[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


 VA LONG-TERM CARE: WHAT'S WORKING, WHAT'S NOT, AND HOW TO BEST SERVE 
                           OUR AGING VETERANS

=======================================================================

                             FIELD HEARING
                         Camarillo, California

                               BEFORE THE
                         SUBCOMMITTEE ON HEALTH


                                OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         MONDAY, JULY 30, 2018

                               __________

                           Serial No. 115-73

                               __________

       Printed for the use of the Committee on Veterans' Affairs

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Available via the World Wide Web: http://www.govinfo.gov
                     
                     
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                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas               ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
BRIAN MAST, Florida
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                      NEAL DUNN, Florida, Chairman

GUS BILIRAKIS, Florida               JULIA BROWNLEY, California, 
BILL FLORES, Texas                       Ranking Member
AMATA RADEWAGEN, American Samoa      MARK TAKANO, California
CLAY HIGGINS, Louisiana              ANN MCLANE KUSTER, New Hampshire
JENNIFER GONZALEZ-COLON, Puerto      BETO O'ROURKE, Texas
    Rico                             LUIS CORREA, California
BRIAN MAST, Florida

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                           
                           C O N T E N T S

                              ----------                              

                         Monday, July 30, 2018

                                                                   Page

VA LONG-TERM CARE: WHAT'S WORKING, WHAT'S NOT, AND HOW TO BEST 
  SERVE OUR AGING VETERANS.......................................     1

                           OPENING STATEMENTS

Honorable Neal Dunn, Chairman....................................     1
Honorable Julia Brownley, Ranking Member.........................     2

                               WITNESSES

Katy Krul, Acting Executive Director, Oxnard Family Circle ADHC..     4
    Prepared Statement...........................................    31
Mike McManus, County of Ventura Veterans Service Officer.........     6
    Prepared Statement...........................................    32
Thomas Martin, Assistant Deputy Secretary, Homes Division, 
  California Department of Veteran Affairs.......................     8
    Prepared Statement...........................................    34
Dr. Teresa Boyd, D.O., Acting ADUSH, for Clinical Operations and 
  Management, Veterans Health Administration, U.S. Department of 
  Veterans Affairs...............................................    10
    Prepared Statement...........................................    35

  Accompanied by:

    Dr. Scotte Hartronft, M.D., Chief of Staff, VA Greater Los 
        Angeles Healthcare System, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

                        STATEMENT FOR THE RECORD

Dr. Bernard Salick, M.D., Chairman & Ceo, Salick Comprehensive 
  Diabetes Centers...............................................    38

 
 VA LONG-TERM CARE: WHAT'S WORKING, WHAT'S NOT, AND HOW TO BEST SERVE 
                           OUR AGING VETERANS

                              ----------                              


                         Monday, July 30, 2018

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                     Subcommittee on Health
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:00 a.m., at 
the Ventura County Office of Education, Salon B and C, 5100 
Adolfo Road, Camarillo, California, Hon. Neal P. Dunn [Chairman 
of the Subcommittee] presiding.
    Present: Representatives Dunn and Brownley.

            OPENING STATEMENT OF NEAL DUNN, CHAIRMAN

    Mr. Dunn. So it is great to be here.
    The Committee will come to order.
    Thank you all for coming here and joining us today. I am 
Congressman Neal Dunn. I represent Florida's Second 
Congressional District. I am honored to serve as the Chairman 
of the Committee on Veterans Affairs' Subcommittee on Health. 
As a veteran and a doctor, ensuring the VA is providing for 
those who have borne the battle is one of my deepest 
commitments in Washington.
    I would like to begin by thanking Subcommittee Ranking 
Member Congresswoman Julia Brownley, whose district we are 
sitting in, for her hard work on the Subcommittee and her 
devotion to the betterment of our Nation's Veterans. I also 
thank you for giving me the opportunity to visit this beautiful 
part of the country.
    During today's hearing we are going to take a closer look 
at the Department of Veterans Affairs long-term care and how it 
can be improved to best serve our aging Veterans. The title of 
the hearing is ``VA Long-Term Care: What's Working, What's Not, 
and How to Best Serve Our Aging Veterans.''
    The average age in veteran population has increased over 
the last few years and as has a number of Veterans who qualify 
for VA support of long-term care. That means the VA is now 
facing the largest demand for long-term care in its history.
    With this in mind, I have questions about how various VA 
long-term care programs work together, what the eligibility 
requirements are for these programs and how the VA will manage 
this increasing demand and what services Veterans would like to 
have available to them as they age. I also want to hear from 
our witnesses about what is and is not working for the VA and 
the private long-term sector care providers here in Ventura 
County.
    Understanding the good, bad, and the ugly on a microscopic 
level can help us see and get the big picture and address some 
of the national long-term care issues. I was, as I am sure many 
of you were, disturbed by recent articles in USA Today that 
alleged poor quality of care at the VA Community Living Centers 
in different parts of the country. Though the VA has briefed 
the Committee on the Department's quality ratings, I remain 
concerned about the quality of the care being provided to 
Veterans in this VA community and others in our living centers 
and in our other systems.
    The three closest Community Living Centers to Ventura are 
in Sepulveda, Long Beach, and Los Angeles. Fortunately all 
three of these facilities earn quality ratings of at least four 
stars, which is I think a credit to the good work being done by 
the staff there.
    I hope the VA will be able to speak to these ratings and 
what might be working well here in Southern California and that 
might not working as well in other facilities around the 
country, as well as how they plan to sustain and improve the 
quality of care provided to the aging Veterans in this 
community. And I am grateful to all of the witnesses for being 
with us this morning to discuss this important issue.
    With that, I now yield to the Ranking Member, Ms. Julia 
Brownley, for any opening statement that she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Dr. Dunn. And first and foremost, 
I want to thank you for traveling out west to be here in my 
district and to help us all to understand the concerns of 
Veterans here in Ventura County and certainly across California 
and the Nation. I appreciate the time you are taking out of 
what I know to be a very, very busy schedule to come and visit 
and I hope you enjoy your time here in the most beautiful 
district in all of California.
    Your commitment to this Subcommittee and the Veterans we 
serve is undeniable and your medical acumen on the Committee 
has been proven to be extremely vital, and we appreciate your 
willingness to hold this hearing on VA long-term care services 
here in Ventura County. So welcome to you and to everyone here 
today.
    As a housekeeping note I just wanted to point out while 
typically we don't have questions from the audience during 
Congressional Committee hearings, but please know that I and my 
staff are here to help however we can and are very open to your 
ideas to improve any of these programs that we discuss today.
    Today's hearing will hopefully raise awareness, provide you 
with critical information and if you have follow-up questions, 
follow-up questions or issues to resolve we will be here as a 
resource.
    During this Congress the Committee has held a number of 
hearings on the caregiver support program and these hearings 
led us to realize that VA long-term care services have somewhat 
flown under Congress's radar for far too long. Overall 
Americans are living longer so we must be prepared for how to 
care for them, and this is especially important at the VA as 
more than 12 million Veterans across the country are over age 
65.
    I was proud to vote to expand the caregiver program as part 
of the Mission Act, however, this program will not meet all of 
the needs of our aging veteran population. This hearing is 
meant to be the first step in ensuring VA's long-term care 
services are designed and implemented in a manner that ensures 
Veterans receive the care they need in a manner that reflects 
their preference.
    Not only will this promote the quality of care Veterans 
receive but it will allow the VA to better allocate its 
resources. Outside of VA, we have seen a significant shift from 
institutional care such as nursing homes to noninstitutional 
care such as medical foster homes. However, as in the case of 
medical foster homes, many of these new innovative types of 
noninstitutional care require the veteran to pay as the VA 
lacks the ability and resources to do so. Just last week the 
House of Representatives passed a long-term care Veterans 
Choice Act that allow VA to pay for up to 900 Veterans per day 
to access medical foster homes.
    Now we must look towards other programs such as home health 
aides and assisted living facilities, among many others, that 
VA offers to aging Veterans and those with disabilities. We 
must ask are there gaps in eligibility, are the programs 
affordable for Veterans, does VA have the resources it needs to 
ensure Veterans are aware of and able to access the programs 
that best fit their long-term care needs.
    In preparing for this hearing I was impressed with the 
number of different programs within VA that are meant to 
support its aging and disabled Veterans.
    However, I am unsure that both VA employees and Veterans 
are fully aware of these programs, their eligibility 
requirements, or how they interact with programs outside of the 
VA.
    By turning a congressional eye towards VA's long-term care 
services, I am hopeful that we can bring more attention to 
these programs, the areas in which they excel and the areas in 
which they may need a little or perhaps a lot of help. 
Obviously, the best way to do this is to speak with Veterans, 
veteran service organizations, VA experts, and my colleagues on 
the Committee. Today's hearing is an effort to establish the 
lines of communication between each of these stakeholders so 
that as we move forward, we are fully informed.
    I appreciate each of today's witnesses for their 
willingness to engage in this conversation and to spread more 
life on these programs and the Veterans they serve.
    I look forward to our discussion today, and Mr. Chairman, I 
yield back.
    Mr. Dunn. Thank you very much, Representative Brownley.
    Before I introduce our witnesses, I want to remind everyone 
that today's hearing is a formal congressional hearing, just as 
if we were holding it on the Hill, but we brought it here to 
you. So we have a routine.
    What we are going to have is one panel of witnesses, and 
only those invited to testify will be permitted to speak. Each 
panel will have 5 minutes for their opening remarks, and I 
respectfully ask that our panelists keep an eye on the timers 
in front of you there which these we brought from Washington. 
These are authentic. I have to live under this pressure as well 
as you.
    We have had some very thoughtful submissions for the record 
for this year from local experts in long-term care such as Dr. 
Bernard Salick of Salick Comprehensive Diabetes Centers and 
Julian Manalo, who is also with CalVet.
    Mr. Dunn. I encourage those watching this hearing to read 
these submissions, which are included as part of the record for 
this hearing and will be available online at our Committee's 
Web site, which is www.Veterans.house.gov.
    There will be an opportunity after the hearing for those of 
you in the audience to come up and speak with myself, 
Representative Brownley, our staff members, if you have 
questions, comments, suggestions, if you need further 
assistance.
    Joining us this morning on our first and only panel is Katy 
Krul, Acting Executive Director for the Oxnard Family Circle, 
an adult day health care; Mr. Mike McManus, County of Ventura 
Veteran Service Officer, the Veteran Service Collaborative; Mr. 
Thomas Martin, Assistant Deputy Secretary, Homes Division for 
California Department of Veterans Affairs; and Dr. Teresa Boyd, 
the Acting Assistant Deputy Under Secretary for Health for 
Clinical Operations and Management within the Department of 
Veterans Affairs, who is accompanied by Dr. Hartronft, Chief of 
Staff of the VA Los Angeles--Greater Los Angeles Healthcare 
System.
    So welcome all of you to here. Thank you so much for being 
here.
    And, Ms. Krul, we are going to begin with you. You are 
recognized for 5 minutes.

                     STATEMENT OF KATY KRUL

    Ms. Krul. Oxnard Family Circle Adult Day Healthcare is a 
medical model day program that provides care for Veterans in 
our community. The Veterans who receive care are at risk for 
skilled nursing placement if they do not receive services at 
the center. They are frail, elderly individuals who require 
intervention from registered nurses, rehabilitative services, 
and assistance with personal care needs including toileting, 
feeding, and bathing. We provide transportation for Veterans 
from their homes to the center, meals, stimulating daily 
activities, social work case management services and 
psychological counseling, massage services, and podiatry care. 
The center also has a specialized memory care unit that we 
developed in conjunction with the Alzheimer's Association.
    Many of the spouses or other family members of our Veterans 
are overwhelmed with the day-to-day responsibility of caring 
for their veteran. We find that the caregivers are at risk of 
experiencing a decline in their physical and mental health 
condition. Our program is the resource for vital respite care 
for many families as it offers day-long extended services for 
five days per week.
    [KK1]Oxnard Family Circle provides care to Veterans who 
have served in World War II, Korea, Vietnam, and Iraq war 
periods. Essential benefits for Veterans in our program are 
camaraderie, the sense of social belonging, and connection to a 
group that is unique to their shared military experiences.
    We develop an individualized treatment plan for each 
veteran that focuses on the specific medical, dietary, and 
psychiatric needs of that person.
    Specialized programming that is provided includes an Equine 
Therapy program, outings that facilitate integration into the 
community, psychological groups, one-on-one counseling 
services, music and memory activities, art therapy, support 
groups for family members, educational events in conjunction 
with the Disabled American Veterans, Alzheimer's Association, 
Public Health and Ventura County Area Agency on Aging.
    Our setting allows the Veterans to function with a sense of 
dignity. In the home setting, they often feel diminished as 
their loved ones assist them with basic activities of daily 
living, including toileting, bathing, having assistance with 
transfers and walking. Many of our Veterans are uncomfortable 
and resistant to family members providing this level of 
assistance. Veterans and their families benefit from the 
personal care assistance that is provided by Oxnard Family 
Circle's professional staff.
    Oxnard Family Circle works closely with the Department of 
Veterans Affairs to coordinate the care needs of Veterans. 
Referrals for adult day health care services may be received 
from the local VA Outpatient Clinic. Many Veterans reside in 
our community who may not be connected with the VA Healthcare 
System. Our staff educates Veterans as to the types of benefits 
that they may receive and assists them with enrolling in the 
health care system.
    We also refer Veterans and families to the Ventura County 
Veterans Services Office for assistance with financial 
benefits. We maintain close communication with the veteran's 
physician and VA social workers during the time that the 
Veterans are enrolled in our program. When a veteran's care 
needs increase so that adult day health care services are no 
longer appropriate, Veterans may be referred to the VA 
Community Nursing Home Program or VA hospice services. Aid and 
attendance may be applied for to pay for care in the veteran's 
home setting or an assisted living facility.
    All Veterans who are VA health care eligible may be 
appropriate for adult day health care services, as long as the 
veteran has been determined to have the following clinical 
conditions: first, three or more activities of daily living 
dependencies; or second, significant cognitive impairment; or 
third, require community adult day health care services as 
adjunct care to community hospice services; or, fourth, two 
activities of daily living dependencies and two or more of the 
following conditions; veterans has dependencies in three or 
more instrumental activities of daily living; has been recently 
discharged from a nursing facility or upcoming nursing home 
discharge plan contingent of home and community-based care 
services; is 75 years-old or older; has had high use of medical 
services defined as three or more hospitalizations in the past 
year and/or utilization of outpatient clinics, emergency 
evaluation units 12 or more times in the past year; has been 
diagnosed with clinical depression; and lives alone in the 
community.
    We are particularly appreciative of the support and 
advocacy that has been provided to us by Congresswoman Julia 
Brownley's office.
    Thank you for allowing me.

