[Senate Hearing 118-192]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-192

                         AN ABIDING COMMITMENT
                TO THOSE WHO SERVED: EXAMINING VETERANS'
                        ACCESS TO LONG TERM CARE

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                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              JUNE 7, 2023

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran, Kansas, Ranking 
Bernard Sanders, Vermont                 Member
Sherrod Brown, Ohio                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
Joe Manchin III, West Virginia       Thom Tillis, North Carolina
Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
Angus S. King, Jr., Maine            Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama
                      Tony McClain, Staff Director
               David Shearman, Republican Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                              June 7, 2023

                                SENATORS

                                                                   Page
Hon. Sherrod Brown, U.S. Senator from Ohio.......................     1
Hon. Jon Tester, Chairman, U.S. Senator from Montana.............     6
Hon. Richard Blumenthal, U.S. Senator from Connecticut...........     6
Hon. Kevin Cramer, U.S. Senator from North Dakota................     7
Hon. Angus S. King, Jr., U.S. Senator from Maine.................     9
Hon. Bill Cassidy, U.S. Senator from Louisiana...................    11
Hon. Jerry Moran, Ranking Member, U.S. Senator from Kansas.......    17
Hon. Mazie K. Hirono, U.S. Senator from Hawaii...................    19

                               WITNESSES
                                Panel I

M. Christopher Saslo, DNS, Assistant Under Secretary for Patient 
  Care Services/Chief Nursing Officer, Veterans Health 
  Administration, Department of Veterans Affairs; accompanied by 
  Scotte R. Hartronft, MD, Executive Director, Office of 
  Geriatrics and Extended Care...................................     1

Jonathan Blum, Principal Deputy Administrator and Chief Operating 
  Officer, Centers for Medicare and Medicaid Services, Department 
  of Health and Human Services...................................     3

                                Panel II

Carl Blake, Executive Director, Paralyzed Veterans of America....    21

Whitney Bell, President, National Association of State Veterans 
  Homes..........................................................    23

Carla Wilton, Chief Operating Officer, Immanuel Lutheran 
  Communities....................................................    24

                                APPENDIX
                           Opening Statement

Chairman Jon Tester..............................................    37

                          Prepared Statements

M. Christopher Saslo, DNS, Assistant Under Secretary for Patient 
  Care Services/Chief Nursing Officer, Veterans Health 
  Administration, Department of Veterans Affairs.................    41

Jonathan Blum, Principal Deputy Administrator and Chief Operating 
  Officer, Centers for Medicare and Medicaid Services, Department 
  of Health and Human Services...................................    48

Carl Blake, Executive Director, Paralyzed Veterans of America....    72

Whitney Bell, President, National Association of State Veterans 
  Homes..........................................................    80

Carla Wilton, Chief Operating Officer, Immanuel Lutheran 
  Communities....................................................    90

                        Questions for the Record

Department of Veterans Affairs response to questions submitted 
  by:

  Hon. Jerry Moran...............................................    95
  Hon. Patty Murray..............................................    98
  Hon. Kevin Cramer..............................................    99
  Hon. Tommy Tuberville..........................................   100
  Hon. Dan Sullivan..............................................   101

Department of Health and Human Services response to questions 
  submitted by:

  Hon. Dan Sullivan..............................................   102
  Hon. Tommy Tuberville..........................................   103
  Hon. Kevin Cramer..............................................   105

                       Statements for the Record

Alzheimer's Association and Alzheimer's Impact Movement (AIM)....   109
American Seniors Housing Association, David Schless, President 
  and CEO........................................................   113
Elizabeth Dole Foundation........................................   116

 
                     AN ABIDING COMMITMENT TO THOSE
                    WHO SERVED: EXAMINING VETERANS'
                        ACCESS TO LONG TERM CARE

                              ----------                              


                        WEDNESDAY, JUNE 7, 2023

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:12 p.m., in 
Room SR-418, Russell Senate Office Building, Hon. Sherrod Brown 
presiding.

    Present: Senators Tester, Brown, Blumenthal, Hirono, 
Sinema, Hassan, King, Moran, Cassidy, and Cramer.

                     SENATOR SHERROD BROWN

    Senator Brown [presiding]. The Senate Veterans' Affairs 
Committee will come to order. I am not Jon Tester, as probably 
most of you know. He will be here shortly. I will just 
introduce the witnesses. I will make no statement, but I will 
introduce the witnesses, and you can proceed; let us do that.
    First of all, I would like to welcome Dr. Christopher 
Saslo, Chief Nursing Officer and Assistant Under Secretary for 
Health for Patient Care Services at the Department of Veterans 
Affairs.
    Welcome, Dr. Saslo.
    He is accompanied by Dr. Scotte Hartronft, Executive 
Director of VA's Office of Geriatrics and Extended Care.
    Dr. Saslo will be followed by Jonathan Blum, Principal 
Deputy Administrator and Chief Operating Officer at CMS, an 
agency at the Department of Health and Human Services.
    Mr. Blum, thank you for your work some years ago when we 
first had discussions about these such things.
    So, Dr. Saslo, the floor is yours. Please proceed.

                            PANEL I

                              ----------                              


               STATEMENT OF M. CHRISTOPHER SASLO
               ACCOMPANIED BY SCOTTE R. HARTRONFT

    Mr. Saslo. Thank you, Senator Brown. Good afternoon, and 
thank you, Senator Brown and other distinguished members of the 
Committee. We appreciate the opportunity to discuss our 
veterans' access to long-term care in both institutional and 
non-institutional settings. I am accompanied today by Dr. 
Scotte Hartronft, Executive Director for the Office of 
Geriatrics and Extended Care.
    The older population in America is growing. For the first 
time in U.S. history, adults over the age of 65 are on pace to 
outnumber children under the age of 18 by the year 2034.
    As veterans age, approximately 80 percent will develop the 
need for long-term services and support. Our top efforts focus 
on supporting our veterans' care with a spectrum of home- and 
community-based services. These programs provide care and 
support for veterans ranging from needs in the home to 
inpatient and long-term care.
    We know that 90 percent of Americans would prefer to age in 
place, in their home or in the least restrictive settings that 
are possible, as long as it is safe to do so. VA supports 
veterans' expressed desire to remain in their homes for as long 
as possible. To support this, VA provides and purchases an 
array of services and programs from qualified providers. In 
fiscal year 2022, VA served more than 400,000 unique veterans 
and spent $3.9 billion on home- and community-based care.
    VA provides and purchases an array of services and programs 
from qualified providers throughout the Community Care Network, 
our contracts, as well as Veterans Care Agreements. VHA has a 
large portfolio of programs to support aging in place, ranging 
from in-home assistance to assist with bathing and dressing all 
the way to licensed VHA clinicians providing primary care in 
the veteran's home. If a veteran is unable to safely remain at 
home, VHA has innovative models to allow veterans to honor 
their preferences for care, such as our Medical Foster Home.
    Additional details on the multitude of programs VHA 
provides can be found in the written testimony.
    When options for living at home are no longer feasible for 
a veteran's care, VA can offer veterans care in a nursing home 
setting in which skilled nursing care along with other 
supportive medical care services are available. All of our 
veterans receiving nursing home care throughout the VA, whether 
provided in one of the 134 VA nursing--VA-operated Community 
Living Centers or purchased by contract in a Community Nursing 
Home, are available.
    Veterans can also choose to receive nursing home care at 
one of the 163 state-owned State Veterans Homes across the 
country that VA maintains partnership with. VA provides quality 
oversight of the State Veterans Homes and provides per diem 
payments for veterans' care throughout the SVH Grant Per Diem 
program.
    VA has already embarked on an accelerated rollout of the 
Veteran-Directed Care program. All VA medical centers will have 
operating programs within the next two years.
    We are also adding 75 home-based primary care teams, 
targeting the expansion to VA medical centers with the highest 
unmet need, such as in our highly rural sites.
    By the end of fiscal year 2026, all VA medical centers are 
required to have a Medical Foster Home program.
    Also, we are piloting a new model of Homemaker/Home Health 
Aide services where the services are being provided by VA staff 
and not community agencies.
    In conclusion, VA's various long-term care programs provide 
a continuum of services for older veterans designed to meet 
their needs as they change over time. Together, they have 
significantly improved the care and the well-being of our 
veterans, even during times of crisis. These gains would not 
have been possible without the 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 the high quality 
care for our Nation's veterans and their families.
    Senator Brown, other members, this concludes my testimony, 
and my colleagues and I are prepared to answer any questions.

    [The prepared statement of Mr. Saslo appears on page 41 of 
the Appendix.]

                   STATEMENT OF JONATHAN BLUM

    Mr. Blum. Senator Brown, Senator Blumenthal, thank you for 
the opportunity to be here today.
    Today, CMS certifies more than 15,000 nursing homes 
throughout the country that serve more than 1 million people on 
a daily basis. That includes veterans. CMS feels that one of 
our core missions is to ensure the safety of the care for all 
nursing home residents. My goal today really is to summarize 
what CMS wants to do, plans to do to improve nursing home 
quality.
    In 2020, when the pandemic first hit this country, too many 
nursing homes were not prepared to contain the pandemic. Too 
many residents died. The system failed too many. CMS rules, CMS 
guidance were not established to adequately ensure the overall 
safety of nursing home residents, the staffs, and their 
families.
    But the good news is the system quickly changed through the 
hard work of nursing homes, their staffs, through better rules, 
through better guidance, through better technical support, 
through better data reporting. Nursing home residents are far 
safer today. We should never again see the death, see the 
despair that we saw during 2020.
    This really is a phenomenal chance now going forward for us 
to change the focus and really think differently for how CMS 
certifies, how CMS oversees, and CMS thinks about the overall 
safety of care. And to that end, the President directed us 
during 2022 through a 28-point plan to change our policies, to 
change our guidance, to change our operations, to really take 
bold but necessary steps, and to this end we have worked 
diligently to put that plan into place.
    We have changed how we survey. We have better survey 
processes going forward. We have changed enforcement. We have 
more timely enforcement going forward. We have changed how we 
think about transparency, putting out more quality data, 
putting out nursing home data regarding the ownership to give 
residents and their families better information for how they 
choose their care. We are working toward building stronger 
staffing standards because we know that when nursing homes have 
sufficient staff they have better quality outcomes. And, we are 
working with the Congress to ensure that we have the adequate 
resources to ensure that CMS can do its work well.
    When fully put into place, we believe strongly this plan 
will boost the overall quality of care and to improve access. 
This will bring more accountability to our programs and bring 
more workers back to nursing homes.
    The best way, we think, to ensure high quality and good 
access is to ensure we have sufficient staff for all nursing 
homes. Patients tell us this, residents tell us this, the staff 
tell us this, and data tells us this. During these past two 
years, we have spent a whole lot of time to talk to residents, 
talk to the caregivers, talk to staffs, talk to operators, and 
the one thing they say to us consistently is that more staff, 
better staff will ensure better quality outcomes and will 
ensure safety and keep facilities open.
    I have personally traveled to many parts of the country 
during the past two years and have seen firsthand nursing home 
care being provided in large urban areas and small rural areas 
and in frontier areas. We know that no one-size-fits-all can 
serve the country well, but we also know that we have great 
urgency to this work.
    But we pledge, CMS pledges, to work in full partnership 
here with the Congress, with all stakeholders to ensure that we 
can better serve residents going forward and better serve the 
public going forward.
    With that, we will yield back time and take any questions 
you may have.

