VA Long-Term Care: Service Gaps and Facility Restrictions Limit  
Veterans' Access to Noninstitutional Care (09-MAY-03,		 
GAO-03-487).							 
                                                                 
In April 2002, at the request of the Senate Committee on	 
Veterans' Affairs, we testified on variation in the availability 
of VA's noninstitutional long-term care services. Congress	 
expressed concern that this variation could mean that some	 
veterans did not have access to noninstitutional services because
of gaps in service availability and because of the restrictions  
that some facilities might place on veterans' use of these	 
services, such as limiting the amount of service a veteran may	 
receive. To address these concerns, we updated and expanded our  
previous work to determine (1) whether veterans' access to six	 
noninstitutional services is limited by service availability and 
restrictions on use and (2) if access is limited, what factors,  
contribute to limited access.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-487 					        
    ACCNO:   A06750						        
  TITLE:     VA Long-Term Care: Service Gaps and Facility Restrictions
Limit Veterans' Access to Noninstitutional Care 		 
     DATE:   05/09/2003 
  SUBJECT:   Elder care 					 
	     Health care costs					 
	     Health care facilities				 
	     Home health care services				 
	     Long-term care					 
	     Veterans benefits					 

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GAO-03-487

Report to Congressional Requesters

United States General Accounting Office

GAO

May 2003 VA LONG- TERM CARE

Service Gaps and Facility Restrictions Limit Veterans* Access to
Noninstitutional Care

GAO- 03- 487

Veterans* access to the six noninstitutional services we reviewed is
limited by service gaps and facility restrictions. Of VA*s 139 facilities,
126 do not offer all six of these services adult day health care,
geriatric evaluation, respite care, home- based primary care, homemaker/
home health aide, and skilled home health care. Veterans have the least
access to respite care, which is not offered at 106 facilities. By
contrast, skilled home health care is

not offered at 7 facilities. Veterans* access is more limited than these
numbers suggest, however, because even when facilities offer these
services they often do so in only part of the geographic area they serve.
In fact, for four of the six services the majority of facilities either do
not offer the service or do not provide access to all veterans living in
their geographic service area. Veterans* access may be further limited by
restrictions that

individual facilities set for use of services they offer. For example, at
least 9 facilities limit veterans* eligibility to receive noninstitutional
services based on their level of disability related to military service,
which conflicts with VA*s eligibility standards. Further, restrictions
placed by many facilities on the number of veterans who can receive
noninstitutional services have

resulted in veterans at 57 of VA*s 139 facilities being placed on waiting
lists for noninstitutional services.

Noninstitutional Long- Term Care Services Not Available to All Veterans,
Based on Geographic Areas, at VA*s 139 Facilities as of Fall 2002

VA*s lack of emphasis on increasing access to noninstitutional long- term
care services has contributed to service gaps and individual facility
restrictions that limit access to care. Without emphasis from VA
headquarters on the provision of noninstitutional services, field
officials

faced with competing priorities have chosen to use available resources to
address other priorities. While VA has implemented a performance measure
for fiscal year 2003 that encourages networks to increase veterans* use of
five of the six noninstitutional services, it does not require networks to
ensure that all facilities provide veterans access to noninstitutional
services. With the aging of the veteran population, the Department of
Veterans Affairs (VA) is likely to see a significant increase in demand
for long- term care. In response to recent GAO findings

that variation exists in availability of noninstitutional services across
VA, GAO was asked to update and expand its previous work to determine (1)
whether veterans* access to six noninstitutional

services is limited by service availability and restrictions on use and
(2) if access is limited, what factors contribute to limited access. GAO
surveyed VA*s 139 medical facilities, visited 4 of them and updated
information collected from a fifth facility visited during earlier work,
and interviewed

headquarters and field officials. GAO is recommending that VA:

ensure that facilities follow VA*s eligibility standards when determining
veteran eligibility for

noninstitutional long- term care services, and refine current performance
measures to help ensure that all VA facilities provide veterans with
access to required noninstitutional services. VA concurred with the
recommendations.

www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 487. To view the full report,
including the scope and methodology, click on the link above. For more
information, contact Cynthia A. Bascetta at (202) 512- 7101. Highlights of
GAO- 03- 487, a report to Congressional Requesters

May 2003

VA LONG- TERM CARE

Service Gaps and Facility Restrictions Limit Veterans* Access to
Noninstitutional Care

Page i GAO- 03- 487 VA Noninstitutional Long- Term Care Letter 1 Results
in Brief 3 Background 4 Veterans* Access Is Limited by Gaps in Service
Availability and Facility Restrictions on Service Use 7 Lack of Emphasis,
Inadequate Guidance, and Other Factors

Contribute to Limited Access 12 Conclusions 16 Recommendations for
Executive Action 16 Agency Comments 17 Appendix I VA Noninstitutional
Long- Term Care Services in Our Review 18

