    [Senate Hearing 118-230]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 118-230

                                  THE STATE OF
                       VETERANS' LONG-TERM CARE IN MAINE

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

                                 FIELD HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                JANUARY 26, 2024

                                   __________

           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
    54-781 PDF                  WASHINGTON : 2024

    -----------------------------------------------------------------------------------

                     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

                                  ----------

                                January 26, 2024

                                                                       Page

                                    SENATOR

    The Honorable Angus S. King, Jr., U.S. Senator from Maine........     1

                                   WITNESSES
                                    Panel I

    Scotte R. Hartronft, MD, MBA, FACP, FACHE, CPE, Executive
      Director, Office of Geriatrics and Extended Care, Veterans
      Health Administration, Department of Veterans Affairs;
      accompanied by Annette Beyea, DO, MPH, Associate Chief of
      Staff, Geriatrics and Extended Care and Community Living
      Centers, Togus VA Medical Center...............................     2

                                    Panel II

    Sharon Fusco, Chief Executive Officer, Maine Veterans' Homes.....    13

    Colleen Hilton, President, Northern Light Home Care and Hospice..    15

    Mike Pooler, Army Veteran........................................    17

    Steven SanPedro, National Council Member, Maine Veterans of
      Foreign Wars...................................................    18

    Joy Barresi Saucier, RN, MHA, FACHE, Executive Director,
      Aroostook Agency on Aging......................................    19

    Paul Saucier, Director, Office of Aging and Disability Services,
      Maine Department of Health and Human Services..................    21

    Kathleen Swinbourne, Family Caregiver............................    23

                                    APPENDIX
                              Prepared Statements

    Scotte R. Hartronft, MD, MBA, FACP, FACHE, CPE, Executive
      Director, Office of Geriatrics and Extended Care, Veterans
      Health Administration, Department of Veterans Affairs..........    41

    Sharon Fusco, Chief Executive Officer, Maine Veterans' Homes.....    48

      Attachment--Maine Veterans' Homes: The VA Small Home Model.....    51

    Colleen Hilton, President, Northern Light Home Care and Hospice..    53

    Mike Pooler, Army Veteran........................................    56

    Steven SanPedro, National Council Member, Maine Veterans of
      Foreign Wars...................................................    58

    Joy Barresi Saucier, RN, MHA, FACHE, Executive Director,
      Aroostook Agency on Aging......................................    60

    Paul Saucier, Director, Office of Aging and Disability Services,
      Maine Department of Health and Human Services..................    64

    Kathleen Swinbourne, Family Caregiver............................    67

                                  THE STATE OF
                       VETERANS' LONG-TERM CARE IN MAINE

                                  ----------

                            FRIDAY, JANUARY 26, 2024

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                         Augusta, Maine
        This field hearing was held pursuant to Notice of Hearing
    on January 26, 2024, at the University of Maine at Augusta,
    Richard Randall Student Center, Fireside Lounge, 46 University
    Drive, Augusta, Maine beginning at 2:00 p.m., Hon. Angus S.
    King, Jr., presiding.

             OPENING STATEMENT OF HON. ANGUS S. KING, JR.,
                        U.S. SENATOR FROM MAINE

        Senator King. This is a field hearing of the Senate
    Veterans' Affairs Committee. In other words, this is a real
    live hearing just like you see in Washington, only it's
    happening here in Augusta, Maine, and I want to publicly thank
    the chair and co-chair of the committee, Jon Tester of Montana
    and Jerry Moran of Kansas who facilitated our ability to do
    this and are supporting this--our ability to do some listening
    and talking, and I'll talk about what the topic is in a minute.
    But I want to thank Jon Tester and Jerry Moran as well as the
    staff. I want to thank my own staff, Teague Morris and Rowland
    Robinson and the staff of the committee here. Behind every
    senator is a very able staff rolling their eyes, just so you
    know. And I also see some friends. This is always dangerous
    when you start recognizing people in the audience because
    there's someone you forget. I used to always miss legislators,
    it was awful. But I have to recognize Tracye Davis and Ryan
    Lilly. Tracye is the head of VA Maine at Togus. Ryan is her
    predecessor who is now in VISN for New England. And then also
    Dave Richmond, the head of Veterans Affairs for the State of
    Maine. So we've got lots of people here with lots of knowledge.
    And here is the topic: Long-term care for veterans.
        Why are we talking about that subject? I can answer that
    question with two numbers. Seven minus seven and 31.
        Over the next 10 years, the veteran population in Maine is
    projected to decline by 7 percent. However, the population--the
    veteran population in Maine above age 85 is projected to
    increase by 31 percent. That really tells you why we're here,
    because we are facing a very serious surge of veteran--of
    veterans needing and being prepared for some type of long-term
    care. And what we're gonna try to talk about today is the
    multiplicity of programs, what's available, how do veterans
    access those programs, how do they know what's available and
    are there ways that we can improve that access, particularly as
    we're dealing with a population that's aging, that may not be
    as technologically engaged so a website or an e-mail may not
    always be the answer. So that's the challenge that we have
    today, to be talking about how do we deal with the needs of
    these wonderful veterans who are going to need more and greater
    services as they age. So that's really the plan that we're
    talking about today.
        We have two panels. The first panel is VA oriented. We have
    Scotte Hartronft.
        Is that good enough, close enough?
        Dr. Hartronft. Yes.
        Senator King. Scotte came up from Washington to be with us.
    He is the Executive Director of the Office of Geriatrics and
    Extended Care. So he's the big guy from Washington on this
    subject. With him is Annette Beyea who is his counterpart here
    in Maine. She's the Chief of Staff--Associate Chief of Staff,
    Geriatrics and Extended Care and Community Living Center at the
    Togus VA Medical Center so we're going to talk with them for a
    while.
        And then we have a second panel that involves providers
    here in Maine and veterans, and veterans' families who can talk
    about the process and where the gaps are.
        Why are we doing this? It's to help me and the committee
    know what we need to do to help. How do we make the system work
    better? And quite often, people in my business feel that the
    work is done when the bill passes. The truth is, the work just
    begins when the bill passes. And one of my favorite sayings is,
    implementation is as important as vision. You can have a good
    idea and a good bill. If it's not adequately implemented, it
    doesn't meet the intended purpose. So the whole idea today is
    to give me ideas which I can then take back and the staff take
    back to the committee to inform our ongoing work in this
    particular area.
        So let's start.
        You have opening statements.
        I'm going to impose a rule that we have in Washington which
    is five minutes because we do have a number of witnesses and--
    by the way, in Washington, when you see these hearings, what
    you don't know is that we have a little digital clock in front
    of us and we have five minutes. And I once asked Senator Tester
    when should I stop when the clock says five minutes? He
    suggested in the middle of the word ``if''. So we want to
    enforce these rules. But, in any case, we're delighted to have
    you with us.
        Dr. Hartronft, please go.
        Dr. Hartronft. Thank you, sir.

                                PANEL I

                                  ----------

    STATEMENT OF SCOTTE R. HARTRONFT ACCOMPANIED BY ANNETTE BEYEA,
                     DEPARTMENT OF VETERANS AFFAIRS

        Good afternoon, Senator King. I appreciate the opportunity
    to discuss veterans' access to long-term care in institutional
    and non-institutional care settings.
        I'm accompanied today by Dr. Annette Beyea, Associate Chief
    of Staff for Geriatrics and Extended Care at VA Maine.
        As an agency dedicated to serving those who served our
    nation, VA recognizes the importance of ensuring that our
    veterans have access to the care they need, especially as they
    age and require long-term support. We are committed to
    delivering compassionate, person-centered care that meets the
    unique needs of each veteran we serve.
        Aging and older veterans make up a significant proportion
    of VHA enrollees, with veterans over the age of 65 representing
    about 50 percent of all VHA enrollees. Additionally, 55 percent
    of current enrolled rural veterans are ages 65 and older.
        Between fiscal year 2023 and 2035, it is projected that the
    number of enrollees age 85 and older will increase by 73
    percent across the country. And the number of VHA women
    enrollees aged 85 and older will increase by a projected 127
    percent during that same period.
        VA, similar to the broader U.S. healthcare landscape, faces
    significant challenges in preparing for the growing population
    of older adults and their anticipated health care needs. Some
    of the biggest known challenges include ensuring an adequately
    trained and available workforce, addressing gaps in geographic
    coverage of care, particularly in rural areas, and providing
    specialized care for conditions like dementia and behavioral
    issues.
        The majority of Americans prefer to age in place either in
    their homes or in the least restrictive setting possible.
    Supporting aging veterans is a priority for the VA. To fulfill
    this commitment, the VA provides a range of programs designed
    for the care and support for veterans of all ages across a
    range of care settings.
        Currently, VA is undertaking one of the largest multi-year
    expansions of home and community-based services. The expansion
    includes programs such as veteran-directed care, medical foster
    home and home-based primary care programs which are all aimed
    at enabling veterans to age in place with necessary support and
    services.
        VA has many multi-year projects dedicated to addressing the
    needs of aging veterans. These projects include pilots,
    initiatives and expansions that are either currently active or
    anticipated. The VA location in Maine is particularly active in
    this regard. These projects aim not only to expand access to
    services, but to ensure that our staff and facilities are well
    prepared to provide best care for aging veterans.
        Some active or anticipated projects specifically related to
    the VA Maine include the Institute for Healthcare Improvements
    Age-Friendly Health Systems initiative, geriatric emergency
    department accreditation, multiple expansion sites of home-
    based primary care teams, an expansion of the existing Veteran-
    Directed Care Program, virtual geriatric specialty care
    services for rural veterans, an active pilot site for VA
    provided homemaker home health services, anticipated virtual
    mental health services, and we're also anticipating Redefining
    Elder Care in America Project pilot.
        So a lot is going on, and many other things are anticipated
    here at VA Maine.
        VA's various long-term care programs provide a continuum of
    services for aging veterans designed to meet their changing
    needs over time. The level of care is unmatched outside of the
    VA. Together, these programs greatly improve the well-being of
    veterans even during times of crisis.
        These achievements would not be possible without the
    consistent commitment of Congress, both in the terms of
    attention and financial resources.
        It is critical that we continue to build on the current
    momentum and preserve the gains made so far. The challenges
    mentioned earlier will require continuous innovation,
    assessment, adaptability, and allocation of resources. Your
    ongoing support is crucial in order to provide high-quality
    care for our nations' veterans and their families.
        Senator King, this concludes my testimony. My colleague and
    I are prepared to respond to any questions you may have.

        [The prepared statement for Dr. Hartronft appears on page
    41 of the Appendix.]