    [The prepared statement of Mr. Blum appears on page 48 of 
the Appendix.]

    Senator Brown. Thank you, Mr. Blum.
    Let me start with Dr. Hartronft. I appreciate your being 
here. My state has 350,000 veterans over the age of 65, 
slightly more than a third of the veterans in our state.
    Dr. Saslo said in his testimony 80 percent of veterans will 
need long-term services and support at some point in their 
life. Of course, veterans, like all Americans, would prefer to 
remain in their homes and receive care there. We know it 
produces better outcomes and improves quality of life. Veterans 
should have that option, of course.
    I am glad to see President Biden's Executive order for 
increasing access to high quality care and supporting 
caregivers, including considering a pilot program for a new co-
employer option, I believe is the term, and provide veterans 
with a choice to direct their own care.
    So, Dr. Hartronft, if you would, what are your plans for 
implementing a pilot program offering veterans that choice? Can 
you give some insights on the scale of the project and on the 
scale of the pilot project? How many of us--I know many of us 
would like to see that program offered to as many veterans as 
possible.
    Dr. Hartronft. Yes, sir. Thank you for the question. Our 
office is working closely with the VA Innovation Center to 
determine feasibility at this time, including determining the 
process and payment, use of authorities, and other means that 
we will be able to implement, as well as the best sites and 
states will be determined and any additional resources needed 
for implementation.
    We think the feasibility stage will be completed in August 
2023. So we are in that feasibility stage, too, because the CEO 
model is kind of a broad umbrella and we are looking for a 
specific model that fits under there, and this ideally will fit 
somewhere between our current programs of Home Health Aide, 
which is agency-provided versus the Veteran-Directed Care, 
which is the veteran chooses their providers. So this will be a 
hybrid between what we already have, just again to find out 
does this model, potential model, work better for certain 
veterans than other programs that we already have.
    Senator Brown. Thank you.
    Dr. Saslo, I have done as I have said in this Committee, 
talked to the Chair, the author of the PACT Act about it, and 
we have worked on a lot of that together. And I have done some 
30-plus roundtables in about half the counties in Ohio, and I 
hear often about the quality of VA care. And certainly people 
come to complain, but most people are pleased with what the VA 
does and are proud to be in that system.
    We know that the VA provides some of the highest quality of 
specialized care for veterans with spinal injuries and 
disorders. In Ohio, we have several VAs and more than two dozen 
community-based clinics, but we have only one spinal cord 
injury and disorder care center. That is in Cleveland. It is 
one of 25 such hubs nationwide. What steps is the VA taking to 
ensure that veterans served at that facility have the necessary 
access to long-term support and services for spinal cord 
injuries and spinal cord disorders, Dr. Saslo?
    Mr. Saslo. So, thank you for the question. One of the 
things that I think is probably a best example is VA continues 
to look at the different staffing models within the areas that 
are needed. Spinal cord injury, long-term care, et cetera, are 
several of the types of staffing methodologies that we look at, 
not only on an annual basis to see what the services are best 
to serve that population, but also how we need to change the 
model based upon the staffing mix within the area of need. So I 
think for VHA as a whole one of the things that we are 
extremely committed to is making sure that the models 
themselves that are requiring additional staffing or changes to 
staffing are opportunities that we look at on a regular basis.
    And I will turn to Hartronft in case he has any additional 
information.
    Dr. Hartronft. Yes. And with those hubs, then we also have 
spokes that go out to each of the other sites on a main hub. 
And then with the SCI veterans, they also have their annual 
evaluations as well as have a specialty team that takes care of 
their care. So part of that is again their group that kind of 
helps care-coordinate for them and would know the resources 
best available for them in their community.
    Senator Brown. Thank you. Last question, and I will turn to 
Chair Tester.
    Mr. Blum, it is important we make sure veterans who choose 
to live in nursing homes are living in safe, high quality 
facilities. The President's budget requested an increase to 
survey and certification funding for fiscal year '24. Explain 
why an increase in that funding is important.
    I know that Chair Tester in this Committee has always 
fought for veterans' increased funding as the Administration 
has. Talk that through for a moment.
    Mr. Blum. Well, I think for CMS, for the past eight years, 
we have had the same budget, a flat budget, for how we can fund 
survey and certification work. That constrains resources. That 
means that states that carry out this work do not have funds to 
plan for how to hire staff. And what we hear from staff--from 
states is they are losing staff to do this important work. So 
we believe in order for us to move forward well, to do 
sufficient surveys, to really ensure safety throughout the 
country, to give the states the funds they need in order to 
carry out this work, that the budget has to grow.
    So the overall constraint is that we have been flat-lined 
for the past eight years. We have more demands. We have more 
complicated situations. So we need those funds to grow to 
ensure that we can fund states, we can fund CMS to carry out 
this important work.
    Senator Brown. Thank you.

                      CHAIRMAN JON TESTER

    Chairman Tester [presiding]. Thank you, Senator Brown.
    I would just ask that my opening statement--in unanimous 
consent, my opening statement be put in the record; hearing 
none, so be it.

    [The opening statement of Chairman Tester appears on page 
37 of the Appendix.]

    Chairman Tester. Senator Blumenthal, you may proceed.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thank you so much, Mr. Chairman. Thank 
you, Senator Brown. And, thank you all for being here today on 
a subject that is so important to our veterans.
    I want to talk about one specific area that is important to 
nursing homes, which is the shortage of nurses, and we have 
talked about this issue with other representatives of the VA. I 
know that you have been working on it. You can talk a little 
bit about what is being done and what more can be done to 
train, recruit, incentivize nurses, who are so critical, do so 
much thankless work, and should be supported and elevated 
rather than taken for granted.
    Mr. Saslo. Thank you for the question, Senator Blumenthal. 
I am actually really proud to say that VHA really has leaned in 
significantly on our efforts to strengthen the workforce. Our 
Office of Nursing Service actually has several different 
pillars that are looking at ways that we can engage, grow, and 
sustain our nursing workforce.
    We have increased the number of our registered nurse--RN 
transition programs. We are also looking at different models of 
training our nursing assistants so that we have an in-house 
opportunity to actually grow the best type of staff that we 
need to be able to ensure the care that our veterans receive.
    We also have made sure that all of our medical centers are 
aware of the different hiring and recruitment and retention 
authorities that are available to them. We have significant 
numbers of recruitment and retention authorities that we have 
put in place, and we have been given support by both the 
Secretary and the Under Secretary to really be as flexible with 
those authorities as possible, ensuring that we are reaching 
out to our population of potential candidates as well as 
sustaining the existing population of nursing staff that we 
have.
    So it is important for us to make sure that the individuals 
that we have already hired and have in place in our 
environments and in our settings really want to stay there as 
well as being able to recruit the best and the brightest talent 
in the future. We have approximately 15,000 positions that we 
need to fill each year to sustain the nursing workforce, and so 
we are looking at every potential option in order to make sure 
that we are growing it.
    As I mentioned in my earlier statement, the staffing 
methodology that we use really is one of the key elements that 
tells us how much staff across the entire enterprise, whether 
it is in long-term care, acute care, or even in the mental 
health arena. So we really are very proud of the steps that our 
Office of Nursing Service has taken in moving that forward.
    Senator Blumenthal. I recently joined a number of 
colleagues in supporting legislation. I believe it is known 
colloquially as the Dole Act. Both parties actually joined in 
supporting this bill in this Committee. Unfortunately, it was 
blocked from passage. I am hoping that maybe my Republican 
colleagues this time around will join in supporting it. It 
would expand access to home- and community-based care programs 
for veterans.
    Can you explain how this measure would improve the lives of 
veterans across the country?
    Mr. Saslo. So our current plan, as I mentioned in my 
opening statement, really is to expand the home-based primary 
care opportunities, making sure that we have that in the most 
rural settings. I think one of the key elements is that it is a 
multidisciplinary approach that we are looking to make sure is 
available. So it is not just our nursing staff but our 
clinicians as well as all of the ancillary support that goes 
with it.
    And I will ask Dr. Hartronft if he would like to expand on 
that just a little bit.
    Dr. Hartronft. Yes, as you know, the Senator Elizabeth Dole 
bill has many components to it, but with the staffing model, I 
think especially workforce, it will give us some--you know, 
working with the Department of Labor and others to see--because 
it is not only a VA problem, obviously. So we need to work with 
subject matter experts in the labor market as well as trying to 
figure out how we can work together to really increase the 
field of direct care providers and others.
    Senator Blumenthal. Thank you very much. My time is 
expired, but again, thank you, and I hope that we continue to 
work together on these issues.
    Thanks, Mr. Chairman.
    Chairman Tester. Senator Cramer.

