that is also going to continue and has to.
    You said that the rules and regulations are going to be out 
in a week. I hope, I assume that is to provide me with some 
sense of comfort or a mission well done. Again I recognize you 
have just been on the job, so I am talking more to predecessors 
of yours, but I am talking to you, because you are now 
responsible and you took the oath.
    And so that is sort of a nice little wrap-up that you do 
more of what the four folks were talking about, and that they 
are wonderful. You have also got this other little burden, 
which you and I know that you cannot get rid of, because all 
people cannot go back to the community for long-term care.
    So, I guess what I want to say is are you trying to kind of 
slide by me on this one? And point out your problems? You have 
not used resources. Others were told not to use resources, but 
that was the first thing that came out of your mouth--I would 
but I cannot--because these other institutionalized are too 
expensive.
    And is that, in terms of the outcome for the veteran, 
unacceptable? I guess I cannot accept it, and if Ms. Dickerson 
can find ways to do things and you are the second-largest 
agency in the entire Federal Government outside of the 
Department of Defense with over 200,000 people, I believe, 
there must be some ways that you can say something other than 
relieve me of this one and I will do the other. Care to 
comment?
    Dr. Roswell. Yes, Mr. Chairman, I appreciate the 
opportunity to comment. First of all, I do agree with you. We 
must maintain our institutional capacity. There is no question 
that many veterans at some point will need institutional care. 
We think we can delay that in many cases, put that off until 
later stages of a disease process and in some cases avoid it 
altogether, but there is no question, the institutional 
capacity will be needed.
    All I was suggesting is that our institutional capacity is 
split across VA staff nursing home beds, which we own and 
operate at an average cost of $380 per day, contract community 
nursing home care, which we procure for veterans in an 
institutional setting in the community at an average cost of 
$185 a day, and skilled nursing home care in homes operated by 
the states through the state grant program that provides 
skilled nursing home care at an average cost to the VA of $50 
per day.
    There are three levels or three different types of 
institutional long-term care, and I am suggesting that if we 
aggregate the total amount in 1998 between those three, that we 
be held accountable to the 1998 level of capacity for all of 
our long-term care institutional beds as opposed to just the 
skilled beds operated only by the VA.
    Now, having said that, finding resources, yes, we have to 
do both. We have to look at non-institutional programs as we 
meet that institutional commitment. My point is that there is a 
fierce demand for resources now as our system has grown, and 
this year we will have over six million veterans enrolled with 
over 4.3 million veterans using the system, reaching levels 
that we have never ever attained in our history.
    When we look at non-institutional care, we find that many 
programs are being developed, and people are finding resources 
just to----
    Chairman Rockefeller. Can I interrupt for a second?
    Dr. Roswell. Certainly.
    Chairman Rockefeller. I apologize. You see that is what I 
call sliding by me and Senator Wellstone. Because, of course, 
there are endless requirements in health care, and of course 
you have budget constraints which you have quickly brought up, 
and of course you have the responsibility, and of course there 
is a war on terrorism, and of course there is homeland 
security, and of course we have gone from a $5.6 trillion 
surplus to $100 billion deficit for a variety of reasons.
    And, of course, you must do your duty and you shall take 
care of these people. So I am not predisposed to say that 
because you have so many veterans who are getting older and 
their problems are getting more complex, that you take what can 
possibly be identified as the most obvious and clearly the 
fastest growing health care problem that you do and will face, 
and say, well, we cannot comply.
    Either VISN 2 is an anomaly or you set up some experiments 
which you are going to keep as experiments, so that there is 
always something good to say about what VA can do. Those regs 
will be in effect in a week, but none of that gives me 
confidence that you are going to actually go ahead and do it. 
And I guess that is what Senator Wellstone and I are looking 
for is that you are going to go ahead and you are going to do 
these things, and you are going to be like Ms. Dickerson.
    You are going to move ahead, and you are going to 
understand what Dr. Moye says that things are going to get much 
more complicated as patients get older. There is not only a law 
and a mandate here, but it is one which seems to take kind of a 
primacy among health care problems that the veterans face.
    I mean it just sort of stands out and hits you, so to 
speak. So I am just inpatient with your answer because I am not 
sure what is going to come of it. We have hearings, and 
somebody said these hearings are very useful. These hearings 
can be very useful. They can also be a wonderful opportunity 
for us to say things, sometimes in goodwill, sometimes in less 
goodwill. Hearings always end. And people from the Federal 
Government are extremely accustomed to handling them; some of 
them handle them extremely well. They know exactly what answers 
to give. Sometimes they tell witnesses what answers not to 
give.
    But in any event, the hearings pass, yet in many case the 
problems persist. And what I think Senator Wellstone and I want 
to know is that you are going to be doing something about this 
on a broad scale and that your nursing home problem is going to 
be right there, and you are still going to find a way around 
it.
    Dr. Roswell. Yes, Mr. Chairman. We have actually submitted 
a plan to be fully compliant with the Mil bill requirements for 
institutional VA long-term care capacity.
    Chairman Rockefeller. To whom?
    Dr. Roswell. To Chairman Smith of the House Veterans 
Affairs Committee, because he requested it. That would bring us 
into compliance with that requirement by the end of fiscal year 
2004, reaching the 1998 VA staff census of 13,391. But that is 
not enough.
    Chairman Rockefeller. I mean is a point by point plan or is 
it a series of generic goals? Plus I would like to have a copy, 
if that would not be inconvenient?
    Dr. Roswell. We can provide you with that.
    Chairman Rockefeller. That would be very nice.
    Dr. Roswell. The plan basically allocates an average daily 
census to each of the 21 VISNs to be achieved this year, and 
then an interim average daily census next year to bring us back 
to that level. It will be at a cost of an additional $161.2 
million to be able to get there, and that is money that will 
have to come from somewhere, but, yes, it is a statutory 
requirement, Mr. Chairman. I respect that. I honor that. We are 
committed to it.
    But there is a cost associated with that, but we will do 
everything we can to move toward that statutory requirement. I 
think the hearing--I wanted to focus, I think you wanted to 
focus, on non-institutional care.
    Chairman Rockefeller. Right.
    Dr. Roswell. And that is----
    Chairman Rockefeller. But I got very hung up when you 
started dangling that $140,000 nursing home cost per year, 
because I felt----
    Dr. Roswell. Well, for example, as you know, I came into my 
current position from being the VISN director in VISN 8. That 
is a VISN I can talk greatly about. Our assigned ADC to 
increase this year is 109 patients. That will cost probably in 
excess of $10 million in additional staff to be able to move 
the census to that level.
    Two and a half years ago, I shared the concerns you have 
echoed this morning and some of our panelists have echoed. I 
took $5 million out of the VISN 8 budget because I found a way 
to find those resources to create a program to meet long-term 
care needs. With less than $5 million a year, we now operate a 
community care coordination service.
    The director is sitting here in the gallery today. That 
community care coordination service provides care in a home 
setting using interactive technology to over 1,300 patients. 
Now the average cost per patient is $2,500 per year. Many of 
those patients are at great risk for nursing home placement and 
would only be in a home care environment were it not for this 
particular program.
    That is important to me. Would I like to expand that? Yes. 
Which is a greater cost? Meeting our average daily census 
requirement in VA staffed nursing home beds is a greater cost 
to add 109 patients than it would be to double or to triple the 
1,300 patients receiving home care services.
    Chairman Rockefeller. Paul, just forgive me, and then I 
will be quiet and go to you.
    Senator Wellstone. I may have to leave anyway. You go 
ahead. I may have to leave.
    Chairman Rockefeller. I do not know why it was that I did 
not leap up when you said we are going to have this all in 
effect by 2004, because my instinctive reaction is that, No. 1, 
this is 2002, and the bill was passed in 1999. So that is a 
nice long chunk of time.
    You do not have to go; do you?
    Senator Wellstone. Actually I have people outside to go to 
see. That is OK. You keep going.
    Chairman Rockefeller. Then you go ahead and ask a question.
    Senator Wellstone. No, no, no.
    Chairman Rockefeller. No, you go ahead.