        Senator King. Thank you.
        Dr. Beyea, do you have a separate testimony?
        Dr. Beyea. I do not have a separate testimony.
        Senator King. Okay, thank you.
        The first question is one that I think is going to come up
    over and over today which is workforce.
        We can have all of the great programs in the world. If we
    don't have the people to staff them, it ain't gonna work.
        Where are we in terms of workforce? And one of the concerns
    the committee has is the amount of time it takes to onboard
    somebody in the VA.
        Talk to me about workforce.
        Dr. Hartronft. Well, the VA faces significant challenges,
    both geriatrics and palliative care due to the--not only the
    workforce, it's a supply and demand issue in the overall health
    care market. But we also are in competition with local health
    care agencies and organizations for the same small supply of
    resources when it comes to those workers.
        So, something that we are doing is competitive marketplace.
    So, what we're doing is trying to provide things such as
    retention, recruitment bonuses. We're doing the debt reduction
    programs. So, there's many things our human resources have been
    really doing as well as the PACT Act had many additional
    resources for the VA to implement.
        Senator King. I would suggest there's two ways to tackle
    this. One is what you were just saying in terms of incentives
    and loan forgiveness and those kinds of things, pay and
    benefits, but also the process itself. The length of time--the
    data we have at the committee is to get hired at the VA,
    something like 28 boxes have to be checked. To be hired at
    Northern Light Health, something like eight boxes needs to be
    checked. So that's something that's within the control of not
    your office but we--you're not going to be able to hire
    somebody no matter what the pay is if you say, oh, you gotta
    put your life on hold for nine months. We're not gonna get
    those people. So, I hope that's something you can take back and
    begin to address.
        Dr. Hartronft. Yes, sir.
        Senator King. We may get into this later. You're aware of
    the CMS rule about staffing ratios?
        Dr. Hartronft. [Nodding.]
        Senator King. My concern about that--and we'll talk to
    others about it--this is a rule that the--CMS is the federal
    agency, it's the Center for Medicaid and Medicare Services. It
    basically issues the rules and the regulations for health care
    facilities that receive federal funds. So they have a great
    deal of power. And they recently have promulgated a new rule
    about staffing ratios in nursing homes which no one can argue
    with that you have a good staffing ratio, that's patient health
    and well-being, it's all good, except there's nobody to hire.
    And my problem with the regulation is it's the best being the
    enemy of the good because if the result is closed nursing homes
    and fewer beds, we haven't gained anything. We're not helping
    veterans if we have--if beds disappear.
        And, by the way, 833 nursing-home beds have disappeared in
    Maine in the last 10 years. Almost a thousand beds have
    disappeared as our population is aging. And my concern about
    the staffing memo or the staffing rule is that it could have
    that further effect unless it's--unless it takes a cognizance
    of the workforce shortage.
        Your thoughts on that subject.
        Dr. Hartronft. Well, of course when it comes to the VA
    owned and operated community living centers, it won't be an
    effect because we currently have staffing that exceeds that.
    But one thing that we'll have to do is--it's really kind of
    hard to predict in each market, of course, how it will have an
    impact, especially with the mix of orality and the already
    existing low number of potential facilities in the area. So,
    what we would have to do in the VA is to really maybe expand
    the number of facilities in response to what we do see an
    impact. We're lucky in the State of Maine, we have great
    partnership with the State veterans homes. And, actually,
    there's more numbers of veterans being treated on an average
    daily census in our state homes than are in our community
    nursing homes or even our CLC. So, Maine specifically----
        Senator King. Well, I think that's--that's something that
    you're going to have to be thinking about because it ties back
    to the workforce problem.
        Dr. Hartronft. Yes.
        Senator King. If you can't--if you can't get enough people,
    you're not going to be able to meet the staffing ratios which
    could mean a loss of capacity rather than a gain for the
    veterans.
        How about home health? I used to travel with my DHS
    secretary in a room and say, how many of you want to go to a
    nursing home? Nobody answered. So the question is: What can we
    do? What can we do to expand and support home health services
    which I think everybody, including veterans, would prefer and
    really ramp that up. Talk to me about how you view that as part
    of the overall toolkit.
        Dr. Hartronft. Yes, the VA has really started the
    initiation with, you know----
        Senator King. Can you move a little closer to the mic,
    please?
        Dr. Hartronft. Oh, myself? Okay.
        Really--we've really started the initiative of aging in
    place, and part of that is the multi-year expansion that I
    mentioned with Veteran-Directed Care, home-based primary care
    as well as medical foster home. But we're also expanding in
    many other areas including making sure that we have a broader
    net when it comes to other services like HHA. We're also doing
    those----
        Senator King. Could you define expansion? Are we talking
    20, 30 percent, 40 percent? I mean----
        Dr. Hartronft. Like Veteran-Directed Care, we're
    practically doubling the number of sites. There was only about
    70 VAs prior to our expansion that had it, and then by the end
    of 2024, they're going to have medical--have Veteran-Directed
    Care at all VAs. And then such as Maine in this--we already had
    a Veteran-Directed Care, but we are currently providing
    additional funding and initiative to expand the existing
    program they already have here. And then we've expanded a
    couple of home-based primary care sites in addition, but
    there's a lot going on, and I'll let Dr. Beyea give us some
    specifics.
        Dr. Beyea. Yes. We've been very fortunate at VA Maine to
    expand our home-based primary care program. Specifically, we've
    added three additional teams in Caribou, Bangor and Augusta. We
    now have eight teams covering eight territories across the
    state. And just to put this into perspective, in FY '22, we had
    a hundred referrals to home-based primary care. In FY '23, we
    had over 400 referrals to home-based primary care. We now have
    over 300 veterans enrolled, we have 80 referrals pending so
    that program is growing.
        As Dr. Hartronft mentioned, innovation is also imperative
    as we think about how to support age-friendly care at a
    population level in the oldest state in the nation. We are very
    fortunate at VA Maine to also receive funding to pilot a
    Homemaker Home Health Aide Certified Nursing Assistant program
    that will allow us to imbed certified nursing assistants as
    part of our home-based primary care teams, so they will be
    functioning as part of the team.
        Additionally, we're expanding medical foster homes. We've
    allocated a coordinator to that program and actually have five
    homes with six veterans enrolled.
        Furthermore, we acknowledge the important role of
    noninstitutionalized care community resources and programs, and
    have intentionally aligned resources and care coordination
    through subject matter experts who truly collaborate and work
    together to be able to meet the veterans' unique needs, whether
    it's homemaker home health aide or perhaps Veteran-Directed
    Care. For example, we're aware that we will be participating in
    a Veteran-Directed Care respite pilot that will allow veterans,
    through the caregiver support program, to receive supplemental
    funding and not have a reduction in their Veteran-Directed Care
    hours, so really aligning and coordinating across those
    programs and services to meet a Veteran's needs is important.
    Additionally, acknowledging that we have 3,700 geriatricians,
    the projected need is 12,000 by 2030 and there are less than 50
    in the State of Maine, so, we need to get innovative.
        Senator King. I'm sorry, 3,700 in the whole country?
        Dr. Beyea. Correct. With an estimated growing need of
    12,000 in 2030. So, the majority of age-friendly care is going
    to be delivered in primary care. So, what we're establishing in
    Portland is a geriatric patient-aligned care team that includes
    a true interdisciplinary, interprofessional team that will
    allow us to provide primary care to a cohort of veterans to
    establish best age-friendly practices so that we can, in a
    phased and strategic approach, disseminate those practices both
    in Portland and then to our more rural CBOCs.
        Additionally, we acknowledge the need for telehealth to be
    a part of this hub and spokes-type model.
        In FY '23, we received funding to establish a telehealth
    interdisciplinary model of care to extend age-friendly
    specialty services to our most rural veterans. We have
    successfully done that in Bangor.
        Senator King. It would be nice to have WiFi in the CBOCs;
    [Laughter.] just saying. Just a little parenthetical. Go ahead.
    That's not your problem.
        Dr. Beyea. So, again, really from a multi-modal perspective
    and approach, figuring out how can we meet the population need
    of aging veterans in Maine. And there is not just one solution,
    it's multifaceted.
        In addition, we talked about recruitment. We know, in our
    CLC, we're approaching a 50 percent vacancy for our nursing
    assistants so we are working intentionally to create innovative
    programs like Grow Your Own where we can actually employ those
    in training to become nursing assistants and pay them
    simultaneously. So, there are lots of things that we're doing
    internally----
        Senator King. It's kind of an apprenticeship model.
        Dr. Beyea. Right.
        The other is with respect to the shortage of geriatricians.
    We really prioritize our academic affiliates. And, so, with
    Maine Medical Center and Northern Lights, we are actually a
    primary teaching site for palliative medicine fellowship
    trainees. Also, with Maine Medical Center, we provide clinical
    training for Internal Medicine and geriatric residents at our
    Portland CBOC as well as geriatric medicine fellows.
        Additionally, 15 minutes down the road from Togus is a
    geriatric medicine fellowship program with four accredited
    fellowship positions. We also serve as a training site for
    those fellows as well.
        So, in thinking about recruitment, we see that fellows
    come, they train at the VA, and they want to stay at VA Maine.
    They see the priority and commitment to true interprofessional
    collaborative practice and interdisciplinary approaches to
    care.
        Senator King. And can I assume that the mission is also
    attractive?
        Dr. Beyea. Very, yes.
        Senator King. That's a big part of----
        Dr. Beyea. That's the primary attraction, yes.
        Senator King. Well, thank you. That was great, and a lot of
    good information.
        One of the things that jumped out at me though is the
    complexity of the system and all of the various programs and
    how does a veteran know what's available? First question is
    knowledge, and the second question--we were talking about this
    with the students--is do we have sufficient people I would call
    navigators, whether they're in the VSOs or--who can help a
    veteran say no, you're not--you're Montgomery or you're post-9/
    11. Where do you fit? What are the programs, home health--do
    you see what I mean? All of the programs in the world don't
    help if you don't know what they are and if the family can't
    find out what they are. How easy is it for a veteran to know
    the various options?
        Dr. Hartronft. I guess we can never over-communicate the
    availability, what resources are available. I, myself, when I
    left the service, I worked with the VSO to get involved--you
    know, the VBA and other things. So, we--this really does take a
    lot of people, and working, strong relationships with other
    organizations such as VSOs or community partners. But also
    internally, there have been many things to where we try
    improving our care coordination. Intensive case management are
    the terms that we want to use, and incorporate more practices
    with interdisciplinary between nursing and social work. So,
    it's really difficult because we have a lot of programs, but
    many veterans need more than just one program to help them stay
    at home. They may need adult day health care, they might need
    some respite, they might need some homemaker home health aide.
    So, it's not a single one-size-fits-all for veterans. So many
    times if the veteran is not in the VA; we want to encourage
    them and help them find the resources to get enrolled. And then
    after that, it's really making sure that they establish with
    their primary care team to coordinate with their social worker
    and their physician or provider to get what services they need
    based on that individual veteran since we can't really paint
    with a broad brush what will individually affect others. So,
    there's always room for improvement, I think----
        Senator King. And the VSOs have an important role to play
    here it seems to be. They're representatives that can act as
    that navigator buddy system for an individual veteran.
        A particular topic--this is sort of a narrow topic but one
    that I'm interested in is falls.
        One out of four people over 65 have a fall in a year. And
    falls are often the beginning of the end and lead to a broken
    hip and hospitalization. What--are there--what can we do to be