                      SENATOR KEVIN CRAMER

    Senator Cramer. Thank you, Mr. Chairman. Thank you, 
gentlemen, for being here and for your service.
    For the two VA witnesses, just right up front, North Dakota 
is like a lot of rural states. We have a lot of nursing 
facilities throughout the state, some with a lot of beds 
available, high quality, and they want to serve more veterans. 
They truly want to serve more veterans, but it is a clumsy 
relationship. The contracting is complicated. Getting paid is 
complicated. I mean, can we simplify this for our veterans so 
that our nursing homes can do what they want to do, and that is 
serve them?
    Is that too simple a question? I am just teeing it up for 
you. But it is a real concern. I mean, it is a real issue that 
we hear a lot about back home.
    Mr. Saslo. Thank you, Senator Cramer. And I truly do agree 
that we want to maximize the efficiencies, our ability to 
engage not only our Community Nursing Homes but the long-term 
care settings that are within the VA itself. And so knowing the 
challenges that we have had with staffing, both in the private 
sector as well as in the VA, one of our goals is to really make 
sure that we can maximize any of the efficiencies when it comes 
to contracting and placement, knowing that we need to maintain 
the expectations of what we are allowed to do through our 
authorities.
    Dr. Hartronft, do you want to add----
    Dr. Hartronft. Yes. And especially now that we are--there 
is some flexibility among the different--whether they want to 
do the typical local contract versus the Veterans Choice 
Agreement or Veterans Care Agreement versus the Community Care 
Network. So each has a particular new fit, potentially better 
for one facility than the other, but I think part of it is 
letting facilities that feel that the typical contract process 
is too tedious--by all means, we should be talking with them 
about the Veterans Care Agreements and other avenues that might 
be better for them and their particular needs.
    Senator Cramer. Yes, no. I mean, that is well said, but we 
already threw out all the options. At least, you mentioned 
flexibility. Flexibility is important. Now you can look at the 
various programs that can fit and then look at the localized 
situation and do the right thing.
    I just worry, and I just see it, you know, in every 
bureaucracy, but it is particularly difficult to watch in the 
VA bureaucracy where a veteran is not getting served that wants 
to be served and has people that want to serve that veteran and 
just some bureaucratic nonsense is getting in the way.
    And I am not blaming you for it. I am just saying, gosh, 
let us simplify complicated things and not complicate simple 
things. And I know you are committed to that, and we want to 
continue to work with you on it.
    Mr. Blum, I want to talk a little bit specifically about 
the staffing challenges. Right? I mean, I hear it everywhere. 
It is not new. It is not new to this industry. It is every 
industry, but it is particularly problematic, obviously, in 
health care.
    Mr. Blum. Yep.
    Senator Cramer. And I have worried a lot about the use of 
contract nurses, and yet, when you need workers, you need 
workers. Right? All of that stuff.
    And I am a little concerned about the talk of staffing 
ratio mandates and the impact that would have on an already 
very stressed situation. You know? So how does that policy help 
I guess is the bottom line, and can we please change it or drop 
it or admit we were wrong or something?
    Mr. Blum. Thank you, Senator, for the question. We are 
still in the process of thinking through what is the best 
policy for how to think about staffing requirements going 
forward. One of the things that we see clearly in our data is 
that those facilities that have more consistent staff, more 
stable staff, they have higher quality outcomes. I was 
traveling throughout the country this year and just saw 
firsthand if facilities can retain staff and attract staff they 
have high quality outcomes and they have better satisfaction 
from their residents.
    What we want to see is a clear signal to the industry for 
how they build programs, how they build connections. We are 
seeing a lot of nursing homes build strong ties to their local 
high schools, their community colleges, their colleges to train 
the next generation of health care workers, nursing home 
workers. So our view is with a clear signal that is carefully 
put together we will build the workforce that we need over time 
to best serve Medicare, Medicaid, and all residents for our 
country.
    Senator Cramer. Well, I do not think you have too much of a 
survey to conclude what your data demonstrated. The question 
is: How do we get there? I love all your suggestions, working 
with local schools, introducing young people to the joys of 
long-term care work, but I am not sure mandating ratios is 
going to get us there. But, with that, I appreciate all your 
attention.
    Thank you, Mr. Chairman.
    Chairman Tester. Thank you for the question. I will follow 
up when I do mine, too, Senator Cramer.
    Senator King.

                   SENATOR ANGUS S. KING, JR.

    Senator King. I want to follow up on the staffing question.
    I mean, we have got enormous staffing problems, and to say 
you have got to have a certain--it seems to me that opens up 
liability questions and it puts the staff under a lot of strain 
because it is just unrealistic right now.
    Mr. Blum?
    Mr. Blum. But in this----
    Senator King. I understand it would be better, absolutely, 
but you cannot conjure people out of thin air.
    Mr. Blum. One of the things that we are seeing and 
experiencing in our data, but also seeing in our travels, is 
that we are seeing a stronger workforce than we had two years 
ago. We are seeing fewer contract dollars, fewer traveling 
nurses, fewer traveling physicians due to just a more stable 
workforce, and so we want to build upon that.
    And the challenge for us is that we see clearly in our data 
that when nursing homes do not meet set standards, minimum 
standards, the quality of care is horrible, that harm happens.
    So our goal is to really find the right balance between 
making sure the nursing homes can fulfill the requirements to 
the Medicare and Medicaid programs, they can have a growing 
staff, but we see the best solution to this tension of better 
quality outcomes and better access through a growth and 
consistent staff.
    So our goal is to send a very clear signal, again back to 
nursing homes, to say: This is what is required to meet basic 
Medicare and Medicaid requirements. And if we do not have that, 
we are going to see less access, we are going to see more 
facilities close, we are going to see worse quality outcomes.
    Senator King. And you are going to have fewer beds for 
veterans to go to.
    Mr. Blum. We believe----
    Senator King. We are not serving veterans if a home closes 
because they cannot meet the staffing standards because they 
cannot find the people. Let us get real here.
    Mr. Blum. We believe----
    Senator King. Do not tell me you are improving service to 
veterans when you just said we are going to see nursing homes 
close.
    Mr. Blum. We do not think they are going to close.
    Senator King. You just said that. Didn't he say--didn't he 
use the word ``close?'' Yes, you did.
    Mr. Blum. That was misspoken. What we want to see is a 
nursing home force that is more stable, that allows nursing 
homes to continue to----
    Senator King. Nobody disagrees with that. The question is: 
How do we get there, and are we in the process of getting there 
setting unrealistic standards that will in fact lead to nursing 
home closures? That is the issue that I think has to be--you 
have to address.
    It is not enough to say we are going to have a good staff 
and we are going to have enough staff. I want to hear how you 
are going to make that happen because we are losing nursing 
homes generally in Maine because of a lack of staff. And so let 
us have some programs to retain--raises, training, career 
ladder, whatever it is going to take--but that is what I want 
to hear.
    And to start with what I believe may be unrealistic 
standards seems to me is backward. We should start with the 
programs to build the staff and maintain the staff that we 
have, then talk about increasing.
    Dr. Hartronft, I have known physicians at VA facilities who 
have left. They are dedicated to the mission. They love the 
veterans. They say, I have become--all I am doing is paperwork. 
I want to be a doctor.
    How do we relieve that issue? How do we--I am sorry, I am 
looking at you but talking to you.
    You understand. You are a physician. These people want to 
treat veterans. They do not want to do paperwork. How do we 
resolve that? And I know people who have left the VA because of 
that issue.
    Dr. Hartronft. Thank you, sir. A lot of that is around 
especially our primary care teams, the primary line care teams, 
and a lot of it is we have guidelines now as to kind of 
staffing of ancillary staff trying to help assist with that. So 
I think part----
    Senator King. I hope that is a focus because I think we 
cannot lose these wonderful physicians.
    Final question. And I realize this has been discussed. We 
really need to talk about beefing up home care. I once was--I 
used to travel the state when I was Governor, with our Human 
Services, and we would be with seniors and elderly folks. How 
many want to go to a nursing home? No hands went up. People 
want to stay in their homes, and also, it is a lot cheaper. It 
is a lot more cost effective.
    Describe to me the VA's home care emphasis. And I know 
there is a pilot program of which Maine is participating, the 
RECAP program. Talk to me about home care as an alternative to 
nursing homes.
    Dr. Hartronft. Specifically, the RECAP program is the 
Redefining Elder Care in America Pilot. And what we are doing 
is piloting using predictive analytics to actually determine 
from all Medicare and VA records as to who is at the highest 
risk for nursing home placement in the next two years, and we 
embed a care coordinator who works with their primary care 
provider to proactively reach out to the veteran and their 
caregiver to see if they need home services because we can 
see----
    Senator King. Because every day you can keep a veteran in 
their home they are happier and the system is saving money.
    Dr. Hartronft. Yes, sir.
    Senator King. I take it that is----
    Dr. Hartronft. Yes, sir.
    Senator King [continuing]. Part of what this project is all 
about. Has it been going long enough to have any results? The 
RECAP pilot.
    Dr. Hartronft. The initial results we have not gotten large 
enough in to really do anything publishable, but at this point 
we have definitely seen people who are happy with the program, 
great feedback, and we have seen that if you look at the pre 
and post with the number of those receiving home care services 
that has significantly increased after that as an intervention.
    Senator King. Good. Thank you. Please keep us informed on 
that.
    Thank you, Mr. Chairman.
    Chairman Tester. Senator Cassidy.