    Senator Wellstone. Just tell me when you are done and I 
will come right back in. I will do that.
    Chairman Rockefeller. OK. I am not going to tell him when I 
am done. [Laughter.]
    Dr. Roswell, are you going to wait until 2004 and then all 
of a sudden the firecrackers go off? I mean is the upper New 
York model going to be replicated all over the place? I mean 
you said you did it yourself, and you seem pretty happy about 
it. So are we going to wait until 2004, or?
    Dr. Roswell. No, it is a ramp up. Our current average daily 
census is 11,000. Marsha can you help me. 11,506 approximately.
    Ms. Goodwin. Yes; 11,506.
    Dr. Roswell. So we have got to go from that number, 11,506, 
to hit an end census of 13,391 by September 30, 2004. 
Obviously, to staff those beds does not meet the statutory 
requirement. The statutory requirement is that the patients in 
the staff beds be at 13,391. So over time we will place 
patients as we add staffing and identify patients that are 
suitable candidates for VA staff nursing home care.
    In the spirit of disclosure, though, it is important that 
this committee understand that VA staffed nursing homes provide 
a very high level of skilled rehabilitation care. 70 percent of 
the people who receive care in VA staffed nursing home beds are 
discharged to home. That is a remarkable statistic.
    But it reflects not so much our clinical outcome as the 
fact that the beds are used primarily for the rehabilitation of 
acute medical and surgical problems, and it is truly not end-
of-life long-term care. That type of care is much more 
compassionately and cost-effectively provided in State home 
beds, the State Department of Veterans Affairs home beds, where 
we have had a major growth over the last several years, and I 
would hate to deter that growth in the State home program, 
because it provides an ideal setting for veterans who have 
continuous stay long-term care requirements and are not 
suitable for care in the home environment.
    Chairman Rockefeller. Secretary Rumsfeld did something 
recently which I kind of liked. He sort of replaced some 
generals who fought wars the way they used to be fought, with 
generals who can fight wars the way they are going to have to 
be fought. I have to assume that he took a lot of criticism for 
that, and I do not know how deep it reaches. I have no idea 
what he had to go through in order to do that.
    The point of my question obviously is that if you go from 
fighting land-massed wars to the kind of wars that we are now 
fighting, you have to change what you do. Now, I am not on the 
Armed Services Committee. I did not have a chance to ask him 
how you get people to redirect their thinking.
    But this is a war that is not waiting for you, and you have 
raised problems. You have to change the culture of bureaucracy, 
and I do not know that you have to change generals, but you 
might, and I am interested in how you personally arrive at how 
you implement this by people who will have to, let us say 
unlike Ms. Dickerson, who is dealing with a specific situation.
    I mean you are dealing with old roles and with people who 
have been doing this for 30 years, and by golly, they are not 
going to have some guy who has just come in as head of health 
and tell them what to do. And so your battle plan for attacking 
that and implementing all of this by 2004 ramped up or not?
    Dr. Roswell. You know you make an excellent point, Mr. 
Chairman. A lot of the way we approach long-term care is in 
traditional models. Now, the 1,300 patients I spoke of in 
Florida are not even counted in our long-term care count 
because they do not fit a traditional model. They are not 
institutional care. They are not adult day health care. They 
are not home-based primary care. So they do not fit in any of 
our traditional categories, and we do not even count them. so 
they are not in our total workload capacity.
    One of the things I will clearly be doing with the 
leadership in the geriatrics and the extended care part of VHA 
will be working to develop new programs, to develop new models 
of care, to use field-based clinicians, like the talented 
people you heard this morning, to define new programs, new 
approaches to care, so that we can have a broader continuum of 
care and we can define how that care is provided, and that will 
lead us to replicate that across that system in a cost-
effective manner.
    Chairman Rockefeller. OK. Look, I am interested in results. 
I am also interested in Senator Wellstone coming back to ask 
his question. [Laughter.]
    And then I am going to dismiss the hearing, and here he is.
    Senator Wellstone. Gee, I forgot. Actually I think, Dr. 
Roswell, I think I do not find myself, it would not surprise 
you, in disagreement with the chairman. I mean I think, you 
know, I feel exactly the same way about it. The one thing that 
also occurs to me, and it is just sort of one comment which is 
in the form of a question, and react any way you want to, is 
also I think there is, you know, look above and beyond our 
saying come on, we are inpatient with the slowness, make this 
happen. We have got models, let us do this. I also think, 
though, that this debate about, Senator Rockefeller, about how 
much it is institutional care versus how much is it going to be 
home-based care.
    You know what I worry about are these sort of zero sum 
games that we are going to have to play. In other words, it is 
a false choice, I mean if we have the resources, and I also 
look at other parts of our health. In our region, we are seeing 
some pretty darn severe strains right now.
    We do not have the adequate funding. So the other thing I 
want to say to you is, you know, if you do not have the 
resources, you got to say it. I mean you got to come up here 
and say to us, listen, we need to do both. We cannot like 
cannibalize, you know, nursing home care for the sake of doing 
home-based care, but home-based care makes a lot more, but 
there is a lot of people that could benefit from that, and then 
there are other needs as well, and you all need to give us the 
resources we need.
    So my appeal to you would be, you know, you have to say it. 
And I frankly think you should. I mean I think a number of us 
are going to work on a supplemental bill. We are going to argue 
we need more resources. Now, Senator Rockefeller is going to 
say there is lots of ways you can get your priorities right and 
deliver some of this care right now, but I also think--I 
personally think you got a big resource problem, and I think 
the VA needs to be bolder in telling us that we need to step up 
to the plate with the resources that you need, but I cannot 
tell you what you need unless you tell me what you need. That 
is the only thing I would add.
    Dr. Roswell. Well, Senator Wellstone, thank you. I 
appreciate your comments and I appreciate your support. In his 
letter to Chairman Smith, Secretary Principi indicated the plan 
to get there, and I do not know that he specified the exact 
cost. He did. He identified that the cumulative shortfall to 
meet the Mil bill requirements is $161.2 million.
    That is an operational shortfall in our budget right now to 
be able to meet the statutory requirement of the Mil bill just 
as it applies to the VA staffed inpatient nursing home 
requirement of the 1998 capacity at 13,391.
    Senator Wellstone. That is on top of the $400 million 
shortfall he identified last November as well?
    Dr. Roswell. It is on top of the $142 million for priority 
seven. Now, the $400 million included management efficiencies 
that are being sustained by the various 21 VISN's, but that 
information, Senator, I will be happy to leave is detailed in 
that letter.
    I guess my concern is that it is so much more than 
institutional long-term care. There is so much we need to do. 
We need to have VA staffed nursing home beds, but we need State 
home beds, more State home beds. We need to use contract 
community nursing home beds, because each meets a different 
need. We clearly need to develop and nurture the innovation and 
the commitment that was seen on the previous panel.
    We need to develop models that allow greater functional 
independence that offset the need for institutional care, to 
preserve the quality of life as long as we possibly can.
    Senator Wellstone. Well, I just want to interrupt you and 
finish. I like what you are saying. I just think that, and, you 
know, look, this is not the VA. I just would love for the VA to 
be a model for the Nation, and I mean we have the same issue 
with the population at large. We have, I think, Senator 
Rockefeller, that we have our collective heads ducked in the 
sand when it comes to the demographics of our country and the 
number of people that are going to live to be 80 and 85, and 
how are you going to have people staying at home in as near 
normal circumstances as possible living with dignity that way, 
and then when they can--I had a mother and father with 
Parkinson's.
    We lived all of this, and then we cannot, then there will 
be good care, you know, high quality care, which we do not have 
in our nursing homes right now, and so it is not just VA, but I 
think the whole point of this legislation was for us to sort of 
lead the way; am I correct? And that we are not doing. But we 
can and you are committed to it, so I just would finish up 
again and say let us make this happen, and at the point at 
which I think you are trapped by your budget, I think frankly 
veterans health care, quality veterans health care is on a 
collision course with the tax cuts.