    much more active in terms of fall prevention? I mean I would
    think that ought to be a sort of basic--somebody comes into
    your system, the first thing, are there grab bars in your
    shower? I mean talk to me about that.
        I've told my staff I want to be the falls senator; without
    falling.
        [Laughter.]
        Dr. Hartronft. Yes, sir, I understand, sometimes you don't
    want to be that kind of subject matter expert.
        Actually for us, that's one of the reasons why we're----
        Senator King. By the way, I got a great piece of advice.
    Someone asked Buckminster Fuller, the famous architect, for
    advice on how to live a long life. His answer was ``always use
    the bannister.'' [Laughter.] That's a pretty good rule, I
    think.
        Go ahead, I'm sorry.
        Dr. Hartronft. Definitely.
        Basically, I think a lot of it is that, you know, many of
    it is prevention and practice, but one reason why we're
    incorporating an age-friendly health system from the Institute
    for Healthcare Improvement is you start imbedding that and
    weaving it across settings because it's--it's not a one-time
    assessment by one care setting. Because over time, a veteran
    goes to the hospital and they get deconditioned, they need to
    be assessed again. So, we're trying to make sure that every
    point of care that they come in contact with, that someone can
    have the mobility--either they're afraid of falling, or they
    are assessed for fall risk, and then they're able to be
    prescribed or put into physical therapy and other evidence-
    based practices. And a lot of times social isolation can happen
    because someone's just afraid of falling. Sometimes just a
    single fall can really impact someone's life to where they're
    afraid to do any other activities. So, it really is part of us
    making sure that at every point of contact within the VA, from
    primary care to inpatient, that they're assessed, and then we
    take that into account. With Age-Friendly, one of the ``M's''
    is ``What Matters.'' So, we want to find out what matters for
    that veteran, that's our first key. And then another ``M'' is
    mobility which includes falls and making sure that we're kind
    of proverbially ``buffing them up'', to help them to do----
        Senator King. There's a big prevention piece here.
        Dr. Hartronft. Yes.
        Senator King. The cheapest health intervention is the one
    that doesn't happen.
        Dr. Hartronft. Yes, sir.
        Senator King. The one that doesn't have to happen. And to
    the extent we can prevent falls--we know there's an epidemic of
    falls in this country. So I hope that that's something that VA
    nationwide would think about in terms of prevention of--we're
    all conscious of costs and costs to the system. So keep that in
    mind, please.
        Dr. Hartronft. Yes, sir.
        Senator King. Assisted living. Again, we're talking about a
    continuum, and people don't necessarily need all of the
    services of a nursing home, but they need some level of
    services. Is assisted living a gap? Is that something we need
    to be thinking about and developing larger, greater capacity?
    Because that strikes me that doesn't really fit into the VA
    system very well.
        Dr. Hartronft. You're correct. Assisted living is a care
    setting that we currently aren't authorized to provide room and
    board and other services. So--that's one reason why we've been
    really hyper-focusing on aging in place in the home itself. And
    then we have to kind of go over to more of the long-term care
    facility. But one thing we've been incorporating is for those
    veterans who do go to assisted living is making sure that we
    incorporate some of the home care services even into that
    setting, when possible.
        Senator King. Well, it seems to me that's an area that we
    should be talking about in Washington.
        Dr. Beyea, do you agree?
        Dr. Hartronft. The VA has issued support for the one bill
    that you mentioned, of course with available resources.
        Dr. Beyea. Yes, I do agree. Given the rising prevalence of
    neurocognitive disorders and need for memory care which often
    requires residential level of care or Adult Day services to
    remain in the community. Access to these services would be
    incredibly helpful to delay nursing home placement and
    institutionalized care----
        Senator King. Right. Every day that you delay a nursing-
    home placement, the veteran is happier and the taxpayers are
    happier.
        Dr. Beyea. Absolutely. And in the interim period, as Dr.
    Hartronft pointed out, we really are investing in home care and
    community-based services for that subset of the population.
        Senator King. VA Maine is doing home care.
        Dr. Beyea. Correct. In addition to the expansion of home-
    based primary care, with our alignment and care coordination
    through care programs like Homemaker, Home Health Aide,
    Veteran-Directed Care, and Adult Day we are able to provide
    Veterans and caregivers with additional support and some
    respite----
        Senator King. And respite is----
        Dr. Beyea. Correct, yes.
        So, as we expand home-based primary care, we acknowledge
    that the need for respite will also increase. And so, in our
    community living centers we're actually developing capacity to
    provide more respite care. Additionally, we look forward to
    that Veteran-Directed Care respite pilot which will allow us to
    provide caregivers respite when appropriate and needed so they
    can get away and see loved ones and do the things that refill
    their cup.
        Senator King. Everything we talked about still comes back
    to workforce, doesn't it? Home-based care, respite care. It's
    all having the people. Let's go back to that. We talked about
    incentives--by the way, I recently learned that no one in the
    Federal Government can make more than the President. That's
    true, isn't it?
        Dr. Hartronft. Yes.
        Senator King. Well, that means you're asking a cardiologist
    to take about a 70 percent pay cut to come work for the VA. I
    think that's something we have to figure out how to waive or
    something. And that is not necessarily what we're talking about
    today, but it is--it's one more barrier if you're talking about
    high-level specialties. But I do want to push you on--and I
    realize you're not the one, but go back and say there's this
    senator up in Maine that's sort of half crazy about this human
    resources function and how long it takes. We've really got to
    work on that because it would be awful to have somebody who's
    ready, wants a mission, wants to do it but they can't wait for
    nine months or a year. So I hope that's something you can push
    on when you get back, and we'll push on it at the VISN level
    too.
        Interagency cooperation, do you--how does the VA coordinate
    with CMS, for example? Because a lot of these placements are
    combined financing. Medicare, Medicaid, VA. Is that a seamless
    operation, or is that a bureaucratic nightmare? How is that?
        Dr. Hartronft. Well, I think part of it too is really the
    choice or preference of the veteran as to which authority they
    want to use. Because, of course, many may have TRICARE, many
    may have Medicare, some have other avenues, but many times of
    course the VA is the primary payer in many cases. But I think
    there is an area for continued collaboration and improvement to
    make sure that veterans over age 65, especially--we're seeing
    the larger picture. Sometimes if they're on Medicare, we don't
    always see some of their care if they're on another or using
    another authority. So, I think that is an area that we could
    continue to improve. We do meet with them; we do have a lot of
    interagency cooperation and collaboration groups, but I think
    that's just the nature of it, if people are--it would be the
    same case of somebody who is seeing multiple primary care
    providers or--you know, just trying to keep everything
    coordinated. It adds a little more complexity to try and
    coordinate care across those different agencies.
        Senator King. Dr. Beyea, help us out here. In your
    observation, are there gaps that we should be filling? In other
    words, like assisted living or payment for caregiving which I
    know is an available program, but what--now is your chance.
    What should we be attending to in the next round of VA and
    veterans' legislation?
        Dr. Beyea. Yes, I would most certainly advocate for
    assisted living facility level of care. I think in terms of the
    non-institutional care piece, we're very well equipped in
    growing and expanding programs and services as well with
    institutionalized care. We have great partnerships with our
    community contracted nursing homes and with our state veterans
    homes----
        Senator King. Certainly that's important. You have what
    amounts to a nursing home at Togus.
        Dr. Beyea. Correct--our community living center.
        Senator King. But you also contract with private sector
    nursing homes for veterans' care.
        Dr. Beyea. We do because often veterans want to remain
    close to their loved ones and close to home. And so, we want to
    create versatility and opportunity for them and to support what
    matters most to them. And with respect to the state veterans
    home, we recently hired a coordinator who is really
    facilitating that partnership between the management at the VA
    as well as the state veterans home, is providing education to
    the staff at the veterans home as well as the VA, supporting
    sharing agreements like with mental health. So in terms of our
    partnerships with respect to long-term care and
    institutionalized care, I think they're growing and we're very
    fortunate. Also, we have been very successful in terms of the
    non-institutional care programs to help veterans age in place,
    which is often what matters most to them, but an opportunity is
    certainly expanding access to assisted living facility care.
        Senator King. That's good.
        Now, one of the things we haven't touched on or we should
    have talked about at the very beginning, only certain veterans
    are qualified for nursing home care, that you have to have--
    combat-related disability to a certain level or various rules,
    but a peacetime veteran, maybe 20 years, doesn't necessarily
    qualify for these services. What services do they qualify for?
        Dr. Hartronft. Well, the nice thing is the home-care
    services aren't dependent on service connection----
        Senator King. So that doesn't have----
        Dr. Hartronft. Home care----
        Senator King. Okay. So that's available to any--to all
    veterans?
        Dr. Hartronft. As long as they meet the clinical needs,
    obviously, they need assistance with activities of daily living
    and they meet the clinical need. But when it comes to VA-paid
    nursing home and community--it is, you know, as you said,
    specifically tied to service connection or specifically to what
    winds back to needs of a nursing home care, and it has to fit
    back to their other plan. Otherwise, many of the veterans that
    aren't qualified for like the VA, then they can go to the state
    veterans homes where we provide per diem--which helps try to
    provide part of the cost of care. So, they do have some avenues
    to kind of work and--that's why it's such a great partnership
    with the state veterans homes and other organizations.
        Senator King. By the way, they must have prepared you for a
    question from me about domiciliary care and the backpay that
    you owe us. [Laughter.] We only passed that bill I think it's
    two years ago this month. Could you speak to Brother McDonough
    about that for me?
        Dr. Hartronft. I'll make sure we'll find out.
        Senator King. That's sort of an--it's not an in-joke, it's
    an in-irritation. That's something we need to attend to.
        Sort of wrap-up comments. How would you--wave a wand and
    what would you like us to tackle in the committee?
        Dr. Hartronft. Well, I think the continued support that
    you've already provided with us with resources and timely
    attention----
        Senator King. It would help if we had a budget, not a
    continuing resolution.
        [Laughter.]
        Dr. Hartronft. No comment. And then--but, yes, I think just
    having y'all's support has been critical. And, again, it will
    continue to be critical for your continued support and
    attention really as we--because we're gonna have to continually
    adapt and evolve to meet these needs as veterans so there's not
    one answer that fits all the problems, but we definitely
    continue your support----
        Senator King. Well, the best news I've heard so far is the
    expansion of the home-based care. I think that's really
    important because this is one of those things where we know a
    wave is coming at us, and shame on us if we're not ready for it
    because it's totally predictable. This isn't a surprising event
    like the storm two weeks ago. This is--those numbers are--you
    know, the actuaries will tell us what we're facing. So I think
    that we really need to do some hard thinking about what the
    gaps are, how we can help fill them. And, of course, the
    workforce issue applies across the board, not only for
    retirement.
        Well, thank you both very much for being here, thank you
    for coming up, and I hope you listen in. And I do want to--what
    I always say at the end of a hearing, any ideas, pass them
    along online or offline. I can forget where I heard things, but
    you are in a position to help us, and we're all on the same
    side here. We're all in the same--have the same goal which is
    improving the lives of our veterans and particularly in this
    case, what we're talking about today, this population that is
    going to be more and more in need of these services. So thank
    you.
        We're going to take a five-minute break which really will
    be a five-minute, and then we'll come back with our second
    panel.
        Thank you all very much.
        [Applause.]