                      SENATOR BILL CASSIDY

    Senator Cassidy. I will begin with an opening statement 
which I have been asked to give on behalf of Senator Moran.
    First, thank you, Mr. Chairman. Thanks to the witnesses for 
being here to discuss how to ensure veterans have access to the 
long-term care and support they need.
    As our veterans sacrificed for us, so we owe them to work 
to identify the gaps in care and find ways to improve the 
experience they receive when they work with VA to fulfill their 
long-term care needs. Access to quality long-term care is an 
important part of honoring our commitment to our veterans, an 
issue that affects the veteran, their families, the caregiver, 
and the community around them.
    I once got a call from an old high school girlfriend who 
just told me her father was in a nursing home, a veterans' 
nursing home, and the frank abuse that she thought he was 
receiving. I have no doubt he was combative. I have no doubt he 
was combative, but that is one of the issues with taking care 
of people who are older. And he was transferred to another 
nursing home, and it went really well.
    So I just use the anecdote because it is one thing to read 
the statement but it is another thing to think of the 
individual patient. So it is an issue that affects a veteran, 
their families, the caregiver, and the community around them.
    I am interested in how do we improve the coordination 
between the VA, the community provider, and other stakeholders 
so the veteran and their families do not have to struggle to 
access the support they earned. I say that because she--going 
back to my high school girlfriend, the only way she got help 
was the fact that her high school boyfriend happened to be a 
U.S. Senator. Now it should not take a bad relationship for her 
in high school to finally pay off 45 years later and how much 
the other person who had a different life experience.
    So I say that because we can all recognize as the 
population of aging of disabled veterans increases the VA will 
need to ensure high quality and adequate staffing for VA 
medical facilities, clinics, and Community Living Centers while 
also expanding its footprint in the community.
    I, we, support the VA's efforts to honor veterans' 
preferences for when, where, and how they receive long-term 
care. The veteran and the veteran's family should have ultimate 
control over their health care decisions for the VA.
    We must also focus on caregiver support and recognize the 
vital role caregivers play in the well-being of a veteran. We 
must provide these caregivers with the necessary resources, 
training, and support to ensure they deliver the best care. Our 
hope is that your testimony will help us figure out how to do 
so, and I thank you for this.
    Let us honor our veterans' service and sacrifice by making 
sure they get the best care we can give them.
    Senator Cassidy. With that, Mr. Chairman, I will then go to 
my questions. Okay. I gave you an example of a woman I know 
whose father had one experience in which she alleged abuse and 
the other in which this same person, same family member, I 
guess proving that she is not entirely unreasonable, had an 
excellent experience.
    So I understand now this is a veterans-run hospital, so I 
guess I have two sets of questions here. CMS and VA both 
provide oversight into these different settings of care; that 
is correct. To what degree do you communicate if one has a 
problem, then the other can follow up on the same problem if 
their visit is intermittent?
    Mr. Saslo. So several of the things--and thank you for the 
question, Senator Cassidy. The aspect of care coordination is 
really one of the things that we have been looking at 
maximizing or increasing the effectiveness when we have our 
veterans that are either within VHA----
    Senator Cassidy. Now when you say ``care coordination,'' I 
think of care coordination as a nursing plan, a care plan, but 
I think in the context of this question you mean: Okay, we have 
looked at this particular facility. They are doing well. They 
are doing poorly. By the way, HHS, you are coming in after me, 
and state agency, you are coming after me again. You need to 
watch out for this, or you need to look for that.
    Mr. Saslo. So there are several levels when we look at the 
care that is being delivered in our Community Nursing Homes. 
And I will ask Dr. Hartronft if he would like to expand on the 
aspects of how we look at the evaluation, the quality of care, 
and then how we communicate and partner with our CMS partners 
in order to make sure that----
    Senator Cassidy. I am less concerned about the particulars 
of how you look at it because I trust that you are looking at 
clinically significant things. What I am more concerned about 
is that if there is a problem that there is communication 
between agencies, and I think this is more of a yes or no, it 
occurs, as opposed to elucidating the process because obviously 
you want a warm handshake.
    Listen, we think that their restraint policy is being used 
too often and too indiscriminately. When you are going to be 
there in two months, will you be sure to look at their 
restraint policy?
    You see where I am going with that, using a particular 
example as opposed to a process.
    Mr. Saslo. I will ask Dr. Hartronft to expand, but--I think 
that there are steps that we do have in place, but I will ask 
Dr. Hartronft.
    Senator Cassidy. And that is to communicate with other 
agencies with jurisdiction?
    Mr. Saslo. Yes.
    Dr. Hartronft. Yes, sir. Many times, whenever we do our 
site visits, which are every 45 days in a contract nursing 
home--they do an onsite visit. And if they do find something at 
a level, they contact either the CMS directly to do, you know, 
a for-cause concern or they talk with an ombudsman. And then 
also vice versa, whenever we are doing our any kind of 
oversight, we manage what CMS--we pull up the latest CMS survey 
just so that we are aware when our folks go in there what they 
were already aware of in their last survey so that we----
    Senator Cassidy. So then that is wonderful. Let me ask you 
this: Just knowing that there is always a spectrum of quality, 
I suspect that there are some nursing homes that really you 
could do them twice yearly, even once yearly, and they are 
going to be pristine, and there are others that 45 days is 
probably not often enough, at least until they come under 
corrective action.
    Dr. Hartronft. Yes, sir. Especially like with the one-star 
facilities, not only do they have the baseline 45-day visit to 
every----
    Senator Cassidy. So one-star is worse quality?
    Dr. Hartronft. Yes, sir.
    Senator Cassidy. And four-star is best?
    Dr. Hartronft. Five-star.
    Senator Cassidy. Okay.
    Dr. Hartronft. And so for the one-stars, based on the 
quality level, there is--the foundation for all is that every 
45-day visit and then an annual assessment. With the one-star 
facilities, it even includes a waiver that has to be approved 
by the local facility director and the network director to 
justify why was that facility chosen over others, and usually 
it might be the only facility available or the best choice. It 
has different levels of scrutiny based on the levels and 
findings.
    And then our staff can also do anytime of ad hoc kind of 
site visits, and they have an oversight committee at each of 
the local VAs as well as what we do on a national level.
    Senator Cassidy. Is there ever--I mean, I presume so, but I 
am just asking for the record. Can a facility be so bad that it 
is busted and never again can a veteran be allowed to be kept 
there?
    Dr. Hartronft. Yes, there has been times where we actually 
go in and meet with these veterans to make arrangements for 
them to be placed other--you know, go to other facilities if it 
gets to that point with a quality concern level.
    Senator Cassidy. Okay, good. Mr. Blum, would you add 
anything?
    Mr. Blum. Just to add that, by law, we have to survey every 
certified nursing home roughly every 12 months, but our teams 
also respond to complaints. And so as we get complaints, 
whether from the VA or any other entity, that is going to drive 
more action to ensure that we can ensure safety.
    So our goal is to really shift resources to where we have 
the most challenge, and that is based upon strong partnership; 
that is based upon looking at complaint data. But the goal that 
we have is to ensure that, one, complying with the law, that 
every nursing home gets surveyed roughly every year, but also 
that we can target resources where we see that lowest quality 
of care.
    Senator Cassidy. And so let me finish by asking this: Just 
going back to the anecdote I gave, which was a little amusing 
but it is a real-life anecdote, if somebody has a complaint to 
make, they feel as if their loved one is not being cared for 
correctly--when I go into nursing homes--and I occasionally go 
in and visit, and the ones I go into are uniformly wonderful. 
But I never see anything saying, if you have a complaint, call 
1-800 file your complaint sort of thing, or if it is a VA 
patient, if your loved one is a veteran, et cetera. Is that 
required to be posted, or how would somebody know that? Because 
I am just struck that again the woman I knew I do not think she 
knew how to make that complaint and she is an RN and all this 
other stuff.
    Mr. Blum. Patients served by CMS programs have the right to 
complain and contact their state process, but there are 
procedures that we can follow up on to describe how patients 
can complain.
    Senator Cassidy. But how would she know of this? Would she 
just have to have the wherewithal to say, it must be on the 
internet someplace?
    Mr. Blum. No. All residents have their rights to complain.
    Senator Cassidy. But I do not know that notification 
process. Now I do want to know the process. Would she have to 
go to the nursing director and say, I would like to make a 
complaint to HHS?
    Mr. Blum. That is one route that she can take.
    Senator Cassidy. That seems actually unlikely to occur to 
many people.
    Mr. Blum. We will get back to you, Senator, with a real 
clear description for how patients can follow up their rights.
    Senator Cassidy. And is there a separate process for a 
veteran who is being covered by the VA to make a complaint?
    Dr. Hartronft. Yes, sir. Again, during those every 45-day 
visits, an in-person social worker or nurse actually interviews 
the veteran in private and allows them----
    Senator Cassidy. Now if a veteran has dementia, though, 
which many of these would, that would not be of help.
    Dr. Hartronft. I am sorry, sir?
    Senator Cassidy. If the veteran has dementia----
    Dr. Hartronft. Yes, sir.
    Senator Cassidy [continuing]. That would not be of help.
    Dr. Hartronft. Yes, they make themselves available to 
caregivers if they are available, or they know that they are 
coming, then they can reach out. If they--if the caregiver were 
to be interested to visit with them, they can leave a note with 
the nurse to give them a call whenever our people are there and 
they can call them back.
    Senator Cassidy. So I guess my--not to beat it, but just to 
ask, how would the family member know that I can speak to the 
social worker of my loved one to make a complaint about--do you 
see what I am saying?
    Dr. Hartronft. Yes, sir.
    Senator Cassidy. How would she know that you were going to 
make your 45-day visit and she could be there in order to speak 
to the 45-day visit?
    Dr. Hartronft. Yes, sir. Again, usually, we--they know that 
they will be coming and--but I think it is something we can 
improve.
    Senator Cassidy. Okay. Well, thank you. I yield.
    Mr. Saslo. If I could just add, Senator, I think one of the 
other pieces that we try to make sure is a consistent process 
and when a veteran is placed that that social worker is 
actually reaching out up front, engaging with the family, the 
caregiver so that they understand what the expectations are, so 
that that 45-day visit that Dr. Hartronft explained is 
something that they should be made aware of up front.
    Now the opportunity always exists for us to be able to 
reinforce when something is not going well for families to be 
able to have the correct number, have the correct person to 
reach out to. So we can certainly take that and look at 
opportunities for improvement.
    Senator Cassidy. Thank you.
    Mr. Saslo. Yes, sir.
    Chairman Tester. Thank you for your questions, Senator 
Cassidy.
    I would just follow up for a second in that if you got a 
situation you cannot expect the loved ones to know how to do 
this. And I think the social worker reaching out is good on the 
veteran side of things. What happens with the others? Which is 
not what this Committee is supposed to be about, but the truth 
is we all have--there ought to be some notifications made by 
the rest home that talks about what the recourse is, and maybe 
in fact that is happening, but it should be happening.
    The only other question I have--and this goes along with 
Senator Cassidy's question, and that is: Do you guys have, your 
agencies have, a mechanism by which if you find something wrong 
you automatically notify CMS or CMS automatically notifies you 
if they are in a rest home, that it does not just happen when 
somebody thinks to notify CMS or somebody thinks to notify the 
VA, but actually you find a problem, you automatically notify 
the other?
    Dr. Hartronft. Yes, sir, that tends to be standard 
operating procedure, that it directly triggers notification to 
CMS and State and others whenever there is a significant 
finding.
    Chairman Tester. All right, on a significant finding. What 
if it is not a significant finding?
    Dr. Hartronft. Especially, I think that depends on what is 
found. I know it sounds funny, but----
    Chairman Tester. Well, the question is we could probably 
have a conversation on what defines a significant finding.
    Dr. Hartronft. Yes.
    Chairman Tester. But if it is a problem, I think both 
should know; that is all.
    By the way, I appreciate all three of you being here.
    Mr. Blum, this is not to be critical at all, but the 
staffing ratio issue, which Senator Cassidy and Senator King 
and probably everybody around this table could talk about, from 
a CMS standpoint is a big issue, and I think I found a 
solution. You said, with a stable staff, you have a better 
outcome, which I agree. What I am hearing on the staffing 
ratios is you are going to require so many RNs for a facility. 
That is a different issue. That is an issue that Senator King 
talked about and Senator Cramer, too.
    You come to north central Montana, and nurses are gold. My 
daughter is one of them. And I would love to have a staffing 
mandate that would give her a job anywhere she wants to go, but 
the reality is stable staff is what you need. I am not going to 
say you do not need any RNs. You certainly do, but stable staff 
is it.
    Now I know you do not have the rule out yet. I know you 
want higher outcomes. We want higher outcomes. But I think the 
point Senator King made, that closing down a rest home is not a 
higher outcome necessarily, okay? Not that there is not times 
when that needs to happen, but we certainly do not want it to 
happen just because they have no other choice because they 
cannot meet the staffing mandate.
    Can you take that back to your folks?
    Mr. Blum. Yes, Senator. And we are still in the process to 
finalize this proposed rule, and we understand that this is a 
very high interest to many people, and we will be happy to 
consider the comment.
    Chairman Tester. So for a number of reasons, in Montana, 
not having anything to do with CMS, we have, I think, lost 11 
rest homes. These folks are elderly folks that are being moved 
to other rest homes, which, as you guys know, a lot of stress, 
a lot of death. And quite frankly--so we need to try to get 
ahead of that curve and try to solve the problems that you 
spoke about without taking the issue apart.
    I want to talk to you on the VA side of things, Dr. Saslo. 
The Veteran-Directed Care program provides veterans the 
opportunity to receive long-term care services in their homes 
by providing them with a budget to hire workers to assist them 
with certain activities. You are familiar with the program.
    On the 18th of April, President Biden released an Executive 
order which, among other things, directed the VA to consider 
expanding VDC to all VA medical centers by the end of next 
year, FY '24. The President also advised the VA develop an 
information plan for VDC expansion by June '23. Would you give 
us an update on a project timeline for expanding that program 
to all VA medical centers?
    Mr. Saslo. So, thank you, Senator Tester. Our goal is to 
actually have the Veteran-Directed Care rolled out to all 
facilities by the end of FY '24.
    Chairman Tester. Yes.
    Mr. Saslo. The expansion--Dr. Hartronft has actually been 
working with the teams across the country----
    Chairman Tester. Sure.
    Mr. Saslo [continuing]. And so I will ask him to give you 
the actual status right now.
    Chairman Tester. Sure.
    Dr. Hartronft. Actually, currently, we are on pace to meet 
the guideline.
    Chairman Tester. Good.
    Dr. Hartronft. And we have actually even had luck in the 
territorial sites as well. We have currently had the 
Commonwealth of the Northern Mariana Islands, and we already 
have in the works the U.S. Virgin Islands, Guam, American 
Samoa, as well. So we are on pace, sir.
    Chairman Tester. I appreciate that. Five minutes goes awful 
fast when you are having fun. I will turn it over to Senator 
Moran.