    I think we cannot do everything. And we have to be honest 
about how much tax cuts and how much revenue, and I think that 
is part of what is facing you. But I am with you. I will work 
with you.
    Dr. Roswell. Thank you very much for your support.
    Senator Wellstone. With you, too. I want to work with you.
    Chairman Rockefeller. You may be more with him than I am. 
[Laughter.]
    Let me conclude with these comments. I think VA loves to 
think of itself as being recognized as a national leader in the 
care of the elderly. And the truth of the matter is that it is 
within those who observe VA and health care, but elsewhere it 
is not recognized as such. It gets an occasional burst and a 
little bit here and there, but it is not. And it needs to be. 
That is point No. 1.
    Point No. 2, you know you have sort of General Motors and 
you have the Federal Government, and sometimes I am not sure if 
there is really any difference in the way they are run, and 
this goes back to, I think, two points. One is that you cannot 
give any testimony or Secretary Principi, and I assume yourself 
that has not been previously cleared by OMB.
    That ought to infuriate you as a health care professional. 
Now, the deal, of course, is that everybody has to be on the 
same page of the song. There have been those who have decided 
not to be. Some have paid a price for it. I think Secretary 
Derwinski could probably tell you something about that. Jesse 
Brown used to be told by President Clinton what the budget was 
going to be, and he said, oh, yeah, and then he would fight for 
more money.
    In other words, I am not making any Republican/Democratic 
comparisons here. What I am saying is that the one main 
question I asked Tony Principi when he came here for 
confirmation, was, are you willing to go head to head with the 
President if you do not get the budget you want? That is what I 
care about more than anything else, that you will go to him, 
demand time and argue your case, whether he likes it or not. 
Just bull right past Andy Card. I mean he is bigger. You are 
bigger than Andy Card. Just bull right past him. In your case, 
you are an Under Secretary.
    And I do not know Mitch Danielsvery well, but I encourage 
you to sort of adopt that kind of mentality, because if you 
mean what you have been saying this morning, then you are 
obviously going to have to fight along with us.
    And where everybody is concentrating on other issues which 
have to do with national security and homeland security, which 
is exactly what our first constitutional responsibility is. In 
the meantime, a thousand veterans are suffering. How are they 
dying and under what conditions? What is VA doing?
    So that what I like to refer to as face time, and that is 
putting yourself on the line, because ultimately that is what 
we do here, if we are doing our jobs. There comes a time when 
you simply have to put yourself on the line, and then you lose 
sometimes, but if you put yourself on the line, people know 
that you mean it. People know if you put yourself on the line, 
if you have put your job at risk, if you have not been afraid 
to offend somebody who is superior in position, then suddenly 
they know that you mean it and all of a sudden you are listened 
to more.
    And that whole dynamic and the absence of its practice in 
Washington is thoroughly not understood by the American people 
who choose but sometimes wisely to ignore Washington all 
together thinking that not much of anything happens here.
    I happen to think a great deal happens here, and I happen 
to know that an enormous amount happens here and only happens 
here that affects long-term care and veterans. So that was not 
just generally directed at you. It was an expression of 
frustration on my part, but it is partly directly at you. At 
some point people take stands, and, for heaven sakes, if you go 
into public service, that is one thing. If you go into health 
care, I mean you do that--for how long to become a doctor?
    Dr. Roswell. Four years of medical school.
    Chairman Rockefeller. Yes.
    Dr. Roswell. An average of 4 to 5 years of residency, yes.
    Chairman Rockefeller. So I mean, in other words, there is 
sort of a large commitment in your life to doing health care 
right, and I would like to see that work for the advantage of 
long-term care in the Department of Veterans Affairs.
    Dr. Roswell. Thank you, Mr. Chairman.
    Chairman Rockefeller. And I thank you, and this hearing is 
adjourned. Also, without objection, the written statement of 
Senator Murray will be made a part of the record.
    [The prepared statement of Senator Murray follows:]
 Prepared Statement of Hon. Patty Murray, U.S. Senator From Washington
    Thank you Mr. Chairman for calling this hearing. Like you, I'm very 
concerned that veterans still do not have universal access to the 
additional long term care benefits we provided for in the 1999 
Millennium Health Care Act. I hope this hearing will help us move the 
process forward quickly so that our older veterans can get the care 
they need.
    I'm also concerned that veterans are losing long-term care options 
because of some of the larger changes that are taking place in health 
care. In Washington State, nursing homes and home health care agencies 
are closing their doors, in part, because of unfair Medicare and 
Medicaid reimbursement rates that punish providers based on their 
geographic location. It's an issue we've got to address to ensure that 
veterans and all seniors have access to long-term care.
    As I mentioned, in 1999, we passed the Millennium Health Care Act 
to add extended care services to the VA benefits package. But the VA 
has been extremely slow in making those benefits available to veterans.
    As the chairman knows, the GAO recently found that:
          ``Two years after the passage of the act, VA has not 
        completely implemented its response to the act's requirement 
        that all eligible veterans be offered adult health care, 
        respite care, and geriatric evaluation.''
    The report goes on to say that: ``access to these programs was far 
from universal in the VA.''
    I understand the VA has gone back to OMB for a third time trying to 
get the final regulations approved so that they can comply with the 
Millennium Act. Frankly, I don't understand why it's taken so long to 
implement the Act. The VA has a legal and a moral obligation to our 
veterans to ensure access to quality long-term care. Of course, today, 
long-term care means much more than just nursing homes. It includes 
home health care, adult day care, adult homes, and respite care.
    When you look at the growing need for long-term care, it's clear 
the VA is going to have to work with private health providers.
    According to the GAO, in FY 2001 the VA spent about $3.1 billion on 
long-term health care and the amount is likely to increase. It's 
projected between the years 2000 to 2020 the US population over the age 
of 85 will increase by 37%, and the veteran population will nearly 
triple. I find these statistic particularly troubling when you consider 
that VA nursing homes beds are very expensive, costing as much as 
$50,000 per year for a veteran. That's nearly $20,000 dollars more 
expensive than the national average.
    Given these statistics, it's clear that the VA will have to 
contract with private health care providers to meet the needs of our 
veterans.
    As the VA has done for ensuring access to nursing homes, we will 
have to turn to private providers, like home health care agencies, to 
help cover the full commitment to our veterans. Unfortunately, the VA 
has committed very few resources to non-institutional settings. In 
fact, of the $3.1 billion the VA spent on long-term care in 2001, only 
8% was devoted to non-institutional settings.
    There is no question that this Issue is resource driven. However, 
it only makes sense to devote more resources to non-institutional 
health care settings to increase our ability to provide for all 
veterans. Home health care offers quality care that allows veterans to 
stay in their home, with their family, in the community. It offers a 
sense of relief as well for family members who are not equipped to 
handle the health care needs of the patient, but who don't want to see 
their loved ones in a nursing home.
    As we have seen with Medicare, home health care offers real 
solutions to acute care and long term care. Home health care providers 
are well trained and can provide a wide range of highly skilled care to 
veterans with special health care needs. However, for veterans in 
Washington state, home health care may not be an option to nursing 
homes.
    Currently, Washington state ranks 45th in average per beneficiary 
costs in comparison to other states. We are well below the national 
average. For example, providers in Florida or Texas can receive almost 
twice as much per home health visit than a provider in Washington 
state.
    This inequity, coupled with the scheduled 15% reduction in home 
health care under Medicare, could cripple home health care in 
Washington state. We've already seen agencies closing or scaling back 
their home health care delivery areas. Hospitals that once actively 
participated in home health care are leaving. This is quickly becoming 
a crisis situation.
    Medicare is penalizing home health care agencies, like doctors and 
hospitals in Washington state for providing more cost effective care. 
Over the lifetime of a Medicare beneficiary, this can mean thousands of 
dollars less spent on their care in Washington state.
    This inequity is already forcing many doctors to leave and causing 
severe health care professional shortages in hospitals. Our hospitals 
cannot compete with hospitals in other states that can pay more because 
they receive significantly more from Medicare for providing the exact 
same service.