        [RECESS]

        Senator King. We now have the second panel. I'm going to
    ask each of our guests to introduce themselves and then--why
    don't we go down the row and introduce yourselves, and then
    we'll go back and have your testimony.

                                PANEL II

                                  ----------

        Ms. Fusco. Good afternoon, everyone. My name is Sharon
    Fusco, and I'm the CEO at Maine Veterans' Homes.
        Ms. Hilton. Good afternoon, I'm Colleen Hilton. I serve as
    the senior vice president for continuum care for Northern Light
    Health, and I oversee, as the president, home care and hospice.
        Mr. Pooler. Mike Pooler, Afghan vet.
        Mr. SanPedro. Steve SanPedro, I represent the VFW, and I
    also am the vice chair of the Maine Veterans' Home Board of
    Trustees.
        Ms. Barresi Saucier. Hi, I'm Joy Barresi Saucier, I'm the
    executive director of the Aroostook Agency on Aging based in
    Presque Isle, Maine.
        Mr. Saucier. I'm Paul Saucier, I'm director of the Office
    of Aging and Disability Services at Maine Department of Health
    and Human Services.
        Ms. Swinbourne. I'm Kathleen Swinbourne, and I'm a family
    caregiver to a Navy Veteran and a Vietnam vet.
        Senator King. Wonderful.
        Sharon, why don't you lead us off. Do you have some
    prepared thoughts?
        Ms. Fusco. Of course.