    [The prepared statement of Katy Krul appears in the 
Appendix]

    Mr. Dunn. Thank you very much, Ms. Krul. Thank you for 
thoughtfully including the admissions criteria for your 
program. That is helpful for us as well as coming into the 
situation.
    Mr. McManus, you are up next for 5 minutes.

                   STATEMENT OF MIKE MCMANUS

    Mr. McManus. Good morning, Chairman Dunn and Ranking Member 
Brownley. Thank you for the opportunity to provide some 
information to the Committee regarding long-term care options 
to Southern California Veterans.
    My name is Mike McManus, and I am the County of Ventura's 
Veteran Services Officer. My staff and I connect fellow 
Veterans, their dependents, and survivors with Federal and 
State benefits and local resources. One of our primary 
responsibilities is connecting Veterans with VA disability 
compensation for such things as post-traumatic stress, 
traumatic brain injury and for conditions resulting from 
physical and psychological injury while in the military. We 
also assist Veterans who enroll in VA health care and refer 
them to local and regional care resources.
    My office has five accredited individuals who interview 
Veterans, file the appropriate benefit claim and advocate on 
behalf of the veteran and make needed referrals to other 
service providers. We also have support staff that enable us to 
meet our client needs.
    The Veteran Services Office has conducted a variety of 
outreach activities to inform the veteran community about their 
benefits, including VA health care. The office currently 
operates out of the main office and 10 field offices. We have a 
variety of partners through the Veteran Collaborative of 
Ventura County that also helps us reach Veterans.
    And just as an example in fiscal year '12-'13 my office saw 
3,572 people. However, our last fiscal year, the one that just 
ended in June we saw 6,764 people. So we are encountering a lot 
of Veterans, briefing them on the benefits, connecting them 
where we can. However, there is, obviously, a lot of work that 
can be done because there are 40,000 Veterans in the county.
    I myself am a retired Air Force Senior Master Sergeant. I 
did nearly 20 years or spent just over 20 years, ended up as 
First Sergeant with one deployment for Operation Iraqi Freedom. 
As a First Sergeant I was involved with briefing the commander 
on anything that had to do with the enlisted members of the 
unit, including physical and mental health.
    I have been the Veteran Services Officer for over eight 
years.
    Ventura County since January of 2010, and it is an honor to 
continue to serve our Veterans. So there are a variety of 
Veterans benefits that are eligible for Veterans when it comes 
to long-term care. Usually the veteran will start by seeing 
their primary care provider or social worker at the Oxnard 
Community Based Outpatient Clinic.
    As I alluded to earlier, Ventura County has over 40,000 
Veterans, thousands more National Guard, Air National Guard and 
Reserve personnel who may over time be eligible for VA long-
term care. Approximately 22,000 Ventura County Veterans served 
in World War II, Korea, and Vietnam and their age ranges from 
65 on up. In addition to the typical ailments of aging, over 
4,100 of these Veterans also have chronic injuries from 
military service. Those are individuals that have filed 
disability compensation claims. So you can anticipate that 
there is an unmet need there because many Veterans have not yet 
filed those claims.
    In essence, we have tens of thousands of Veterans in 
Ventura County and many of those will need some form of long-
term care. I feel there is a large unmet need in the community 
due to misperceptions on the part of Veterans and the lack of 
information from the VA. My staff and I have spoken with 
countless Veterans who thought that Medicare, TriCare, or the 
VA will provide for their long-term care needs. They aren't 
aware that Medicare provides very little in terms of long 
care--long-term care, TriCare even less, and the VA only if the 
veteran is eligible, typically 70 percent service-connected or 
higher. And, of course, based on clinical need.
    As outreach to the military veteran community increases 
from organizations such as my office and those that are members 
of the Veteran Collaborative of Ventura County. The number of 
Veterans seeking services increases and we need to be able to 
better educate them on their realistic options.
    In addition to veteran misperceptions, there is a lack of 
information provided to Veterans regarding VA long-term care. 
Now, in Ventura County, and I am just going to run down through 
some of the options that I am aware of that my office helps 
connect Veterans to; first we will learn more about the VA 
nursing home on the campus of the Greater LA Medical Center 
campus; the VA also has three Community Living Centers or what 
we used to refer to as nursing homes in Ventura County, Coastal 
View Health Care Center in Ventura and Shoreline Care Center is 
in Oxnard; and I recently learned of Maywood Acres also in 
Oxnard.
    Typically a vet has to be 70 percent service-connected or 
higher, and I bring this up is because for those individuals 
that are service-connected in Ventura County, only 4 percent 
are 70 percent or above. Now, of course, it also means that 
where there is an option for Veterans that are enrolled in VA 
health care that require hospice and nursing home could also be 
eligible for a VA nursing home care, but I just want to be able 
to illustrate that 4 percent are 70 percent or higher. So what 
about the rest of our Veterans? So in some cases maybe they 
turn to Medi-Cal, you know, there is also Home Health Aides 
which are very important.
    Mr. Dunn. Finish real quickly if you can.
    Mr. McManus. All right. I was already self-editing there.
    So a veteran's primary care provider, they are usually 
where this starts, especially when it comes to Homemaker and 
Home Health Aide Care programs, which basically the VA 
contracts for someone to come into the veteran's home and 
provide care for the veteran and respite for the family care 
member.
    Katy already touched on Oxnard Family Circle which is a 
vital service to the county. There are several hospice 
providers that also play a part in this long-term care, 
Livingston Memorial Visiting Nurse Association and VITAS are a 
couple in the county that have routinely received positive 
comments.
    And I also just want to briefly comment everything we have 
talked about is on the VHA or the Veterans Health 
Administration site but on the Veterans site there is also aide 
and attendance on the VPA side of the house. We can certainly 
connect them. But again, there are eligibility requirements. 
The vet needs someone to come in and provide assistance with 
some essential activities of daily living, maybe the veteran, 
is a patient in a nursing home or they have some visual acuity 
issues.
    I can certainly go on but my time is up so I would just 
like to thank the Chairman and the Ranking Member Brownley for 
this opportunity.

    [The prepared statement of Mike McManus ppears in the 
Appendix]

    Mr. Dunn. Thank you, Mr. McManus. I do appreciate the 
inclusion of some of your organization's structure and the 
quantification of some parts of your budget. In general more 
quantification of these things is helpful to us in Washington. 
So that quantification is good going forward.
    I will tell you that in Washington you would have been cut 
off, like, a minute and a half ago.
    Mr. McManus. I appreciate your indulgence.
    Mr. Dunn. Mr. Martin, you are now recognized for 5 minutes.

                   STATEMENT OF THOMAS MARTIN

    Mr. Martin. Thank you for the opportunity to be here today 
and facilitate this conversation amongst us. Projecting future 
health care needs is a top priority for CalVet at the moment. 
So this is a very good time for us, and I think it is a good 
opportunity for more communication and collaboration between 
the State and Federal Government and also private providers.
    So first let me start with some background information on 
our program. CalVet operates eight Veterans Homes located 
throughout the States; each offers a range of care options, so 
independent living, assisted living, skilled nursing and 
skilled nursing secured-memory care units. The homes vary in 
size from 60 to 900 beds, and we are very proud to say that all 
of our homes, all of the Medicare-rated homes are at four or 
five stars.
    In total, we care for about 2,400 Veterans and spouses and 
as Congresswoman Brownley knows we have the Ventura Veterans 
Home nearby. It is a state-of-the-art 60-bed assisted living 
facility, and it is a personal favorite of mine, but don't tell 
the other homes.
    So to be eligible for admission applicants need to be 
former active duty military personnel. They must age or 
disabled. They must be California residents and they must 
qualify for long-term care from the VA. And we also admit 
spouses for certain situations.
    We also have priority admission for Metal of Honor 
recipients, former prisoners of war, homeless Veterans, and 
Veterans with high service-connected disability ratings.
    So the Veterans homes are closely connected to the VA in 
four primary areas. The VA annually certifies and surveys our 
Veterans Homes to ensure residents receive quality health care 
in a safe living environment; second, the VA also pays a per 
diem for all of our qualified Veterans. It ranges from, give-
or-take, $50.00 to $500 or more depending on location, the 
service-connected-disability rating, and the care needs of the 
Veterans; third, the VA funds up to 65 percent of construction 
costs for approved projects, to include the Ventura home 
nearby; and finally, of course, many of our residents continue 
to receive specialty services and other forms of services from 
the VA.
    So I understand that one of the goals of this hearing is to 
discuss strategic planning for veterans' long-term care, which 
as I said this fits quite well with what we are working on at 
the moment.
    We know there are clear generational differences between 
each generation of Veterans. Our residents right now are World 
War II vets, Korean war Veterans, and Vietnam era Veterans, and 
with what we have seen now there are clear--again, there are 
clear differences in how late they wait to apply for long-term 
care which means they tend to come in older and with more 
significant health care issues. There's differences in the 
level--the type of community environment they want to be 
surrounded in, the level of privacy they want, and the type of 
activities they are interested in.
    So again, at the moment CalVet has undertaken a census 
statewide needs assessment to identify this generational change 
both in terms of the demands of the generation and also in 
terms of the level of support that is going to be needed for 
them. Our intention is to take this data and to translate it 
into really what we should look like in the future, and 
obviously this means we need a good sense of what resources are 
available beyond just the veteran's homes and how we connect 
into that.
    It is pretty clear that there is going to be a high demand 
for skill nursing in the future, there is going to be sustained 
need for secured memory care units for dementia patients, and 
we also expect more demand for mental and behavioral health 
programming that focuses on post-traumatic stress, substance 
abuse, and other conditions that, frankly, don't fit the model 
of a long-term care patient in the classical sense.
    And finally, most importantly, we hope to better understand 
how the VA, Veterans Homes, and nonprofit organizations and 
private facilities are or aren't equipped to meet these needs, 
to meet these challenges and how we can best bridge the gap to 
ensure that Veterans get the full spectrum of care that they 
have earned.
    So with that said, I think the most important thing I can 
say is that there really is no single provider that can offer 
everything for every veteran. If there is one thing to take 
away from that, I think that is the most important thing.
    So we certainly look forward to the VA's leadership in 
outlining where they expect providers to be, and again, I would 
like to thank you for this opportunity to be here today and for 
setting this up for us.

    [The prepared statement of Thomas Martin appears in the 
Appendix]

    Mr. Dunn. Thank you for being here and thank you for your 
testimony, and you mentioned taking the census, or I took note 
of you saying it, you said you will have some data and data is 
what we run on. So please include Representative Brownley and 
our Committee in that report, if you would, please.
    Dr. Boyd, you are now recognized for 5 minutes.

                 STATEMENT OF TERESA BOYD, D.O.

    Dr. Boyd. Good morning, Chairman Dunn, Ranking Member 
Brownley, and Members of the Subcommittee. I appreciate this 
opportunity to discuss VA long-term care for Veterans and their 
choices for care as they age or face catastrophic injuries or 
illnesses.
    I am accompanied today by Dr. Scotte Hartronft, Greater Los 
Angeles Healthcare System's Chief of Staff.
    The VA's Office of Geriatrics and Extended Care or GEC is 
committed to optimizing the health and well-being of Veterans 
with multiple chronic conditions, life limiting illness, 
frailty, or disability associated with chronic disease, aging, 
or injury.
    GEC's programs maximize each veteran's functional 
independence and lessens the burden of disability on Veterans, 
their families, and caregivers, as in the case of the 77-year-
old World War II veteran, airplane mechanic, and retired 
country physician diagnosed with debilitating Parkinson's whose 
care is delivered by occasional admissions to a community 
nursing home, assisted in the home by Homemaker Home Health 
Aide, and the support of his spouse with respite care; or the 
69-year-old Vietnam veteran, West Point grad, with devastating 
diagnosis of metastatic lung cancer who is able to spend his 
final days in his home under hospice care with family; and 
finally, the 32-year-old Navy veteran with a life-long medical 
diagnosis who no doubt will rely heavily on our VA system of 
care as he ages with a chronic disease.
    As Veterans age, approximately 80 percent will develop that 
need for long-term services and support.
    The aging of the veteran population has been more rapid and 
represents a greater proportion of the VA patient population 
than observed in other health care systems. GEC's programs 
include a broad range of long-term services and supports, one 
of which is home and community-based services.
    This program supports independence by allowing the veteran 
to remain in his or her own home for as long as possible by 
using one or more of these services, including adult day health 
care, home-based primary care, Homemaker Home Health Aide, 
palliative and hospice care, respite care, skilled health home 
care, telehealth, and veteran-directed care.
    In addition to improving care for Veterans, home and 
community-based services reduces costs for the Department. VA 
financial obligations for nursing home care in the fiscal year 
2017 reached $5.7 billion. The number of Veterans with service-
connected disabilities rated 70 percent or more for whom VA is 
required to pay for nursing home care when indicated is 
projected to double from 500,000 to 1 million Veterans between 
2014 and 2024.
    Therefore, if nursing home utilization continues at the 
current rate among veteran enrollees without even considering 
inflation, the cost to VA for providing nursing home care for 
enrolled Veterans can conservatively be estimated to reach more 
than $10 billion within the next decade.
    There is an urgent need to accelerate the increase in the 
availability of these services since most Veterans prefer to 
receive care at home, and the VA can improve quality in a lower 
cost by providing care in these settings.
    States have found that through their Medicaid programs they 
have been able to reduce costly nursing home care by balancing 
their expenditures for long-term services and supports between 
institutional and home and community-based settings. VA's 
spectrum of home and community-based services include adult day 
health care. This is one of the strongest sources of caregiver 
support and respite and is greatly valued by Veterans and their 
family caregivers who rely on this program to help the veteran 
to remain at home as long as possible.
    While VA does not have sufficient data regarding the cost 
benefit of this program, the Medicare program for all-inclusive 
care of the elderly is based largely on this program and has 
demonstrated strong success in helping frail older adults at 
highest risk for nursing home placement to instead remain 
living at home.
    Nursing homes are settings in which skilled nursing care is 
available 24 hours a day. All Veterans receiving nursing home 
care through the VA must have a clinical need, as mentioned, 
for that level of care. VA strides to use nursing hoecake when 
a veteran's health care needs cannot be safely met in their 
home.
    VA also maintains strong working relationships with the 
States in the oversight and payment of Veterans care through 
State Veterans Homes. There are currently 156 State Veterans 
Homes across all 50 States, including one here in Ventura, 
California. We recognize and appreciate the commitment of all 
of our partners here today.
    VA's various long-term care programs provide a continuum of 
services for older Veterans designed to meet the needs as they 
change over time. Together they have significantly improved the 
care, well-being, and dignity of our Veterans, including that 
77 year-old World War II veteran, that was my father; the 69 
year-old Vietnam veteran, he was my eldest brother; and the 32 
year-old Navy veteran, he is my stepson.
    The gains and the long-term care provision of care would 
not have been possible without consistent congressional 
commitment in the form of both attention and financial 
resources. Your continued support is essential into providing 
high quality care for our Veterans and their families present 
and future.
    Mr. Chairman, this concludes my testimony. My colleague and 
I are prepared to answer any questions. Thank you.