    These regional inequities have resulted in vastly different levels 
of care and access to care. For example, in Florida many Medicare 
beneficiaries have access to prescription drugs and prescription 
eyeglasses in the Medicare+Choice program.
    In Washington state, there are no plans available that offer 
prescription drug coverage much less eyeglasses. I don't want to see 
the same thing happen to our veterans.
    Veterans, regardless of where they live, deserve access to quality 
nursing home options. Unless the VA plans on creating competing home 
health care agencies in Washington state for veterans only, there may 
be limited access to this option.
    It's unfair and unjust to provide vastly different levels of care 
for veterans depending upon where they live.
    I urge the VA to work with CMS to ensure that home health care 
agencies in all states are stable and affordable. Home health care must 
be an option for veterans. With the advances in medical research and 
the aging veteran population, the VA has to explore and invest in 
alternatives to nursing homes. In many cases, these alternatives 
provide a more appropriate level of care.
    I've been supportive of efforts to address these inequities, and 
I'll continue to work on it. I again want to thank the Chairman for 
holding this hearing and for helping to ensure our veterans have 
options when they need long term care.

    Chairman Rockefeller. Thank you. The hearing is adjourned.
    [Whereupon, at 12:20 p.m., the committee was adjourned.]
                            A P P E N D I X

                              ----------                              

 Prepared Statement of Hon. Ben Nighthorse Campbell, U.S. Senator From 
                                Colorado
    Thank you, Mr. Chairman, for holding this hearing today. I look 
forward to hearing from the panelists regarding the VA's efforts to 
provide alternative long term care services.
    In my meetings with veterans from Colorado, one of the issues of 
greatest concern is health care. The vets want to know that they will 
be able to get quality care when they need it.
    I am encouraged that in recent years, Congress has invested 
substantial resources to improve the quality and accessibility of VA 
medical care and to make that care available to more veterans. As I 
understand, the number of individual veterans served by the VA has 
increased by 65% in the last 7 years. But, nearly all of that increase 
has been in primary care provided by outpatient clinics.
    Now, as the age of the our veterans population rises, we are 
looking at services needed by older patients. In the 106th Congress, 
under your leadership, Mr. Chairman, we enacted legislation directing 
the VA to expand its geriatric services to include nursing home care, 
assisted living arrangements and home care options.
    Today, it is time to look at those programs to determine how we are 
doing. Are our elderly and disabled veterans being offered the options 
we have promised them? Are they able to choose home care rather than 
institutional care? Can they find adult day care services? Are their 
family caregivers able to find relief services?
    Speaking as a veteran, I believe we need to do all we can to help 
those who have so honorably served all of us.
    Mr. Chairman, again, I thank you for holding this hearing and look 
forward to hearing details of how the VA is addressing the long term 
care needs of our vets.
                                 ______
                                 
           Prepared Statement of the Alzheimer's Association
    Mr. Chairman and members of the Committee:
    The Alzheimer's Association appreciates the opportunity to submit 
the following statement to the Committee on Veterans Affairs for the 
hearing entitled ``Options to Nursing Homes: Is VA Prepared?''
    The Alzheimer's Association is the premier source of information 
and support for the four million Americans with Alzheimer's disease. 
Through its national network of chapters, it offers a broad range of 
programs and services for people with the disease, their families, and 
caregivers and represents their interests on Alzheimer-related issues 
before federal, state, and local government and with health and long-
term care providers.
    Over the past few years, the VA has embarked on several exciting 
projects to improve care for veterans with Alzheimer's disease and 
other dementias. Our comments in this statement will focus on two 
specific projects currently underway within the VA system.
    advances in home based primary care for end of life in advanced 
                            dementia (ahead)
    Advances in Home Based Primary Care for End of Life in Advanced 
Dementia (AHEAD) is a rapid-cycle improvement project intended to help 
VA staff identify problems in dementia care, implement clearly defined 
steps to address them, and evaluate outcomes. The first group of AHEAD 
sites included teams of 3-5 VA staff members from Home Based Primary 
Care units at 20 Veterans Integrated Service Networks (VISN's). The 
teams worked from January-September 2001, and focused on four areas of 
improvement: early intervention, symptom management, staff education, 
and caregiver support. Outcome data show improvements in each of these 
areas at many of the sites. A second group of AHEAD sites is now 
underway.
         chronic care networks for alzheimer's disease (ccn/ad)
    Chronic Care Networks for Alzheimer's Disease (CCN/AD) is a longer-
term project that is being implemented in the VA's upstate New York 
network (VISN 2). CCN/AD is a 7-site national demonstration project 
that is jointly sponsored by the Alzheimer's Association and the 
National Chronic Care Consortium (NCCC). It is intended to provide 
coordinated health care and supportive services for people with 
Alzheimer's disease and other dementias by linking Alzheimer's 
Association chapters and health care systems. VISN 2 is the only VA 
participant in the national demonstration. Since 1997, it has worked 
closely with four local Alzheimer's Association chapters to coordinate 
care and improve outcomes for veterans with dementia.
    VISN2 leadership and staff have strongly and consistently supported 
the development and implementation of CCN/AD. While the VA central 
office and individual networks and medical centers have previously 
provided extensive resources and leadership in Alzheimer's research and 
demonstration projects to improve Alzheimer's and dementia care, this 
is the first time VA and Alzheimer's Association chapters have worked 
together at this level and with this intensity. The Alzheimer's 
Association believes that the change and improvement in Alzheimer's and 
dementia care in VISN 2 are truly impressive.
    With the support of the Senate Committee on Veterans Affairs and 
the VA central office, AHEAD and CCN/AD could be replicated in other VA 
networks across the country, and the benefits of these innovative 
projects could be extended to many more veterans with Alzheimer's 
disease and other dementias. The Alzheimer's Association is especially 
enthusiastic about the potential for replication of CCN/AD because of 
the value of coordinated medical care and supportive services for 
people with these conditions, and the remainder of our statement 
focuses on this project. We would point out, however, that the 
experience and knowledge developed by VISN 2 in its work with 
Alzheimer's Association chapters over the past five years could provide 
a valuable basis for similar working partnerships between VA facilities 
and other community agencies. Such partnerships could improve the care 
available to veterans with other chronic conditions, which, like 
Alzheimer's disease, require both medical care and non-medical, 
community-based services.
            the visn2--alzheimer's association partnerships
    In upstate New York, CCN/AD has been implemented through VA/
Alzheimer's Association partnerships at the network and VA medical 
center levels. VA staff at the Albany, Bath, Canandaigua, Syracuse, and 
Western New York VA medical centers have worked closely with the four 
Alzheimer's Association chapters that serve the same geographic areas. 
Overall policy has come from the network level, but detailed procedures 
for training, referrals, assessments, and joint care management have 
been developed at the medical center/chapter level.
    The creation and maintenance of these working partnerships has 
involved each partner learning about the organizational structure, 
practices, and available services of the other. VA staff have learned 
about training programs, informational materials, family educational 
workshops, and support groups provided by the Alzheimer's Association 
chapters. Chapters have learned about the wide array of institutional 
and non-institutional services provided by the VA. VA medical centers 
have designated a single point of contact for referrals from the 
chapters. Likewise, if veterans and their families agree and give 
formal, informed consent, VA staff can fax their names and contact 
information to the chapters so that the chapters can reach out to them 
with supportive services.
                            the ccn/ad model
    The CCN/AD model was developed by physicians, other health care 
professionals, and Alzheimer's Association chapters from the seven 
participating sites, including VISN2 and the upstate New York chapters. 
It is intended to address common problems in the care of people with 
Alzheimer's disease and other dementias in VA and non-VA settings and 
to meet the needs of the person as a whole, not just his/her 
Alzheimer's disease or dementia.
    The model includes recommended procedures and tools for 
identification of people with possible dementia, diagnostic assessment, 
ongoing care management, and family support. It is available from the 
National Chronic Care Consortium's website at www.nccconline.org.
                   implementation of ccn/ad in visn2
    CCN/AD was first implemented in Syracuse, with the Syracuse VA 
Medical Center and the local Alzheimer's Association chapter 
functioning as the pilot site for VISN 2. The Robert Wood Johnson 
Foundation provided a one-year $100,000 grant to support the pilot 
test.
