VA Long-Term Care: The Availability of Noninstitutional Services 
Is Uneven (25-APR-02, GAO-02-652T).				 
                                                                 
Noninstitutional long-term care services are delivered by the	 
Department of Veterans Affairs (VA) to veterans in their own	 
homes and other community locations. The Veterans Millennium	 
Health Care and Benefits Act requires VA to offer long-term care 
services to eligible veterans, including services provided in	 
noninstitutional settings. More than two years after the act's	 
passage, VA has yet to offer eligible veterans adult day health  
care, geriatric evaluation, or respite care. Although VA	 
published proposed regulations that would make these services	 
available in noninstitutional settings to eligible veterans, the 
regulations had not been finalized as of April 17, 2002. To be	 
responsive before its draft regulations were made final, VA	 
issued a policy directive requiring that these three services be 
available in noninstitutional settings. GAO found, however, that 
both the services required by the act and VA's other		 
noninstitutional services were unevenly available across the VA  
system. 							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-652T					        
    ACCNO:   A03168						        
  TITLE:     VA Long-Term Care: The Availability of Noninstitutional  
Services Is Uneven						 
     DATE:   04/25/2002 
  SUBJECT:   Health care services				 
	     Long-term care					 
	     Veterans benefits					 
	     Health resources utilization			 
	     Health services administration			 

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GAO-02-652T
     
A

Test i mony Before the Committee on Veterans? Affairs, U. S. Senate

For Release on Delivery Expected at 9: 30 a. m. VA LONG- TERM CARE Thursday,
April 25, 2002 The Availability of

Noninstitutional Services Is Uneven

Statement of Cynthia A. Bascetta Director, Health Care- Veterans?

Health and Benefits Issues

GAO- 02- 652T

Mr. Chairman and Members of the Committee: I am pleased to be here today to
discuss noninstitutional long- term care services offered by the Department
of Veterans Affairs (VA). These services, such as homemaker services and
adult day health care, are delivered to veterans in their own homes and
other locations in the community. VA will see increasing demand for long-
term care in the

coming years as the veteran population ages. Of particular significance is
the expected tripling of the number of veterans age 85 and older- the group
most in need of long- term care. Although not all veterans? care needs can
be met in noninstitutional settings, veterans may prefer such care because
it allows them to remain in their homes or in other settings that are less
restrictive than institutions.

VA generally provided or paid for long- term care on a discretionary basis
until passage of the Veterans Millennium Health Care and Benefits Act in
November 1999. 1 The Millennium Act required VA to offer certain longterm
care services to eligible veterans, including services provided in
noninstitutional settings. In particular, adult day health care, geriatric
evaluation, and respite care are to be made available to eligible veterans.

As part of our ongoing work addressing the availability of noninstitutional
long- term care in VA, you asked us to provide information on (1) VA?s
efforts to expand noninstitutional long- term care in response to the
Millennium Act?s requirements, 2 and (2) the noninstitutional long- term
care services that VA?s medical facilities offer. My statement focuses on
the information we provided in a letter on VA?s noninstitutional long- term
care services, 3 which is being released today. That letter is based on data
from a survey of all 139 VA medical facilities, 4 interviews with officials
in VA?s

Geriatrics and Extended Care Strategic Healthcare Group, and interviews 1
Pub. L. No. 106- 117, 113 Stat. 1545 (1999). 2 Although nursing home care
and domiciliary care are also required by the act, we do not address these
requirements.

3 VA Long- Term Care: Implementation of Certain Millennium Act Provisions Is
Incomplete, and Availability of Noninstitutional Services Is Uneven (GAO-
02- 510R, March 29, 2002). 4 Although VA has 172 medical centers, in some
instances 2 or more medical centers have consolidated into health care
systems. Counting health care systems and individual medical centers that
are not part of a health care system as single facilities, VA has 139
facilities.

with VA field officials responsible for long- term care services. To
determine which noninstitutional long- term care services to include in our
survey, we compiled a list of the services as identified by VA officials and
in VA documents. (Descriptions of these noninstitutional services are
provided in appendix I.)