Appendix II Scope and Methodology 19

Appendix III Availability and Utilization of Six Noninstitutional Long-
Term Care Services by VA Medical Facility or Health Care System 22

Appendix IV Comments From the Department of Veterans Affairs 27

Appendix V GAO Contact and Staff Acknowledgments 28 GAO Contact 28
Acknowledgments 28 Related GAO Products 29

Tables

Table 1: VA Long- Term Care Workload and Expenditures, by Care Setting,
Fiscal Year 2002 6 Contents

Page ii GAO- 03- 487 VA Noninstitutional Long- Term Care Table 2:
Noninstitutional Services in Our Review Offered by the Five VA Facilities
We Visited 20 Table 3: Availability and Utilization of Six
Noninstitutional LongTerm

Care Services at VA Medical Facilities (July 2002) 22 Figures

Figure 1: Noninstitutional Long- Term Care Services at VA*s 139 Medical
Facilities 8 Figure 2: Noninstitutional Long- Term Care Services, Based on
Geographic Areas, at VA*s 139 Medical Facilities 9 Abbreviations

HCS health care system VA Department of Veterans Affairs

This is a work of the U. S. Government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. It may contain
copyrighted graphics, images or other materials. Permission from the
copyright holder may be necessary should you wish to reproduce copyrighted
materials separately from GAO*s product.

Page 1 GAO- 03- 487 VA Noninstitutional Long- Term Care May 9, 2003 The
Honorable Bob Graham Ranking Minority Member Committee on Veterans*
Affairs

United States Senate The Honorable Lane Evans Ranking Minority Member
Committee on Veterans* Affairs

House of Representatives The Honorable John D. Rockefeller IV United
States Senate

The Department of Veterans Affairs (VA) spent about $23 billion on health
care in fiscal year 2002, including about $3.3 billion on long- term care.
Demand for VA long- term care is likely to increase significantly during
the next decade. Because of the aging of the veteran population, VA
estimates that the number of veterans age 85 and older* those most in need
of longterm care* will more than double, from about 640, 000 currently to
about 1.3 million in 2012. Due to changes in VA*s eligibility standards
more older veterans will be eligible to receive VA health care, including
long- term care services.

In recent years, VA has increased the proportion of its long- term care
spending on care in noninstitutional settings, such as veterans* own
homes. This is consistent with the preference of many veterans and others

to receive care in their homes or in other settings, such as adult day
health care centers, that are less restrictive than institutions. For
example, some veterans receive assistance in their homes with bathing and
dressing provided by home health aides. However, VA has traditionally
provided

the bulk of veterans* long- term care in institutional settings, such as
nursing homes, which is reflected in VA*s spending for long- term care
services. In fiscal year 2001, more than 90 percent of VA*s long- term
care spending was for institutional long- term care.

In November 1999, the Congress passed the Veterans Millennium Health Care
and Benefits Act (Millennium Act), 1 which required that VA provide

1 Pub. L. No. 106- 117, 113 Stat. 1545 (1999).

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 03- 487 VA Noninstitutional Long- Term Care veterans access to
three services adult day health care, geriatric evaluation, and respite
care. VA chose to meet the Millennium Act

requirements by issuing a directive in October 2001 requiring that
facilities provide adult day health care, noninstitutional geriatric
evaluation, and noninstitutional respite care to veterans in need of such
services. 2 In April 2002, at the request of the Senate Committee on
Veterans* Affairs, we testified on variation in the availability of VA*s
noninstitutional longterm

care services. 3 Your offices expressed concern that this variation could
mean that some veterans did not have access to noninstitutional services
because of gaps in service availability and because of the restrictions
that some facilities might place on veterans* use of these

services, such as limiting the amount of service a veteran may receive. To
address these concerns, you asked us to update and expand our previous
work 4 to determine (1) whether veterans* access to six noninstitutional
services is limited by service availability and restrictions on use and
(2) if access is limited, what factors contribute to limited access. The
six noninstitutional services you asked us to examine are the three that
VA requires as a result of the Millennium Act adult day health care,
geriatric evaluation, and respite care and three additional
noninstitutional services* home- based primary care, skilled home health
care, and

homemaker/ home health aide. See appendix I for information on these six
noninstitutional long- term care services.

To do our work, we surveyed each of VA*s 139 medical facilities to obtain
data on the types of services offered and the number of veterans receiving
the six noninstitutional long- term care services, 5 and where access to
services was limited, we identified the reasons why services were limited.

We compared these survey data to the data we obtained in our fall 2001
survey of VA long- term care services to determine the extent to which

2 The act requires that VA provide noninstitutional extended care services
to enrolled veterans until December 31, 2003. 3 U. S. General Accounting
Office, VA Long- Term Care: The Availability of Noninstitutional Services
Is Uneven, GAO- 02- 652T (Washington, D. C.: Apr. 25, 2002).