    Once the pilot test was completed successfully, the Foundation 
provided an additional $700,000 grant for two years of full 
implementation to be completed in October 2002.
    Over the past three years, extensive training has been provided, 
first in Syracuse and then in the other medical centers. Hundreds of VA 
staff members have received training about Alzheimer's disease, 
dementia, and effective approaches to care. As the project has matured 
in the main medical centers, training has also been offered in some of 
VISN 2's community-based outpatient centers (CBOCs), e.g., in Elmira, 
Rochester, and Rome, NY.
    VA staff throughout VISN 2 have been trained to recognize the 
warning signs of dementia and to refer veterans with possible dementia 
for a diagnostic evaluation and possible enrollment in CCN/AD. As of 
April 2002, more than 450 veterans have been enrolled. Some of these 
individuals are in the early stages of Alzheimer's disease or another 
dementia, but others are in later stages and have simply not been 
identified previously. Available data indicate that nationally, only 
20-40 percent of people with dementia have received a diagnostic 
evaluation. The numbers were probably somewhat higher in VISN2 even 
before CCN/AD because some of the medical centers already had 
diagnostic clinics. Still, however, many veterans with dementia had not 
been identified and diagnosed. CCN/AD procedures and tools are helping 
to address this problem. In addition to efforts by VA staff, the local 
Alzheimer's Association chapters have begun asking callers whether they 
are a veteran or a family caregiver of a veteran. If they are, the 
chapter is able to make an expedited referral into the VA for that 
individual or family.
    Diagnostic assessment is occurring in all of the medical centers 
and CBOCs. The CCN/AD model includes a recommended assessment that not 
only supports the diagnostic process but also provides valuable 
information about the veteran and his/her family that can be used for 
care planning. Each VA medical center has made adaptations to the model 
to fit with pre-existing practices at that center, available staff, and 
other resources.
    At each of the five main medical centers, VISN 2 has created a new 
dementia care manager position. These five VA employees provide and 
coordinate training, encourage, assist with, and oversee the CCN/AD 
identification and assessment procedures, and work with Alzheimer's 
Association chapter staff to develop project procedures and eliminate 
barriers to better care.
    Ongoing care management for veterans enrolled in the project is 
provided by the dementia care managers, other VA specialists and 
primary care providers, and chapter staff. The dementia care managers 
and chapter staff talk frequently with each other about the needs of 
particular veterans and their families and how those needs can be met. 
Both the dementia care managers and chapter staff make referrals to 
other community agencies. Occasionally, in particularly difficult 
situations, the dementia care manager and a chapter staff member have 
made joint home visits. More often, however, one or the other is able 
to solve the problem and obtain the needed care for the veteran.
    In VA medical centers were there is a dementia clinic, ongoing 
medical and non-medical care management has been provided in the 
dementia clinic. Over time, as the number of enrollees has increased 
and primary care providers have become more knowledgeable and 
comfortable with Alzheimer's and dementia care, these functions are 
being shifted to primary care. In medical centers where there is no 
dementia clinic, CCN/AD project staff have worked with VA primary care 
physicians, physician assistants, nurse practitioners, and others from 
the beginning to provide medical and non-medical care management.
    In each of the five medical centers, resource rooms have been set 
up with print and video materials about Alzheimer's and dementia for 
veterans, their families and VA staff. Print materials are also 
available in racks in public areas of the VA, and chapter staff contact 
veterans' families to offer educational materials and other chapter 
services. Support groups are provided at the medical center and in the 
community by chapter staff or VA staff that have received training from 
the chapters.
                                outcomes
    The evaluation of CCN/AD will continue for another year with 
funding from the Retirement Research Foundation and the Robert Wood 
Johnson Foundation. Thus, final results are not yet available. 
Responses to mail surveys of VA physicians, nurses, social workers, and 
others show positive attitudes about the project model and the 
partnership with the Alzheimer's Association chapters. Survey responses 
also show general agreement that implementation of the CCN/AAD model 
and participation in the partnership with chapters will lead to earlier 
identification of dementia, improved communication between VA staff, 
veterans with dementia, and their families, and greater awareness of 
needed treatments and services. Preliminary findings from telephone 
interviews with veterans who are still able to respond and their 
families indicate high satisfaction with the care they are receiving 
through the project.
    Information about CCN/AD enrollees' use of VA and chapter services 
will eventually be available to analyze the cost impact of the project. 
Since there is no control group, cost information from the project will 
only be suggestive, although it is possible that data from other VA 
networks could be used for general comparison.
    Many people with Alzheimer's disease and other dementias also have 
serious coexisting conditions such as heart disease, diabetes, and 
cancer. Available data show that these coexisting medical conditions 
increase the cost of care for people with Alzheimer's and dementia. 
Likewise, Alzheimer's and dementia increase the cost of coexisting 
medical conditions. Thus, a person with Alzheimer's disease and 
diabetes is likely to have higher medical costs than a person with only 
Alzheimer's or only diabetes. Greater attention to the management of 
coexisting Alzheimer's, dementia, and other serious medical conditions 
could improve outcomes and reduce costs of care. Little work has been 
done in this area thus far, primarily because of lack of knowledge 
about Alzheimer's disease and dementia and widespread failure to 
identify and diagnose these conditions in most health care systems. By 
increasing staff knowledge about Alzheimer's and dementia and ensuring 
identification and diagnosis of veterans with these conditions in VISN 
2, CCN/AD has laid the necessary groundwork for future projects to 
improve management of coexisting medical conditions, with likely 
positive effects on both quality of care and costs.
                potential for replication is other visns
    The CCN/AD model is available for use by any health care system. 
The model was originally designed to be flexible enough to work in the 
diverse, real world settings of the seven participating sites. As noted 
earlier, some adaptations to the model have been made at each of the 
VISN2 medical centers, thus creating a rich array of procedures and 
tools that could be adopted by other VA networks. The site has a 
project manual that includes the CCN/AD model and tools, site policies, 
work plans, budgets, timelines, and data collection instruments. 
Training curricula are also available. Perhaps as valuable as these 
formal products is the extensive experience VISN 2 has accumulated in 
partnering with Alzheimer's Association chapters. These partnerships 
are essential in providing coordinated care for people with Alzheimer's 
disease, dementia, and many other chronic conditions, and VISN 2's 
knowledge in this area is a potentially valuable resource for other VA 
networks.
    For the Alzheimer's Association, the CCN/AD project in upstate New 
York has provided opportunities to reach physicians, other health care 
professionals, veterans with dementia, and family caregivers we would 
not have reached otherwise. We are impressed with the dedication and 
skill of VISN 2 clinical and administrative staff, and we are grateful 
for the time and resources the network has devoted to this project. We 
hope the project will continue to grow in VISN 2 and that other VA 
networks will want to replicate it in their health care systems.
                            recommendations
    The Alzheimer's Association recommends that the Senate Committee on 
Veterans Affairs and the Veterans Health Administration (VHA):
          1. encourage and support replication of the AHEAD and CCN/AD 
        projects in VA networks and medical centers across the country. 
        Both projects require significant staff time and other 
        resources, but the VA is already serving huge numbers of 
        veterans with Alzheimer's disease and other dementias, 
        including many whose conditions have not yet been identified 
        and diagnosed. AHEAD and CCN/AD are vehicles for improving care 
        for these veterans. CCN/AD creates partnerships with 
        Alzheimer's Association chapters that can facilitate non-
        institutional, community-based care and augment the efforts of 
        VA staff.
          2. Given the groundwork already created by CCN/AD in VISN 2, 
        the Alzheimer's Association also recommends that the Committee 
        and the VHA encourage and support research and demonstration 
        projects to improve the management of coexisting medical 
        conditions in people with Alzheimer's disease and other 
        dementias. As noted earlier, this is an important next step in 
        improving quality and reducing cost of care for veterans with 
        these conditions.