       STATEMENT OF SHARON FUSCO, CHIEF EXECUTIVE OFFICER, MAINE
                            VETERANS' HOMES

        Well, thank you for the opportunity to speak with you again
    today, Senator King; it's my pleasure to do so.
        We've heard a lot today about workforce, and I'm going to
    get right to the bottom line because my written testimony is
    very detailed, and I don't want to read it to you.
        Senator King. The practice is you say, I move that my
    written testimony be submitted for the record.
        Ms. Fusco. There you go, I move that. [Laughter.] So--but I
    do want to give you sort of the bottom line up front. It's also
    what I'm known for.
        So very bluntly, the nursing home industry is in crisis. We
    are on a precipice of collapse, and the reason for that is very
    simple. Yes, we have workforce issues, and I'm not going to
    underplay the importance of them, but more than that, our
    reimbursement rates fail to cover the total cost of care. We
    simply cannot afford to continue to steal from the future of
    our homes to pay for our present. And that happens because--
    again, it doesn't matter what rate we're talking about, whether
    we're talking Medicaid, Medicare, VA, all of them fail to fully
    cover the cost of care.
        Senator King. What's the gap? Could you put a number on it?
        Ms. Fusco. I can tell you that last year it was $17.1
    million for the Maine Veterans' Homes.
        Senator King. What's that as a percentage?
        Ms. Fusco. It's about 15 percent of our budget.
        Senator King. In other words, if the cost of care is 100,
    what are you getting?
        Ms. Fusco. About 15 percent is the gap.
        Senator King. Fifteen percent is the gap?
        Ms. Fusco. Yes. And we don't have unlimited investment
    resources or capital replacement funds. I've got about a 36-
    month runway.
        Senator King. So that's compounded by additional
    regulations that increase cost but don't provide any additional
    funds; is that correct?
        Ms. Fusco. That is absolutely correct.
        And so when we think about that, and as the executive
    charged with taking this organization into the future, I'm also
    thinking about, well, what comes next and how do I prepare for
    that? You're gonna hear today about wonderful collaborations
    that are bringing organizations together into partnership to
    address social determines of health such as transportation,
    social isolation, food insecurity; but are they adequately
    funded? And the answer is no. We've heard about great pilots
    and we're so proud to be a part of them, but are they
    adequately funded to help us think about the innovation we need
    to our programs to serve the next generation of veterans? And
    the answer is no. And my favorite, and I promise not to get on
    a soapbox, is technology. Technology will fundamentally change
    what it means to have a disability and to care for somebody
    with a disability. Technology for the person who can't see and
    helps them see. You talked about falls. What if we could
    predict them? Guess what? That technology is here today, but I
    don't have the investment funds available. I don't have the
    funding available to prepare my infrastructure to take
    advantage of that, and our veterans deserve that. So funding is
    the primary issue. You put a number on it, but I'd like to put
    a face on it.
        I want you to envision Bart. Bart is a young man that's in
    his late 80s. He's one of the first veterans I met, was very
    proud to take me and show me his uniform and the whistle he
    used to translate commands from the captain to the crew. He's
    got his photographs, all of those memories that he's so proud
    of, but his memories are on a wall for a reason. Bart has
    dementia, and he needs 24/7 care that is just not possible in
    the home. He's not acute so he's not going to end up in a
    hospital. We need that step in between, and it needs to be
    funded for folks like Bart, and we need to do it in a way that
    honors them.
        The rest of Bart's story is that about three weeks ago, I
    was in the home the day Bart died, and what I saw was
    absolutely heartwarming. I saw people who were visiting other
    residents come out of the hallway. I saw staff, who weren't
    addressing immediate care needs, come to the hallway, and as
    Bart's body came down that hallway, flag draped over the body,
    they stood at attention, they saluted, they put hands over
    hearts and then they got into cadence behind that body and they
    walked him out to the hearse for his final trip to his resting
    place. Now, isn't that the care that we want to be providing
    for our veterans? We need a sustainable system of care. And if
    we want that sustainable system of care, we have to fund it.
    Our veterans deserve it.
        Senator King. Could you not be so indirect?
        Ms. Fusco. Read my testimony.

        [The prepared statement of Ms. Fusco appears on page 48 of
    the Appendix.]

        Senator King. Sharon, thank you. That's powerful and on
    point. I really appreciate it.
        Colleen from Northern Light.
        Ms. Hilton. Sure. Do I need to say that about the previous
    testimony--the testimony that I've submitted being read into
    the record?
        Senator King. Yes, if you want it in the record----
        Ms. Hilton. Can I make that motion for everybody up here?

                STATEMENT OF COLLEEN HILTON, PRESIDENT,
                  NORTHERN LIGHT HOME CARE AND HOSPICE

        Good afternoon, Senator King, and I appreciate the
    opportunity to participate today in this important hearing.
        I want to mention, I also serve as the president for the
    Home Care and Hospice Alliance of Maine which includes all of
    the home care and hospice providers across this great state.
        I've been a registered nurse and have dedicated my career
    to caring for patients in the home and in community-based
    settings. Our nurses, therapists and hospice clinicians care
    for patients throughout the State of Maine in both urban and
    rural settings. We have traveled 3.5 million miles last year to
    deliver that care. We are also a unique home care organization
    providing a number of public health services including
    vaccinations, homeless shelter nursing services and
    transportation of fresh food to patients at home addressing
    Maine's food insecurity challenge. As we know Maine is the
    oldest--has the oldest population in the country, and this
    includes our aging veterans.
        Veterans receive their home care and hospice through a
    number of different benefits: Medicare, Medicaid as has already
    been stated, and through the VA Togus Medical Center. We cared
    for 489 veterans last year through the VA process. Our home
    health services focus on recovery, quality of life,
    independence with the goal to reduce emergency room visits and
    hospital readmissions. The number of patients cared for every
    day across Maine exceed all of the bed capacity in our local
    hospitals. I want to say that again. We care for more people in
    the home than all of our hospitals across the State of Maine.
    The level of acuity is also rising as more and more medical
    interventions are happening on an outpatient basis or a
    surgical procedure that once resulted in a prolonged hospital
    stay are now discharged on the very same day. Hospice care is
    also growing in Maine, and that is good news where once we were
    lagging in utilization in 2021, we ranked 13th. Maine has four
    inpatient hospices across the state, one in Presque Isle,
    Rockport, Auburn and Scarborough. I'm especially pleased to
    report that we have housed veterans whose families needed
    respite at our hospice houses. Using respite allows families
    and caregivers enough support to enable the patient to return
    home to live out the remainder of their life surrounded by
    their loved ones.
        I am deeply concerned that the home care services for
    veterans and all individuals in need is at risk due to the
    significant payment reduction that CMS started in 2020 when a
    new payment model was implemented. Congress charged CMS with
    ensuring budget neutrality and give the agency authority to
    change payment rates in this model. The ongoing threat to home
    health payments is exacerbated to MedPac's annual
    recommendation to Congress for continued cuts. In January,
    MedPac voted to recommend to Congress that they reduce Medicare
    coverage for home health by 7 percent in 2025; 7 percent.
        We're stuck in a vicious cycle----
        Senator King. Your costs didn't go down? Your cost didn't
    go down----
        Ms. Hilton. Our cost went up, wage escalated, everything
    escalated, medical supplies escalated and reimbursement went
    down, as a recommendation.
        This is just causing industry instability, payment
    reduction proposals that threaten access to care.
        In the Senate, there is a bill titled Save the Medicare
    Home Health Program. The goal is to stop CMS from imposing
    certain cuts and direct MedPac to consider their analysis, the
    impact of all payers on access to care, for the home health
    benefit.
        We anticipate that veterans, patients and families will
    experience historic access challenges to home health care. And
    it's not because there isn't a need or a demand for these
    services but rather due to the workforce crisis--and it is a
    crisis--high inflation impacting cost and Medicare payment
    reductions, they impact our ability to hire and retain staff.
        Maine continues to struggle with the statewide shortage of
    RNs, currently projected to be more than 2,000 by 2025. One
    solution to resolving this nursing shortage is supporting nurse
    faculty, and I know that your office is working with Lisa
    Harvey-McPherson and working on this issue.
        We already have regions in Maine with minimal or no access
    to home care services. In responding to payment rates below the
    cost of providing care, providers have reduced services to
    distant geographic regions and/or reduced the actual number of
    patients that they will accept in due care.
        Due to the rural nature of our service area, we invested 15
    years ago in the use of telehealth and remote patient
    monitoring to broaden our reach to serve seniors across the
    State of Maine. On any given day, we are caring for 500
    patients from Fort Kent to Southern Maine who are taking
    advantage of this technology. Using this technology, we can
    support----
        Senator King. Do you find--excuse me. Do you find the
    patients are receptive to using telehealth?
        Ms. Hilton. Very receptive. Eighty years old, 90 years old,
    they know how to use the equipment and it's easy to use.
        Using this technology, we can support people suffering from
    chronic disease, and I believe that the pandemic truly
    demonstrated the value of using this technology in the home.
    When we were able to--when we were in the midst of the global
    pandemic, telehealth with video capability was incredibly
    beneficial. In 2023, we cared for 260 veterans to enable them
    to age in place with the support of telehealth.
        I urge this committee to focus on the impact that Medicare
    and Medicaid payment policy is having on veterans' access to
    post-acute care services.
        Thank you.

        [The prepared statement of Ms. Hilton appears on page 53 of
    the Appendix.]

        Senator King. Thank you, Colleen.
        Mike?
        Mr. Pooler. Yes, sir; my written testimony into evidence,
    please.

                 STATEMENT OF MIKE POOLER, ARMY VETERAN

        Good afternoon, Senator King. I appreciate the opportunity
    to discuss veterans access to long-term care. And I really have
    to apologize to you up front, sir. As you can see here by this
    panel, I have the face for radio and the voice for print so
    bear with me for a while, and we'll get through this.
        Senator King. People have told me that too so----
        [Laughter.]
        Mr. Pooler. I know you work with Bernie Sanders, sir, so
    I'm sure you're used to it.
        My name is Mike Pooler. My wife Sue was a resident of the
    Augusta, Maine Veterans' Home from October 2016 to April 2023.
    I'm also extremely fortunate to be on the Maine Veterans' Home
    Board of Trustees.
        My wife Sue was diagnosed with dementia in 2013 at the age
    of 48 and needed full-time professional memory care by
    September of 2016.
        In between these dates, I was fortunate to be able to
    privately hire caregivers to come to our home and look out for
    Sue during the day. These people, along with Sue's sister,
    provided daytime and some weekend care while I was working for
    the Maine Army National Guard. I had the night shift and
    weekends while I continued to work. During this home caregiving
    time, I never looked into any support from the VA for Sue's
    caregiving. I have a 90 percent disability rating from the VA,
    and my understanding is that there's no caregiving support for
    spouses of veterans.
        In September 2016, we were extremely fortunate to the--we
    were extremely fortunate, the administration of the Augusta
    home was very prompt in responding to our needs. All of the
    stars aligned, and it took three to four weeks from the time I
    called MVH until Sue was admitted in October 2016.
        During Sue's stay, it was obvious from the start that the
    staff at Augusta were and continue to be special people. One of
    the nurses I met, as she was talking to Sue, stated that she
    would never lie to Sue and would always tell her the truth. She
    was not going to tell Sue something just to calm her down.
    That's indicative of the dignity and respect the staff gives
    each and every resident. The staff takes great pride in the
    fact that they care for veterans and their spouses, many times
    usually sacrificing higher wages at other places to take care
    of them.
        Over the years, and especially during the past three years,
    there have been tremendous staff turnover. As you may be aware,
    people with dementia need to see consistent faces to help them
    alleviate stress. Also each dementia patient has a unique need
    that staff learn during their time with the residents which
    leads to higher quality of care. Over the years of visiting our
    spouses--and we had a little coffee klatch of husbands there
    that would talk to each other--the staff became a second family
    to many of us. They would tell us how our spouses are doing,
    any trends they see, what made them laugh, what's working for
    them or any changes in behavior. Many weeks I spent more time
    with the staff than the rest of my family. Sue passed in 2023.
        Senator King, what you need to do: Stabilize the workforce.
    This is directly tied to increased reimbursements, as you've
    heard, which need to be tied to inflation. A most stable
    workforce understands the residents better, notices things that
    are off sooner which could lead to finding problems before they
    cannot be resolved. These unresolved issues lead to worse
    outcomes and a higher cost down the road.
        There needs to be a way to have national guardsmen and
    reservists who have not been on active duty or deployed to
    become eligible for access to the state veterans homes. Absent
    many more wars, this will only be the way to continue the
    viability of the Maine veterans home system.
        I look forward to your questions. Thank you.