In summary, more than 2 years after the act?s passage VA has not completed
its response to the act?s requirement that eligible veterans be offered
adult day health care, geriatric evaluation, and respite care. Although VA
published proposed regulations that would make these three services
available in noninstitutional settings to eligible veterans, 5 the
regulations had not been made final as of April 17, 2002. To be responsive
to the act?s requirements before its draft regulations were made final, VA
issued a policy directive requiring that these three services be available
in noninstitutional settings. VA also offers other noninstitutional
services. At

the time of our review, however, both the services required as a result of
the act and VA?s other noninstitutional services were unevenly available
across the VA system. Background VA served about one- third of its fiscal
year 2001 long- term care workload,

or average daily census, in noninstitutional settings (see table 1).
Noninstitutional care accounted for about 8 percent of VA?s long- term care
costs during the same year. 5 66 Fed. Reg. 50,594 (2001).

Table 1: VA Long- Term Care Workload and Costs, by Care Setting, Fiscal Year
2001 Long- term care setting Average daily census a Total cost

Institutional b 45,033 $2,888, 659, 000 Noninstitutional 23,205 239, 939,
000

Total 68,238 $3,128, 598, 000

Source: VA. a The average daily census represents the total number of days
of inpatient care for institutional care

and the total number of outpatient encounters for noninstitutional care,
each divided by the number of days in the year. These figures may overstate
the number of veterans receiving noninstitutional services because some
veterans may receive more than one noninstitutional service on a particular
day. b Institutional long- term care includes care that VA provides or pays
for in nursing homes and other

residential settings.

The proportion of VA?s long- term care costs for noninstitutional care has
doubled over the past decade, as shown in figure 1. This has occurred as
part of a larger trend within VA toward reducing its heavy reliance on
inpatient care. Nevertheless, VA?s costs for noninstitutional long- term
care remain small relative to its costs for institutional long- term care.

Figure 1: VA Long- Term Care Costs, By Care Setting, Fiscal Year 1991 -
Fiscal Year 2001

1991 2001 4%

Noninstitutional 8% long- term care

96% Institutional

92% long- term care Source: VA.

Medicaid- the nation?s largest purchaser of long- term care- has seen a
similar increase in the proportion of its long- term care costs for
noninstitutional services. As in VA, the proportion of Medicaid?s long- term

care costs for this purpose has doubled, from 13 percent in 1990 to 27
percent in 2000. However, similar to VA, the bulk of Medicaid?s long- term
care costs are still for institutional care. VA is one of several federal
agencies attempting to emphasize noninstitutional long- term care. Executive
Order 13217, 6 signed in June 2001, directs six federal agencies to evaluate
their policies, programs, statutes, and regulations to determine whether any
should be revised or modified to improve the availability of
noninstitutional services for qualified individuals with disabilities. 7
Although VA was not among the agencies named in the order, VA joined the
effort on a voluntary basis and

subsequently reported that it will evaluate its noninstitutional long- term
care services to determine whether any could be expanded or modified to
further promote noninstitutional services to veterans with disabilities.

VA will face increasing demand for long- term care as our nation?s veteran
population ages. VA statistics show that, although the total number of
veterans will decline in the next 10 years, the number of veterans age 85

and older will triple during that time. This will significantly increase the
need for VA?s long- term care resources because although a chronic physical
or mental disability may occur at any age, the older an individual becomes,
the more likely it is that a disability will develop or worsen. Indeed,
while about 4. 8 percent of persons age 65- 84 report a disability, the
proportion nearly quadruples to 18. 1 percent among those 85 and older. 8

6 66 Fed. Reg. 33,155 (June 18, 2001). 7 The agencies were the Departments
of Education, Health and Human Services, Housing and Urban Development,
Justice, and Labor, and the Social Security Administration.

8 These data represent individuals reporting a problem with two or more of
the following six activities of daily living: bathing, dressing, eating,
transferring between bed and chair, toileting, and getting around inside the
home. Data are from the Department of Health and

Human Services? 1994- 95 National Health Interview Survey on Disability.