    The Alzheimer's Association commends the Committee on Veterans 
Affairs for calling this important hearing on non-institutional long 
term care issues in the VA. Under Chairman Rockefeller's stalwart 
direction, the Committee on Veterans Affairs has worked consistently to 
improve the quality of health care and to develop a long term care 
system for our nation's veterans that provides options for care at 
home, in the community and in good care facilities.
    In addition, the Association sincerely appreciates Chairman 
Rockefeller's particular commitment to veterans with Alzheimer's 
disease, not only in the area of long term care but also in raising 
awareness about the need for increased research funding both at the 
National Institutes of Health (NIH) and in the private sector. Through 
the Blanchette Rockefeller Neurosciences Institute at the West Virginia 
University Health Sciences Center, fundamental neurosciences research 
is underway to find practical solutions to Alzheimer's disease and 
other cognitive impairments.
    Thank you again for the opportunity to submit this statement for 
the record.
                                 ______
                                 
  Prepared Statement of James R. Fischl, Director, National Veterans 
       Affairs and Rehabilitation Commission, The American Legion
    Mr. Chairman and Members of the Committee:
    As an advocate for veterans and the nation's largest veterans 
service organization, The American Legion feels compelled to submit, 
for the record, its views on the subject of your most recent hearing--
Alternatives to Nursing Homes--Is VA Prepared? With the ever-growing 
aging veteran population, it is critical that the Department of 
Veterans Affairs (VA) position itself in such a way as to be able to 
adequately take care of all the needs of these veterans to include 
long-term care.
    With the VA health care system transforming itself from a 
``hospital'' system to an ``integrated health care'' system, so too has 
VA's approach to long-term care evolved from an institutional setting 
to a non-institutional, community based and home based setting.
    The enactment of Public Law (PL) 106-17, the Veterans Millennium 
Healthcare and Benefits Act, marked the first step down the long road 
to ensuring, mapping out and implementing a comprehensive long-term 
care plan for veterans.
    While conceding that this legislation was complex, the VA has 
allowed nearly two years to go by without fully implementing the 
provisions of the law. The law requires that all eligible veterans be 
offered adult day health care, respite care, and geriatric evaluation. 
To date, VA has instituted only three of the provisions of the law:
     Mandatory nursing home care for veterans rated 70% and 
above and for any service-connected veteran who needs nursing home care 
for a service-connected disability;
     Pilot programs to evaluate varying models of all-inclusive 
care for the elderly; and
     An assisted living pilot to evaluate that particular 
program was initiated in the Pacific Northwest.
    It will take two to three more years for the pilot programs to be 
fully evaluated as to whether they are a cost-effective means of 
providing long-term care (LTC). In the mean time, veterans continue to 
struggle to obtain LTC by the VA.
    LTC within VA is a continuum of care provided over a period of time 
to veterans who suffer from severe chronic service-connected 
disabilities and conditions of aging and/or the disease process. Within 
VA, long-term care includes:
     home health care;
     adult day care;
     community residential care;
     specialized rehabilitation care, including Alzheimer's and 
Dementia care;
     psychogeriatric care;
     domiciliary care;
     assisted living;
     hospice and respite care;
     geriatric assessment and management;
     skilled and unskilled care;
     nursing home care; and
     Geriatric Research, Education and Clinical Centers 
(GRECCS).
    One of the more innovative approaches to LTC within VA has been the 
use of telemedicine. Telemedicine technology allows VA to reduce travel 
time and costs while improving efficiency and providing better quality 
of care. The Senior Companion Program is another example of saving 
money, yet keeping LTC in the home of the veteran. The Advances in Home 
Based Primary Care for End of Life in Advancing Dementia (AHEAD) 
program is yet another alternative to institutional care that the VA is 
evaluating. While all of these programs sound great, they are only 
offered to a small portion of the veteran population in need of LTC.
    VA's plans for long-term care include:
     achieve an integrated care management system that 
incorporates all of the patient's clinical care needs;
     provide more care in home and community-based settings as 
opposed to inpatient settings, when appropriate;
     achieve greater consistency in access to and quality of 
care provided in all settings;
     achieve greater consistency across the system in assessing 
patients for extended care and in managing care, including post 
institutional care;
     continue to emphasize Veteran Health Administration (VHA) 
research and educational initiatives that will improve delivery of 
services and outcomes for VA's elderly veteran patients; and
     continue to develop new models of care for diseases and 
conditions that are prevalent among elderly veterans.
    These plans are honorable; however, the caveat to achieving these 
plans is that it must be done within ``existing programmatic 
resources.'' In essence, VA can only do so much and then the money runs 
out. When it does, the bill payer becomes the veteran.
    The evolution of LTC from an institutional setting to a non-
institutional setting brings with it many issues that need to be 
addressed. One of those is accountability of the patient and for that 
matter, whether the veteran is informed and understands exactly what is 
going on with his or her care. Another, of course, is quality of care 
being provided by non-VA staff and how is this being monitored.
    Finally, The American Legion strongly contends that veterans, who 
are accepted into the health care delivery system provided by VA, must 
remain the responsibility of the Department. VA's charge includes 
providing quality improvement oversight for LTC provided by the 
Department or through private contract. If a veteran is accepted as a 
long-term care patient, no matter when or under which existent 
provision of a law, he or she remains the responsibility of the VA 
medical care system regardless of their medical condition.
    Congress and the Executive Branch must recognize that it is 
incumbent upon them to provide VA adequate resources for the purposes 
of providing LTC to the nation's veterans. VA must continue to meet the 
demand veterans will undoubtedly place on the health care system in the 
next 30 years. The reality of quality LTC for veterans requires a 
financial commitment on the part of the legislative and executive 
branches of this government, and a coordinated treatment effort on 
behalf of VA.
    We can never forget the commitment ``. . . to care for him who 
shall have borne the battle, and for his widow and his orphan.''
    Thank you for allowing The American Legion an opportunity to 
express its views on this critical issue.
                                 ______
                                 
  Prepared Statement of Arlene Davidson, Vice President, Planning and 
         Development, Evercare, a Unitedhealth Group Affiliate
    Mr. Chairman and Members of the Committee:
    Evercare is pleased to have the opportunity to provide testimony 
for the record of this Committee hearing on long term care alternatives 
for veterans. Evercare is a division within the Ovations business 
segment of UnitedHealth Group. UnitedHealth Group is a diversified 
health care company that provides a broad spectrum of resources and 
services to help people achieve improved health and well-being through 
all stages of life. United is comprised of five major business 
segments: Ovations, UnitedHealthcare, Ingenix, Specialized Care 
Services and Uniprise. United has been operating since 1974 and 
currently serves nearly 35 million Americans in all 50 states. The 
Ovations business segment, of which Evercare is part, is dedicated to 
serving vulnerable individuals including the frail elderly, chronically 
ill, disabled and low income families.
    Evercare is dedicated to meeting the long term care needs of this 
nation and we have on several occasions in the past offered testimony 
in support of the development of new long term care options for 
veterans. Our mission is to optimize the health and well being of 
aging, vulnerable and chronically ill individuals. Evercare was started 
in 1987 in Minnesota by two nurse practitioners and with its 
acquisition of Lifemark Corporation in 2001, has grown into a 
diversified award-winning healthcare organization participating in 
government programs in over 15 states. During our 18 years in the long 
term care market, we have seen the emergence and maturing of many 
Medicaid, Medicare and other government programs. Our demonstrated 
ability to address complex health care needs and to provide customized 
services has consistently resulted in exceptional customer 
satisfaction, improved clinical outcomes, and increased efficiency. 
Some of these results are discussed in a recent article published by 
Robert L. Kane, MD in the April 2002 issue of the Journal of the 
American Geriatrics Society. We applaud and offer support to this 
Committee's efforts in examining new models to address the long term 
care needs of veterans and seeking effective ways to deliver quality 
long term care services.