4 U. S. General Accounting Office , VA Long- Term Care: Implementation of
Certain Millennium Act Provisions Is Incomplete, and Availability of
Noninstitutional Services Is Uneven, GAO- 02- 510R (Washington, D. C.:
Mar. 29, 2002). 5 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.

Page 3 GAO- 03- 487 VA Noninstitutional Long- Term Care availability had
changed since that survey. To gain an understanding of facilities*
noninstitutional long- term care operations we also interviewed

VA officials in headquarters and in each of VA*s 21 network offices, 6
visited 4 VA medical facilities* located in Memphis, Tennessee; Richmond,
Virginia; Tucson, Arizona; and Walla Walla, Washington and updated
information collected from a fifth facility in Albany, New York, which we
visited for our previous report on noninstitutional services. These five
facilities were chosen based on variation in both the number and type of
noninstitutional services they offered. In addition, we evaluated
directives and regulations and other guidance related to these six
noninstitutional

services issued by VA headquarters, networks, and individual facilities.
For a complete description of our scope and methodology, see appendix II.
Our work was conducted from June 2002 through April 2003 in accordance
with generally accepted government auditing standards.

Veterans* access to the six noninstitutional long- term care services in
our study is limited by the lack of service availability and restrictions
on their use. Of VA*s 139 facilities, 126 do not offer all six of the
services. Veterans have the least access to noninstitutional respite care,
which is not offered by 106 VA facilities. By contrast, skilled home
health care is not offered at 7 facilities. Furthermore, veterans* access
to care is more limited than

these numbers suggest, because even when facilities offer these services
they often do so in only parts of the geographic area they serve. In fact,
for four of the six services noninstitutional respite care, home- based
primary care, adult day health care, and noninstitutional geriatric
evaluation the majority of facilities either do not offer the service or
do not offer the service in the entire geographic area they serve.
Veterans* access may be further limited by restrictions that individual
facilities set for use of services they offer. For example, 9 facilities,
in conflict with VA*s eligibility standards, limited veterans* access to
noninstitutional

services based on their level of disability related to military service.
Further, restrictions placed by many facilities on the number of veterans
who can receive noninstitutional services have resulted in veterans at 57
of VA*s 139 facilities being placed on waiting lists for noninstitutional
services.

6 VA originally created 22 networks, but in January 2002 VA merged 2
networks into a single network, leaving the agency with 21 networks.
Results in Brief

Page 4 GAO- 03- 487 VA Noninstitutional Long- Term Care VA*s lack of
emphasis on increasing access to noninstitutional long- term care services
and a lack of guidance on the provision of these services have contributed
to service gaps and individual facility restrictions. VA headquarters has
not emphasized increasing access to these services by

establishing measurable performance goals as it has for other priorities
such as maintaining workloads in VA nursing homes. Without such
performance measures, field officials faced with competing priorities have
chosen to use available resources to address other priorities. VA has
implemented a performance measure for fiscal year 2003 that encourages
networks to increase veterans* use of five of the six noninstitutional
services, but it does not require networks to ensure that all network
facilities provide veterans access to noninstitutional services. Moreover,

VA has not provided facilities with adequate guidance on the provision of
noninstitutional respite care, even though most have had little experience
in providing the service. Some networks and facilities are confused about
how to provide the service and as a result some are not providing the
service. VA has also not provided adequate guidance on which

noninstitutional services are required. In particular, VA has not
specified whether the home health services requirement includes one, all,
or some combination of home- based primary care, homemaker/ home health
aide,

and skilled home health care. In the absence of VA headquarters guidance
on what home health services are required, VA facilities vary in their
interpretations of what services they must provide. To help ensure that
veterans have access to noninstitutional long- term care services and that
such services are offered uniformly throughout VA, we are recommending
that VA take actions to increase emphasis on

provision of these services, provide adequate guidance on their provision,
and ensure that VA*s eligibility standards are used to determine
eligibility. VA concurred with our recommendations, discussed preliminary
actions it plans to take, and stated that it will provide a detailed
action plan to

implement our recommendations after this report is issued. Changes in VA*s
eligibility standards have resulted in an increase in the number of
veterans who are eligible to receive VA health care, including
noninstitutional long- term care services. The Veterans* Health Care

Eligibility Reform Act of 1996 7 authorized VA to provide health care
services not previously available to veterans without service- connected