    [The prepared statement of Teresa Boyd appears in the 
Appendix]

    Mr. Dunn. Thank you very much, Dr. Boyd.
    And we will start the questioning now.
    I want to comment that your testimony was very nationally 
based, which is, of course, what you do. We are here in Ventura 
County. We are hoping to get kind of a granular view of Ventura 
County or at least maybe bring it down to the VISN 22 level. So 
if even in your position cannot drill down to a specific visit 
or county, we can't do it either. So we are hoping that we can 
find out how things work on a county level.
    I will now yield myself 5 minutes. So I will have to 
restart that clock since I was editorializing. So I will now 
yield myself 5 minutes for some questions.
    Let me start out, if I may, with you, Dr. Boyd. Mr. Martin 
made a great comment about a census and data gathering and 
looking at shortcomings and what do we need in the way of data, 
what are we going to need in the future to treat our Veterans. 
Is this being done throughout all the VISNs or all the States 
and if not, should it be.
    Dr. Boyd. So that is a good question. We are currently at 
the national level looking at this, because as I mentioned in 
the testimony and also in the written testimony, we are very 
concerned about this coming upon us now.
    We can drill down to individual VISNs and regions by 
looking at our forecasting models as well, so you can be 
assured that this is being done. What we do with that and how 
we parse it out to the different programs is yet to be decided, 
but we are definitely very concerned and are on top of that.
    Mr. Dunn. So while we are talking, your written statement 
referred to 20 centers of excellence in the VA. What are these 
centers of excellence and what do they do? What is their role?
    Dr. Boyd. So the 20 centers of the excellence actually help 
us. We can have a whole hearing on this but in a nutshell, they 
really help us with our innovations and what we can do in 
moving forward.
    I do believe that we have it right here with VISN 22, and 
Dr. Scotte Hartronft can do a little bit of bragging about that 
site, but in essence they help us with looking at the world of 
the possible and how we can implement changes and actual 
clinical practice in the field. So with your permission I would 
like Dr. Hartronft to discuss a very good program here within 
the GLA area.
    Mr. Dunn. That may be a conversation for another time.
    Somebody mentioned--I think it was you, Mr. Martin, or 
maybe Mr. McManus--was the hospice care, and that is a subject 
near and dear to my heart. I think hospice care is 
underutilized. I think it is an important part of medical care 
and I think it is a very compassionate and helpful thing to do.
    Surely Medicare reimburses whatever program is providing 
hospice, whether it is VITAS Oxnard or a VA program. Has the VA 
filed against Medicare insurance for the hospice care that they 
provide to Veterans?
    Dr. Hartronft. It is my understanding, no.
    Mr. Dunn. No? Is that your understanding?
    Mr. Martin, CalVets, do you know that.
    Mr. Martin. I am not aware--
    Mr. Dunn. Why wouldn't they?
    Dr. Boyd. Hospice care is available to any enrolled 
veteran.
    Mr. Dunn. It is also available to any Medicare patient. I 
got out over my skis there.
    So on the subject of telehealth, I was interviewing a 
doctor in another city, another visit, and he said that by far 
and away the most efficient that he gets is in the telehealth. 
He was saying he sees 30 to 35 patients a day in telehealth 
versus 12 to 14 if he is in a clinic.
    First of all, that is a very low number for a clinic, I 
happen to know, but also maybe we should do more telehealth. 
And I am not sure who should address that. Maybe Dr. Hartronft?
    Dr. Hartronft. Locally telehealth has come a long ways and 
one thing we are finding out is how to--because as you imagine 
telehealth is only as strong how you are able to get the 
communication to both sides, and now currently we have had a 
lot of success with having specialties that could be at West 
Los Angeles that could then have care out into our smaller 
community clinics, but now we are also, like with mental 
health, they are developing a way to send a link to the veteran 
by e-mail and they can actually use that as a way to do tele-
mental health to their home. So we are--
    Mr. Dunn. He was actually Skyping or the version of Skyping 
that you are in the V.A.
    Dr. Hartronft. Yes, sir. So we are evolving with 
telehealth. I think actually the easiest we make it for the 
patient, the veteran in their home the more acceptable and 
accessible it will be.
    So I think we have already overcome having to have somebody 
go to their homes and removing the technological challenge to 
now where you can send them a link that they click on and then 
go through email, and you can imagine. So I think the 
telehealth is becoming a much more robust, and as you said 
being able to provide mental health in their home and other 
services is going to be the key.
    Mr. Dunn. Let me say that the VA is in a unique position to 
develop this capability because we don't rely on the State 
Boards, State medical examiners.
    So with that, I am going to yield to Representative 
Brownley.
    Ms. Brownley. Thank you, Mr. Chairman.
    Dr. Boyd, I wanted to drill down a little bit with you on 
this issue of institutional versus home or community-based 
services or care, and certainly over the past couple of decades 
Federal financing and delivery of long-term care, particularly 
for the largest Federal pair of long-term services, which is 
Medicaid--we say Medi-Cal here in California--has shifted to 
toward the provision of care at home and community-based 
settings rather than institutional care.
    I think I read somewhere in the briefings prior to this 
meeting that Medicaid/Medi-Cal is roughly around 50 percent and 
the VA is roughly around 31 percent. So if you could speak a 
little bit to what is the right proportion that you see across 
the Nation in terms of where the VA is and if we are not there 
yet, what are we doing to get there.
    Dr. Boyd. Thank you. Great question. And you are absolutely 
right, we can learn a lot from our State partners in various 
States as well. We do need--as a VA we do need to move upstream 
and not wait for institutional care, and we are learning that.
    There are many programs, as we mentioned, that are not just 
in the community. We have some programs in the home and 
community-based settings that are dual based, whether the VA 
may provide some of it or we buy some and purchase some from 
our community partners, but we need to focus on more of that, 
and whether that means reaching out and developing those 
partnerships either through contracts and with some of the new 
legislation with regards as Choice fades away, we will have 
contract negotiations as well.
    So that in our mind is where we need to be, moving it back 
to the left so that our Veterans can stay safely at home with 
caregivers or supplementing those needs, whether it be the 
adult day health care during the day and in the evenings or the 
weekends they have Homemaker Home Health Aide and respite care.
    But you are absolutely right, we have lessons learned and 
we are moving in that direction so our Veterans can choose to 
age gracefully and safely at home.
    Ms. Brownley. Thank you for that. I know in Washington we 
talk a lot about this, and we spent a lot of time back in 
Washington talking about the caregiver program and the 
Committee has worked towards expanding the caregiver program 
post-9/11 Veterans where it was previously just pre-9/11 
Veterans. But I think we all agree that in the long-term it is 
a win-win situation because Veterans prefer to stay in their 
home generally, and I believe also that many of these in-home 
services or community-based services at the end of the day is 
less expensive in the long run than institutionalized care is. 
And we know this bubble is coming through, you know, we call it 
the gray tsunami coming through, and I think we just got to 
make sure that we have clear and articulate plans on how we are 
going to address that so as our aging community ages no one is 
falling through the cracks.
    I wanted to also ask, I think there is perhaps some 
confusion and certainly in terms of reading the materials prior 
to the meeting, you know, I was also getting a little confused 
as well. And this is really about trying to understand, we 
are--and you listed most of them, I think, Dr. Boyd, in your 
testimony of all of these long-term care options, and some, as 
Mr. McManus mentioned, require a veteran to be 70 percent 
disabled or higher in order to be recipients of some of these 
services.
    But there are a lot of these programs that are based on 
physician's decision and clinical needs. So if you could kind 
of break down for me, and I think that is important for 
certainly our Veterans here in Ventura County to understand 
what the programs are, and certainly Mr. McManus who spends his 
days, that is all he does is help and assist Veterans in our 
community, to understand where, you know--I think that there 
are less programs that require the 70 percent disability 
requirement than there are just simply clinical decisions. So 
if you could break that down a little bit.
    Dr. Boyd. Yes, I will. Thank you. And I did make note of 
that when Mr. McManus was giving his oral testimony.
    It dawned on me, Congresswoman Brownley, that we need to do 
a better job of getting that information out, and I 
specifically wrote that down, what are we doing and how can be 
better at that and being a push instead of a pull organization 
with regards to information.
    But you are absolutely right, and please, Dr. Hartronft, 
let me know if I stumble here, but really the 70 percent 
service-connected or greater really falls into our--are to 
provide for those Veterans in our CLCs are provided nursing 
home care.
    Beyond that, most of the other--and the State Veterans 
Homes has their eligibility as well--but beyond that, the other 
long-term services and supports, you are an enrolled veteran, 
you are eligible for those if you meet the clinical need.
    And many times I start a conversation not only with the 
veteran but with the family, with their caregiver, with their 
support system as well to get the complete picture, and early 
on even, although it doesn't go directly to the eligibility 
part, it goes to the veteran's preferences. So we start very 
early in our partnership with our Veterans, is that 
relationship in discussing goals of care; so where do they want 
to be and what is most important to them.
    And so again, that is where we fit around those services 
that they are eligible for as enrolled Veterans. So I hope that 
helps a little bit.
    Ms. Brownley. Thank you. I have exceeded my time. Mr. 
McManus and I are both in trouble, but I yield back.
    Mr. Dunn. A stern note will follow.
    So that actually was exactly where my first question was 
going to go.
    I think that you mentioned that it is a hard time for 
people to know what they are eligible for, but this Committee, 
Members of this Committee who care about this, it is hard for 
us to understand what is available nationally, let alone in the 
granular level each county, each VISN, each locality may have 
certain things that available that aren't available anywhere 
else. And so if we don't know how to use it, if our staff 
doesn't know how to use it, how in the world are the Veterans 
going to know how to use it.
    I have actually seen some early programs that are, again, 
coming from outside the VA, not inside, that are trying to 
organize that approach based on the location, the geolocation 
of the veteran, and I am going to be bringing more of that into 
the Committee as we go forward back in Washington.
    But that would be a great thing to have, a flow sheet. And 
I guess actually I should say start with a national flow sheet 
and then fill in the location, even the geolocation you are in 
and what additional support is available for Veterans through 
that. So that is a commentary that is very, very, very 
important that we should meet on back in Washington.
    Dr. Boyd, in your testimony you said 80 percent of Veterans 
will develop a need for long-term services. What percentage of 
those Veterans meet the criteria for VA paid nursing home care 
nationally? So that is a national question. Should be in your 
wheelhouse.
    Dr. Boyd. So the question is with regard--
    Mr. Dunn. So if 80 percent of all Veterans are going to 
need long-term services as they age, what percentage meet the 
VA nursing home 70 percent disabled criteria or the necessary 
critically ill criteria?
    Dr. Boyd. I don't have that national number for you, but I 
will get it for you.
    Mr. Dunn. It is an important thing for us to consider since 
we are talking about $100 billion a year, right. So we need to 
know what that comes up at.
    Dr. Boyd. Absolutely.
    Mr. Dunn. Also, let me address if I can the foster homes. 
Representative Brownley talked about that.
    The medical foster homes to us, to the people who have come 
to us in Washington to testify, seem to be very popular options 
and they are very cost-effective. So what are our plans for 
expanding that program, Dr. Boyd or Dr. Hartronft, whoever? I 
think it is Dr. Boyd.
    Dr. Boyd. So yes, the medical foster home is actually a 
very good program for many of our Veterans. It is not for 
everyone. We do have about 1,000 enrolled--
    Mr. Dunn. Which is a pretty small number.
    Dr. Boyd. It is a small number. It is a very small number. 
There are over 700 medical foster homes, caregiver sites 
involving most States, although we do know that this is 
expanding in many others.
    The average cost is about $2,400 per month, and that is on 
the veteran. What we do know--
    Mr. Dunn. There is no hope for the veteran's benefits if 
they qualify for certain benefits, that that money couldn't be 
paid to the foster home?
    Dr. Boyd. If that is an authority that would be--
    Mr. Dunn. We just passed that authority.
    Ms. Brownley. The President hasn't signed it yet, but we 
did pass that.
    Mr. Dunn. It is coming.
    Dr. Boyd. I will be glad to talk about it next time.
    Mr. Dunn. I am a little ahead here again, but I think that 
is a popular--the Veterans are telling us they like it. It 
saves us a bunch of money. It saves the taxpayer. I think we 
ought to be able to lean into this as soon as we get the 
signature on the final document.
    Mr. McManus, one of your primary roles is to assist 
Veterans enrolling in the health care system. Can you walk us 
through that enrollment?
    Mr. McManus. Sure. So basically it is going to start with 
discussing, reviewing their DD 214 or their discharge document 
to see if they are in need. You have some basic eligibility, 
and they have actually got that form; and then, of course, 
there is a 10-10EZ, which is the application form used by the 
VA. They then take both their DD 214 and that application to 
the Oxnard CBOC and they talk with either Dan or Scott and they 
review their DD 214 to make sure they have got the qualifying 
length of service or maybe a campaign metal if they are a 
recent Iraq or Afghanistan vet just discharged from service 
then they will enroll them. And then there is a vesting 
physical that will come where the veteran provides blood, 
urine, and then they eventually meet with their primary care 
doctor to review those results as well as whatever might be on 
the veteran's mind.
    The veteran could also go online and enroll online and then 
ultimately be contacted by the Oxnard CBOC and be scheduled for 
that vesting appointment.
    Mr. Dunn. So I know that the online--and I will end this 
very quickly--but I know that the online system has gotten 
better over the last few years, but I tried to use it to enroll 
just to get a card four years ago and I am still waiting.
    I yield to the Representative Brownley.
    Ms. Brownley. Thank you, Mr. Chairman.
    So, you know, we are, and Dr. Boyd reviewed many of the 
programs within her testimony in terms of services, 
noninstitutional care services and institutional long-term care 
services and it goes from home-based primary care, community 
residential care, medical foster homes, generic evaluations, 
palliative care, Homemaker Home Health Aide, noninstitutional 
respite, skilled home care, home hospice, Veterans-directed 
home and community-based services, adult daycare, those are the 
noninstitutional ones.
    Institutionalized ones are the Community Living Centers, 
which I understand we have one both in Los Angeles and in 
Sepulveda, and community nursing homes, State Veterans Homes, 
which we know very well here in Ventura County. But that is a 
lot. That is a lot.
    And going back to Mr. McManus's point, and Dr. Boyd, you 
have already said we have got to do some better training here, 
that we have much more in a pull situation than actually making 
sure that our Veterans and people like Mr. McManus have the 
information, not to mention that our CBOC here in Ventura 
County is a contracted-out facility, so I even wonder how well 
the physicians within the CBOC are trained to understand 
exactly what programs are available to them.
    So while we are here in Ventura County I just want to get a 
firm agreement from you, Dr. Boyd, that we can bring some 
professionals, VA professionals into the county so that we can 
have a roundtable discussion or whatever to inform our Veterans 
to inform our physicians and certainly inform Mr. McManus and 
the county who are tremendous partners in all of this. So--
    Dr. Boyd. Absolutely.
    Ms. Brownley. Very good. Very good.
    The other thing I just wanted to briefly hit on in terms of 
institutional care, it is stated by the VA that institutional 
care--Veterans can receive institutional care if they are 
nonservice-connected Veterans if there is room, the caveat of 
if there is room.
    So what percentage are we talking about in terms of 
Veterans who are in nursing homes, the VA is, I presume, is 
paying for it but are nonservice-connected.
    Dr. Boyd. So I do not know the national numbers on that, 