    Recently, Evercare was awarded a contract by the Southern Arizona 
Veterans Administration Health Care System (SAVAHCS) for a pilot case 
management program for veterans living in the community and in need of 
long term care services. This pilot, targeted to veterans living 
throughout the State of Arizona, is one example of how the Evercare 
care management approach can be applied to offer new long term care 
alternatives to veterans. In this testimony we provide not only an 
overview of our care management approach but also some examples of long 
term care program models in which our approach has been effectively 
applied. It is our hope that this testimony will help define options 
for future program development.
                our care management philosophy and model
    Central to any of the long term care program models in which we 
operate is Evercare's approach to care management. Our approach for 
aged and disabled individuals is a client-centered model that 
encourages the involvement of the client, their family, caregivers, 
physicians or primary care provider and our care manager in a 
collaborative effort. It is a holistic approach, designed to maintain 
the highest quality of life and functional status of the individual 
while minimizing reliance on services that are traditionally more 
restrictive and less effective in containing costs. This inclusive 
philosophy supports an overall goal of coordinating timely, quality, 
and appropriate health services while addressing medical, social, 
behavioral, environmental and financial considerations in each care 
plan. Our care managers achieve this goal through collaboration with 
the enrolled individual and his or her family to create a care plan 
that maximizes the individual's self-determination and respects 
individual wants and interests. In the coordination, facilitation and 
implementation of the full spectrum of acute and long term care needs, 
Evercare's care managers strive to maintain, and if possible, increase 
each enrollee's level of independence, individuality, choice and health 
status.
    Evercare care managers work with the individual, his or her family, 
the primary care provider (PCP), our internal clinical experts, and 
other providers as partners on a team to design, coordinate, and manage 
the plan of care that achieves the results specified by the 
individual's goals. Care managers additionally identify the full range 
of health care resources and medical coverage available to each client, 
including Medicaid, Medicare, or private long term care insurance 
policies. This design and approach allows care managers to react 
immediately to changes in a client's condition, proactively intervene, 
coordinate care and service needs, and manage any necessary changes in 
the individual's plan or setting of care. In addition, the care manager 
assists the individual and his or her family in identifying attainable 
health and functional status goals, and provides education and 
supportive services on preventive medicine, healthy choices, and self-
care techniques as appropriate.
                            company overview
    Our continuum of product lines includes Medicaid and Medicare 
health plans, government contracts, and a nationwide information, 
consultation, care management and referral service, all designed for 
frail, elderly, disabled or chronically ill individuals. Through these 
businesses we serve over 658,000 individuals, including providing 
comprehensive care management for approximately 150,000 individuals 
through publicly funded and managed care contracts. In addition, more 
than 2.5 million people have access to our nationwide information, 
referral, consultation, and care management services.
    Evercare has experience coordinating long term care services 
through the following program models:
     Stand alone care and disease management programs offered 
in a fee-for service environment with reimbursement for administrative 
costs on a per participant per month basis;
     Eldercare consultation and referral services provided on 
an as needed, fee-for service basis through an insurer or payer as part 
of a greater long term care benefit package;
     Care management services delivered as part of a long term 
care single entry point (SEP) and/or primary care case management 
(PCCM) program administration contract;
     Capitated long term care health plan models designed to 
coordinate with traditional Medicaid acute care coverage; and
     Full-risk health plans (health maintenance organization or 
preferred provider organization) integrating acute, behavioral, and 
long term care funding.
    In addition to the overall program model type, other important 
program design issues include whether participation is mandatory, how 
program eligibility is defined, what delivery settings are included, 
and the referral/outreach processes used to identify and enroll 
eligible individuals. Differences among our existing programs are 
described in the examples that follow.
Arizona Case Management Services for Veterans
    Customer/Client: Southern Arizona VA Health Care System
    Company/Product Line: Lifemark Corporation, Evercare Connections
    Start Date: January 2002
    Through Evercare's Lifemark division, we provide care management 
services to referred veterans statewide with reimbursement for 
administrative costs on a per participant per month basis. Program 
participants, referred through local Contracting Officer Technical 
Representatives (COTRs), must require a nursing home level of care and 
reside in community settings. Care management services include initial 
assessment, care planning, maintenance of a statewide home and 
community based provider referral network, periodic reassessment, and 
ongoing management with regular communication with VA providers and 
other personnel. Our approach to cost containment includes a strong 
emphasis on coordination of benefits with other payor sources, 
improving access to care in rural areas, introducing appropriate social 
services and decreasing fragmentation of care delivery.
    Outcomes: Since the program is new (January 2002), no outcome data 
is yet available.
Arizona Medicaid/Elderly and Physically Disabled Long Term Care 
        Management
    Customer/Client: Arizona Health Care Cost Containment System 
(AHCCCS), Arizona Long Term Care System (ALTCS)
    Company/Product Line: Evercare of Arizona, Evercare Select
    Start Date: January 1989
    Evercare of Arizona, through its Evercare Select product, has been 
an ALTCS program contractor since the inception of the program in 1989 
through the Federal Medicaid Section 1115 waiver program granted to the 
State of Arizona. As ALTCS' largest private contractor, Evercare has 
demonstrated that services can be integrated cost effectively in a 
managed care environment through incorporating sound principles of 
intensive care management, utilization management, and quality 
assurance.
    Evercare's care managers work with the enrollee, the enrollee's 
family or guardian, and his or her Primary Care Provider (PCP) in order 
to blend and deliver services to assist the enrollee in maintaining the 
highest level of functioning through the most appropriate, cost 
effective plan of care. Evercare enrollees have choices within a wide 
array of primary care, acute care, ancillary services, behavioral 
health services, nursing home placement, and home and community based 
services (HCBS). Evercare'' strong HCBS network allows our enrollees to 
have access to a full continuum of services, including adult foster 
care, assisted living homes, assisted living centers, adult day health 
centers, attendant care services, emergency alert systems, group 
respite, home health services, personal care, homemaker services, 
respite care, hospice care, home delivered meals, and home 
modifications.
    Outcomes: Independent evaluations have shown increased consumer 
satisfaction, cost savings and decreased rates of institutionalization 
as a result of this program. Evercare has increased its HCBS population 
from five percent participation of all clients in 1989 to 51 percent in 
2001, significantly decreasing institutionalization. Other financial 
and utilization outcomes for this period showcase its strength in cost 
effectiveness. During this period we reduced the hospital length of 
stay from seven to five days and decreased nursing home expenses from 
$1,424 to $1,110 per member per month with an estimated overall medical 
cost savings of over $2.5 million. By offering a breadth of HCBS 
services through a highly developed network, Evercare has been able to 
develop a program that has improved access, financing, service delivery 
and follow-up while eliminating fragmentation, duplication of services, 
and unnecessary utilization. These findings have been substantiated by 
a 1996 Evaluation of Arizona's Health Care Cost Containment System 
Demonstration report by Laguna Research Associates. In addition, an 
October 2000 report by the AHCCCS showed that consumers are very 
satisfied to satisfied with their long term care services.
Texas STAR+PLUS Medicaid Long Term Care Health Plan
    Customer/Client: State of Texas Department of Human Services
    Company/Product Line: Evercare of Texas/HMO Blue STAR+PLUS
    Start Date: January 1998
    Since 1998, Evercare has provided administrative services and care 
management for HMO Blue STAR+PLUS. The STAR+PLUS Medicaid long term 
care program is designed to foster care coordination for individuals 
dually eligible for Medicare and Medicaid, and elderly and disabled 
people eligible for Medicaid-only. STAR+PLUS bundles Medicaid covered 
services into one integrated coordinated care program designed to 
control health care costs while improving access and coordination of 
services to enrolled individuals. STAR+PLUS provides incentives for 
dual eligibles to enroll in Medicare+Choice plans to further integrate 
health care services. For all Medicaid enrollees, including dual 
eligibles, Evercare is at-risk for the cost of home and community based 
services that are covered by Medicaid. In addition, Evercare provides a 
seamless transition along the continuum of health care services by 
coordinating acute care services reimbursed under the Medicare program. 
We have applied to become a Medicare+Choice program to assume risk for 
these services, to complete the integration. This care management 
function enhances continuity of care and the enrollee/care manager 
relationship. The Evercare program includes assignment of care managers 
to match the cultural and language aspects of Houston's diverse 
population (i.e., Vietnamese, African American, Asian American, 
Russian, and Hispanic).