As a result of this demographic pressure, concerns have been raised for some
time about VA?s ability to meet the expected rise in demand for longterm
care services. In 1997 VA established a Federal Advisory Committee on the
Future of VA Long- Term Care composed of national leaders in longterm care,
and charged it with evaluating VA long- term care services and developing a
strategy for meeting future needs. In its June 1998 report, 9 the committee
stated that VA long- term care was unevenly funded and

recommended that VA expand noninstitutional long- term care services and
emphasize these services, when clinically appropriate, for veterans needing
long- term care.

VA?s Response to the The Millennium Act requires VA to provide adult day
health care-

Millennium Act Is Not noninstitutional care in which health maintenance and
rehabilitative services are provided to frail elderly veterans in an
outpatient day setting. Complete

The act also requires that VA provide two additional services, geriatric
evaluation and respite care, 10 but does not specify whether these services
must be provided in institutional or noninstitutional settings. More than 2
years after the act?s passage, however, VA has not completed its response to
the act?s requirement that all eligible veterans be offered these three
services. In October 2001, VA published proposed regulations to add the
three required services in noninstitutional settings to its medical benefits
package, the standard health plan available to all veterans enrolled

in VA?s health care system. As of April 17, 2002, final regulations had not
been published, although VA officials told us that VA sent draft final
regulations to the Office of Management and Budget for approval on March

14, 2002. To be responsive to the act?s requirements before its draft
regulations were finalized, however, VA issued a policy directive in October
2001 requiring that its medical facilities ensure that veterans have access
to adult day health care, geriatric evaluation, and respite care in
noninstitutional

9 Department of Veterans Affairs, VA Long- Term Care At The Crossroads:
Report of the Federal Advisory Committee on the Future of VA Long- Term Care
(Washington, D. C.: June 1998).

10 Geriatric evaluation involves evaluation of veterans with particular
geriatric needs and is generally provided by VA through one of two services,
geriatric evaluation and management or geriatric primary care. Respite care
is a program in which brief periods of care are provided to veterans in
order to give veterans? regular caregivers a period of respite.

settings. A VA headquarters official told us that VA headquarters will soon
begin monitoring medical facilities to ensure that they provide access to
these three services in noninstitutional settings. Both VA?s directive and
its proposed regulations specify that geriatric

evaluation and respite care be provided in noninstitutional settings even
though the act does not state whether they must be provided in institutional
or noninstitutional settings. (Adult day health care is by definition a
noninstitutional service.) VA officials told us that VA chose to make clear
its intent to have these services provided in noninstitutional

settings because they were already widely offered in institutional settings.
In fact, prior to the act VA was not authorized to provide noninstitutional
respite care- until then, VA could provide respite care only in
institutional settings. In contrast, prior to the act VA provided both adult
day health care and noninstitutional geriatric evaluation; VA headquarters
encouraged facilities to offer these services and provided guidance for
facilities to use

when doing so. When VA issued its policy directive in October 2001, it was
far from its goal of universal access to these three noninstitutional
services, as shown in figure 2. Among the three services, adult day health
care was most widely available, followed by geriatric evaluation and respite
care. VA officials

told us that noninstitutional respite care is not widely offered because
until the Millennium Act VA was not authorized to provide respite care in
noninstitutional settings.

Figure 2: Number of 139 VA Facilities Offering Certain Long- Term Care
Services Required by the Millennium Act and Available in Noninstitutional
Settings, Fall 2001 140

VA facilities offering service 120 100

80 60 40 20

0 Adult day

Geriatric Respite health care

evaluation a care VA long- term care service

Source: GAO survey of VA facilities; VA headquarters data. Note: Responses
to our survey were submitted in September and October 2001. a ?Geriatric
evaluation? encompasses facilities reporting geriatric evaluation and
management services in our survey and additional facilities reported by VA
headquarters as offering geriatric primary care.