but I can tell you this, that the Veterans that are not 70 
percent or greater service-connected are the majority of 
Veterans. So I don't know the national numbers. I will get that 
to you when I get back with you about the other promise for the 
eligible.
    And about the resources available, so if there is a 
clinical need and there is a bed within the VA CLC, we 
absolutely will bring that veteran in. If there is not but 
there is still a clinical need and there is no other option, a 
safe option for that veteran, then we do look to the community; 
although there is a I think 180-day cap on the VA paying for 
that, but in that interim they have tremendous coordination 
case and care management with the family and the veteran to see 
what is the next step, and they don't do it on day 180, they do 
it on day one to help with that transition.
    Ms. Brownley. Very good. So just in terms of we are using 
CLC, for the audience that is a Community Living Center which 
is like a nursing home, but they are associated with medical 
centers across the country. So if you are in the hospital in 
L.A. or getting care from Sepulveda, this is used you go there 
for rehabilitation and other kinds of things. It is not 
necessarily a very long term. Everybody that is there, it is 
assuming that they are going to recover and go home in that 
sense.
    But the question is, do we have the appropriate number of 
Community Living Center beds across the country? I certainly, 
you know--again, back in Washington we talk about nimbleness 
and following where the demands are across the country, and 
Ventura County is a perfect example of large demand, we have 
increased our CBOC but are we going to increase services here 
in Ventura County like Community Living Centers and like some 
of these other services that we have been talking about.
    Dr. Boyd. So with regards to overall--and I apologize for 
not mentioning what CLC meant earlier to the audience here--
with regards to the actual number, I don't foresee in the near 
future building more Community Living Centers. What we need to 
do, though, is look at rightsizing our Veterans that we have 
that need, the institutional care, and again, use the 
opportunities to work with our partners in the community and 
move that upstream.
    Ms. Brownley. But do we have wait times for people to get 
into these beds?
    Dr. Boyd. To my knowledge we do not have wait times for the 
combination of Community Living Centers and--excuse me--CLCs 
and the nursing homes.
    If we have a 70 percent or greater service-connected 
veteran who needs care and we do not have an available bed, 
say, it is going to be available in 10 days or 15 days or 
whatever, we will take care of that veteran in a community, in 
a contract nursing home that the patient and the family agree 
to. So we will take care of that.
    Ms. Brownley. Thank you. I yield back.
    Mr. Dunn. So that last question that Representative 
Brownley asked, particularly about the wait times, is there a 
long wait time, significant wait times to get into these beds? 
I am going to direct that question to Mr. Martin. I think he 
might have a better feeling for it locally.
    Mr. Martin. I can't speak to CLC facilities. I can speak to 
our Veterans Homes. So we do have wait times for most levels of 
care.
    Mr. Dunn. Roughly.
    Mr. Martin. It varies depending on location and the level 
of care.
    Mr. Dunn. On average days.
    Mr. Martin. So Ventura, it is probably a matter of handful 
of months at the smaller facility here. But we do something 
similar to them. We can refer them to other facilities that can 
take them pretty quickly depending on level of care.
    Mr. Dunn. Did I hear you say months?
    Mr. Martin. Correct. Yes.
    Ms. Brownley. This is a very popular one. This one in 
particular is very popular but it only has 60 beds.
    Mr. Dunn. That actually gets into another question I had, 
and I was intending to give it to Mr. McManus but maybe, Mr. 
Martin, you can comment too.
    We talked about the waiting list. So there is very much a 
preference for certain ones. Is there a preference for 
different programs?
    Mr. Martin. Certainly, yes. As I mentioned in my prior 
testimony, there is certainly a lot more demand for skilled 
nursing and for the highest levels of care.
    Mr. Dunn. Memory units?
    Mr. Martin. Yes, in particular memory--
    Mr. Dunn. How are you set up for memory units? Are you 
short?
    Mr. Martin. I am sorry?
    Mr. Dunn. Are you short?
    Mr. Martin. Yeah. There is a lot of demand for memory care 
units, and it is actually a relatively new offering that we 
have only started in the last handful of years.
    Mr. Dunn. I thought that Oxnard--I thought I saw where you 
are an outpatient memory unit. Can you explain to me how that 
works?
    Ms. Krul. We have special areas designated for those who 
have compromised memory. This area is secure and people who are 
there receive specialty care. They have higher level of nursing 
care. They have higher level of personal care. Those people 
require one-on-one feeding. Those people require maybe three-
to-one toileting just because it is complicated and--
    Mr. Dunn. So this would be for like 10 to 12 hours a day?
    Ms. Krul. It depends. If family needs them to be the whole 
day, it would be like as early as 7:00 a.m. and as late until 
5:00 p.m. It could be possible that, yes.
    Mr. Dunn. And then when the family picks them up, they 
are--
    Ms. Krul. We provide transportation.
    Mr. Dunn [continued].--back on the family setting.
    Ms. Krul. That is correct.
    The best part of this unit is that it is complete nursing 
care, whatever medications are to be administered, they are 
administered; if there is other nursing care or health care is 
needed, it is done.
    People are in a controlled, safe environment, have special 
activities to stimulate them to get their memory maybe not 
turned but at least they are not anxious, they are not pacing, 
they have a controlled environment; and the families really 
appreciate that a lot because during the day they can take care 
of themselves, go to their own doctor appointments, go to work, 
and that is a huge relief because the burden of caregiving is 
the biggest burden for families.
    Mr. Dunn. So let me turn to Dr. Hartronft again.
    How much does your--you take care of the whole VISN or just 
the GLA?
    Dr. Hartronft. Just the GLA.
    Mr. Dunn. How much does GLA spend on long-term care, total, 
all of them?
    Dr. Hartronft. Okay. For all of our NIC programs it was--
the obligations in fiscal year '17 were approximately 40 
million. The contract in the community nursing homes was 
approximately 29 million of that.
    Mr. Dunn. Thank you. That is quantification. That is 
numbers that help us.
    I want to go back one more to Dr. Boyd, I think. Veteran-
directed care, a certain niche of care that has been funded 
where you budget the veteran and they sort of contract their 
own care.
    What do you think about the program? I think it is popular. 
It doesn't seem to be widely available. Talk to me.
    Dr. Boyd. Yes. On Veterans-directed care we have 62 VA 
programs in 18 VISNs. It is fairly popular in some locals. We 
do have programs in 18 of our VISNs, so all of our VISNs. There 
are 62 VA programs, 36 States, but only a little over 2,200 
Veterans are utilizing the program.
    Again, as Ms. Krul had mentioned, this is a program where 
they do need assistance in more than three ADLs, and there are 
some other eligibility requirements, but this is a unique 
partnership that VHA has with local aging and disability 
networks within communities. So we do rely on that. It may very 
well be that the VHA or VA medical center wants to have the 
program, but they really need to work with that local agency, 
and sometimes there are some administrative technical things 
that we do try to work out.
    And the program is not for every veteran. Someone within 
the veteran's family or the veteran him or herself needs to be 
able to manage a budget and this is not always something that 
we see. So it is not for everyone.
    Mr. Dunn. Do you think we can grow it?
    Dr. Boyd. I do believe that there are pockets where we 
could grow it. And I have had some personal experience coming 
from the field. It does go to that local relationship with the 
area on agency--agency on aging, and that partnership, and we 
just need to figure out what the barriers are in some of these 
areas and try to promote it from within. So I do believe that 
we could.
    Mr. Dunn. Representative Brownley and I are going to call a 
5-minute recess but over that recess I want you to be thinking 
about that program and the potential for fraud. So 5-minute 
recess.
    Mr. Dunn. I rule it back in order, and we yield 15 minutes 
to Representative Julia Brownley.
    Ms. Brownley. We are making history here. I have never been 
yielded to anybody. So thank all of my constituents who are 
here today, and I guess convincing the Chairman to give me 15 
minutes. So I will absolutely take it.
    So along the line of questioning that we have been on here, 
I wanted to ask about memory care. I think probably it is a 
fair statement to say that the VA is probably behind and needs 
some catching up in terms of providing the appropriate memory 
care needs. I know that there is some dementia care in some of 
our facilities across the country, VA run facilities like the 
Community Living Centers. I think we offer dementia services 
there.
    In terms of just locally, do we provide dementia services 
in L.A. or Sepulveda?
    Dr. Hartronft. At both those sites it depends on what 
severity level you are in. In the early phases we had things 
such a wander guards, but we do not have a dedicated, like, 
secure unit. And that has been some of the challenges, that 
they are also sparse in the community as well. So that is one 
area that we are looking at.
    Ms. Brownley. And one area that you are looking at and 
looking at more opportunities for community partnership?
    Dr. Hartronft. Yes, ma'am.
    Ms. Brownley. Thank you. And we are not talking a lot about 
the caregiver program today here in this hearing but as I 
mentioned we have spoken a lot about the caregiver program back 
in Washington, D.C., and to me I think and I think for all the 
Members on really both sides of the aisle, it is a matter of 
equity to have the post-9/11 men and women receive the 
caregiver services if that is something that they want and so 
we expanded that caregiver service.
    Now, I understand that the caregiver services wasn't under 
the umbrella of long-term care because if you are doing pre-9/
11 that is going to be younger men and women generally who are 
receiving that care. It is probably because they are quite 
physically disabled and need the help and assistance.
    But as we open this up to post-9/11 Veterans it is going to 
be an older clientele which we are going to serve. So I am just 
wondering if there is any conversation about once this program 
gets instituted and fully up to speed, are you thinking about 
potentially merging the caregiver program under the auspices of 
all of these long-term care programs?
    Dr. Hartronft. At the local level it would make sense for 
us to make it under noninstitutional care essentially, 
especially as the people allow, because the nice thing with the 
caregiver program is they go in and make sure the home is safe, 
they give training to the caregiver and make sure the caregiver 
is able to, and as you do that, as you imagine with aging 
spouses and other challenges, that is something that would be 
important so that you can make sure of the safety of the home 
and other issues. So that will be an extra plus for many of our 
Veterans.
    Ms. Brownley. And what is the VA doing with regards to 
memory care in trying to assess that and looking at a well-
articulated plan to move forward? Dr. Boyd?
    Dr. Boyd. So you hit on something that has really been very 
much in the forefront since my very short time in my new role 
as well.
    We have a lot of catchup to do there. We do have dementia 
care. We had our prior with geriatrics evaluation and 
management clinics and primarily that really dealt with our 
dementia and our more elderly patients, our more frail 
patients. What we have learned from our MHIC partners, and that 
is an acronym, but our Mental Health Innovation Centers as well 
as our Geriatric Centers of Innovation is that we can 
definitely buff up and improve early on; and again, I am 
talking about moving it back to the left when we first see 
signs let's be more sensitive to that and we see those flags 
before we get down the road where now we have to have 
institutional care. So we are looking at that.
    I don't have it in front of me but there is significant 
research as well in this area, and one thing that I do want to 
mention is that--and this really goes to our community partners 
as well--with regards to dementia and the behavior issues that 
we many times see, unfortunately that keeps a lot of our 
Veterans, many of our Veterans from being able to go to the 
community in a less restrictive or institutionalized setting 
than they would like.
    And what we have learned--we have five VISNs now where we 
have had this innovation program of behavioral recovery 
outreach teams that are actually going to interface with the 
community. If we have a veteran in one of our CLCs, our 
Community Living Centers, that they really could with the 
proper attention and continuation of goals of care and their 
treatment could actually function at a less restrictive area 
and that is where they want to be, then what we would do, we 
actually send VA folks to that setting, that non-VA setting to 
work with them, actually have those folks come in and see the 
veteran in their then surroundings.
    So we work with them on the behavior and some of the memory 
issues, so they don't rebound or need hospitalization as well. 
So again, it is about veteran preference. So that is an 
innovative idea and we are very, very--but we need more like 
that.
    Ms. Brownley. Thank you.
    Dr. Hartronft, I have listed out all of these programs, 
noninstitutional/institutional. Can you give me an assessment, 
are all of these programs available here in Ventura County?
    Dr. Hartronft. Currently, no. At this point we do not offer 
veteran-directed care services.
    Specifically what we do instead is use a combination of the 
other noninstitutional care programs to provide the care that 
the Veterans need.
    Another opportunity is the one that Dr. Boyd just 
mentioned. It is not a specific NIC program, but it is the 
behavior outreach which I think will help us work with our 
community partners even better.
    I guess in Ventura County we specifically have purchased 
skilled home care, which is one of our NICs as well as 
Homemaker Home Health, and we also have the contract adult day 
health care and community nursing homes and the State Veterans 
Homes, are the primary ones that we can provide right now as 
permanently here in Ventura County.
    Ms. Brownley. But some of the other programs that we have 
mentioned here today could be available to Veterans. I mean it 
is not there. My guess--I don't have the data, but my guess is 
there are other programs online there because we don't know 
about the programs.
    Dr. Hartronft. Yes, I agree. I agree with Dr. Boyd's 
assessment earlier is working with our community VSOs, Veteran 
Service Organizations, and partners and letting them know what 
is available as to--and then we figure out what is the need for 
this area. It is very important.
    As you can imagine every county has its own markets 
available so you can't really do a template for every county. 
So that is why working with our community partners is so 
important.
    Ms. Brownley. Very good.
    In terms of the CalVet home here, which we all take a lot 
of pride in and I have been to that facility many, many times 
and see lots of happy Veterans there and their families, and it 
is also, Dr. Dunn, these Veterans can also have their spouses 
at this facility. So it is a really a wonderful place.
    I am curious to know what California's Department of 
Veteran Affairs does to look at the data, establish needs 
throughout the State of California and sort of what the process 
is. Are you building any new homes in the State of California 
or is this something that was great in its day, but we are 
never going to expand upon it?
    Mr. Martin. As you know, the Ventura Veterans Home was 
opened I believe in 2009. It was part of a wave of five new 
Veterans Homes that were built in 2009.
    Ms. Brownley. When is the next wave and where is it?
    Mr. Martin. We are not prepared to answer that question 
yet.
    So there was a needs assessment done about 15 years prior 
to determine the future programming needs, and that is where 
skilled nursing was identified, secured memory care units were 
identified, which is how we tripled our capacity in a handful 
of years.
    And right now we are taking a step back, having opened all 
these new facilities, finished construction and ramp up, we are 
taking a step back and taking a look at the data and see where 
the numbers really lead us, keeping in mind industry changes 
and VA directional changes in terms of noninstitutionalized 
care but also identifying that there are plenty of Veterans who 
really need a nursing home or secure unit or something similar 
where other noninstitutional programs don't quite work with 
them.
    So we are going through this need's assessment process 
right now. We have actually had some great support from the VA 
in getting data and subject matter expertise and we are hoping 
for a study to be finished on time by the end of next year.
    Ms. Brownley. And so I just want to bifurcate here. Long-
term plan, you are going to have it next year but just in terms 
of Veteran Homes is that incorporated into that plan so that in 
a year we would sort of know what the CalVet plan is for new 
homes throughout the State?
    Mr. Martin. Correct, yes. So we--
    Ms. Brownley. Okay. That is good.
    So, you know, just in terms of this long-term care and some 