                      SENATOR JERRY MORAN

    Senator Moran. Chairman, thank you, and I thank Senator 
Cassidy for filling in for me this afternoon.
    Let me ask to the VA: Does the Department of Veterans 
Affairs have adequate authorities and flexibility needed to 
partner with community long-term care facilities and to 
providers to provide care to veterans in their communities and 
potentially reduce the demand on VA-owned and operated CLCs?
    Dr. Hartronft. Yes, again, sir, we have--of the three 
authorities, the one that has actually taken off more 
considerably is the Veterans Choice Agreements or Veterans Care 
Agreements, the VCAs. Most of the local contracts we call 
IDIQs, and then we also have the CCNs. So we have agreements 
for over 8,800 nursing homes in the country. We have veterans 
in every one of those homes, but we have agreements and 
coverage for that many.
    So we--again, we like to find out which of those three 
authorities fit best for each of the nursing homes because some 
find--may not like the aspects or realms of a contract. So we 
can use the VCA. That may be able to be more low, negotiated a 
little bit different for them, versus them joining the 
Community Care Network.
    Senator Moran. What should happen when a small-town nursing 
home comes to me and says: We would like to care for our 
veterans in our community, but we have no contract with the VA. 
What can you do to help us?
    Dr. Hartronft. I would have them directly contact their 
local VA and just explain that (a) they are interested because 
it always helps to have a facility that shows the interest in 
serving veterans, (b) also they can find out is there an unmet 
need especially in their area because especially in the rural 
areas it is always nice to have some redundancy to give 
veterans better choice, to be closer to their support networks 
and others. So it is really contacting their local VA to find 
out how they can do either the contract, the VCA, and joining 
the Community Care Network.
    Senator Moran. Your authorities preceded the Choice Act. So 
when you use the word ``choice'' in one of those three options, 
it is really not related to the Choice Act, correct?
    Dr. Hartronft. My apologies, sir.
    Senator Moran. No, no. No, I am just clarifying for myself.
    Dr. Hartronft. Yes, sir.
    Senator Moran. There was no apology necessary.
    Dr. Hartronft. Okay.
    Senator Moran. And then following the Choice Act--I do not 
know whether the Choice Act affected your capabilities to 
provide care in the community for veterans at a nursing home.
    Following that was the MISSION Act. I would like to know if 
it, which is now operational--does it give you additional 
authorities, make it easier for a veteran to get nursing home 
in a community, or unchanged?
    Dr. Hartronft. I think the VCAs have really helped in that 
niche between formal contract and our Community--the Community 
Care Network is even relatively new for us. So that added over, 
you know, 6,000, I think, sites just by joining the CCN. So, 
yes, I think with adding the VCA, if a facility is not 
interested in a traditional contract, then we are able to ask 
them and explain a VCA to see if that fits their needs. And 
many of them--that is where more of our growth here recently 
has started to become.
    Senator Moran. Would you assure me that there are no 
particular biases in the VA toward care within a VA facility 
versus a veteran who chooses his or her care to occur in a 
community?
    Dr. Hartronft. We do not see that on a large scale. We do 
not have any evidence of that because really our CLCs, our VA-
owned CLCs, really serve a different population than many that 
are served in contract nursing homes and our State Veterans 
Homes. Many of them are more short-term rehab. There is a two 
times higher level of PTSD. We have got higher levels of 
traumatic brain injury and certain diagnoses as well as other 
issues.
    Senator Moran. So in many instances, they serve a different 
type of veteran, a veteran with a different circumstance in 
their lives?
    Dr. Hartronft. Yes, each program tends to serve veterans 
differently. If they are more stable, the CNHs, contract 
nursing homes, help them to get closer to their caregivers and 
their support versus sometimes our CLCs can also be more of a 
short-stay rehab or, you know, tune them up or some sort of 
other rehab-type potential for folks and different populations.
    Senator Moran. And of course, then we have our State homes 
as well.
    Dr. Hartronft. Yes, sir.
    Senator Moran. I think there is--it is difficult for 
families and veterans to determine the long-term care resources 
that are available to them. One of the provisions that we have 
included in the Elizabeth Dole Home Care Act is to require the 
VA to inform veterans and caregivers participating in PCAFC 
programs their eligibility in other long-term care programs. 
What is the VA doing now to ensure that veterans and their 
families are receiving those resources, that information?
    Dr. Hartronft. I think right now what we have tried to do 
is to have every veteran that is enrolled in the VA--them and 
their caregivers can make an appointment with their primary 
care PACT-assigned social worker because we like to have the 
provider involved. And that person can then determine what 
level of care coordination they need, and then they can also 
let them know their eligibility when it comes to like 
institutional nursing home care but then also the fact that 
most of our home care is not eligibility-based or priority-
based in the sense of--and then helping them to the next step. 
So we try to let the social work and care coordination team 
really serve as kind of the landing spot to help all those 
folks then figure out where they need to be, and they can be 
handed off to the right kind of care level.
    Senator Moran. Thank you. I just would encourage you to 
make sure that the answer you just gave me is true across the 
country, true in every VISN. It is not an infrequent 
circumstance in which a witness or someone from the VA 
conversations that I have with VA officials, this is what our 
policy is, but not necessarily known or operational in places 
in Kansas and across the Nation.
    Dr. Hartronft. Yes, sir, I think we can always improve, and 
we definitely will take the feedback.
    Senator Moran. Thank you.
    Chairman Tester. Senator Hirono.

