[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
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
54-470 PDF WASHINGTON : 2024
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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
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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
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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
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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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