collaboration with the VA and your collecting all of this data, 
the VA is collecting the data as is CalVet, and how are the two 
agencies collaborating? How are they using it?
    I mean, obviously, you have just said there is going to be 
a report. Maybe I should ask the VA.
    Are you going to have a report also where this 
collaboration can come from?
    Dr. Boyd. As far as the State goes, that would be with the 
area VA Medical Center Directors with regards to any plans for 
the State Veterans Homes here within California.
    Mr. Martin. Maybe I should speak too. We have received some 
support from--I know you have a data analysis unit in your 
headquarters in D.C., so we were receiving support from them 
for collecting this data for our support and our--
    Ms. Brownley. I just think that the CalVet raises an 
important issue, and I think the fact that you are drawing on 
the data to create a long-term plan is really important.
    I also think that as we go through this in terms of the VA 
servicing Veterans we are going to find gaps in those services 
and so I think the way to fill those gaps is through community-
based programs with CalVet and more collaboration, and I think 
that there is probably in some cases greater efficiency and 
better use of the taxpayer dollars in this collaboration and 
making sure that we don't have duplication.
    And so I guess I am really kind of looking for are these 
words on a piece of paper or are we actually, you know, engaged 
in collaboration in terms of where we can--how we can best 
collectively serve our Veterans?
    Mr. Martin. So our process, we are still in the infancy of 
our process right now. So we are going to be in a more robust 
stakeholder process and community engagement process as part of 
our project.
    So again, it is very early. Right now we are trying to get 
raw numbers to get a sense of what data already exists so that 
we are not revisiting the wheel and then based out of that then 
it could be a matter of applied analysis, applied science.
    Ms. Brownley. Dr. Boyd, you know, before we close out this 
hearing I wanted to ask you directly about the USA Today 
reporting relative to the nursing home ratings, and their--I 
think Dr. Dunn cleared up some of this in his opening comments 
but in that particular article it said that Sepulveda had a 
three-star rating, the VA rating is a five-star rating, is my 
understanding, at least based on the VA data here that is what 
it is.
    Dr. Boyd. So on the Sepulveda was actually five-star.
    Ms. Brownley. Yes.
    Dr. Boyd. And the GLA was actually a four-star.
    Ms. Brownley. And in the article, the article states that 
it is an issue around transparency and getting this information 
out so when people are making decisions, they have the best 
information in front of them, and I think that there is some 
agreement in terms of the VA of making sure that we do put out 
this information.
    It was also mentioned in several of the articles that there 
might be, that the VA had underlying data that might shed light 
on how VA develops its nursing home ratings and why some VA 
facilities seem to score lower when compared to the private 
counterparts and there was, I think, a commitment on a promise 
for a report to be out by July 1st.
    Are you aware of this report that the VA committed to?
    Dr. Boyd. Yes, ma'am, and this report is actually posted on 
a public-facing Web site at www--
    Ms. Brownley. So there was one report but then there was 
supposed to be another sort of backup report that would shed, I 
think, more light on the process and I think that second one 
was supposed to be released on July the 1st.
    Dr. Boyd. So what you may be inferring is the redacted 
long-term care institute records that went into the specifics 
of the quality metrics. That takes some time to get those 
redacted because they have patient information in them. That is 
probably what you are talking about.
    Ms. Brownley. In terms of nursing home ratings that don't 
have very good scores, I think we are fortunate here that we 
have two that do, and it sounds like our community partner 
scores are generally pretty good. At least that is what Mr. 
McManus reported. But what are we doing, what are we doing to 
kind of rectify this situation and improve upon those who have 
the lower scores?
    Dr. Boyd. So a couple of things.
    Ms. Brownley. It sounds pretty urgent to me.
    Dr. Boyd. Yes, and thank you for that question.
    So about a year ago, as you know, VA did get on the journey 
to adopt CMS--that is the Centers for Medicare and Medicaid 
Services--a methodology with which to have a star rating, and 
it is basically divided up into three areas, and you are right, 
we did very well, we fared very well with the private sector in 
two of the three sections, that being on our annual surveys 
accreditation as well as our nurse staffing model.
    We did have some opportunities in the quality measurement 
section. That is the third of the three areas that figure into 
the overall scoring. In fact, 11 of our sites scored only one 
star in the quality measurement area, and what we have done is 
this. We took a deep dive in that and what we found is that--
and by the way, if you go onto the Medicare site as well, they 
actually have a disclaimer saying that it is not a when it is 
done, it is not the--that is not the one thing that the family 
should look at totally; it is a starting point. It is a 
snapshot in time for CMS of patient care at that time.
    What we found was that we had not done a very good job of 
documenting because it is not something that we had really 
disciplined ourselves for. The other thing is that our case mix 
in our CLCs, our Community Living Centers, is quite different 
than in the private sector.
    As many of you know, it is no surprise, we have spinal cord 
injury patients that we absolutely will care for in our CLCs, 
and we have our hospice care within our CLCs as well, and we 
will care for them, and also we have serious and mentally ill 
residents as well that do require some of the anti-psychotic 
medications.
    Those three major categories increase the complexity of our 
case mix and they will skew some of the numbers. It is not a 
defense at all by any means. It is not an excuse. It is 
reality.
    And so after we clarified documentation which we hope that 
will really reflect the quality of care that all of our 
residents are receiving, it is currently not being seen in the 
chart, and hopefully that will improve that. And we do look 
forward to having congressional visits to all our CLCs so that 
they can see the quality of care delivered there.
    Ms. Brownley. And I hear what you are saying and concur 
with what you are saying to some degree, and I think it is 
important in many respects for the VA to compare themselves to 
the private sector, I think that that is important, and I do 
believe that Veterans, our customers, our patients, typically 
the cases are more complicated and certainly are cases that you 
are not going to see as frequently in the private industry.
    But then I would argue we need higher standards for our 
Veterans because their cases are complicated and they are 
dealing with an abundance of different issues, and so, 
therefore, we should be far above and certainly not behind 
comparatively.
    And we have certainly spoken, had many, many, many, many 
hearings in Washington about the overuse of drugs and 
medication and opioid addiction, and this is Dr. Dunn's, it is 
one of his favorite topics, and if we are showing that we are 
overmedicating and that we may need to overmedicate slightly 
more than in private industry, but that is a real concern as it 
was reported in USA Today and I want to make sure that we get 
down to the bottom of it.
    And so I have exceeded my 15 minutes and so I yield back to 
the Chairman. Thank you very much. I won't tell any of my 
Members back in Washington that you made--
    Mr. Dunn. You cannot reveal how long this went over in 
Washington. I will be pilloried. So I yield to myself 15 
minutes.
    Ms. Krul, I have a quick question for you. You noted that a 
lot of your Veterans are at risk for skilled nursing placement 
and that the services you provide delay their nursing home 
placement. Do you have a sense of how much you are able to 
delay that?
    Ms. Krul. Yes, I do. We, in some cases, completely avoid 
placement. So our care is in some cases absolutely, if not for 
us, the person would 've [KK2]been placed. So our care with all 
the meals, with all the nursing care, with all the personal 
care allows the veteran to live at home and continue--
    Mr. Dunn. I know it is difficult. Have you developed a way 
to average the delay? Is there any way to quantify that? I 
understand it is a difficult metric.
    Ms. Krul. Yes and no. And we have several Veterans who 
absolutely have been with us for several years and would have 
been in the nursing home if not here. So these several years of 
quality of [KK3]life and living at home is there.
    Some people who have stuck with us sometimes decline so 
much that our level of care is not appropriate for them anymore 
and then we refer them to other--
    Mr. Dunn. But there are substantial savings for all the 
time that they--
    Ms. Krul. Absolutely.
    Mr. Dunn. Let me ask you another question. Do you work with 
any of the VA caregiver coordinators, the ones we were talking 
about earlier in terms of respite for them, the caregiver 
coordinator?
    Ms. Krul. We work. How we work--
    Mr. Dunn. Obviously, what you are doing is you are taking 
that veteran and coordinating care for them?
    Ms. Krul. Yes. Absolutely.
    Mr. Dunn. Are you giving respite to the care coordinators 
as well?
    Ms. Krul. We absolutely do, just because we have a social 
work department, and that social work department coordinates 
care with the Department of Veterans Affairs. So people who 
will provide that care at home or otherwise don't need to do 
this. So our social workers coordinate everything what the 
veteran needs. We call directly in to the Department of Veteran 
Affairs social workers. They have very strong clinical staff, 
and they help us a lot with the coordinating care of the 
veteran.
    Mr. Dunn. Very good. So something we were talking about a 
little earlier, there was the memory care and it keyed me to 
one of the points--one of the things that the VA, has another 
mission which is research and we actually have a fairly large 
research program across the country and some of that research 
is focused on dementia, Alzheimer's, TBI, PTSD, all the various 
mental problems that are so common in our Veterans. I know you 
do research in the GLA. Do you do research in those areas?
    Dr. Hartronft. Yes, sir. Between our MIRECC, which is the 
mental illness type of research and also the geriatric 
research, some of our caregivers look at everything from 
traumatic brain injury to aging and also more of the social 
factors; many times things like having a caregiver and then 
this respite and adult day health care, because one of the 
factors of increasing the veteran's chance of being 
institutionalized is caregiver burnout. So there are so many 
variables.
    Mr. Dunn. I get that. But you are doing clinical trials 
down there in L.A. What is the availability up here in Ventura 
to participate in those clinical trials for these Veterans up 
here?
    Dr. Hartronft. That is a good question. I think that is 
another area we can improve.
    Mr. Dunn. Are either CalVet or are you aware of any 
availability of clinical trials inside the Veterans 
Administration up here in Ventura? So Ventura patients?
    Mr. McManus. No.
    Mr. Martin. I am not aware of it.
    Mr. Dunn. So the GLA is fortuitously located in very close 
proximity to world class academic centers that are doing 
research in these very areas, UCLA, Cedars Sinai, USC, et 
cetera. Do you work with them?
    Dr. Hartronft. With the community partners you mean, sir?
    Mr. Dunn. No. In research.
    Dr. Hartronft. Yes. UCLA and many of our partners we 
overlap in many of the areas with aging and also traumatic 
brain injuries and other areas, yes, sir.
    Mr. Dunn. And in my experience, we used to share a lot of 
faculty back and forth. Does that still happen?
    Dr. Hartronft. Yes, sir.
    Mr. Dunn. I was thinking about prostate cancer myself in my 
own niche of interest in medicine. You have some amazing 
prostate cancer research going on in L.A.
    With researchers at the institutions I mentioned, are they 
working with your center?
    Dr. Hartronft. Yes, sir. We have a lot of overlap with 
them, NIH funding, VA funding.
    Mr. Dunn. So the VA funding is, of course, of immediate 
interest to us but also the NIH funding. Often, they 
collaborate on the same programs. And this stuff is deep, deep, 
deep in the Veterans, and it is actually also attached to the 
Agent Orange concerns as well as prostate cancer.
    So that is an area that is of keen concern and if these 
Veterans up here in Ventura could participate in those clinical 
trials, I think that would be a very real--I think that would 
be a benefit for them. They are not going to find any better, 
deeper, more knowledgeable faculties than are available right 
here in this VISN; not the county but the VISN. So that is an 
important thing to put on the radar.
    And I would like to come back actually. I have been out 
here a number of times on prostate cancer as a civilian. I 
guess I will have to go back as a Veterans Administration 
official.
    Turning my thoughts one more time to a fond subject that I 
was reminded when a gentleman walked in here, the canine 
services. How much do they cost like on a per vet basis, would 
you say? This is typically for PTSD mental health.
    Nobody has a feeling for that number? No granular numbers 
on that? That ought to be something to know. We all like it. I 
am a dog person and I like dogs, but I think we ought to have a 
feeling for what the cost is on that.
    Do you have a feeling for what diagnoses the canine 
assistance program is applicable to other than PTSD? Nobody? 
Dr. Boyd?
    Dr. Boyd. So in fact, it can be for any need, any clinical 
need or psychosocial need that the veteran has, actually.
    Mr. Dunn. I mean like anxiety or--
    Dr. Boyd. Or seizures. It could be for a lot of different 
things, yes, sir.
    Dr. Hartronft. Diabetes.
    Mr. Dunn. So we are going to be visiting the GLA Med 
Center; if not the med center, the long-term care centers this 
afternoon. We certainly look forward to getting down there and 
talking with you.
    Do you have any more pressing questions?
    Ms. Brownley. I just have one more question.
    Mr. Dunn. I yield to Representative Brownley.
    Ms. Brownley. So Dr. Dunn and I were in a hearing, I think 
it was last week and what we were discussing was some rule 
changes around prosthetics and in some of the testimony--and 
Dr. Boyd, this question is really for you--and I don't know 
whether you are aware of some of the proposed rule changes with 
regards to prosthetics, but in testimony coming from many it 
was stated that in the rule change that issues like metal alert 
devices or personal emergency response systems or medical I.D. 
bracelets may no longer be provided to Veterans by the VA 
because of the way this rule has been changed.
    And we, the Committee Members, argued very strongly against 
this, that this would be a very dangerous road to travel and 
how important that is, particularly as we are talking about 
today, and the reason I am bringing it up is about Veterans 
staying in home.
    So I am just wondering if you could comment if indeed the 
VA goes through with this rule change, what are the impacts 
going to be on the institutionalized care or long-term care 
services.
    Dr. Boyd. Thank you for the question. I am not familiar 
with the legislation and the technical--
    Ms. Brownley. It is not legislation. It is rule changes.
    Mr. Dunn. It is promulgated inhouse at the VA.
    Dr. Boyd. So I am not familiar with that. I definitely am 
interested. You have sparked my interest in that especially 
with the conversation here today. I would like to take that for 
the record and definitely get back to you. I wrote it down and 
that is one that really brings up a good point.
    Ms. Brownley. I mean, I think Dr. Dunn and I, we were 
definitely--
    Mr. Dunn. We agree.
    Ms. Brownley [continued].--on the same wavelength and I 
think that based on this discussion my takeaway was that there 
is a big disconnect between the lawyers and the clinicians and 
that we need to get to the bottom of it but weighing in on 
issues that are under your jurisdiction would be very helpful 
in terms of ensuring that we get it right.
    Dr. Boyd. I will definitely take that back. Thank you.
    Mr. Dunn. Let me associate myself with those remarks 
because it doesn't make sense. And it really was--it appeared 
to be a very heavy-handed unilateral rules-making exercise that 
took no input from the VSS and no input from Congress.
    So I think if you could go back and correct the direction 
of the ship on that, that would be greatly appreciated.
    Let me tell you, we are going to adjourn this, but we will 
make ourselves available for some few minutes certainly, and 
our staffs here are available, and I hope you will take 
advantage of also the outstanding witness panel that we have to 
ask questions of them.
    Thank you all very much for this productive and 
enlightening hearing. I can assure you that the future of VA 
long-term care and the quality of that care which you seem to 
enjoy an unusual high level out here in Ventura will continue 
to be a focus of this Subcommittee.
    Thank you to the Ranking Member, Representative Julia 
Brownley. Thank you for requesting this hearing in the first 
place, and I have enjoyed us getting out of D.C. for a little 
while and seeing what the good folks of the West Coast are 
doing for fun.
    If there are no further questions, we are now excused.
    And I ask unanimous consent that all Members have 5 
legislative days to revise and extend their remarks and include 
extraneous material. And, without objection, that is so 
ordered.
    This hearing is now adjourned.

