[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
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                   U.S. GOVERNMENT PUBLISHING OFFICE                    
54-781 PDF                  WASHINGTON : 2024                    
          
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                 SENATE COMMITTEE ON VETERANS' AFFAIRS

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

                              ----------                              

                            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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