Availability of Other Uneven availability of noninstitutional services is
not limited to the three

Noninstitutional services that VA requires its facilities to offer in
response to the Millennium

Act. Although at least nine different noninstitutional long- term care
Services Is Also services are provided or contracted for by VA (including
the three services Uneven that VA requires as a result of the act),
considerable unevenness exists in what services are offered by individual
facilities. For example, 123 VA facilities reported offering skilled home
health care, 11 while about half as many facilities- 63- reported offering
community residential care. Figure

3 shows the number of VA?s 139 facilities at which these nine
noninstitutional long- term care services are offered.

11 Skilled home health care consists of professional home health care
services, mostly nursing services, purchased by VA and delivered by non- VA
health care providers.

Figure 3: Number of 139 VA Facilities at Which Noninstitutional Long- term
Care Services are Offered, by Service (Fall 2001) 140

VA facilities offering service 120 100

80 60 40 20

0 aide

home care day care

Geriatric based

care care

Hospice care care

respite care Homemaker/

health Skilled health Adult health evaluationa Home- primary Community

residential Alzheimer's/ dementia Home home VA long- term care service

Source: GAO survey of VA facilities; VA headquarters data. Note: Responses
to our survey were submitted in September and October 2001. a Includes
facilities reporting geriatric evaluation and management services in our
survey and additional

facilities reported by VA headquarters as offering geriatric primary care.

Similar variation exists in the number of services offered by individual
facilities. For example, while several facilities reported offering at least
eight of the nine noninstitutional long- term care services we identified,
one facility reported offering only one noninstitutional service, and two
more facilities reported offering none at all.

These results are similar to the distribution of services noted by the 1998
Advisory Committee on the Future of VA Long- Term Care, which stated that VA
long- term care- institutional as well as noninstitutional- was not
available universally and that access to long- term care was often
restricted. Similarly, a VA headquarters official we spoke with noted that
VA?s

noninstitutional long- term care services are not equally accessible across
the country. Concluding As the veteran population ages, VA will face
increasing demand for longterm

Observations care services. Providing more even access to noninstitutional
longterm

care services across VA facilities, including those services now required as
a result of the Veterans Millennium Health Care and Benefits Act, could help
VA meet this demand while at the same time offering

veterans more options from which to choose. Mr. Chairman, this concludes my
prepared statement. I will be happy to answer any questions you or the other
committee members may have.

Contacts and For more information regarding this testimony, please contact
me at (202) Acknowledgments 512- 7101 or James Musselwhite at (202) 512-
7259. Joe Buschy and Steve

Gaty also made key contributions to this statement.

Noninstitutional Long- Term Care Services

Appendi x I

Offered by VA  Adult day health care: health maintenance and rehabilitative
services provided to frail elderly veterans in an outpatient day setting.

 Alzheimer?s/ dementia care: specialized outpatient services such as
behavioral and medical management provided to veterans with Alzheimer?s
disease or related dementias.

 Community residential care: a service in which veterans who do not require
hospital or nursing home care- but who (because of medical or psychosocial
health conditions) are unable to live independently- live

in VA- approved community residential care facilities; VA pays
administrative costs only.

 Geriatric evaluation: evaluation of veterans with particular geriatric
needs, generally provided by VA through one of two services: (1) geriatric
evaluation and management (GEM), in which interdisciplinary health care
teams of geriatric specialists evaluate and manage frail elderly veterans,
and (2) geriatric primary care, in which outpatient primary care, including
medical and nursing services, preventive health care services, health
education, and specialty referral, is provided to geriatric veterans.

 Home- based primary care: primary medical care provided in the home by VA
physicians, nurses, and other VA healthcare professionals to severely
disabled, chronically ill veterans whose conditions make them

unsuitable for management in outpatient clinics.

 Homemaker/ home health aide: home health aide and homemaker services, such
as grooming, housekeeping, and meal preparation services.

 Home respite care: home- based services provided to veterans on a short-
term basis to give veterans? caregivers a period of relief or respite.

 Hospice care: home- based palliative and supportive services for veterans
in the last phases of incurable disease so that they may live as fully and
as comfortably as possible.

 Skilled home health care: medical services provided to veterans at home by
non- VA health care providers.

(290184)

GAO United States General Accounting Office

a

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