    [Whereupon, the Subcommittee was adjourned.]


                           A P P E N D I X

                              ----------                              

                    Prepared Statement of Katy Krul
    Oxnard Family Circle Adult Day Healthcare is a medical model day 
program that provides care for Veterans in our community. The Veterans 
who receive care are at risk of skilled nursing placement if they do 
not receive services at the center. They are frail, elderly individuals 
who require intervention from registered nurses, rehabilitative 
services, and assistance with personal care needs including toileting, 
feeding, and bathing. We provide transportation for Veterans from their 
homes to the center, mels, stimulating daily activities, social work 
case management services and psychological counseling, massage 
services, and podiatry care. The center also has a specialized memory 
care unit that we developed in conjunction with the Alzheimer's 
Association.
    Many of the spouses or other family members of our Veterans are 
overwhelmed with the day-to-day responsibility of caring for the 
Veteran. We find that the caregivers are at risk of experiencing a 
decline in their physical and mental health conditions. Our program is 
the resource for vital respite care for many families as it offers day-
long extended services services for 5 days per week.
    Oxnard Family Circle provides care to Veterans who have served in 
World War II, Korea, Vietnam, and Iraq war periods. Essential benefits 
for veterans in our program are comradery, the sense of social 
belonging, and connection to a group that is unique to their shared 
military experiences. We develop an individualized treatment plan for 
each Veteran that focuses on the specific medical, dietary and 
psychiatric needs of that person. Specialized programming that is 
provided includes an Equine Therapy program, outings that facilitate 
integration into the community, psychological groups, 1:1 counseling 
services, Music and Memory activities, Art therapy, support groups for 
family members, educational events in conjunction with the Disabled 
American Veterans, Alzheimer's Association, Public Health and Ventura 
County Area Agency on Aging.
    Our setting allows the Veterans to function with a sense of 
dignity. In the home setting, they often feel diminished as their loved 
ones assist them with basic activities of daily living including 
toileting, bathing, having assistance with transfers and walking. Many 
of our Veterans are uncomfortable and resistant to family members 
providing this level of assistance. Veterans and their families benefit 
from the personal care assistance that is provided by Oxnard Family 
Circle's professional staff.
    Oxnard Family Circle works closely with the Department of Veteran's 
Affairs to coordinate the care needs of Veterans. Referrals for Adult 
Day Healthcare services may be received from the local VA Outpatient 
Clinic. Many Veterans reside in our community who may not be connected 
with the VA Healthcare System. Our staff educates Veterans as to the 
types of benefits that they may receive and assists them with enrolling 
in the healthcare system.
    We also refer Veterans and families to the Ventura County Veterans 
Services Office for assistance with financial benefits. We maintain 
close communication with the Veteran's physician and VA Social Workers 
during the time that the Veteran is enrolled in our program. When a 
Veteran's care needs increase so that Adult Day Healthcare Services are 
no longer appropriate, Veterans may be referred to the VA Community 
Nursing Home Program or VA Hospice services. Aid and Attendance may be 
applied for to pay for care in the Veteran's home setting or an 
assisted living facility.
    All Veterans who are VA Healthcare Eligible may be appropriate for 
Adult Day Healthcare Services, as long as the Veteran has been 
determined to have the following clinical conditions:

    1.Three or more Activities of Daily Living Dependencies (ADL), or

    2.Significant Cognitive Impairment, or

    3.Require CADHC services as adjunct care to community hospice 
services, or

    4.Two Activities of Daily Living Dependencies and two or more of 
the following conditions:

    a)Has dependency in three or more Instrumental Activities of Daily 
Living (IADL);

    b)Has been recently discharged from a nursing facility, or upcoming 
nursing home discharge plan contingent of home & community-based care 
services;

    c)Is seventy-five years old, or older;

    d)Has had high use of medical services defined as three or more 
hospitalizations in the past year and/or utilization of outpatient 
clinics/emergency evaluation units twelve or more times in the past 
year;

    e)Has been diagnosed with clinical depression;

    f)Lives alone in the community.

    We are particularly appreciative of the support and advocacy that 
has been provided to us by Congresswoman's Julia Brownley's office.
    Thank you for allowing me this time to talk about the services that 
are provided by Oxnard Family Circle Adult Day Healthcare.
    On behalf of Oxanrd Family Circle ADHC:

    Katy Krul,
    Acting Executive Director

    Maria Meza,
    Program Director

                                 
                   Prepared Statement of Mike McManus
    Ventura County Human Services Agency

    Good morning, Chairman Dunn, Ranking Member Brownley, and Members 
of the Committee. Thank you for the opportunity to provide information 
to the Committee regarding long term care options to Southern 
California veterans through the Greater Los Angeles Department of 
Veterans Affairs (VA) Healthcare System.
    My name is Mike McManus and I am the County of Ventura, Veteran 
Services Officer. My staff and I connect fellow veterans, their 
dependents, and survivors with federal and state veterans' benefits and 
local resources. One of our primary responsibilities is connecting 
veterans with VA disability compensation for such conditions as Post 
Traumatic Stress, Traumatic Brain Injury (TBI), and for conditions 
resulting from physical injury while in the military. We also assist 
veterans to enroll in VA health care and refer to local and regional 
care resources.
    The Veteran Services Office has five accredited personnel who 
interview veterans, file the appropriate benefit claim, advocate on 
behalf of the veteran, and make needed referrals to other service 
providers. We also have support staff that enable us to meet client 
needs. The Veteran Services Office has conducted a variety of out reach 
activities to inform the veteran community about benefits, to include 
VA health care. The office currently operates out of the main office 
and 10 field offices to make it as convenient as possible for veterans 
to meet us. We partner with a variety of organizations helping connect 
veterans to earned benefits and services. One primary source of 
partnership is through the Veteran Collaborative of Ventura County, 
which is led by the Veteran Services Office. The VSO is reaching more 
veterans than ever before. In Fiscal Year 12/13 the office saw 3,572 
people, however, by Fiscal Year 17/18 office staff assisted 6,764 
people (source: VetPro). In FY 12/13 the Veteran Services Office 
connected county veterans with over 8.75 million dollars in federal 
benefit payments, but by FY 16/17 (latest year stats available), those 
benefit payments totaled over 11.5 million dollars (source: 2018 
California Association of County Veteran Service Officer Annual 
Report).
    I am a retired Unites States Air Force Senior Master Sergeant. I 
spent the last seven years of my 20 years in the military as a First 
Sergeant with one deployment for Operation Iraqi Freedom in 2003. As a 
First Sergeant I had overall supervision over all enlisted personnel 
with my units. I advised the unit commanders on all matters affecting 
their enlisted force to include issues involving mental & physical 
health and substance abuse, and those conditions that might impact 
service members, their families, their career, and the unit.
    I've been the County's Veteran Services Officer since January 2010. 
My staff and I and partners such as the Ventura County Area Agency on 
Aging, assist Ventura County veterans needing long term care. There are 
a variety of options available to veterans, provided they are enrolled 
in VA health care and are made aware of the various program options. 
Usually, the veteran would start by seeing their primary care provider 
and social worker at the Oxnard Community Based Outpatient Clinic.
    Ventura County has over 40,000 veterans, thousands more National 
Guard, Air National Guard, and Reserve personnel who may over time be 
eligible for VA long term care. Approximately 22,000 Ventura County 
veterans served in World War II, Korea, and Vietnam and range in age 
from 65 up. In addition to the typical ailments of aging, over 4,100 of 
these veterans also have chronic injuries from military service.
    In essence you have tens of thousands of veterans in Ventura County 
and many of these will need some form of long term care. I feel there 
is a large unmet need in the community due to misperceptions by 
veterans and lack of information from the VA. My staff and I have 
spoken with countless veterans who thought Medicare, Tricare, and/or 
the VA would provide for their long term care needs. They aren't aware 
that Medicare provides very little long term care, Tricare much less, 
and the VA only if the veteran is eligible, typically 70 percent 
service connected or higher. As outreach to the military/veteran 
community increases from organizations such as the Ventura County 
Veteran Services Office and the Veteran Collaborative of Ventura County 
the number of veterans seeking services increases and we can better 
education them on realistic options.
    In addition to veteran misperceptions, there is a lack of 
information provided to veterans regarding VA long term care options. 
There are a variety of options viable to veterans, including:
    -VA nursing home care on the campus of the Greater LA Medical 
Center, care through one of the community nursing homes the VA 
contracts with such as Coastal View Health Care Center in Ventura and 
Shoreline Care Center in Oxnard, and care in one of the California 
Department of Veterans Affairs (CalVet) Veterans Homes that provides 
memory and/or skilled nursing care. The Homes are a wonderful 
experience for the veterans living there, however, most California 
veterans will not have the opportunity due to lack of beds.
    Typically, a vet must be 70% service connected or higher to be 
eligible for VA nursing home care. Many veterans assume they're 
eligible once enrolled in VA health care, but that's not the case. Only 
four percent (4%) of Ventura County veterans have a service connected 
rating of 70% or higher.

    -In some cases, the veteran turns to Medi-Cal to provide nursing 
home or health care aid. In this case, the Veteran Services Office will 
refer the veteran to a county Human Services Agency Community Service 
Center for information and enrollment. We will do what we can to 
connect a veteran with their VA benefit, but in some cases the veteran 
is ineligible for VA health care (e.g. Other Than Honorable Discharge), 
is not 70% service connected for injuries from service, or the veteran 
simply decides not use the VA for personal reasons.