        [The prepared statement of Mr. Pooler appears on page 56 of
    the Appendix.]

        Senator King. Thanks, Mike.
        Steve SanPedro, thank you for joining us. Steve is in my
    office so often in Washington, the next time he comes, I'm
    going to charge him rent.
        Mr. SanPedro. I'll be there in March.
        [Laughter.]
        Senator, I'd like to submit my written testimony for
    official record.
        Senator King. So moved.

     STATEMENT OF STEVEN SANPEDRO, NATIONAL COUNCIL MEMBER, MAINE
                        VETERANS OF FOREIGN WARS

        Mr. SanPedro. Good afternoon, Senator King. It is my honor
    and privilege to address you today regarding access to long
    term care for veterans in Maine.
        As a veteran myself, I have great concern for the future
    care of veterans here in Maine. These men and women have served
    their country and deserve to be cared for as the true heros
    they are. The Maine Veterans' Homes' ability to do this is very
    much in jeopardy due to today's rising healthcare.
        Maine Veterans' Homes has a unique challenge of meeting
    requirements from both the state and the VA, adding the need
    for additional resources to cover expenses not incurred by
    similar facilities. Inflation and the skyrocketing increases in
    cost of goods have created a financial deficit that can't be
    met causing great hardship.
        Reimbursement rates no longer are in line with today's cost
    of veterans' care. The current VA reimbursement rates are
    $115.62 for per diem care, and $49.91 for domiciliary care.
    These stipends in conjunction with Medicare, Medicaid,
    commercial healthcare insurance and private pay are all used to
    assist the veteran in paying for their care. However, funds
    still fall way short of the cost to care for these veterans. As
    a nonprofit entity, we are left to absorb this difference.
        However, if you are rated at 70 percent or higher disabled
    by the VA, your care is taken care of by the VA with no stipend
    and at a lower rate of cost. The VA has set a price no matter
    what type of care the veteran receives if they are rated at 70
    percent or more. Long term, skilled and assisted living care do
    not cost the same. There should not be a set rate.
        Like many other things, the pandemic made an already
    strained healthcare system even worse. Over the last three
    years, we have seen a large increase of healthcare professional
    leave the field not to return. Many seasoned professionals
    chose to retire, others didn't want to endanger their families
    and chose to switch careers in an effort to be safe. This
    caused the medical field to see shortages like never before. As
    a result of this, organizations like ours are forced to
    participate in wage wars and hire more contracted nursing at
    double and triple regional rates in an effort to fill very
    necessary positions. A secondary effect of the staffing
    shortages is the workloads that have been much more to bear for
    the professionals----
        Senator King. So it's a vicious circle. The workload goes
    up, the staff burns out and leaves, and then you've got another
    gap.
        Mr. SanPedro. Yes, Senator.
        That concludes my comments.

        [The prepared statement of Mr. SanPedro appears on page 58
    of the Appendix.]

        Senator King. Thank you.
        Joy. Thank you for coming from Aroostook.
        Ms. Barresi Saucier. You're welcome, my pleasure.
        Thank you for the opportunity to testify today, and I'd
    like to submit my written testimony for the official record.
        Senator King. So moved.
        Ms. Barresi Saucier. Thank you.

      STATEMENT OF JOY BARRESI SAUCIER, RN, MHA, FACHE, EXECUTIVE
                  DIRECTOR, AROOSTOOK AGENCY ON AGING

        At the Aroostook Agency on Aging, we know that people want
    to age in their home communities, and when they do so, they
    fare better and they also make their community stronger. Our
    core mission at Agency on Aging is to help this to occur.
        Nationally, there are 622 Agencies on Aging funded in part
    by the Older Americans Act. Agencies on Aging provide a variety
    services and function as a national network with unique assets
    and flexibilities that address many challenges faced by older
    people including veterans.
        All agencies serve as aging and disability resource centers
    providing confidential, unbiased information and support to
    older people, those with disabilities and their caregivers.
    These agencies often act as the first and only responder to
    those with questions or challenges that impact their ability to
    live independently. The agencies intimately understand the
    complexities of public programs, rural challenges and the
    formal and informal community supports that exist at the local
    level. In Maine in fiscal year '22, the Agencies on Aging
    provided responses to over 291,000 requests for information and
    assistance.
        At the Aroostook Agency on Aging, through over 20 programs
    and services that includes information, wellness--including
    falls preventions in-home services and respite services. We
    directly impact over 5,000 individuals each year, nearly 300 of
    which are veterans.
        With more than 25 percent of Aroostook County over the age
    of 65, we're central to the well-being of our community----
        Senator King. I saw that in your testimony.
        Take note of what she just said. Twenty-five percent of the
    residents in Aroostook County today are over 65. That's
    extraordinary.
        Ms. Barresi Saucier. We are where the nation is going. We
    are already there.
        A recent Community Needs Assessment by the Aroostook County
    Health Improvement Partnership highlighted how several rural
    disparities, just a couple that I'll mention, is that in
    Aroostook County, the rate of disability is 25 percent higher
    than the statewide rate. Alzheimer's disease is the highest of
    any county in the State of Maine.
        Nearly half of older adults living alone live outside of
    the service health communities, and over half of the population
    over 65 lack financial resources necessary to afford basic
    expenses.
        These factors linked with other factors, like lack of
    access to primary and specialty care, limited access to public
    transportation, older housing stock, fewer community supports
    and the workforce challenges already mentioned.
        We also, through this survey, gathered lived-experience
    information including the following statements from veterans:
    One said, ``if I don't get the help I need, I go without. We're
    so isolated here. It's kind of hard if I need help or need to
    ask somebody a question.'' Another shared, ``anytime you need
    medical attention, we have to travel somewhere,'' and he
    mentioned Bangor and Boston. A third commented, ``the financial
    issues impact your psychological issues because you're worried
    about, do I have enough money to pay the bills, am I going to
    have enough food, am I going to be able to make my
    appointments? ''
        Due to the intensity of the challenges and the resource
    limitations in rural communities, I believe it's imperative to
    continue to leverage local assets and collaborations.
        One excellent current example of such a collaboration is
    the Veteran-Directed Care Program which is conducted by VA
    Maine in partnership with three of the Agencies on Aging. We
    see the benefits of these programs and how they empower
    veterans to determine their own care plans as well as cover the
    cost of other goods and services specific to their needs.
        Although we've had limited referrals to this program in
    Aroostook County, we believe it can be a good option. Some of
    the barriers to participation include lack of awareness of the
    program, difficulty identifying a worker and challenges with
    managing the program on their own. Securing additional
    resources for targeted outreach by both the VA and agencies
    could improve the use as well as program revisions that would
    allow utilization of technology to enable distant caregivers to
    serve as authorized representatives may help.
        In addition, there's a few other opportunities I'd just
    like to mention, between VA and Agencies on Aging that could
    happen that might strengthen navigation of community resources
    and integration of specialty services.
        Again, we're aging and disability resource centers. We
    could leverage this resource to strengthen services for those
    living in rural communities where formal VA supports are
    limited.
        In addition, we also could make connections with
    specialized community services. In Aroostook right now, through
    an ACL grant, we're developing a regional community-based
    memory center to serve those with dementia and their
    caregivers. I think this is an opportunity for a collaboration.
        In closing, there are many other opportunities to address
    these rural disparities. They are innovative, we are
    innovative, the VA is being very innovative. The Agencies on
    Aging stand ready to further partner with the VA to improve
    awareness of services and access to these services, which are
    issues that often prove challenging to those living in most
    rural areas of America.
        Thank you for the opportunity.

        [The prepared statement of Ms. Barresi Saucier appears on
    page 60 of the Appendix.]

        Senator King. Thanks, Joy.
        Paul?

       STATEMENT OF PAUL SAUCIER, DIRECTOR, OFFICE OF AGING AND
       DISABILITY SERVICES, MAINE DEPARTMENT OF HEALTH AND HUMAN
                                SERVICES

        Mr. Saucier. Good afternoon, Senator King, and thank you
    for providing this forum to talk about this important issue for
    veterans.
        I will use the broader term, long-term services and
    supports, to describe a continuum of services that includes
    caregiver support, home care, adult day services, assisted
    living, residential and nursing facilities.
        MaineCare, Maine's Medicaid program, is the largest payer
    of long-term services and supports in the state. This is true
    nationally as well. In 2021, Medicaid paid for 44 percent of
    national expenditures, and the VA paid less than 2 percent.
    Many Maine veterans rely on MaineCare for long-term services
    and supports including 42 percent of Maine Veterans' Homes
    nursing home residents.
        Although the federally administrated VA system and the
    state administered MaineCare program operate independently from
    one another, they face similar challenges in this post-pandemic
    era. Attracting and maintaining a well-trained workforce is the
    single greatest challenge facing long-term services and
    supports in Maine. This is an area in which the Federal
    Government can have meaningful impact through a substantial and
    sustained effort in partnership with states and providers.
        The need for long-term services and supports will continue
    to grow as Maine's population ages, and the single biggest
    constraint to growth is the availability of workforce. Maine
    has invested more than $300 million with funding provided
    through the American Recovery Plan Act, enhanced Federal
    Medicaid match, Federal CDC grants and other one-time sources.
    This federal funding has been put to good use and is greatly
    appreciated, but Maine's structural workforce challenges are
    not going away. This is a long-term problem that will require
    sustained federal support over time.
        Pay is certainly important, and Maine has made a
    significant commitment to this area by adopting payment policy
    that assures rates will cover wages for direct support workers
    that are at least 125 percent of the State's minimum wage. The
    State's minimum wage is indexed to inflation and as it rises,
    so will Maine's LTSS rates.
        Pay is not the only factor influencing the supply of direct
    support workers. Availability and portability of training is
    another key factor. To that end, Maine is adopting a universal
    direct support worker credential that will enable workers to
    apply their expertise across home and facility settings for
    individuals with physical, intellectual or age-related needs.
    This complements efforts in small house models and elsewhere
    toward universal workers who engage with residents to assist
    with multiple needs and preferences including personal care,
    meal preparation, laundry and social activities. The approach
    is more person-centered, efficient and satisfying to both the
    worker and the resident which has been associated with higher
    quality care. Green Houses, one specific form of small-house
    model, had documented staff turnover rates that are half those
    of traditional nursing homes. This is a very promising area to
    which the VA could contribute with more research and
    development from its own experience. The VA has funded the
    construction of several small-house models across the country
    including one right here in Augusta. We would all benefit from
    understanding the outcomes and operational best practices
    emerging from these homes.
        Maine has also seen that self-directed care can be an
    important part of the workforce solution by expanding and
    providing more information about our self-directed home care
    options. Maine has grown this option during and after the
    pandemic. In most cases, self-directed care is provided by a
    family member, but the use of non-related caregivers is also
    rising. This is another area in which the VA can assist, and we
    welcome the expansion and availability of its Veteran-Directed
    Care programs.
        I'd like to conclude with some thoughts about system
    balance. The VA and Maine state long-term service and support
    programs share an interest in ensuring a system that has a
    necessary balance of home--and community-based services and
    institutional services. Older adults have consistently
    expressed an overwhelming preference for aging in their own
    homes, which is reason enough to pursue more HCBS options. But
    we also learned during COVID that having an appropriate balance
    contributed to the resilience of our system. Maine's nursing
    homes have not yet been able to return to pre-pandemic
    occupancy levels. They're serving fewer people today than they
    did before the pandemic. Fortunately for Maine, the story's
    been quite different in the home care sector. To be sure, home
    care has also experienced workforce challenges, yet Maine's
    three largest home care programs grew by 17 percent during the
    pandemic, serving nearly a thousand more individuals today than
    they did at the pandemic's onset.
        The VA has recognized the importance of balance, projecting
    increasing growth of its HCBS options over time in a recent
    government accounting office report. To date, the VA's current
    balance lags Maine's and most states, and Maine welcomes a
    significant increase in VA home care options.
        Thank you for the opportunity to testify today.