    Outcomes: Independent evaluations of the STAR+PLUS program have 
also shown increased consumer satisfaction, cost savings and improved 
quality. Evidence of our success in managing the STAR+PLUS population 
is demonstrated by an internal cohort study of 310 enrollees in the 
program, who experienced, over a two-year period, a decrease in 
inpatient days and days per thousand of 43 percent, and a decrease in 
paid claims of 22 percent. Furthermore, a 1999 study by the Public 
Policy Research Institute of Texas A&M University (STAR+PLUS Medicaid 
Managed Care Waiver Study: An Independent Assessment of Access, Quality 
and Cost-Effectiveness) found that this waiver program saved the State 
of Texas over $6 million without impeding access to care or quality of 
care. Furthermore, a 1999 overall enrollee satisfaction survey 
conducted by the Texas Health Quality Alliance showed results of 
``seven or higher on a scale of zero to ten'', where ten is most 
satisfied and zero is least satisfied.
Florida Diversion and Long Term Care Programs
    Customer/Client: Florida Department of Elder Affairs and Agency for 
Health Care Administration
    Company/Product Line: Health and Home Connection; ElderCare
    Start Dates: 1998 (Health and Home Connection); 1987 (ElderCare)
    Evercare operates two separate Medicaid programs in Florida aimed 
at assisting frail elders and disabled individuals to live in the 
community. Health and Home Connection is a Florida Diversion Project 
serving enrollees over the age of 65 in Osceola, Orange and Seminole 
counties under a 1915(c) waiver and monitored by the Department of 
Elder Affairs. These complex health care individuals require assistance 
with activities of daily living, have dementia or some other chronic 
illness or degenerative disease requiring daily nursing intervention. 
There are currently 446 voluntary enrollees whose health care needs are 
managed through our extensive care coordination programs and services. 
ElderCare is a similar program in South Florida (Dade and Broward 
counties) funded by the Frail Elder project and monitored by the Agency 
for Health Care Administration. ElderCare is for persons over the age 
of 21 at risk of institutionalization due to chronic illness, 
disability and/or in need of assistance with activities of daily 
living. There are 3,700 voluntary enrollees.
    Outcomes: Estimated savings for the State of Florida from the 
Office of Program Policy Analysis and Cost Accountability are $18 
million per year for the Diversion Project. ElderCare has potential 
savings estimated at $8.6 to $25.7 million per year. The savings are 
estimated for diversion of enrollees from institutionalization to more 
cost-effective community-based settings enabled by our comprehensive 
care management approach. A November 2001 study by the Department of 
Elder Affairs found Health and Home Connection had the highest average 
rating of satisfaction with our care managers and highest satisfaction 
(89 percent) with overall long term care services when compared to 
other participating contractors.
New Mexico LTC Link Single Entry Point Administration
    Customer/Client: New Mexico Human Services Department/Medical 
Assistance Division
    Company/Product Line: Evercare Connections
    Start Date: July 2001
    LTCLinkNM is an information and referral 
service specializing in long-term care services for disabled, elderly, 
chronically ill and vulnerable individuals of any age within the State 
of New Mexico. The service was implemented and is managed by Evercare's 
comprehensive national database of long term care providers, which 
includes both institutional and home and community based providers. The 
State of New Mexico created this program in July of 2001 to help 
eliminate the need for individuals to make numerous calls or trips to 
various organizations in the hopes of finding appropriate resources. 
Through this information service, Evercare assists individuals and 
other concerned parties in locating services to maximize their 
independence and quality of life.
    This type of centralized information system is used by states to 
simplify the process for individuals as they access publicly funded 
programs for medical or social services. Other states, such as 
Colorado, rely on similar providers (in Colorado, called Single Entry 
Point Agencies, or SEPs) to provide initial screening and ongoing case 
management and assessments. A program such as this may be particularly 
beneficial for the VA, due to the intricacy of the benefit structure 
and the complexity of the care needs of many veterans. Evercare is 
capable of providing care management services coupled with single entry 
point administration.
Nationwide Medicare+Choice Long Term Care Demonstration Project and PPO
    Customer/Client: Centers for Medicare and Medicaid Services (CMS)
    Company/Product Line: Evercare, Evercare Choice
    Start Date: January 1987
    Since 1987, Evercare has operated a Medicare program, called 
Evercare Choice, serving the frail elderly in institutional settings. 
This program has been operating under a CMS demonstration since 1995. 
Through a unique care management program that utilizes teams of nurse 
practitioners and primary care physicians, the Evercare model 
coordinates care for nursing home residents with an emphasis on areas 
such as prevention, early detection, collaboration with the primary 
physician, and communication with families and nursing staff. This 
geriatric clinical model seeks to avoid costly and traumatic transfers 
to the hospital and improve enrollees' quality of life. As a result of 
clinical success and superior cost effectiveness, Evercare Choice has 
expanded to include sites in six states, including participating in the 
Minnesota Senior Health Options program for dual eligibles and has led 
to the development of additional Medicare+Choice (M+C) plans reaching a 
total of over 23,000 individuals. Last year, Evercare opened the 
nation's first M+C PPO in Ohio. This year, Evercare will launch a new 
M+C HMO product for community-based dual eligibles in Texas and further 
expand the PPO model to additional states. Over 70 percent of the 
enrollees in Evercare Choice are dual eligibles, the average age our 
enrollees is 85 and 85 percent suffer from some form of dementia.
    Outcomes: Evercare is one of the most successful Medicare 
demonstration projects and has produced impressive results in reducing 
hospitalizations, improving quality of care and family satisfaction. 
The success of the nurse practitioner model of care coordination is 
highlighted in studies conducted measuring affects on hospital 
admissions, clinical outcomes and enrollee satisfaction. Specifically, 
Kane discusses in the JAGS article higher satisfaction among Evercare 
enrollees when compared to a control group. The project has 
demonstrated 26-50 percent reduction in hospital admissions with a 
slight decrease in mortality while improving clinical indicators and 
consistently achieving 95 percent satisfaction rates with the families 
of this frail population. Excluding deaths, the disenrollment rate for 
enrollees in this program is less than one percent, data further 
underscoring the overall programmatic excellence.
Nationwide Eldercare Consultation, Information and Referral
    Customer/Client: The Lutheran Brotherhood
    Company/Product Line: Evercare Connections
    Start Date: July 1997
    The Lutheran Brotherhood contracts with Evercare Connections to 
provide elder consultation, information and resources to their long 
term care insurance policyholders on a nationwide basis. This contract 
has been in place since July 1997 and over 50,000 Lutheran Brotherhood 
policyholders currently have access to this valuable service.
    Under the terms of this agreement, Lutheran Brotherhood 
policyholders may call a dedicated toll-free telephone number and speak 
with an Elder Care Specialist who assists in determining the type and 
availability of services necessary to support their elder care needs. 
The Elder Care Specialist will offer multiple provider or service 
options in the desired geographic location drawn from Evercare 
Connections' provider database. This national database contains 
detailed information on over 90,000 long term care providers and 
community based services. The policyholder will receive an information 
packet that contains information relevant to their need. This 
information packet contains detailed provider profiles and other 
helpful information such as educational brochures and guides to assist 
in evaluating a provider. If desired, the Elder Care Specialist may 
assist the policyholder by scheduling provider appointments or 
implementing services.
                                summary
    Evercare has experience in operating a number of different long 
term care program models tailored for the unique needs of veterans, 
Medicaid, Medicare and/or fee-for-service individuals. We provide 
service to government and private entities that are based on the care 
principles of a client-centered approach, integration, and the least 
restrictive and safest setting. Our experience and expertise in 
implementing and managing these programs can serve as a best practices 
resource to the Veterans Administration. We are thankful for the 
opportunity to present our capabilities and ideas to the Senate 
Committee on Veterans Affairs and look forward to future opportunities 
to collaborate with the Committee and the VA on the development of new 
long term care alternatives for veterans.

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