7 Pub. L. No. 104- 262 S:S: 101, 104, 110 Stat. 3178- 79, 3182- 83 (1996).
Background

Page 5 GAO- 03- 487 VA Noninstitutional Long- Term Care disabilities or
low incomes. 8 As required by the act and due to an anticipated increase
in demand for VA health care from these changes in eligibility, VA
established an enrollment system to manage veterans* access to care. This
system includes eight priority categories for enrollment, with higher
priority given to veterans with service- connected

disabilities, lower incomes, or other recognized statuses such as former
prisoners of war. If sufficient resources are not available to provide
care that is timely and acceptable in quality for all priority groups, the
act requires VA to limit enrollment nationally, consistent with the eight
priority groups. If needed, enrollment restrictions would begin with the
lowest priority category. On January 17, 2003, VA announced that it would
no longer enroll priority 8 veterans, those in the lowest priority
category, for the duration of the year. 9 VA long- term care includes a
continuum of services for the delivery of care to veterans needing
assistance due to chronic illness or physical or mental disability.
Assistance with veterans* needs takes many forms and is

provided in varied settings, including institutional care in nursing homes
or in noninstitutional settings preferred by many veterans, including
inhome care services and community- based services such as adult day
health care centers. Long- term care also includes respite care services
that temporarily relieve a veteran*s caregiver from the burden of caring
for a

chronically ill and disabled veteran in the home. VA offers long- term
care services directly or through other providers with which VA contracts.

VA provides most of its long- term care to veterans in institutional
settings, such as VA nursing homes or state- owned veterans* homes rather
than in noninstitutional settings. In fiscal year 2002, VA served about 36
percent of its long- term care workload, or average daily census, in
noninstitutional settings (see table 1). That same year noninstitutional
care accounted for 9 percent of VA*s long- term care expenditures. In
contrast, noninstitutional 8 A service- connected disability is an injury
or disease that was incurred or aggravated while on active military duty.
VA classifies veterans with service- connected disabilities according to
the extent of their disability. These classifications are expressed in
terms of percentages* for example, the most severely disabled such veteran
would be classified as having a service- connected disability of 100
percent. Percentages are assigned in increments of 10 percent. 9 Priority
8 veterans are primarily veterans with no service- connected disabilities
who have incomes above established limits for geographic regions set by
the U. S. Department of

Housing and Urban Development to reflect regional costs of living.
Priority 8 veterans enrolled prior to January 17, 2003, remain enrolled to
receive VA health care benefits.

Page 6 GAO- 03- 487 VA Noninstitutional Long- Term Care care accounted for
about 29 percent of Medicaid*s long- term care expenditures in fiscal year
2001, the most recent year for which data are

available. 10 Table 1: VA Long- Term Care Workload and Expenditures, by
Care Setting, Fiscal Year 2002 Long- term care setting Average daily
census a Total expenditures

Institutional 43,363 $2,979,156,000 Noninstitutional 24,126 283,098,000
Total 67,489 $3,262,254,000

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. Thus, the figures represent VA*s workload
during the year and not an unduplicated count of veterans in these
settings because some veterans receive more than one service. VA has
delegated decision making regarding financing and service delivery for
long- term care and other health care services to its 21 health care
networks. VA allocates resources for health care to each of the 21
networks primarily through the Veterans Equitable Resource Allocation
system, in which networks are funded through a formula reflecting the
number and types of veterans receiving care in the network, including
those receiving long- term care. 11 In turn, VA*s networks have budget and
management responsibilities that include allocating resources received
from headquarters to facilities within their networks* including resources
used to provide long- term care services.

10 Medicaid, the joint federal- state health- financing program for low-
income individuals, is the nation*s largest funding source for long- term
care. In fiscal year 2001, Medicaid expenditures on long- term care
totaled $75. 3 billion. 11 For more information on VA*s resource
allocation system see U. S. General Accounting Office, VA Health Care:
Allocation Changes Would Better Align Resources with Workload, GAO- 02-
338 (Washington, D. C.: Feb. 28, 2002).

Page 7 GAO- 03- 487 VA Noninstitutional Long- Term Care Veterans* access
to the six noninstitutional services in our review adult day health care,
geriatric evaluation, respite care, home- based primary

care, homemaker/ home health aide, and skilled home health care* is
limited due to gaps in availability and facility restrictions on use of
the services. Of VA*s 139 facilities, 126 do not offer all six
noninstitutional services. Facilities that do offer a service do not
always offer the service to veterans in the entire geographic area the
facility serves. Further, veterans* access to the six noninstitutional
services may be limited by restrictions

that individual VA facilities place on service use. Some of these facility
restrictions conflict with VA eligibility standards which state that most
services are to be available to all enrolled veterans regardless of
priority group. The restrictions include providing services only to
certain veterans

or limiting the number of veterans who can use services at any one time.
Access to care is limited because many VA facilities do not offer the six
noninstitutional services in our review. Of VA*s 139 facilities, 126 did
not offer all of the six noninstitutional services in fall 2002, a pattern
similar to that in fall 2001. (See fig. 1.) The least commonly available
service of the six we reviewed in 2001 and 2002 was noninstitutional
respite care. This service was not available at 110 of VA*s 139 facilities
in fall 2001, and as of