                    SENATOR MAZIE K. HIRONO

    Senator Hirono. Thank you, Mr. Chairman. I know that the 
United States is experiencing a rapidly aging population. So 
there is going to be a need for, I would say, a wide range of 
long-term care facilities. Does the panel agree that we should 
have flexibility in the kind of facilities that are provided, 
including the option of community-based long-term care homes?
    So in order to do that--because we cannot keep up with 
continuing to build, for example, veterans' homes that can 
provide long-term services. We cannot keep up. Hawaii, in fact, 
is building another 45-bed skilled nursing facility for 
veterans, and that hardly is going to be adequate for the 
needs.
    So one of the things that I want to mention and talk about 
is that we in Hawaii often resort to community-based group 
homes where people, five to six unrelated people, can get the 
care that they need, and this is not a particular model that 
the VA reimburses for. So I am wondering whether VA and CMS 
support the kind of long-term care options for veterans that 
are more in line with the kind of group home facilities license 
that we have in Hawaii.
    Anybody want to respond?
    Mr. Saslo. So, thank you, Senator Hirono. One of the things 
that I think is akin to what you just discussed is our concept 
of the Medical Foster Home. And so those types of settings, 
where we have the availability of individuals who are willing 
to take our veterans in and provide that long-term care or the 
type of care that that veteran is specifically in need of, 
really is one of the things that we continue to move forward 
with and we continue to expand. I think that we have identified 
numerous types of levels of care that are specific to a veteran 
depending upon their need, whether they can still remain in 
their homes, such as a Veteran-Directed Care opportunity or if 
they are not ready to go to a nursing home or if a Medical 
Foster Home is more in line with that.
    One of the things I am sure you are aware of is that we are 
required to expand our Medical Foster Homes----
    Senator Hirono. Yes.
    Mr. Saslo [continuing]. And we are also going to be paying 
for Medical Foster Homes for the veterans, where typically, in 
the past, the Medical Foster Home was paid for by the veteran 
individually. So we have lots of opportunities to grow as well 
as expand other ways to deliver the care the way the veteran 
wants it.
    Mr. Blum. For CMS, we want to support the care setting that 
our beneficiaries want to receive, and so we are eager to work 
with states to support more flexible options. And so the 
principle that we want to see going forward is that our CMS 
programs support the care that our beneficiaries want to 
receive in the setting that they want to receive it.
    Senator Hirono. You want to add something?
    Dr. Hartronft. Yes, ma'am. Part of it, too, is also letting 
veterans become aware of other benefits from like the VBA, such 
as Aid and Attendance, and pensions, and others that can help 
them finance assisted living and other arrangements. So many 
times, if we cannot directly pay the room and board in certain 
situations, then we try and make sure that we have got them 
streamlined, working with VBA, and we try to help them with 
that. As well, as Dr. Saslo mentioned, we have got this pilot 
where we can--especially for certain veterans, we can now 
actually pay for their room and board as part of the recent 
bill, and we are going to pilot that.
    Senator Hirono. So I misspoke when I said that we are 
building a 45-bed--no, we have--I meant to say we have 45 
large-scale skilled nursing homes but about 1,200 adult 
residential care homes in a state like Hawaii, where there is 
much more support for community-based aging. I do not know 
whether this is a model that can be utilized in other states, 
but in Hawaii it is where a lot of our seniors go. And my 
mother started off in a rather large skilled nursing facility, 
and then she was moved to a smaller facility where there is 
much more of the kind of care, the same level, pretty much 
skilled nursing care.
    But it works in Hawaii. So I am wondering whether a lot of 
our veterans would not be happier not so much in these large 
facilities but in smaller facilities, and reimbursement is 
really important in these instances. So I would encourage you 
all to continue to move in that direction and allow for that 
kind of treatment experience for our veterans.
    Mr. Saslo. Thank you, Senator Hirono.
    Senator Hirono. Thank you.
    Mr. Saslo. We will certainly take that back to look at it 
and explore the opportunities.
    Senator Hirono. Thank you, Mr. Chairman.
    Chairman Tester. Thank you, Senator Hirono.
    You guys are free. You are welcome to stay. We have got a 
second panel coming up, folks representing veterans and some of 
the facilities that care for them.
    But I just want to thank all three of you for what you do, 
appreciate it very much. Thank you for being a part of this 
hearing.
    So with the second panel, we are going to hear from Carl 
Blake, Executive Director of Paralyzed Veterans of America; we 
are going to hear from Whitney Bell, who is the President of 
the National Association of State Veterans Homes.
    And, Whitney, I believe you are from North Carolina, 
correct?
    Ms. Bell. Yes.
    Chairman Tester. Yes. And then Carla Wilton, who is the 
Chief Operating Officer of Immanuel Lutheran Communities in the 
great State of Montana and the great city of Kalispell.
    And so we want to welcome you folks to talk about what is 
going on, on the ground, with the facilities that you represent 
and the veterans you represent moving forward.
    So, Mr. Blake, you have the floor. It looks like by the 
clock you got five minutes, but know that your entire statement 
will be a part of the record.

                            PANEL II

                              ----------                              


                    STATEMENT OF CARL BLAKE

    Mr. Blake. Thank you, Mr. Chairman. You have all of the 
detailed statement that we submitted. I debated what I wanted 
to discuss today in going over all the different details and 
different issues that are outlined, but I think I would rather 
respond to some of what I heard over the first panel, some of 
the discussion.
    Senator Brown said, before you came in, that in Ohio, 80 
percent of veterans in that state will eventually need long-
term care. I hate to break the news to him, but 100 percent of 
veterans with spinal cord injury will need long-term services 
and supports over most all of their life, not just when they 
age, but from the point of acute injury for the rest of their 
life. So they may be a 20-year-old with an acute injury; they 
will need long-term services and supports forever.
    So I appreciate the idea that 80 percent of veterans might 
need it. Our members need it now and all the time.
    I heard a comment. I may have misunderstood it, but I 
thought one of the last comments I heard was about using A and 
A veterans' benefits to pay for, or offset the cost of, care 
because the cost for long-term services and supports is high. 
That is nonsense.
    I do not think we should be telling veterans that your 
earned benefits should be what you use to pay for your care 
because the VA cannot afford to pay for your care. I am not 
going to tell our members that. I would dare anyone to say the 
same thing to any veteran, that that is what the expectation is 
because it certainly is not.
    There was some discussion here about the feasibility of 
expanding services, and it was in the context of, I think, 
Homemaker/Home Health. Our members do not have time to wait for 
feasibility studies on expanding some of these types of 
programs.
    Long-term services and supports are a reflection of the 
long continuum of care that our members engage with the VA in. 
They have an acute injury. They get acute care. They get acute 
rehab. In most cases, they will transition into the home, 
receive home- and community-based services and want to live 
most or all of their life in as independent a fashion as 
possible. And some of them will eventually end up back in the 
VA in a long-term care facility that is managed under the SCI 
system of care because, frankly, Community Nursing Homes and 
CLCs, those types of things, they do not serve our members. In 
many cases, they are not even accessible to our members, 
physically accessible.
    And so they run into barriers repeatedly. As you know, we 
have had conversations with your staff and Senator Moran's 
staff about the 65 percent cap for home- and community-based 
services. That is a serious barrier to accessing the care that 
our members need.
    For the actual physical infrastructure of VA, I do not know 
if the Committee is aware of this, but there are six long-term 
care specific SCI centers in the entire VA health care system. 
Six. As of last week, that equated to 160 beds in the entire VA 
health care system for SCI-specific long-term care. One of 
those facilities is west of the Mississippi River. One. In Long 
Beach, California. Two-thirds of the country is served by one 
single long-term care facility for SCI-specific needs.
    There is a footprint being built in Dallas. There is an 
expansion being done in San Diego. It still will not matter. 
That is not enough to meet the needs of our members, who will 
end up there more often than not because that is the complex 
care that they need and, frankly, the VA delivers it best for 
our members.
    So we hear repeatedly about the challenges of it just costs 
a lot to do this. We understand that. Our members do not care. 
We should not be telling them, look, we cannot really afford 
this right now because it is expensive. That is bullshit. We 
found a way to get the PACT Act done.
    This group of veterans all, universally, need long-term 
services and supports, and we are telling them we can only do 
so much because we can only afford so much. This is the core of 
what the VA does. These are veterans with severe disabilities, 
who have the highest demand of needs across the entire system, 
and they are being told, you are probably going to have to 
wait.
    Senator Cramer said something in a little bit different 
context in his comments earlier. He said--and I think he 
directed it at the VA and maybe to some degree CMS, and said, 
we just need to do the right thing. That statement applies to 
more than VA and CMS. It applies to the people that sit around 
this dais. It applies to us. Do the right thing.
    Our members are tired of political posturing and election-
year politics that are standing in the way of much-needed 
reforms like the Dole Act, like the CAREERS Act, like the BUILD 
Act. Just get it done. Do the right thing.

    [The prepared statement of Mr. Blake appears on page 72 of 
the Appendix.]

    Chairman Tester. Appreciate you, Carl, appreciate your 
passion. And, the message is clear. Thank you.
    Whitney.

                   STATEMENT OF WHITNEY BELL

    Ms. Bell. Thank you. Chairman Tester and members of the 
Committee, as President of the National Association of State 
Veterans Homes, I am pleased to offer testimony on the role 
state homes play providing long-term care to veterans, the 
impact of the pandemic, and how Congress and VA can strengthen 
state homes to allow us to care for America's heroes.
    Mr. Chairman, my full-time job is administrator of the 
State Veterans Home in Fayetteville, North Carolina. However, 
today I am pleased to share the combined experiences, 
observations, and recommendations of my NASVH colleagues.
    As you know, the State Veterans Homes program is a 
partnership between the Federal Government and states that 
provide long-term residential care to aging and disabled 
veterans through 163 state homes located in all 50 states and 
in Puerto Rico. State homes provide half of all Federally 
supported nursing home care to veterans, and we do so with less 
than 20 percent of the VA's nursing home budget.
    Although states own and operate the homes, VA has wide-
ranging oversight authority, performing at least one 
comprehensive week-long inspection annually. We also have 
regular and frequent inspections by state and local 
authorities, and about three-fourths of our homes are also 
inspected by CMS.
    Mr. Chairman, there are an estimated 8.4 million living 
veterans aged 65 or older, including 1.3 million 85 or older. 
However, the average number of veterans in VA-supported nursing 
homes on a daily basis, whether it is VA CLCs, contracted 
Community Nursing Homes, or State Veterans Homes, is only about 
32,000 veterans. That is less than half of 1 percent of the 8.4 
million veterans 65 or older, and it is a significant decrease 
since the onset of the pandemic.
    Over the past decade, VA has been placing greater focus and 
resources on rebalancing institutional and non-institutional 
care. While NASVH certainly supports providing veterans more 
home and community options, there should be in addition to, not 
a subtraction of, facility-based care. The need for traditional 
nursing home care is neither diminishing nor will it ever go 
away.
    Mr. Chairman, when COVID-19 first emerged, state homes were 
among the first institutions to take significant precautions. 
However, the outbreak and spread of COVID-19, particularly its 
asymptomatic form, made it virtually impossible to prevent any 
from entering into any facility or location in the country. 
Despite the precautions we took, including enhanced PPE, 
suspension of visitation and new admissions, screening of staff 
and residents, and strict social distancing, tragically, the 
lack of vaccines, treatments, and testing made all nursing 
homes a prime target. And, State Veterans Homes were 
particularly susceptible because our residents are primarily 
older men with significant disabilities and comorbidities who, 
studies show, are more in danger from COVID-19.
    As the pandemic stretched from months to years, the impact 
in our finances has been devastating. To help limit the loss of 
financial support during the pandemic, Congress authorized 
temporary waivers from occupancy rates and veteran percentage 
requirements during the pandemic, but when the public health 
emergency ended on May 11th, state homes are now losing 
significant financial support from the VA.
    Chairman Tester, we want to thank you and Senator Murkowski 
for introducing the CHARGE Act, which would reinstate the 
waiver for bed-hold occupancy requirements, providing a 
significant financial boost.
    My written testimony also includes a number of other policy 
and legislative recommendations, but I will briefly mention 
just a couple. First and mostly important, NASVH urges Congress 
to increase our basic per diem to 50 percent of the cost of 
care and fully fund the State Home Construction Grant program. 
NASVH also strongly supports S. 495, the Expanding Veterans' 
Options for Long-Term Care Act to create assisted living 
programs for veterans. We thank you, Chairman Tester, and 
Senator Moran, for introducing this legislation and for 
including State Veterans Homes.
    Mr. Chairman, NASVH looks forward to continuing to work 
with this Committee to ensure that aging and ill veterans have 
greater access to a full spectrum of long-term care options, 
whether at home or in nursing homes.
    That concludes my statement, and I will be pleased to 
answer any questions that you or the Committee may have.

    [The prepared statement of Ms. Bell appears on page 80 of 
the Appendix.]