    -A veteran's VA primary care provider may also request a veteran's 
use of the Homemaker and Home Health Aide Care program, which use an 
organization that has a contract with the VA. A Homemaker or Home 
Health Aide can be used as a part of an alternative to nursing home 
care, and as a way to get respite care at home for veterans and their 
family caregiver. This program can help keep a veteran in their home.

    -Ventura County is blessed to have Oxnard Family Circle providing 
adult day health care for veterans. They provide skilled services from 
nurses, therapists & social workers, case management and help with 
activities of daily living. This vital program provides mush needed 
respite care for a family caregiver. This program can help keep a 
veteran in their home.

    -There are several hospice providers in the county assisting 
veterans such as Livingston Memorial Visiting Nurse Association and 
Vitas. We've routinely heard positive comments about these two service 
providers as they assist veterans and their families at end of life. 
Hospice providers not only comfort the veteran, but refer to the 
Veteran Services Office so we can speak with the veteran or a family 
member about VA benefits. Many times, this is the first time such a 
discussion has occurred.

    -The above programs come from the Veterans Healthcare 
Administration (VHA), but now I want to mention a benefit provided by 
the Veterans Benefits Administration (VBA), that can help veterans. Aid 
& Attendance (A&A) is a monthly amount paid in addition to either 
disability compensation or pension when the veteran requires the aid of 
another person in order to perform essential functions of daily living, 
or they are bedridden, or are a patient in a nursing home, or who are 
limited to a corrected 5/200 visual acuity or less in both eyes. The 
A&A benefit can be used by the veteran to pay for a care giver to enter 
their home or to help pay the cost of living in an assisted living 
facility. This benefit is helpful, but by no means covers the cost of 
care.

    The Veteran Services Office and our many partners will continue to 
assist our veterans. However, I feel the VA should counsel every 
veteran that is 70% service connected or higher on his or her long term 
care options. Ideally, this would be done via local town hall meetings 
so veterans can address specific circumstances with VHA representatives 
well versed in the many VA programs.
    The VA should also educate veteran service organizations on VA long 
term care programs so they can assist in counseling veterans on their 
options.
    I also feel the VA should expand their community partnerships with 
adult day health care provides to prolong veterans in their own homes 
and to provide respite for their care givers.
    I'd like to thank Chairman Dunn and Ranking Member Brownley for 
this opportunity.
    Points of contact from organizations reference above:

    Ventura County Area Agency on Aging, Victoria Jump at 805 477-7300
    Coastal View Health Care Center, Jill at 805 642-0156
    Shoreline Care Center, Mike Frasier at 805 746-9681
    Oxnard Family Circle, Katy Krul at 805 385-4180
    Livingston Memorial Visiting Nurse Association, Diana Davis at 805 
509-9280
    Vitas, David Mack at 805 437-2100

                                 
                  Prepared Statement of Thomas Martin
    Members of the Subcommittee:

    Thank you for the opportunity to provide written testimony 
regarding the future of veterans' long-term care. Understanding and 
projecting healthcare needs has become a top priority for the 
California Department of Veterans Affairs (CalVet) and we welcome any 
efforts to improve collaboration between the state, the federal 
government, and private providers. As I will discuss later in my 
testimony, the Subcommittee and CalVet are grappling with similar long-
term care issues, parallel work which may offer opportunities for 
collaboration and innovative partnerships.

Background

    CalVet operates eight Veterans Homes throughout the state, offering 
comprehensive services including medical care, dentistry, pharmacy, 
activities, , and various rehabilitation modalities programming. 
Ranging in size from 60 to 900 residents, the Veterans Homes are 
located in Barstow, Chula Vista, Fresno, Lancaster, Redding, Ventura, 
West Los Angeles, and Yountville.
    To be eligible for admission, applicants must be former active duty 
servicemembers who were discharged under other-than-dishonorable 
conditions; in addition, they must be aged or disabled California 
residents who qualify for health care from the U.S. Department of 
Veterans Affairs (VA). Spouses of veterans may be eligible for joint 
admission. Priority admissions are available for recipients of the 
Medal of Honor, former prisoners of war, homeless veterans, and those 
with 70% or greater service-connected disability ratings. Today, the 
Veterans Homes care for up to 2,400 veterans and spouses.
    Every state throughout the country operates at least one Veterans 
Home, each of which is closely connected to the VA. The VA annually 
surveys and certifies these facilities to ensure residents receive 
quality health care in a safe living environment. Once certified, the 
VA pays a per diem for all qualified veterans, ranging from 
approximately $50 to more than $500 per day, depending on the veteran's 
location, service history, and care needs. In addition, the VA funds up 
to 65% of construction costs for approved projects. Finally, many of 
our residents receive specialty and other services from the VA.

Demographic Changes

    CalVet is at a turning point in its history. For nearly 130 years, 
the State of California operated no more than three Veterans Homes that 
emphasized dormitory-style independent living units with shared 
bedrooms and bathrooms. Beginning in 2009, five additional Veterans 
Homes opened in response to an increased demand for higher levels of 
care throughout the state and strong support for veterans' programming. 
As this construction and expansion period is ending and we are seeing 
the beginning of a massive demographic shift in the veteran population, 
CalVet is again exploring how veterans' care needs have changed in 
recent decades, how to coordinate with and take best advantage of 
proximity to VA support, how best to utilize the resources it has, and 
how the Department can best position itself for the future.
    There are clear generational differences among veterans and these 
translate into differences in how they utilize long term care. Current 
residents served in World War II, in the Korean War, and - in 
increasing numbers - during the Vietnam Era. Different generations of 
veterans have very different physical, psychological, and emotional 
care needs, as well as different preferences for how they spend their 
time and the ways in which they interact with their peers.
    Today, we see veterans are applying for admission later in life, 
caring for themselves for as long as possible and arriving at our 
Veterans Homes with greater care needs than prior applicants. A growing 
number of applicants were previously homeless and require substance 
abuse and mental health services. The demand for higher levels of care 
and specialty services has increased significantly.

Long-Term Care Needs Assessment

    To meet the coming demographic changes, CalVet is undertaking an 
extensive statewide needs assessment. We have recruited several highly 
skilled individuals to lead this effort, using an array of surveys, 
studies, and datasets to develop projections. Based on all of these 
projections and the programming and resources of our facilities, CalVet 
will identify potential shortcomings in services while exploring the 
role of the Veterans Homes and other providers in bridging those gaps. 
The VA has graciously provided access to its data as well as support 
via subject-matter expertise, and we greatly appreciate its assistance 
with CalVet's project.
    While our research is ongoing, we expect the assessment to confirm 
and reinforce some of the trends we already notice. For example, we 
anticipate continued demand for skilled nursing care as veterans live 
longer and have more complex healthcare issues. In particular, there 
will likely be a sustained need for secured memory care units for 
veterans with dementia-related illnesses.
    CalVet also expects more demand for mental and behavioral health 
programming focusing on post-traumatic stress, substance abuse, and 
other conditions. Veterans with these conditions may not fit the 
classical model of a long-term care patient.
    Finally, and perhaps most importantly, CalVet hopes to develop a 
better understanding of how the VA, Veterans Homes, non-profit 
organizations, and private long-term care facilities are or are not 
equipped to meet these challenges and what the VA's long-term plans are 
so all providers understand their respective roles in veterans' care.
    No single entity can offer every service for every veteran. As 
healthcare providers, it is critical that we work together to identify 
our current and future roles in serving the aging veteran community. 
This hearing is an excellent opportunity to work toward that goal.

Conclusion

    We are in the leading edge of a massive shift in the veteran 
population demographic. Veterans' healthcare needs and preferences are 
evolving, and their service providers must anticipate and adapt to 
those changes. CalVet will continue to collaborate with the VA and with 
industry leaders to ensure veterans receive the full spectrum of care 
that they earned in service of their country. Again, thank you again 
for the opportunity to address the Subcommittee and for convening this 
hearing on veterans' long-term care.

                                 
                Prepared Statement of Teresa Boyd, D.O.
    Good morning Chairman Dunn, Ranking Member Brownley, and Members of 
the Subcommittee. I appreciate the opportunity to discuss VA long-term 
care for Veterans and Veterans' choices for care as they age or face 
catastrophic injuries or illnesses. I am accompanied today by Dr. 
Scotte Hartronft, Chief of Staff, Greater Los Angeles Healthcare 
System.

Introduction

    VA's Office of Geriatrics and Extended Care (GEC) is committed to 
optimizing the health and well-being of Veterans with multiple chronic 
conditions, life-limiting illness, frailty or disability associated 
with chronic disease, aging, or injury. GEC's programs maximize each 
Veteran's functional independence and lessen the burden of disability 
on Veterans, their families, and caregivers. VA believes that these 
programs also honor Veterans' preferences for health and independence 
in the face of aging, catastrophic injuries, or illnesses by advancing 
expertise and partnership. The overarching goal of GEC is to provide 
optimal service to these Veterans while also empowering them with 
access, choice, and balance in their care. VA has recognized the 
importance of GEC programs and services by designating GEC, along with 
Primary Care and Mental Health, as a foundational service for the 
Department.

An Aging Population

    Nearly 50 percent of the more than 9 million Veterans currently 
enrolled in the VA health care system are age 65 years or older. 
Between 2016 and 2026, the number of enrolled Veterans age 70 and older 
is projected to increase by 30 percent, from 3 million to an estimated 
3.9 million. During the same time frame, the number of enrolled 
Veterans age 70 and younger is projected to decrease by 8 percent. The 
number of Veterans over the age of 85 enrolled in the system has 
increased almost 11-fold between 1999 and 2014 and is projected to 
surge more than 17-fold by 2034.
    As Veterans age, approximately 80 percent will develop the need for 
long term services and supports (LTSS). Most of this support in the 
past has been provided by family members, with women providing most of 
the care. The number of potential family caregivers per older adult in 
America is currently seven, but the number of potential family 
caregivers will drop to four in 2030. The availability of these 
potential family caregivers can be jeopardized due to work 
responsibilities outside the home. Moreover, many Veterans are 
divorced, have no children, are estranged from their families, or live 
long distances from family members. This is especially true for the 
increasing numbers of women Veterans who are at higher risk for needing 
LTSS due to their longer life expectancies and greater risk of 
disability than men at any age.
    The aging of the Veteran population has been more rapid and 
represented a greater proportion of the VA patient population than 
observed in other health care systems. Addressing the needs of these 
Veterans was recognized as a priority in the early 1980s. This led to 
development of 20 currently-existing centers of excellence called 
Geriatric Research, Education, and Clinical Centers and innovative 
models of care to meet this population's needs. The innovative patient 
care programs developed within VA have been shown to optimize Veterans' 
function, prevent unnecessary and costly nursing home admissions and 
hospitalizations, reduce unwanted and unnecessary tests and treatments, 
and thereby reduce health care costs.

GEC Programs In-depth

    GEC's programs include a broad range of LTSS that focus on 
facilitating Veteran independence, enhancing quality of life, and 
supporting family members and Veteran caregivers. Many of the services 
provided via these programs are not available in any other health care 
system. The four categories of LTSS are Home and Community-Based LTSS, 
Facility-Based Care and Hospice Care, Ambulatory Care, and Inpatient 
Acute Care.

Home and Community-Based LTSS

    Home and Community-Based services (HCBS) support independence by 
allowing the Veteran to remain in his or her own home as long as 
possible. More than one service can be received at a time. These 
programs include the following:

      Adult Day Health Care: A program Veterans can go to 
during the day for social activities, peer support, companionship, and 
recreation. The program is for Veterans who need skilled services, case 
management, and help with activities of daily living. Most Adult Day 
Health Care is purchased from community providers, but some VA medical 
centers (VAMC) also provide this service within their facilities.
      Home Based Primary Care (HBPC): Health care services 
provided to Veterans in their homes. A VA physician supervises the 
health care team that provides the services. This program is for 
Veterans who have complex health care needs for whom routine clinic-
based care is not effective.
      Homemaker/Home Health Aide: A trained person comes to a 
Veteran's home and helps the Veteran take care of him or herself and 
his or her daily activities. These aides are not nurses, but they are 
supervised by a registered nurse who will help assess the Veteran's 
daily living needs.
      Palliative and Hospice Care: This program offers comfort 
measures that focus on relief of suffering and control of symptoms so 
that Veterans can carry out day-to-day activities. It can be combined 
with standard treatment and started at any time through the course of 
an illness. VA established palliative care teams in every VAMC over a 
decade ago. Only 67 percent of non-VA hospitals with greater than 50 
beds have palliative care teams.
      Respite Care: This service pays for a person to come to a 
Veteran's home or for a Veteran to go to a program while their family 
caregiver takes a break. Thus, the family caregiver is allowed time 
without the worry of leaving the Veteran alone.
      Skilled Health Home Care: Short-term health care services 
that can be provided to Veterans if they are homebound or live far away 
from a VAMC. The care is delivered by a community-based home health 
agency that has a contract or provider agreement with VA.
      Telehealth: This service allows the Veteran's physician 
or nurse to monitor the Veteran's medical condition remotely using 
monitoring equipment. Veterans can be referred to a care coordinator 
for enrollment in Home Telehealth services by any member of their care 
team. Enrollment is approved by a VA provider for Veterans who meet the 
clinical need for the service.
      Veteran-Directed Care: This program gives Veterans of all 
ages the opportunity to receive the Home and Community-Based Services 
they need in a consumer-directed way. Veterans in this program are 
given a flexible budget for services that can be managed by the Veteran 
or the family caregiver. As part of this program, Veterans and their 
caregiver have more access, choice, and control over their long-term 
care services.