fall 2002, noninstitutional respite care was not available at 106 of VA*s
139 facilities. In contrast, the most widely available service we reviewed
was skilled home health care, which was offered at all but 7 facilities.
For a complete list of the services each VA facility reported offering,
see

appendix III. Veterans* Access Is

Limited by Gaps in Service Availability and Facility Restrictions on
Service Use

Access to Care Is Limited by Service Gaps Across VA

Page 8 GAO- 03- 487 VA Noninstitutional Long- Term Care Figure 1:
Noninstitutional Long- Term Care Services at VA*s 139 Medical Facilities

Note: Includes services provided directly by facilities or through
contracts with other providers as of fall 2001 and fall 2002. Veterans*
access to these services is further limited because among facilities that
offer services, many do so in only parts of the geographic area they
serve. Our fall 2002 survey showed that for four of the six services
noninstitutional respite care, home- based primary care, adult day health
care, and noninstitutional geriatric evaluation the majority of the
facilities either did not offer the service or did not offer the service
in the entire geographic area they serve. As shown in figure 2, 42
facilities did

not offer adult day health care and an additional 76 facilities did not
offer it in their entire geographic service area. As a result, where
veterans live in a facility*s geographic service area sometimes determines
whether they can access the services offered by the facility. The
remaining 21 facilities reported that they offered adult day health care
in all parts of their geographic service areas. Offered

Not offered

Homemaker/ home health

aide Respite care Home- based

primary care Geriatric

evaluation Adult day

health care Skilled home

health care 0

20 40

60 80

100 120

140

Source: GAO.

VA facilities 2001 2002 2001 2002 2001 2002 2001 2002 2001 2002 2001 2002

Page 9 GAO- 03- 487 VA Noninstitutional Long- Term Care Figure 2:
Noninstitutional Long- Term Care Services, Based on Geographic Areas, at
VA*s 139 Medical Facilities

Note: Includes services provided directly by facilities or through
contracts with other providers as of fall 2002. VA may also arrange for
veterans to access three noninstitutional longterm care services from non-
VA sources even though VA does not pay for these services. The Millennium
Act and VA policy allow facilities to make available to veterans the
services required as a result of the Millennium Act adult day health care,
noninstitutional respite care, and noninstitutional geriatric evaluation
through other providers or payers

while still overseeing the care delivered using a case management
approach. 12 However, VA headquarters has neither issued guidance on the
use of case management to meet this requirement under the Millennium Act
nor has it monitored the extent to which facilities use this option.

Further, the use of case management by VA to make these three services 12
Case management includes assessment of the veteran*s care needs, care
planning and implementation, referral coordination, monitoring, and
periodic reassessment of the veteran*s care needs. 0 20

40 60

80 100

120 140

Homemaker/ home health aide Respite care Home- based

primary care Geriatric

evaluation Adult day

health care Skilled home

health care

Offered in entire geographic area

VA facilities

Source: GAO. Offered but not in entire geographic area

Not offered

Page 10 GAO- 03- 487 VA Noninstitutional Long- Term Care available to
veterans is limited by the eligibility of veterans for these other sources
of care. That is, if veterans are not eligible for other sources of

care, such as Medicaid and Medicare, and VA does not provide the service,
then veterans will likely not have access to the three services. Access to
care is further limited by the restrictions that some facilities place on
the six noninstitutional services in our review. These restrictions
include (1) limiting services to veterans with certain levels of
serviceconnected disability, (2) limiting the amount of service that
veterans can receive, and (3) establishing a maximum number of veterans
who can receive a service at any time.

We found that nine VA facilities imposed their own eligibility
restrictions on access to noninstitutional services based on veterans*
serviceconnected disabilities. We identified five of these nine facilities
through comments facilities made in our survey, although we did not
systematically ask facilities this question in our survey. Because we did

not systematically ask in our survey, it is possible that additional
facilities may impose similar eligibility restrictions. Other VA
facilities may have also instituted similar restrictions on access. These
restrictions conflict with VA eligibility standards and result in
inequitable access for veterans enrolled at these facilities. VA*s
eligibility standards state that most services are to be available to all
enrolled veterans, regardless of priority

group. 13 In our survey of VA*s 139 facilities, 5 facilities provided
additional comments indicating that they limit certain services* including
adult day health care, homemaker/ home health aide, skilled home health,
and respite care* to veterans with service- connected disabilities. Four
of the 5 facilities limit services to veterans with service- connected
disabilities of 70 percent or greater. In addition, one of the facilities
we visited provides

homemaker/ home health aide services to veterans with service- connected
disabilities of 70 percent or greater. Another facility we visited
provides the service primarily to veterans with service- connected
disabilities of 70 percent or greater or veterans with service- connected
disabilities of at least 60 percent for a single condition; other veterans
may receive the