    Chairman Tester. Well, thank you for making the trek up 
here to Washington, DC, Whitney, and we appreciate your 
testimony.
    Carla Wilton, you are up.

                   STATEMENT OF CARLA WILTON

    Ms. Wilton. Good afternoon, Chairman Tester and members of 
the Senate Veterans' Affairs Committee. My name is Carla 
Wilton. I am the chief operating officer for Immanuel Lutheran 
Communities in Kalispell. We are a full-service retirement 
community providing independent living, assisted living, memory 
support, post-acute therapy services, and long-term care to 300 
older Montanans.
    I would like to start by thanking you, Chairman Tester, for 
representing Montana so well and for your advocacy to expand 
veterans' benefits to assisted living, particularly through 
Senate Bill 495 that you introduced earlier this year. This 
important legislation creates a common-sense approach to 
identifying and securing greater options and opportunities for 
Montana veterans to access important long-term care services.
    In October 2021, we finalized a Community Nursing Home 
Indefinite Duration Indefinite Quantity contract with the VA. 
We typically have about 15 veterans in our building at any one 
time, and eight of those qualify for the CNH contract. The 
remaining are eligible for hospice contracts.
    Although Immanuel's relationship with the VA has been a 
positive one, we do have a couple of concerns. The first is the 
timing of payment, and I think Senator Cramer mentioned that. 
In fact, just last week, we received our payment from February, 
March, and April.
    Second, when a veteran moves into our community, they 
change their primary care provider to our medical director, 
which is fine in terms of their primary care. However, if they 
need a referral to a specialist, our medical director is not 
able to order that referral. They have to go back--we have to 
go back to the VA to get that referral, and that often can be 
delayed for several weeks, obviously, calling--causing the 
family and the veteran to have to wait to receive the care that 
they need.
    As you have heard, during the pandemic, nursing homes 
across the United States lost nearly 250,000 workers. That was 
15 percent of our workforce, and we continue to struggle to 
recruit and rebuild. In Montana, we lost over 1,000 of our 
5,500 workers, nearly 20 percent.
    Immanuel experienced similar losses of team members during 
this time. Sometimes we were unable to admit new residents due 
to our inability to care for them because of our low staffing 
numbers. We raised staff wages almost 25 percent across the 
board, and for the first time in our organization's 65-year 
history, we brought in agency staff. Although this came at 
great expense, we have a responsibility to provide services to 
those living on our campus.
    While many other health care sectors in the country have 
recovered, nursing homes still need 190,000 workers to return 
to pre-pandemic levels. 190,000 staffing challenges in long-
term care existed prior to COVID-19, and the pandemic 
exacerbated them into a full-blown crisis. Caregivers are 
burned out after fighting the virus. There is a nationwide 
shortage of nurses, and nursing homes lack the resources to 
compete for workers due to chronic government underfunding. We 
would love to hire more nurses and nurse aides, but the people 
are not there.
    Now CMS is planning to release minimum staffing 
requirements for nursing homes. Increasing staffing 
requirements at a time when we cannot find the people to fill 
open positions is a dangerous policy. We need a comprehensive 
approach to recruit and retain long-term caregivers, not an 
enforcement approach.
    Earlier this year, Chairman Tester led a bipartisan letter 
to CMS on this very issue, discouraging CMS from taking a one-
size-fits-all approach and urging the agency to address the 
significant workforce shortages affecting rural America. Thank 
you, Senator Tester and other VA Committee members for signing 
this important letter.
    In Montana, 60 percent of our residents are on Medicaid, 
and rates have been very low. As a result of decades of low 
reimbursement combined with the expense of the pandemic and 
difficulty in recruiting and retaining staff, 11 Montana 
nursing homes closed in 2022. That is nearly 15 percent of our 
total nursing homes across the state. Several of these were in 
rural communities that only had one nursing home to begin with. 
It was heartbreaking when residents had to leave their home and 
move far from family and friends.
    These closures brought much focus on Medicaid rates in this 
year's legislative session. Rates are not finalized, but we 
anticipate coming out of the session with rates somewhere 
between 253 and 268. It costs us about $350 a day to provide 
care and services to a resident. So although we are grateful 
for the increase, we will still be losing 80 to 100 dollars per 
day on our Medicaid residents.
    Our current VA contract rate is based on our Medicaid rate. 
It is about 16 percent plus Medicaid--over Medicaid. When our 
new Medicaid rate is published, the rate will be somewhere in 
the high 200s to low 300s, which is getting closer but still 
falls short.
    I understand that the VA also offers Veterans Care 
Agreements as an alternative to contracts we have. However, 
those nationally established rates, based on a discount of 
Medicare, fall below our proposed new Medicaid rates, making it 
even more difficult for Montana veterans to access Community 
Nursing Home services.
    All residents, including our veterans, are affected by low 
Medicaid reimbursements, which are set by states with little 
Federal oversight. We believe CMS should play a greater role in 
assuring Medicaid rate adequacy and assuring that the rates 
being paid reflect the reasonable costs. They should do that in 
keeping with their own regulations and health safety and 
quality standards.
    No one wants better access, more staff, excellent care more 
than I do. I do this work because I care, but those who pay for 
the services must also be willing to support the cost of those 
goals for our veterans and others in our care.
    Thank you for the opportunity to testify. I am happy to 
answer any questions. And if you find yourself in northwest 
Montana, we would love to give you a tour.

    [The prepared statement of Ms. Wilton appears on page 90 of 
the Appendix.]