    It should be noted that Adult Day Health Care, Home Based Primary 
Care, Homemaker/Home Health Aide, Palliative and Hospice Care, Respite 
Care, and Skilled Home Health Care are all part of the Standard Medical 
Benefits package all enrolled Veterans with clinical needs receive.
    While HCBS continues to improve care for Veterans, it has also 
helped reduce costs for the Department. VA financial obligations for 
nursing home care in fiscal year (FY) 2017 reached $5.7 billion. The 
number of Veterans with service-connected disabilities rated 70 percent 
or more, for whom VA is required to pay for nursing home care, if it is 
needed, is projected double from 500,000 to 1,000,000 Veterans between 
2014 and 2024. Therefore, if nursing home utilization continues at the 
current rate among Veteran enrollees, without consideration of 
inflation, the costs to VA for providing nursing home care for enrolled 
Veterans can conservatively be estimated to reach more than $10 billion 
within the next decade.
    Fortunately, appropriate targeting and use of the programs and 
services available through GEC, especially those services that are 
provided in home and community based settings, can reduce the risk of 
preventable hospitalizations and nursing home admissions and their 
associated costs substantially. Therefore, VA has increased access to 
HCBS over the last decade. There is an urgent need to accelerate the 
increase in the availability of these services since most Veterans 
prefer to receive care at home, and VA can improve quality at a lower 
cost by providing care in these settings.
    States have found that through their Medicaid programs they have 
been able to reduce costly nursing home care by balancing their 
expenditures for long term services and supports between institutional 
and home and community based settings. Nationally, more than 50 percent 
of Medicaid expenditures for LTSS are for home and community based 
personal care services. Comparable personal care services (Home maker/
Home Health Aide, Respite, and Adult Day Health Care) accounted for 
$0.89 billion (11.1 percent) of VA's LTSS obligations in FY 2017. The 
total budget of all HCBS including personal care services accounted for 
31 percent of the LTSS budget obligations in FY 2017. Current annual 
per Veteran costs for nursing home care are 8.6 times the annual costs 
for HCBS within VA.
    Residential Settings are supervised living situations that provide 
meals and assistance with activities of daily living. These settings 
require the Veterans to pay their own rent, but HCBS can be provided if 
the Veteran has certified needs and is enrolled in the VA health care 
system. Medical Foster Homes (MFH) fall within this category. MFHs 
provide an alternative to nursing homes in a personal home at 
substantially lower costs. VA provides program oversight and care in 
the home by HBPC, while the Veteran pays on average $2,400 per month 
for room, board, and daily personal assistance. MFHs currently operate 
in 45 States providing care for over 1,000 Veterans each day at a 
significant cost savings as compared to care provided in community 
nursing homes. Additionally, Veterans express much higher levels of 
satisfaction from care provided through the MFH program. Currently, 
non-VA MFH models are available in only two states.

Facility Based Care

    Nursing homes are settings in which skilled nursing care, along 
with other supportive medical care services, is available 24 hours a 
day. All Veterans receiving nursing home care (NHC) through VA, whether 
provided in a VA-operated Community Living Center (CLC) or purchased by 
contract in a community nursing home (CNH), must have a clinical need 
for that level of care. VA strives to use NHC when a Veteran's health 
care needs cannot be safely met in the home. Certain Veterans have 
mandatory eligibility for nursing home care. These Veterans have 
service-connected disabilities rated at 70 percent or greater or who 
need nursing home care for service-connected conditions. Veterans with 
mandatory nursing home eligibility can be provided care in a VA CLC or 
a private nursing home under contract with VA. Consideration is given 
for Veterans' preferences based upon clinical indication and/or family/
Veteran choice, when possible. Veterans without mandatory nursing home 
eligibility, a population that makes up the majority of Veterans, 
receive care on a resource available basis. If these Veterans are 
admitted to the CNH Program, placement at VA expense is limited to 180 
days. More non-mandatory Veterans who need nursing home care usually 
receive that care in VA CLCs rather than in private nursing homes at VA 
expense.
    VA also maintains strong, working relationships with the states in 
the oversight and payment of Veterans' care through State Veterans Home 
(SVH). Through this partnership, states provide care to eligible 
Veterans across a wide range of clinical care needs through services 
including nursing home care, domiciliary care, and adult day health 
care programs. VA provides construction grant funding during the 
initial construction of the state home, continuing operating funds for 
eligible Veterans through a grant and per diem program, and ongoing 
quality monitoring to ensure Veterans in SVHs receive high quality care 
in accordance with VA standards. Currently, there are 156 SVHs across 
all 50 states, including one here in Ventura, California.

Ambulatory Care and Inpatient Acute Care Programs

    Finally, GEC offers Ambulatory Care programs including Geriatric 
Patient-Aligned Care Teams (GeriPACT), and Inpatient Acute Care 
Programs including Geriatric Evaluation and Management (GEM) and a 
variety of dementia and delirium programs. GeriPACT clinics provide 
longitudinal, interdisciplinary team-based outpatient care for high-
risk, high-utilization, and predominantly (but not exclusively) elderly 
Veterans. The teams have enhanced expertise for managing Veterans whose 
health care needs are particularly challenging due to multiple chronic 
diseases, coexisting cognitive and functional decline, as well as 
psychosocial factors. GeriPACT integrates and coordinates traditional 
ambulatory and institution-based health care services with a variety of 
community-based services and strives to optimize independence and 
quality of life for these particularly vulnerable Veterans in the face 
of their multiple interacting cognitive, functional, psychosocial, and 
medical challenges. GeriPACT panel sizes are one-third smaller than 
regular PACT teams and have a social worker and a pharmacist as core 
members. By helping Veterans maintain function, preventing unnecessary 
hospitalizations, nursing home admissions, and unwanted tests and 
procedures, the total costs of care for targeted high-risk Veterans are 
about 15 percent lower when they are managed in GeriPACT than when 
managed by regular Primary Care PACT teams. Currently, only about half 
of VAMCs have GeriPACT, and VA is working to expand this program to 
larger Community-Based Outpatient Clinics.

Conclusion

    VA's various long-term care programs provide a continuum of 
services for older Veterans designed to meet needs as they change over 
time. Together, they have significantly improved the care and well-
being of our Veterans. These gains would not have been possible without 
consistent Congressional commitment in the form of both attention and 
financial resources. It is critical that we continue to move forward 
with the current momentum and preserve the gains made thus far. Your 
continued support is essential to providing high-quality care for our 
Veterans and their families. Mr. Chairman, this concludes my testimony. 
My colleague and I are prepared to answer any questions.

                                 
                        Statement For The Record

                          BERNARD SALICK, M.D.
    Chairman Dunn, Ranking Member Brownley, and Members of the 
Subcommittee:

    The purpose of this hearing is intriguing on a number of levels. 
Long-term care, a topic of interest to all people, comprises a growing 
sector of health care and is of special significance for the VA. Our 
nation, as a whole, is aging. This underscores the 21st Century health 
care system's success in extending our years today.
    I commend the VA and this Committee for their wisdom in seeking 
alternative options to provide long-term health care to our Veteran 
population, given its particular range of needs, challenges and 
resources. Long-term health care services encompass a broad spectrum, 
including medical foster homes, adult day care, community living 
centers, caregiver programs and skilled nursing facilities. Each of 
these covers a specific set of health care needs. Each is required. 
Each is well-suited to a particular segment of the patient base. And 
each faces a key requirement - to maintain maximum health and 
capability for every Veteran for as long as possible.
    Obviously, significant differences in health care needs of Veterans 
exist within these various long-term care options; and catastrophic 
disease and accidents intervene as we age. Thus, every long-term care 
option must be buttressed by access to specialized, comprehensive and 
coordinated acute and chronic care.
    I am honored to offer my thoughts and experiences, garnered through 
40-plus years in pioneering the creation of comprehensive outpatient 
diagnostic and treatment centers for catastrophic diseases. Our team 
has developed and refined a successful formula for delivering care to 
patients suffering from cancer, end-stage renal disease, HIV/AIDS, 
cardiovascular and many other diseases. Today we stand ready to meet 
the next challenge.
    Several years ago, I began surveying our nation's health care 
landscape for areas requiring enhanced medical treatment. I concluded 
diabetes to be the significant catastrophic disease of epidemic 
proportion, standing at the forefront in desperate need of redesign, 
reinvigoration, and a medical approach that forms the basis of The 
Salick Formula to treat catastrophic disease.
    Therefore, we have determined diabetes to be the necessary and 
logical next step for The Salick Team to target. It is an exponentially 
growing disease afflicting more than 30 million Americans, 24% of whom 
remain undiagnosed.

      The American Diabetes Association reports diabetes to be 
the ``most costly chronic illness in the country, with expenses 
totaling $327 billion in 2017.''
      They document, ``one of every seven health care dollars 
is spent directly treating diabetes and its complications.'' Any person 
suffering from diabetes can expect medical expenditures 2.3 times 
higher than other diseases.

    Given these facts, it is obvious diabetes threatens the long-term 
health of our nation, and it is draining our economic strength. 
Following extensive scrutiny of where to most effectively target this 
disease, it became evident diabetes poses one of its greatest threats 
to America's Veteran population. The VA's patient enrollment of more 
than nine million is characterized by a high prevalence of patients 
with diabetes (twice the national average).

      One of every four enrolled patients in the VA Health Care 
System has diabetes.
      Moreover, 80% with diabetes also have microvascular 
complications, such as blindness and end-stage renal disease.
      And 70% suffer from obesity.
      Of those receiving service-connected disability 
compensation, more than 431,000 have diabetes. The number of diabetes 
diagnoses increases proportionately as our Veterans age.
      More than 35% of VA's patient population become stricken 
with one or more chronic conditions. A Stanford study shows that 
treating patients with one or more chronic conditions consumes 72% of 
the VA's Health Care budget.

    The VA Health Care System and the Salick Comprehensive Diabetes 
Centers are able to fit well together to form a participating joint 
venture that will bring a new paradigm to the ever-increasing diabetes 
epidemic facing the globe. The Salick Formula lends itself well to 
complement the VA System. We have developed a model - beginning with 
two Centers - that could be replicated into a nationwide network of 
comprehensive, outpatient, 24/7 diabetes centers and satellites. The 
Center model would follow the Salick Formula:

    a)First, by focusing on preventative care and educating the 
population on lifestyle changes that can prevent complications.

    b)Second, by providing coordinated care through a team of 
practitioners that manage all of a patient's diabetes-related 
conditions and comorbidities (including complications of diabetes which 
make up over 93% of costs of the disease) and that work in an 
interdisciplinary fashion in a single location to develop an overall 
care plan, based on demonstrated best practices, that best suits the 
needs of each patient.

    c)Third, by offering Veterans and military families the convenience 
of a ``one stop shop'' location that can provide virtually all 
diabetes-related treatments for patents and that offer the convenience 
of full staffing on a 24/7/365 basis.

    d)Fourth, by locating satellite facilities in areas of greatest 
need to provide immediate access to care for our nation's chronically 
underserved populations, in metropolitan and in less populated areas - 
which the CDC has identified as regions with the highest concentrations 
of diabetes and pre-diabetes.

    In selecting appropriate venues to begin locating and jointly 
operating comprehensive diabetes centers in a coordinated assault 
against this disease, two areas of the nation stand out:

    1)California:

    a.Home to over 1.8 million Veterans; 325,000 in Los Angeles, 81,000 
of whom have diabetes; nearly all of those have micro, or macrovascular 
complications.

    b.The VA Greater Los Angeles outpatient clinics and inpatient wards 
are already at capacity in attempting to deal with this population, 
with estimated encounters of only 90,000/year at the West Los Angeles 
VA.

    c.Veterans and their families who suffer from diabetes and its 
complications, and who presently do not receive coordinated care for 
all of their related complications or adequate care management, could 
benefit significantly from a 24/7 top quality comprehensive center. 
These Centers will improve outcomes and reduce acute episodes and 
hospitalizations, thereby improving care while controlling costs.

    d.It appears that Veterans with diabetes are encountering 
significant hurdles in obtaining approvals for bariatric surgery, a 
growing treatment for this disease. A very low percentage of Veterans 
have been approved for this compared with the general public.

    e.Additionally, the entire Southern California area is home to 
Veterans and active duty military from Los Angeles County extending to 
29 Palms, Camp Pendleton, and the San Diego area; including the U.S. 
Naval Hospital.

    2)Alabama:

    a.Ground Zero for the Centers for Disease Control and Prevention's 
``Diabetes Belt'' (U.S. counties >12% prevalence of diabetes), Alabama 
ranks 2nd nationally (14.6%) according to 2016 Kaiser Family Foundation 
study; 500,000 Alabamians have diabetes; by 2030 that number is 
estimated to reach 661,000.

    b.Neighboring states also high: Mississippi (13.6%); Arkansas 
(13.5%); Louisiana and Georgia (12.1%); Florida (11%). Alabama also 
ranks high in Adult Onset Hypertension (2nd at 40.4%); Obesity (3rd at 
35.7%); and lack of exercise (31.5%).

    c.Numerous military bases and an extensive VA Health Care System 
are located within Alabama and its neighboring states.

    Diabetes patients in civilian, VA and DOD health care systems often 
face additional problems when their primary care physicians become 
disconnected from specialist interventions they receive when forced to 
seek late-night and weekend Emergency Room visits. These weekend and 
evening ER encounters can result in in-patient hospitalizations, often 
without the knowledge or participation of their local family doctors. 
Emergency care for diabetes patients in acute circumstances, when 
provided in a disconnected manner from a patient's primary care 
physician, can significantly minimize benefits they could have received 
and result in extreme cost.
    The Salick Team is interested in developing a unique agreement with 
the VA which might enable construction and joint operation, with the 
VA, of innovative 24/7 Comprehensive Diabetes Centers and satellite 
facilities. These Centers would benefit from our history of 
successfully managing treatment of chronic and catastrophic diseases 
which then would be focused on diabetes - and its related complications 
which account for over 93% of the costs of treating diabetes. These 
Centers would be available to Veterans, including those in all types of 
VA long-term care facilities and programs. Further, they would be 
designed to take advantage of state-of-the-art technologies, outcome 
measurements, and advanced scheduling procedures to avoid unnecessary 
emergency hospitalizations via 24/7 access to specialists and 
procedures putting the patient's needs first - during any day or hour a 
patient needs medical care.
    I salute the VA and this Committee for your continuing efforts, 
creativity and determination to improve health care for our nation's 
Veterans. Our Team stands ready to join the VA and this Committee in 
your valiant mission to ``best serve our aging heroes.''

    Thank you.

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