13 Although VA issued a regulation on September 17, 2002, granting
priority for appointments to veterans with service- connected disabilities
of at least 50 percent and veterans needing care for a service- connected
disability, the regulation does not change other veterans* eligibility to
receive services. Veterans* Access to Care Is

Further Limited by Individual Facility Restrictions

Some Facilities Limit Access to Services Based on Veterans* Service-
Connected Disability

Levels

Page 11 GAO- 03- 487 VA Noninstitutional Long- Term Care service, but only
for 6 months. In addition, one network official told us that 2 facilities
in his network limit homemaker/ home health aide services to veterans with
service- connected disabilities of 70 percent or greater because under the
Millennium Act VA must pay for nursing home care

when such veterans need it. 14 According to this official, because
homemaker/ home health aide services can keep veterans in their own homes
rather than in nursing homes, providing the service to such veterans can
delay the need for nursing home care and the resultant financial
obligation for the facilities.

The amount of service veterans receive may depend on which facility
provides their care. Facilities vary in the limits they set. Some
facilities restrict the amount of a noninstitutional service a veteran can
receive once the veteran has been authorized to receive care. For example,
a network official told us that one network facility offers veterans up to
24 hours per week of homemaker/ home health aide services while a facility
official in another network told us their facility provides no more than
10 hours per week. A facility we visited in another network does not place
any restrictions on the amount of homemaker/ home health aide services
provided.

Facility officials noted that they can serve more veterans if they limit
the amount of service provided to each veteran. One facility we contacted
provided veterans no more than 2 days per week of adult day health care.
Because of this restriction, veterans whose medical needs require more
adult day health care pay for the service themselves, find another payer

such as Medicaid, or forego the additional service. At another facility we
visited, veterans without service- connected disabilities were limited to
2 full days or 3 half days per week regardless of medical need. In 1998,
this facility also reduced the number of homemaker/ home health aide hours

provided each week from 21 to 8 in order to increase the number of
veterans who could be provided the service. At both facilities, officials
emphasized that the purpose of limits on the amount of service provided
was to increase the number of veterans who could receive at least some of
the service.

14 The Millennium Act requires that VA provide nursing home care to any
veteran who needs such care and who has a service- connected disability of
70 percent or greater, or to any veteran needing such care specifically
for a service- connected disability, even if the disability is less than
70 percent. Access Is also Limited by Restrictions on the Amount of
Services Provided

Page 12 GAO- 03- 487 VA Noninstitutional Long- Term Care In our survey of
VA facilities, 57 of 139 facilities reported maintaining a list of
veterans waiting for at least one of the services in our review. These
facilities told us in effect that they are not meeting all their veterans*
needs

for noninstitutional services. Many facilities place limits on the total
number of veterans they serve by establishing a budget cap* the maximum
number of veterans who can receive a particular service at any time. For
three of the six services in our study* home- based primary care,
homemaker/ home health aide, and noninstitutional geriatric evaluation*
most facilities reported in our survey that despite offering the service,
they were currently unable to provide services to additional veterans
within their budget caps. Additional veterans needing services would have
to wait until space or resources became available.

A lack of VA emphasis on increasing access to noninstitutional long- term
care services, inadequate VA guidance on providing these services, and
other factors have contributed to limited access for veterans. VA had not
provided measurable standards for the provision of these services until
fiscal year 2003 or oversight to monitor their provision as it has for
highpriority

services. VA guidance on the provision of noninstitutional longterm care
services has left unclear to some facilities how one service is to be
defined and provided and whether some of the services in our review are a
part of what VA requires be made available to veterans who need them.
Other factors, such as availability of contractors to provide a service,
also contribute to the lack of access for specific services.

VA network and facility officials told us that VA headquarters has not
emphasized increased access to noninstitutional long- term care services
but emphasized other priorities. As a result, these officials said they
use

their resources for the priorities VA headquarters emphasizes rather than
noninstitutional services. For example, officials in 9 of VA*s 21 networks
told us that VA headquarters* emphasis on the performance measure that
requires networks to maintain workload in VA nursing homes has led them to
devote resources to nursing home care that they might otherwise have

used to provide noninstitutional services. One network director told us
that the *pressure* from VA headquarters to maintain nursing home
utilization is much greater than that to offer noninstitutional services.
In another network, an official at a VA facility not offering three of the
services in our study told us that these services were *victims of
competition for resources.* In other words, the facility had not funded
these three noninstitutional services because facility officials had
chosen to devote resources to other services. Another network director
told us Access at Many Facilities Is Restricted by Limits on the Number of
Veterans Served

Lack of Emphasis, Inadequate Guidance, and Other Factors Contribute to
Limited Access

VA Has Not Emphasized Increased Access to Noninstitutional LongTerm Care
Services

Page 13 GAO- 03- 487 VA Noninstitutional Long- Term Care that, if forced
to choose between funding different services, the network would allocate
resources to services included in a performance measure.