    Chairman Tester. Oh, I will, and thank you for the work 
that you do, Carla.
    Ms. Wilton. Yes, thank you.
    Chairman Tester. Thank you.
    Senator King.
    Senator King. Thank you, Mr. Chairman. We have been through 
a long hearing here without the word ``dementia'' coming up, 
and it seems to me that that is going to be a growing part of 
your delivery of services as veterans age.
    On January 5th, 2021, not January 6th, but January 5th, the 
Congress passed a bill requiring reimbursement for domiciliary 
care. We still do not have the regulations for that. That is a 
long time ago, over two years. We are going to be--I have a 
bill to move this process along. Can I have the support of the 
National Association on this issue?
    Ms. Bell. Absolutely. Thank you. We do have states that are 
affected by that. We are anxiously awaiting what these 
regulations look like. It has created a small hole in the 
continuum of care for veterans with dementia who are not quite 
ready for skilled nursing.
    Senator King. Exactly.
    Ms. Bell. So if that could be under the microscope, it 
would help a lot.
    Senator King. And when this regulation comes out, the 
reimbursement should be retroactive to the day of the passage 
of the legislation. Our veterans should not suffer because of 
the delay in issuing these regulations. Would you agree?
    Ms. Bell. Yes, sir. Yes, sir.
    Senator King. Thank you. One of the most serious problems 
facing seniors is falls, and one of my problems with our whole 
sort of reimbursement system is we will pay for a broken hip 
but it is very complicated to get a grab bar installed in 
someone's house. There are a number of bills. Senator Casey has 
some bills on this.
    Talk to me about prevention. Isn't that something we should 
be working on here, Ms. Wilton from Montana?
    Ms. Wilton. Yes, I mean, that is a problem, a lot of the 
problem with our health care system. Right? That we are very 
reactive. We are responsive when something goes wrong.
    Senator King. We pay for illness, not wellness.
    Ms. Wilton. Yes, we pay for--yes, exactly. And so, I mean, 
in our industry, I think you mentioned two of our highest 
concerns. You know, falls and dementia happen often in our 
buildings and cost both our residents and the organizations in 
terms of staffing and a lot of other things.
    So you know, we are looking at all kinds of fall 
prevention. There is some AI out there that can help anticipate 
falls. But you know, it all costs money, and like you said, it 
is hard, too.
    Senator King. But it is penny-wise and pound-foolish.
    Ms. Wilton. I know it.
    Senator King. To be not spending $150 for a grab bar and 
then pay $40,000 for a broken hip.
    Ms. Wilton. Agreed.
    Ms. Bell. Yes, sir.
    Senator King. And there are various programs around falls, 
but my sense it is not anybody's priority and it is not 
adequately funded.
    Ms. Wilton. Yes, it is hard to get it paid for.
    Ms. Bell. Yes.
    Senator King. Thank you.
    Mr. Blake, you testified with great passion. Give me again 
the picture. Your paralyzed veterans, particularly spinal cord 
injuries, really demand a very high level of care. Are they 
receiving it now in the VA system?
    Mr. Blake. I would say the short answer is yes, but that 
answer has some nuance. I can tell you that veterans that are 
served directly in the SCI system of care get the best care in 
the world. There is not a comparable system to that. I think 
once you start to get out into the community, in terms of acute 
care, it just does not really exist in that fashion.
    In terms of home- and community-based services, I think the 
answer is yes, they get quality care, but in many cases it is 
restricted. There are limitations to what they can acquire 
because of cost, obviously, because of--there was a discussion 
earlier about staffing. There are challenges with agencies that 
provide home health support for our members, too.
    Senator King. Right.
    Mr. Blake. So there is this sort of--there is this web of 
challenges that make receiving care, when they are home and in 
the community, more difficult. That is not to say they do not 
get good care, but they do not always get all of the care they 
need or when they need it.
    For example, I was chatting before the hearing with the 
folks about one of our members who can only get--he has to get 
into bed, and he needs home assistance. So I talk to him 
frequently, and at 7:00 at night he says, I am going to bed 
now, because that is what he has to get. So he does not live 
the life that you might live or I might get to live because 
those are the restrictions that he is forced to contend with 
because of way the home health system works.
    That is a long-winded answer. It is a yes and no answer is 
the challenge.
    Senator King. I understand. But, thank you for your 
passion. I want to thank all of you.
    I have to leave, Mr. Chairman. I have an appointment with 
the new Commandant of the Marine Corps, of all people you do 
not want to leave waiting, the Commandant of the Marine Corps. 
Thank you, Mr. Chairman.
    Chairman Tester. It is okay.
    Ms. Wilton, you noted in your testimony that Montana's 
Medicaid rates, which the Montana legislature recently voted to 
raise, although may not be adequate enough, that you are 
thankful for it. The Governor has not signed the increase yet; 
you know that. Will it be insufficient to cover the cost of 
providing nursing home care? You said that that bill produced 
probably 253 to 268 bucks a day?
    Ms. Wilton. Mm-hmm, correct.
    Chairman Tester. And your actual costs were three what?
    Ms. Wilton. 350.
    Chairman Tester. 350. Just curious, when the Governor put 
out a study on what the rates would be, what did that say?
    Ms. Wilton. So it said that the rates needed to be a little 
over 300, but then they took a discount for available beds. 
They took an occupancy discount, and so they recommended--the 
study recommended 278.
    Chairman Tester. Yes. So look--and you also pointed out 
that we have got 11 nursing homes that are closed in Montana, 
doubtful that those nursing homes will ever reopen again.
    Ms. Wilton. No.
    Chairman Tester. And I would say this, that low Medicaid 
reimbursement rates often leave nursing homes with no choice 
but to close their doors. You are between a rock and a hard 
place. And quite honestly, I watched the legislature from afar, 
thank God, and what I saw was money that was available that 
they refused to use on it.
    I would just say that when these folks are underfunded it 
impacts everybody, including our veterans. They are left with 
fewer options. Loved ones are required to stay in facilities 
that are a long ways away, and this is not like driving between 
Washington, DC. and Baltimore. This is like driving a half a 
day or a full day to get to see these folks. So it is a big 
problem, so I was a little disappointed in what transpired 
there.
    But can you tell me, as an operator of a 300-people 
facility that covers soup to nuts, what are the kind of 
decisions you have to make when those rates for reimbursement 
are too low to cover the costs?
    Ms. Wilton. Yes, it is difficult, and I would say it is not 
that--this has been going on for decades in Montana, that rates 
have not been high enough. And so you saw the extreme difficult 
decision that 11 buildings had to make, right?
    Chairman Tester. Yes.
    Ms. Wilton. In fact, I talked to an administrator from the 
only building that we have in Gallatin County, which is the 
county that Bozeman sits in, one of the larger counties in 
Montana. There is one nursing home, about almost 70 beds. And 
she said that they have been running in the red since 2012 and 
the only reason they are still open is because it is county-
owned and the county has supported it. They passed--the voters 
passed a levy to keep it open.
    I think the difficult decisions we have to make are 
considering how many residents we can serve with the staff that 
we can afford to have, and it is a fine balance, right, because 
you have to have--they say, in our business, occupancy is king. 
But if you are losing money on every resident, you have to 
figure out kind of where that sweet spot is, how many residents 
you can care for and with the staff you can afford.
    I think we have to focus more on payer mix than we would 
like to. You know? We have to like try to manage, you know, our 
Medicare business and our private pay business to make up for 
some of the Medicaid business even though it is probably folks 
that are on Medicaid and veterans that need the service as much 
or more.
    There is tons of buildings across Montana that have lots of 
deferred maintenance, that have not had any capital dollars to 
put into maintenance for a really long time. I talked to 
another--I sit on our Montana Health Care Association Board of 
Directors. I talked to another administrator from a small rural 
community, and she said they have not had any capital dollars 
for at least five years. It is just emergency fixes as things 
break. She has holes in the floor. The flooring needs to be 
replaced. The AC does not work, so they have coolers in the 
corridors.
    I think it is a--buildings are having to do ongoing 
analysis of products to use. You know, maybe have to use a 
cheaper product even though it does not work as well. In some 
cases, there is a decrease in services. You might--you know, 
buildings that provided seven-day transportation, you know, 10 
years ago are now providing, you know, four or five days.
    I think there is just some small things that we have to let 
go of. You know, maybe not as many parties with food and 
decoration, you know, that kind of enhance the day-to-day lives 
of residents.
    And so, you know, I think it is a difficult--it is a really 
hard business to manage with the increased regulations all the 
time----
    Chairman Tester. Right.
    Ms. Wilton [continuing]. And decreased funding.
    Chairman Tester. So in the previous panel--you listened to 
it because I saw you.
    Ms. Wilton. I listened.
    Chairman Tester. And I would talk to the CMS gentleman, Mr. 
Blum, about the surveys that they had done about staffing 
stability, which only makes sense, by the way, if you got the 
same people coming to work every day----
    Ms. Wilton. Totally.
    Chairman Tester [continuing]. Who know the system, and it 
works better.
    But I may have stepped out of bounds. I said, hey, look. 
The staffing mandate. The problem is really the requirements on 
our ends. I want you to respond to that. Is that the issue 
here, or is it just staffing period; you cannot find enough 
folks?
    Ms. Wilton. So nurses and CNAs are difficult also; they 
are, just especially in communities that have seen such an 
increase in housing. I do not know how other states have been 
affected, but Montana has seen huge growth, and housing has 
gotten really expensive. And so we are--you know, we are 
starting our CNAs close to $20 an hour, and you cannot--they 
cannot afford to rent an apartment.
    Chairman Tester. Right.
    Ms. Wilton. And so it is hard to recruit CNAs.
    And you know, if you live somewhere--we happen to live in a 
place that has a lot of summer traffic, and so during the 
summer we compete heavily with hotels and restaurants----
    Chairman Tester. Sure.
    Ms. Wilton [continuing]. In our housekeeping and dining 
departments.
    So you know, I would say it is across the board. You know, 
it is--yes, yes, it is across the board. Yes.
    Chairman Tester. I have got you. It is fair to say that you 
are not alone in this, and that is why the reimbursement is so 
tough.
    Ms. Wilton. Correct.
    Chairman Tester. I mean, look, the work that your people 
do, dealing with--all across the board here, it is hard work.
    Ms. Wilton. Yes.
    Chairman Tester. I mean, it is hard work, and not everybody 
is wired for it.
    Ms. Wilton. No.
    Chairman Tester. And so what you pay makes a difference 
whether people are going to do that or go flip hamburgers at 
McDonald's.
    Ms. Wilton. Right.
    Chairman Tester. I want to talk about the Dole Act. You 
talked about it a little bit, Carl. One of the big 
disappointments I have had this session is a bill that came out 
of Committee, which was a package of five bills that passed 
this Committee unanimously, all bipartisan, were held up on the 
floor I believe because of potential--of perceived political 
gamesmanship. I want you to speak as to the impacts on your 
members as they wait for the Elizabeth Dole Act to become law 
because Washington, DC is playing politics.
    Mr. Blake. Well, first, I would say I do not think your 
perception is wrong. I would say that is many of our 
perceptions about why it did not happen as well. Could be 
wrong. That is our perception.
    Chairman Tester. Yes.
    Mr. Blake. I could go on about the 65 percent cap, which is 
not actually in the bill that went to the Senate floor. I 
understand, and I know that was sort of a negotiating point.
    Chairman Tester. Sure.
    Mr. Blake. But there are other important items in there 
because the Veteran-Directed Care program is one of the many 
high priorities for us. Homemaker/Home Health.
    Senator Moran talked about informing veterans just because 
it is mandated in the bill, which is kind of crazy to think 
that the bill would require notifying veterans about these 
things, but I use my national president as a perfect example, 
Charles Brown. He is served by the West Palm Beach VA, and he 
struggles to find home services, and he wants to be at home.
    Chairman Tester. Yep.
    Mr. Blake. And so as a consequence, he has clamored for the 
Veteran-Directed Care program for a while. So imagine our 
surprise when our staff discovered that the Veteran-Directed 
Care program is actually provided out of the West Palm Beach VA 
Medical Center and he did not know it because the VA had never 
told him that. That is a problem. And I am sure that story is 
the same across the country.
    There are too many of our members, virtually all of them 
currently, who rely on these services every single day, and I 
think that the Dole Act will open up the availability and just 
make people aware of what those options are and maybe put some 
pressure on VA to actually start moving forward.
    I appreciated that the VA said that they believe they are 
on track to meet the President's directive regarding VDC by the 
end of FY '24. We will be watching closely because that matters 
to our members.
    Chairman Tester. Darn right. Okay. Thanks, Carl.
    I want to talk about the CHARGE Act. Ms. Bell, you 
referenced it in your opening statement, and I know that not 
unlike any other nursing homes, State Veterans Homes have faced 
staffing challenges. That is exactly why the good Senator from 
Alaska, Senator Murkowski, and I teamed up to introduce the 
CHARGE Act to extend critical authorities related to veteran 
homelessness, caregivers, and State Veterans Homes.
    Our bill includes an extension that you also talked about, 
the bed-hold waiver, too. State homes are not financially 
penalized if you have a staffing shortage.
    And why I keep saying ``staff'' and why I brought it up in 
the previous panel is I can speak from a Montana perspective, 
and I will tell you what; we just need more folks, more staff, 
across the board. And if we do not do that, if we do not get 
that staff--and workforce takes a while to develop--it just 
puts folks in a bad situation.
    So, Ms. Bell, can you speak to the importance of the CHARGE 
Act in assisting State Veterans Homes who are caring for our 
veterans?
    Ms. Bell. Yes. One of the new developments in the bed-hold 
waiver not being active is one of my colleagues is here from 
Long Island State Veterans Home, and he had to reduce his bed 
count by 10 on Friday, and it is going to cost him about 
$70,000 a month because of this bed-hold waiver not being in 
place.
    It costs us when we are already struggling with staff as 
these are facilities across the country that have already 
closed wings or units----
    Chairman Tester. Yes.
    Ms. Bell [continuing]. Because you do not have the staff to 
take care of the veterans and you cannot admit because you do 
not have the staff to take care of them. All this takes time.
    So it is going to impact--he is the first, and there may be 
more, and we do not want that; we really do not. We want to be 
able to care for veterans and care for more and be able to 
admit.
    Chairman Tester. Yes. Well, I appreciate you guys coming on 
in. We see Carl Blake regularly, and we appreciate your input 
all the time. Ms. Bell, it is good to have you here. North 
Carolina is a pretty good jog, but it ain't nothing compared to 
what Carla Wilton had to make coming from Montana. Okay? So we 
appreciate you all being here.
    And I also want to say thank you to the Veterans staff who 
stayed here. Thank you, fellows. I appreciate it. It means a 
lot, and I think it is smart, so just thanks.
    I want to thank both panels, the witnesses from both 
panels.
    You know, we talk about a promise we make to our servicemen 
and women when they sign up to serve, and that includes high 
quality care when they need it when they come back home. It is 
obvious that we have more work to do to be able to meet that 
obligation, and I look forward to partnering with anybody who 
will partner with me and folks on this Committee to make sure 
that we meet that obligation.
    So with that, we will keep the record open for two weeks. 
Once again, thanks to the folks who testified, and we are 
adjourned.
    [Whereupon, at 4:48 p.m., the hearing was adjourned.]

                            A P P E N D I X

                           Opening Statement
                           
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                          Prepared Statements

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                        Questions for the Record
                        
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                       Statements for the Record

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