        [The prepared statement of Mr. Saucier appears on page 64
    of the Appendix.]

        Senator King. Thank you.
        Kathleen. And, Kathleen, don't we know each other? Did you
    go to Mt. Ararat?
        Ms. Swinbourne. Uh-huh.
        Senator King. With one of my sons, I think.
        Ms. Swinbourne. James.
        Senator King. James, James. That's Maine, isn't it?
        Ms. Swinbourne. He and I were Senate Pages together----
        Senator King. Oh, that's right, that's right.
        Go ahead, Kathleen.

                   STATEMENT OF KATHLEEN SWINBOURNE,
                            FAMILY CAREGIVER

        Ms. Swinbourne. Good afternoon, Senator King. Thank you for
    the opportunity to participate in this Senate Veterans' Affairs
    Committee field hearing on long-term care services for veterans
    in Maine.
        I'm from Topsham, I'm a registered nurse, licensed massage
    therapist, long-time yoga instructor and previous business
    owner. I'm here to share my experience as a family caregiver
    for my father Clare John Swinbourne, an 85-year-old Navy
    veteran with 20 years of service and three tours in Vietnam. My
    dad was exposed to Agent Orange and suffers from Parkinson's,
    dementia and PTSD.
        In 2012, my dad was diagnosed with Parkinsonism systems,
    and from the instruction of the family physician, he was
    encouraged to apply to the VA for disability but was denied due
    to the diagnosis ``Parkinsonism'' rather than Parkinson's
    disease.
        My active care began in 2019--I'm about to describe a fall.
    At that point, my dad had been living with Parkinson's symptoms
    for seven years. His gait was off, and he walked with a cane.
    He was struggling with his executive function, and experiencing
    intense mood swings and long bouts of depression. One day in
    December of that year, he suggested we hang wreaths in the
    front of my parents' home. We walked to the front, and he
    gestured for me to walk ahead of him. He was often self-
    conscious of his slow and laboring walk. I went ahead and in
    moments, I was startled by his yells behind me. I turned to see
    my dad lying on the ground with blood on his hand and knee. I
    ran to help him. I could tell by the blood and shock in his
    eyes had he had no warning that his body was going to give out
    on him. He was embarrassed and apologetic, and I helped him to
    his feet. I know not to do this now, but I put my arm in his
    and aborted the wreath-hanging and led him inside so that I
    could care for his wounds. We walked down the stairway--or,
    excuse me--we walked down the driveway to the garage and took
    one step in the door, and we both crashed down onto the cement.
    My dad landed on the same bloody knee and hand. The fall
    happened so quickly, I had no opportunity to brace myself or
    protect him from falling. This time he was sobbing and in
    shock. I held my dad for a long time as he cried. I can't say I
    knew how he felt, but I realized with the Parkinson's disease
    it was progressing, and the body he knew and trusted his whole
    life was beginning to betray him.
        I eventually got him to his feet. Inside, I cleaned and
    dressed his wounds, and put him in his comfy recliner. All the
    while he was apologizing to me still for falling. I told him it
    wasn't his fault. And once I got him settled, I went downstairs
    in a separate room and cried uncontrollably. I sat there for a
    long time crying and praying because I knew I needed to figure
    out how to care for him with this disease, but it was
    overwhelming.
        The next day I called his primary care doctor and put in a
    request for an urgent referral for home care, and the next day
    they sent Chan's, which was wonderful, and began with a social
    worker who interviewed my parents and I about my father's needs
    as well as needs of the home. And at the end, she pulled me
    aside and said, we are more than happy to help you but because
    he's a veteran, I really encourage you to apply for his
    disability because he will be taken care of so well.
        So the next day I got in touch with the American Legion,
    and a representative at the health administration--excuse me,
    the business administration side of the VA and she was
    wonderful, and she gave me a long list of appointments and to-
    dos that took me a little bit over a year and a half to
    complete. Mind you, it was the start of the pandemic so we'd
    have appointments scheduled and we'd show up and we weren't
    supposed to be there, or it was canceled, or there was an
    outside agency in Florida scheduling us in Maine and sending us
    to Massachusetts. And I would try to reschedule and spend a
    week trying to figure out who to talk to and how to change it.
        During this time of pursuing the disability, which is more
    of the administrative piece, I was also trying to figure out
    how to teach my parents about the disease, and make sure that
    we were having somewhat of harmony and support within the home.
        And if anyone has been with someone whose mind is going
    into dementia and Parkinson's, it's brutal. So I think during
    the year and a half of the pandemic, I didn't really sleep
    because I was awoken by night terrors and my mom wouldn't sleep
    so I was always running on empty. So I'd call this poor woman
    at the administrative side and cry and ask her, is there any
    way that I could get help? And she turned me on to the 1-800
    line, the VA, which I will tell everyone about, who can access,
    because it's incredible. And I remember that conversation, she
    calmed me down, and told me about the caregiver program up in
    Maine and literally connected me while we were on the phone,
    and that was a game changer. And they told me about the
    program. The next day--that's my thing--the next day I applied
    and in a few months, became part of the family caregiver
    program so that I could get a small stipend, but I was more
    interested in having the educational support and counseling so
    that I was doing an okay job, if I could, in taking care of my
    dad.
        Also the help with the caregiver program, they told me
    about handicapping the home. I pursued the HISA grant which was
    similar to the disability process. It took me about a year, and
    only because there was one hang-up in sending the right faxed
    form from the outside occupational therapy practice to the VA.
    But they had sent an OT team to our home to evaluate what my
    dad needed, and then they sent the write-up back to the primary
    care office. And then I would wait. And then I would call them,
    did you send the form? Yes. Call the primary care at the VA.
    Did you receive the form? No, we haven't. So that went on for
    weeks and finally I was like, who is telling me the truth? And
    I talked to the manager of the OT practice and she said, I know
    someone at the VA, I'm going to figure out what the halt is,
    and it was a specific form that they needed to fill out that
    they didn't know. Finally got that through and within a year or
    so, I handicapped the home. And I want to just give credit to
    the VA and the prosthetics department. They're incredible. Just
    like the business administration side, they gave me everything
    I needed to do, it's just very time consuming.
        Senator King. So the problem wasn't the service, it was the
    time to get the service; is that correct?
        Ms. Swinbourne. Yes, and doing the right steps and telling
    the right people, yes.
        Um--sorry. As I was getting this all figured out, we were
    also realizing my dad's needs were increasing so I began the
    process of applying for the re-adjudication of his benefits
    when he was denied in 2012. And also the administrative side
    helped me with the right forms to fill out. We submitted them,
    and waited a long time for a response. And this poor
    representative, I called her every week, what's happening, are
    we going to find out? Because I was trying to plan for the
    future, and I knew that we were going to use the money to pay
    for the rest of the construction to handicap the home, and also
    to pay for an additional caregiver alongside my mom and I.
        So I reached out to your office, and that's when I
    connected with your staff, and they were incredibly supportive
    in helping me figure out and locate where the application was.
    And within two weeks, we had the backpay.
        So after that, I then applied for full-time status with the
    caregiver program and I was denied. There wasn't, in my
    experience, a lot of evaluation or assessment to why I was
    denied, but we were denied, and the stress was increasing. I'm
    just--I'm going to advance a little bit. The stress sort of was
    coming from the progression of my father's disease. And we
    realized this past summer, he probably needs to be in a home,
    even though that's not something we wanted to do. So we moved
    into the Maine Veterans' Home, which is beautiful, and we joke
    in the family, it's the Hilton of elderly spaces. But his
    dementia is so severe that he needs more intense observation
    and care.
        I was trying to collaborate with the primary care team at
    the VA, and it was a little bit difficult to close that circle
    in getting support in I guess you would say taking away his
    rights to make decisions so that we could make sure he'd stay
    there safely because he wanted to leave. Every day he was
    calling me, ``Kath,'' and causing a lot of ruckus. And we
    brought him home for Christmas, and he ended up not going back.
    Very long story short, he's now at the long-term care at the
    VA. We're very happy. One of the first things that he said to
    me when I went to visit him is, ``I feel safe,'' and that's
    important.
        I'm here today to share this story of caring for veterans
    for--to share this story so that other people caring for
    veterans don't give up. I'm also here to share the things that
    I feel need improvement at the VA. I'm so happy with the
    benefits we've received, even though many times it felt like I
    was trying to bust down a brick wall. But once the wall came
    down, I was able to tap into the wealth of resources for my dad
    and myself.
        I wish I had a case manager or a medical social worker to
    guide me through the appropriate channels and check points to
    regularly evaluate my dad's conditions and needs, and to make
    sure his medical records were alwaysup-to-date to help us move
    through this stage from being at home to the nursing level of
    care.
        I know this is the intention of the VA to provide a medical
    social worker. We were assigned one, but this wasn't our
    experience. It was very difficult for me to connect to the
    primary care team, and also with them to communicate with the
    caregiver program. We often fell upon our next steps through
    crisis, and I was regularly asking for help, but so often my
    phone calls weren't returned. When my dad went into rehab, I
    was undergoing extensive months of a long process to re-apply
    for the full-time care, and also Vet Direct care. By the time
    there was a decision, simultaneously my dad was in the hospital
    and then ended up at MVH.
        In an ideal world, veterans and families would benefit from
    the medical social worker to educate them on the process of the
    disease and its progression, to guide them through the proper
    channels in moving from the home to the nursing home.
        Additionally, the medical social worker can bridge the
    families to the providers for regular geriatric evaluation and
    management and the caregiver program upon immediate diagnosis
    of the war-related disease.
        I feel the VA has all the big pieces that can help. It's
    the little stuff connecting the dots between the programs where
    I feel it falls apart.
        I'm so grateful for your office, Senator King. I contacted
    them again for assistance when I was unable to receive return
    calls or clear guidance from the staff at the VA. I'm certain
    the support of your office is what allowed me to experience
    progress and momentum in my dad's care. However, I don't feel
    veterans and families need to take it to this level. Calls
    should be returned, guidance needs to be available, and the
    application process is too extensive for aging veterans who
    don't have a young family member or advocate who can give
    them--who can give up their job to pursue their benefits and
    care. For five years, I temporarily gave up my career and
    income for my dad because I love him, and I believe in honoring
    those who fought for our freedom, but I've greatly compromised
    my financial, physical, mental and also emotional stability due
    to the constant stress and time commitment.
        If I had been compensated for the care for his full-time
    needs, I may have felt differently or may feel differently, but
    I was doing full-time work for part-time pay and also trying to
    go to nursing school. It was an idealistic hope that I could
    take care of him if need be.
        I believe the VA is a wonderful organization with an
    abundance of resources for families and veterans, and I'm
    hoping that the refinement of better communication and
    correspondence and leadership from the primary care team can
    create positive change for veterans and families.
        Thank you.