One way VA emphasizes services is through performance measures, which VA
establishes to monitor network officials* progress toward meeting certain
VA strategic goals, such as increasing veteran access to services. VA has
demonstrated that requiring network officials to meet measurable
performance standards can promote change. For example, since their
inception in fiscal year 1996 VA performance measures have included a
measure for providing immunizations to prevent pneumonia to veterans age
65 and older and those at high risk of the disease. VA increased the
percentage of veterans in this population who received the immunization
from 26 percent in fiscal year 1996 to 81 percent in fiscal year 2002.

In October 2002, VA introduced a performance measure for noninstitutional
long- term care which requires all networks to provide noninstitutional
services to a portion of their enrolled veterans needing such services
14.4 percent in fiscal year 2003 and 16 percent in fiscal year 2006. 15
The fiscal year 2003 goal for this measure will require the

majority of networks to increase utilization of their noninstitutional
services. The performance measure includes five of the services in our
review but does not include noninstitutional geriatric evaluation.
However, the performance measure does not require networks to ensure that
veterans can access noninstitutional long- term care services at all
network facilities. Instead, network targets can be achieved in the
current performance measure if networks increase utilization at facilities
that already offer noninstitutional services.

VA headquarters has provided inadequate guidance to networks and
facilities on the provision of noninstitutional respite care to address
confusion in the field about what this service is and how it should be
provided. This confusion exists, in part, because VA has limited
experience with noninstitutional respite care and VA traditionally
provided respite care in institutions such as nursing homes.
Noninstitutional respite care, by contrast, is provided only in
noninstitutional settings, such as a veteran*s own home. 15 According to
VA, when it plans for noninstitutional services it assumes that the vast
majority of veterans will choose to use their Medicare benefits for home
health care. VA Has Provided Inadequate Guidance on

the Provision of Noninstitutional Respite Care

Page 14 GAO- 03- 487 VA Noninstitutional Long- Term Care Although
noninstitutional respite care has been required by VA for over a year, VA
has not issued adequate guidance on the provision of noninstitutional
respite care and VA staff told us they were unsure how to develop a
noninstitutional respite care service. VA issued a directive in

October 2001 that requires all facilities to provide noninstitutional
respite care to veterans in need of the service yet it inadequately
defines noninstitutional respite care and does not provide facilities with
information regarding how to provide the service. For example, the

directive states that noninstitutional respite care may be provided in a
home or other noninstitutional settings. However, it does not specify
which noninstitutional settings may be used for the purpose of respite
care. In fact, officials in 6 of the 21 networks we contacted indicated
that there was confusion in their networks about how to establish
noninstitutional respite care programs and 1 of these networks reported
this was the reason facilities in the network were not providing the
service. Further, in our survey, six facilities reported that they offer
noninstitutional respite care in community nursing homes, which are
institutional settings, thus not meeting the requirement for
noninstitutional respite care. VA headquarters officials said they are
developing a

handbook that will define and provide guidance on the provision of
noninstitutional respite care. VA requires that facilities offer a home
health service benefit as part of VA*s medical benefits package. 16 VA
headquarters officials told us that the home services benefit includes
home- based primary care, homemaker/ home health aide, and skilled home
health care. However, VA policy does not specify whether one, some
combination, or all three home health services are required under the home
health services benefit. Currently 138 out of VA*s 139 facilities offer at
least one of these three home health services, 59 facilities offer two of
the three services, and 66 facilities offer all three. Without clear
guidance to facilities on what services they must make available in order
to fulfill the home health

services benefit, facilities vary in their interpretation of what is
included in the benefit and headquarters cannot ensure that veterans have
access to the services to which they are entitled.

Because facilities and networks vary in their interpretation of what is
included in the home health services benefit, facilities do not uniformly