        [The prepared statement of Ms. Swinbourne appears on page
    67 of the Appendix.]

        Senator King. Thank you. That was very moving and important
    for us to hear. Thank you.
        It seems to me to start with your testimony, as I
    mentioned, the problem that you had with the VA wasn't with the
    programs or the adequacy, it was the time, and I'm delighted my
    office could help, but it shouldn't take that step to get that
    help.
        Was this--did you get the sense this was a lack of, again,
    of workforce? Just too much burden on the people at the VA?
        Ms. Swinbourne. Yes.
        Senator King. I'm sorry nobody said we're not gonna return
    these phone calls, it just didn't happen.
        Ms. Swinbourne. Yes. I think it was a lack of staffing
    which I feel very empathetic toward, yes.
        Senator King. Let me move, Joy, to something that you
    touched on very briefly. One of the concerns--and I've heard
    this when I've met with their agencies, particularly in rural
    Maine, is an epidemic of loneliness. Could you talk about that,
    and the fact that so many of our seniors are isolated with very
    little--I remember being in Washington County and there was a
    lady there who said the only person she ever sees is the Meals
    on Wheels driver. Talk to me about that problem. It doesn't
    strictly relate to the VA, but I think it touches on what we're
    talking about. There are certainly veterans who are in this
    category.
        Ms. Barresi Saucier. Yes, we definitely hear this in rural
    Maine and nationally too. This is really becoming its own form
    of an epidemic, the epidemic of loneliness. The rural community
    Health Improvement Partnership project that we have just been
    undertaking with some state funding brings 20 community
    partners together to talk about social determinates of health.
    And the needs assessment that we did found that this is not
    only the issue of social isolation, but the issue of belonging
    is a challenge in our rural communities. And so we've
    prioritized that as one of the four areas that we'll be
    focusing on in our Community Health Improvement Partnership.
        In Aroostook County, a couple things we are doing, because
    we do understand that with distance comes disparities. You
    know, I tell people that driving from the top of Aroostook to
    the bottom is like driving from Albany to Boston. It's very
    hard to conceptualize that until you do it in a day. We all
    have done it in a day before----
        Senator King. I think Brunswick or Portland is halfway
    between Madawaska and New York City. People don't realize how
    tall Maine is.
        Ms. Barresi Saucier. It's a big space. It's sparsely
    populated, but yet we believe that no matter what community you
    live in in Aroostook County, that you need access to services.
        We recently received, through congressionally directed
    spending, thanks to Senator Collins and Senator King, a project
    called Access Points for Aging where we're collaborating with
    20 communities in Aroostook County, these are primary and
    secondary service-hub communities, to install an actual
    footprint in that community, an existing community space, where
    there can be a partnership between the community, age-friendly
    community, municipality, Agency on Aging, healthcare, other
    social service agencies to have a place where people can go to
    access information. These are outfitted with technology. All 20
    will be able to be linked together. So if you're in Danforth,
    you can provide a Tai Chi presentation to Fort Kent.
        Senator King. Will that access information include
    information about VA availabilities?
        Ms. Barresi Saucier. As I said in my written testimony, I
    think this is a great opportunity to link the VA into that
    network in our area. This isn't something that all AAAs have.
    It really is a demonstration pilot. We expect that others will
    want to follow suit, and already another agency is trying to
    follow suit with this concept as well.
        And then in addition, we have--related to social isolation,
    I believe it was 2020, we were the recipient of a community
    care corp grant which allowed us to develop and establish a
    program called Friendly Volunteers. We have friendly visitors,
    callers, helpers and techies. These are trained background
    check volunteers, community volunteers, that we match to older
    people that need a connection. It's a very, very popular
    program. The challenge with this type of program though is that
    that was one-time funding, that was one-time two-year funding
    and now we're faced to try to--well, how do we piece this back
    together without a full-time coordinator to do this work? This
    is another great example of an existing resource that could be
    tweaked to match veterans with veterans. The infrastructure is
    all there. We just need resources to continue to make these
    type of programs run.
        Senator King. Thank you.
        Steve, I noted you nodding during Kathleen's testimony. Can
    the VSOs serve as navigators, helpers? Is that a function that
    would be useful in the situation of the delays and the
    unanswered phone calls?
        Mr. SanPedro. You're referring back to Kathleen's
    testimony?
        Senator King. Yes.
        Mr. SanPedro. I'm sure we can advocate.
        Senator King. That's what I'm suggesting.
        Mr. SanPedro. Absolutely. I don't know if we would change
    it, but I mean I will tell you personally that Ryan, Tracy and
    Jennifer, you guys do a tremendous job providing healthcare and
    benefits.
        Just two days ago----
        If you don't mind me sharing, Jennifer.
        --I reached out to Jennifer about a veteran that had an
    issue with her claims process, and she felt she wasn't being
    heard and she wasn't being taken care of. A different regional
    team was looking into it. Jennifer's team took over it, and
    long story short, this veteran walked away feeling like she was
    heard and that she was cared for and she's very happy, and I
    told Jennifer that before.
        So I think we have--the overall thing that I hear from
    veterans across the state is they do believe in that VA
    healthcare, they do want to use it. The national VFW did a
    survey, and overwhelmingly veterans want to use VA healthcare.
    Is it perfect? No. But tell me a healthcare system that is.
        I believe that we have leaders there that want to help us,
    they care. They truly enjoy their jobs----
        Senator King. For the record, I totally agree with that
    statement.
        Mr. SanPedro. Yes. What I would have done, if she reached
    out to me or--you know, I would have reached out to them
    because that's typically what I do. I don't--you know, I
    don't--I know everybody doesn't have that access, but I do, and
    that's what I do. I just say, Jennifer, can you help me? Here's
    another one. This isn't the first time Jennifer has helped me.
    And I've reached out to Tracy and when Ryan was here, I worked
    with Ryan. They are great partners with the VSOs, and they
    truly believe in taking care of veterans. So I simply would
    have advocated for her, and I believe that it would have been
    taken care of. However, there is a problem with some of the
    processes. I mean they're labor intense.
        You know, one of the things that I would have said, if you
    asked about veterans, how do they feel, most veterans want to
    stay at their home. But if they can't, they--a lot of them
    prefer to go to Maine Veterans' Homes. Not because I sit on the
    board but because that's true. However, a lot of them are not
    close to a Maine Veterans' Home, and they want their families
    to be able to visit. So the VA contracted homes, many people
    don't even know about them. There's 10 of them in the State of
    Maine, and most veterans don't know about them.
        Senator King. These are the private nursing homes that are
    contracted for by the VA?
        Mr. SanPedro. Correct. But most of them don't know about
    it, and who do they turn to, you know, and how do they learn
    about it? So there's definitely an education problem. Not in
    the State of Maine, in the whole Nation, on what the VA can do
    for ya. Whether it's just getting out of the military or filing
    a claim or getting your healthcare, a lot of people just don't
    know what the VA has for them, and there's so many programs
    that they provide for our veterans and no veteran should----
        Senator King. So awareness is a big part of the issue?
        Mr. SanPedro. Yes. And, you know, like thank you for
    signing the bill that I came to you in September or sponsoring
    the bill that I came to you in September about the TAP
    program----
        Senator King. The President signs the bills.
        [Laughter.]
        Mr. SanPedro. Right. We're working on it, right?
        But that simple thing of allowing the VSOs to come in
    during TAP, it costs the United States zero dollars. And you
    take----
        Senator King. TAP is the Transition Assistance Program?
        Mr. SanPedro. Transition Assistance Program. You would
    think that that would be a simple thing, but we have to get a
    law to pass to let the VSOs to come in during TAP to show--to
    help start the claim process.
        Senator King. To make the contact?
        Mr. SanPedro. Correct. So education to me, I think, would
    solve a lot of our problems, and I do think that it would solve
    Kathleen's problems.
        Senator King. Thank you.
        Paul, I want to talk a bit about reimbursement. What's
    the--for MaineCare, which is a lot of what we're talking about,
    what percentage of those dollars are federal, and what
    percentage is state?
        Mr. Saucier. So Maine gets about 62 percent federal these
    days. And, as you know, that changes with economic conditions
    in the state. Administrative costs are 50 percent federal and
    50 percent state.
        Senator King. So on a dollar to a nursing home, the State
    of Maine puts up roughly 40 percent, the feds 60?
        Mr. Saucier. That's right.
        Senator King. Sharon, you said something, and we sort of
    blew by it, and I want to get back to it. You said--I think you
    said I have a 36-month runway. What did you mean by that?
        Ms. Fusco. What I meant by that was that we are in a
    situation where we have to use funds that we reserve for
    capital replacement. Like rehabbing buildings, maintaining
    buildings, keeping our infrastructure in good shape. Those
    funds today are being used to pay for services today.
        Senator King. So you're using capital to pay operations?
        Ms. Fusco. Correct.
        Senator King. Always a bad place to be.
        Ms. Fusco. Yes. And understand that, you know, because we
    are a private nonprofit, we're a little different as a state
    veterans home. We are charged to do that. The state doesn't pay
    for our buildings and our replacement buildings and things of
    that nature. So we've done the right thing over the years,
    right? We've invested that money so that we have a pool so that
    when we need capital replacement, we can do it. But when we
    have to make payroll and it's the choice between making payroll
    or not.
        Senator King. You're dipping into savings to pay the rent.
        Ms. Fusco. Exactly. And that steals from our future, and it
    also means I can only do that so long before I have to say, I
    got to close the doors because I can't make payroll. And that
    runway is 36 months. We've done what we can to extend it.
        Senator King. So the 36 months is when you run out of
    your----
        Ms. Fusco. Yes, at current spend rates, yes.
        Senator King. That's a scary thought, isn't it?
        Ms. Fusco. It is.
        Senator King. We don't have a representative on the panel,
    the private nursing home industry, but, Sharon, you're in this.
    Tell me your thoughts on the CMS staffing role.
        Ms. Fusco. I think it's bad policy. And it's not because I
    don't believe that, yes, if we had more staff and more people
    available, that's great. But it's bad policy because, one, we
    don't have the workforce, and if we learned nothing else
    through the pandemic when we had a mass exodus of the workforce
    from this industry, what we learned was we had companies
    swooping in to save the day by charging us three to four times
    for those nurses.
        Senator King. These are the traveling nurses companies?
        Ms. Fusco. And these are those traveling nurses. And what
    happens in that situation is they are not committed to quality
    as MVH defines it. They're fine individuals. If you're a
    traveling nurse, this isn't about you. But what it's about is
    that you don't know why we do things the MVH way. We got to
    five stars as a CMS rated nursing home because we have quality
    standards that we expect all of our employees to meet. And when
    you're a traveling nurse, you're there for what; 60, 90 days?
    You're not vested in my quality program. And you heard Mike say
    how difficult it is to build a relationship with somebody who's
    not vested in the mission. And you're creating a culture where
    I've got some employees that I can pay my rate, and others that
    I have to pay three and four times that rate. Imagine what it's
    like standing next to somebody who's doing the same job as you
    who's getting three times what you're being paid. It's
    criminal.
        Senator King. It's not exactly a morale booster.
        Ms. Fusco. No, it's not. Now, I will say, we have done a
    great job of working to eliminate temporary staffing in our
    homes. But with work--if CMS comes down and says, ``hey, you
    have to do this, you have to have this'', we will be right back
    to temporary staffing. I mean those private nursing homes are
    gonna be back to it.
        Senator King. They're also going to be facing closure;
    aren't they?
        Ms. Fusco. They already are. And now CMS is going to impose
    a staffing mandate that will increase their cost not just
    because they have to hire more people, but because we're going
    to be in this competition for people.
        Senator King. Colleen?
        Ms. Hilton. Yes, I'd like to add to that.
        In Northern Light Health, we have eight nursing homes, six
    we jointly own with another healthcare company. Prior to the
    pandemic, we would advertise for a nurse in Lincoln, Maine;
    three years not a single applicant. Three years, no applicant.
    That nursing home eventually we converted to residential care.
    Seaport in Ellsworth just closed. Deer Isle, during the
    pandemic, right at the tail end of the pandemic closed. There's
    now not a nursing facility or a skilled nursing facility in
    Hancock County.
        Senator King. I don't think there's one in Washington
    County either.
        Ms. Hilton. There's Milbridge right on the edge, but people
    in Hancock County will now have to travel to Milbridge or to
    Bangor. And so it is baffling at a time when five nursing homes
    I think have closed since the pandemic, and you mentioned the
    800 and something beds that have disappeared in the last five
    years that we are----
        Senator King. As the population ages.
        Ms. Hilton. As the population ages, as the needs are
    increasing that we are actually mandating 24-hour nursing care
    when we can't produce it and we have a projected shortage, and
    you can't fast track a nurse. You know, your wife's a nurse.
    You can't fast track a nurse to fill that gap, and we're all
    dealing with, in every sector of healthcare, those tough
    questions of do we pull in that contracted labor for three
    times the cost, or do we say to this family, this patient, we
    can't provide care to you?
        Senator King. Sharon, don't you have a whole wing at the--
    we had a hearing at the Augusta home, and there was a part that
    isn't open, right?
        Ms. Fusco. Well, we have since, I'm happy to say.
        Senator King. You staffed it up?
        Ms. Fusco. We staffed it up, and we're actually near
    capacity in that home, but it took us a year and a half to do
    it.
        Senator King. Well, I thought Mike made an important point
    because we're all talking about hiring people but, Mike, you
    made the point about stability and retention.
        Mr. Pooler. Yes, sir. Yes, the folks that are there, great.
    You know, with dementia patients, like I said, they need to
    have that stability with the staff so they can, you know--
    they're never gonna get better, but they're not--the decline
    will be less. And if they can find issues sooner, they can fix
    them sooner before they have to travel to the hospital for an
    operation. So that stability from the family level is critical.
        Senator King. If retention is the goal, one of the ironies
    is that as you have gaps and you have longer hours and--that is
    a vicious downward spiral because people burn out.
        Is that your experience, Colleen?
        Ms. Hilton. It's just a phenomenon of what we're dealing
    with. And I think it did actually truly start right before the
    pandemic, but certainly exacerbated by the pandemic. There
    are--you know, there are significant needs across our state,
    and people do chase money. And if they can go 30 miles over
    here and increase their wage, I can't begrudge them for that.
    But we've seen wage escalation, in some of the nursing homes,
    up to 20, 30 percent, and it's still not enough to retain----
        Senator King. To hold the people.
        Ms. Hilton. To retain the people. Every one of us are
    focused on retention. That's really where we spend the vast
    majority of our time, but the workforce is very migratory right
    now because of, I think, the socioeconomics and the workload
    which is so intense and hard.
        Senator King. The good is we have a historically low
    unemployment rate, but that creates the question of the
    migratory workforce.
        I'm not going to make light of this issue, but I'll share a
    story.
        The first month that I was Governor, we had a retreat for
    the cabinet where we went out to Newry, Maine where they had a
    ropes course, and ropes courses do various things. It's to
    build teams and those kinds of things. And part of it was to go
    way up on a rope and have a rope around your waist and fall off
    and have the person below hold you. It was, you know, trust and
    all that. Well, it happened the guy who was holding me was a
    guy named John Orestis who happens to be a nursing home owner.
    And so I'm falling off and dangling 40 feet above the ground
    and I had been down here for about a month and John said,
    Governor, what do you think of nursing home reimbursement
    rates? [Laughter.] I said, whatever you need, John, let me
    down. [Laughter.] But it is--it is a serious problem. And
    you're squeezed, you have increasing expenses and virtually no
    increase in revenues. I mean that can't work for very long.
        Ms. Hilton. No.
        Senator King. Other thoughts before we conclude?
        Thank you all. This has been wonderful testimony.
        By the way, this is my favorite part of my job is hearings
    and asking questions and learning and writing down ideas. I
    have lots of things for Tester and Moran to work on when we get
    back.
        Other thoughts you want to be sure to get on the record?
        Paul, you would like a greater increase of federal funds
    for MaineCare?
        Ms. Saucier. One of the very efficient ways to distribute
    federal money is by providing a special federal matching rate
    for targeted activities, and that's one of the things I would
    recommend. It would be very efficient for CMS to, for example,
    give a 75 percent federal match rate for any workforce related
    activities and make that very broad. The workforce money that
    we received through the recovery act and others has been put to
    great use. That was a very large $130 million bonus program
    here in Maine that went to all HCBS, Home and Community Based
    Service providers, for example. Those--many of those are small
    providers that are not in a position to write a grant or to
    HRSA or, you know, otherwise directly receive federal funds.
    But through the state, I think that could be very beneficial.
        Senator King. I like the idea. In other words, additional
    federal funds not generally but targeted toward workforce
    retention?
        Mr. Saucier. Targeted--right, right. Yes, I think that
    would be one--one way to go with it. I mean just to give you a
    sense of how big this problem is, senator, in the CMS proposed
    rule that you've been asking about, there was notice that HRSA
    would invest $75 million as part of the regulatory--the new
    regulation. Maine invested $300 million, one small state, in
    the last three years. My belief is that it helped stabilize the
    workforce. It did not fix it, and that's just one state. So the
    $75 million that HRSA would be offering is--I mean it's----
        Senator King. For the whole country?
        Mr. Saucier. For the entire country. Which is why I say, I
    mean HRSA does certain things really, really well and----
        Senator King. Define HRSA.
        Mr. Saucier. Health Resource Service Administration.
    They're the federal agency that focuses on the healthcare
    workforce, and they're--especially larger providers can benefit
    a lot from HRSA grants. The state has--you know, the universal
    benefit--the universal curriculum, that I mentioned, was funded
    with HRSA funding, but it's out of reach for a lot of these
    small providers that we really depend on. Home care providers
    sometimes are two employees. And so, you know, we really need
    to be able to reach them.
        Senator King. By the way, that's a problem across the
    board. We had an Armed Services Committee hearing this week
    about the inability of many small businesses to interact with
    the Pentagon. It's just too much, too much paperwork, and we're
    losing innovation and capabilities that we need.
        Final point on that, it suggests itself. How about
    innovation and technology? Are there ways to deliver services
    more efficiently and effectively at the same or less dollars?
    In other words, is that another way to approach this?
        Colleen, you're nodding.
        Ms. Hilton. Yes, I'd love to take----
        Senator King. The record doesn't show when you nod. That's
    why----
        Ms. Hilton. Oh, sorry.
        We invested, probably 15 years ago, in technology so we pay
    for it. It's not reimbursed. It's not covered by the Medicare
    benefit. There are small parts of--bits and pieces that they
    may cover but we are--and, again, this was clear through the
    pandemic when we couldn't get into some homes, we could drop
    ship equipment to a home, and could get video eyes on people in
    their home and do assessments as best we could. So it is a
    helpful additive to what we do. It can't replace someone that
    needs personal care assistance and toileting and those sorts of
    things, but it's typically not covered by most of the
    insurances. So for an organization like mine which has done,
    over time, pretty well--we go from, again, Fort Kent to
    Kittery, coverage. Last year we were 10 million in the hole, 10
    million to the negative, a very efficiently run organization,
    and we are gambling on our investments in technology because it
    has to--reimbursement has to catch up with it because it is one
    of the solutions to the workforce shortage.
        Senator King. One of the things--during the pandemic, there
    were rules waived for reimbursement for telephone and
    telehealth, and they were--we've been fighting--we want to keep
    that permanent.
        Ms. Hilton. We do too.
        Senator King. Because telehealth is a huge opportunity. And
    as I think one of you mentioned, the patients are okay with it.
    And I understand that there's a lower appointment-missing----
        Ms. Hilton. Correct. For home visits and for behavioral
    health, it's often preferred.
        For us using it with chronic care disease management,
    congestive heart failure, we can catch things early, treat them
    early with preestablished protocols, and that person never goes
    to the hospital, doesn't have to take up time in an office.
    They can be treated at home and continue on their----
        Senator King. Prevention, prevention, prevention.
        Ms. Hilton. Prevention, public health.
        Ms. Barresi Saucier. Can I add to the telehealth comment?
        Senator King. Please.
        Ms. Barresi Saucier. I just want to mention our evolving
    memory care center in Presque Isle, is a collaboration between
    the Aroostook Agency on Aging and Acadia Mood and Memory Clinic
    in Bangor. And this model creates a comprehensive hub for
    Aroostook County where we can do everything from work with
    Acadia on early diagnosis and treatment through service
    coordination, family caregiver support, community education,
    and respite care. And the telehealth components are going to
    allow us, with Dr. Singer who has a 600-person wait list, to
    fast track one person from Aroostook County every week into his
    program using telehealth. So we're really excited about this
    opportunity to--as a community-based organization to be a hub
    for a telehealth project.
        And just my other comment, I'm so excited to hear about
    everything that the VA is doing related to the community-based
    programs, and I just want to remind about the fact that
    Agencies on Aging have across the country these amazing assets
    and established infrastructure that if we can partner together,
    we can do great things so look us up across the country. There
    are 622; it's just a great use of existing resources rather
    than recreating resources when this network already exists so
    thank you.
        Senator King. I want to thank all of you. This has been
    very informative. I've got lots of notes. As you drive home
    tonight, when you think of oh, I should have said this, send it
    forward. Be in touch with my office so that we can have the
    benefit of your thinking.
        It's wonderful to see all of you, most of you I know and
    have seen before.
        Kathleen, I will tell James I saw you.
        And it's been very, very helpful and informative.
        Thank you so much. Thank you all.
        [Whereupon, the above-named hearing was concluded at 4:02
    p.m.]

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