16 The medical benefits package is the set of services to be available to
all enrolled veterans. VA Guidance Does Not

Specify Which Home Health Services Are Required

Page 15 GAO- 03- 487 VA Noninstitutional Long- Term Care offer the same
home health services. For example, at one facility we visited, an official
told us that the facility interpreted the home health services benefit to
mean that veterans must have access to skilled home

health care* which the facility made available to all veterans. The
facility restricted veterans* access to its homemaker/ home health aide
and homebased primary care services because facility officials did not
believe these services were required under the home health benefit.
Similarly, in another network an official told us that the network
interpreted the home health services benefit to include all three home
care services home- based

primary care, homemaker/ home health aide, and skilled home health care.
As a result, access to these three services varies according to facility
interpretation of what is required. Without clear guidance to facilities
on what services they must make available in order to fulfill the home
health care services requirement, headquarters cannot ensure that veterans
have access to the home health services to which they are entitled and
veterans

are likely to experience variation in the benefits package. Other factors
limiting access to services include lack of contractors, difficulty hiring
needed staff, and limitations imposed due to distances VA staff can
travel. The lack of contractors is particularly important in adult day
health care, where 62 facilities that either did not provide adult day
health care at all or only did so in parts of their geographic service
areas reported that they experienced difficulty in finding local
contractors to provide the service. In addition, 63 facilities cited
insufficient facility staff as the reason for not offering geriatric
evaluation or only offering it to a portion of their geographic service
area. Officials in VA headquarters told us that many facilities have been
unable to recruit clinically trained

geriatric staff, such as geriatricians and geriatric nurse practitioners,
needed to operate this service. For home- based primary care, 94
facilities that did not offer the service at all or did not do so in all
parts of their geographic service area reported that they did not do so
because many veterans live outside of the facility*s home- based primary
care service area. VA guidance limits the service to veterans who live
within a locally established radius of the facility because Other Factors
Limit the

Availability of Noninstitutional Services

Page 16 GAO- 03- 487 VA Noninstitutional Long- Term Care home- based
primary care staff travel from the facility to veterans* homes to deliver
care. 17 Veterans* access to the six noninstitutional long- term care
services we reviewed is limited and highly variable across the country.
Extensive gaps in services exist at many facilities either because they do
not offer the services or do not offer it in all parts of their service
areas. Moreover,

individual facility restrictions on veterans* use of services means that
access may be further restricted. These include facility restrictions
based on veterans* levels of service- connected disability that are
inconsistent with VA eligibility standards. Facility restrictions have
resulted in waiting

lists for services at many facilities. The end result is that veterans*
access to these services is often limited or nonexistent based on where
they live. Shortfalls and unevenness in veterans* access to
noninstitutional long- term

care services have resulted because VA headquarters has not provided
adequate guidance and emphasis on making these services available. VA has
not provided sufficient guidance to clear up confusion at facilities as to
how noninstitutional respite care services are provided or to make clear

which home health services facilities must provide. As a result,
facilities vary in their interpretation of which services to provide,
creating unevenness in their availability. Furthermore, VA has not
sufficiently emphasized the importance of providing these services to
encourage networks and facilities to make them a priority in their overall
service continuum. In particular, VA has not developed a performance
measure that would help ensure the provision of these services
consistently across VA facilities.

To increase access to noninstitutional long- term care services and make
access more even across networks and facilities, we recommend that the
Secretary of Veterans Affairs direct the Under Secretary for Health to:

 ensure that facilities follow VA*s eligibility standards when
determining veteran eligibility for noninstitutional long- term care
services;

 define and provide guidance on noninstitutional respite care; 17 At two
facilities we visited where home- based primary care is offered, officials
told us that veterans would likely be provided home health care through a
contract service if they lived outside of each facility*s home- based
primary care service area. Conclusions

Recommendations for Executive Action

Page 17 GAO- 03- 487 VA Noninstitutional Long- Term Care  specify in VA
policy whether home- based primary care, homemaker/ home health aide, and
skilled home health care are to be available to all enrolled

veterans; and

 refine current performance measures to help ensure that all VA
facilities provide veterans with access to required noninstitutional
services.

In commenting on a draft of our report, VA agreed with our findings and
conclusions and concurred with our recommendations. VA stated that it will
add eligibility sections in each new directive and handbook it issues
concerning noninstitutional long- term care programs and develop

performance measures to underscore the importance VA places on its
noninstitutional long- term care programs. VA, however, did not provide
details on how it plans to address our recommendations, but instead stated
that it will provide a detailed action plan to implement our
recommendations in response to the issuance of this report. VA*s written
comments are in appendix IV.

As agreed with your office, unless you publicly announce its contents
earlier, we will plan no further distribution of this report until 30 days
after its date. At that time, we will send copies to interested
congressional committees and other parties. We also will make copies
available to others upon request. In addition, the report is available at
no charge on the GAO

Web site at http:// www. gao. gov. If you or your staffs have any
questions about this report, please call me at (202) 512- 7101. Another
contact and key contributors are listed in appendix V.

Cynthia A. Bascetta Director, Health Care* Veterans* Health and Benefits
Issues Agency Comments

Appendix I: VA Noninstitutional Long- Term Care Services in Our Review
Page 18 GAO- 03- 487 VA Noninstitutional Long- Term Care  Adult day
health care: health maintenance and rehabilitative services provided to
frail elderly veterans in an outpatient setting during part of the day.

 Geriatric evaluation: evaluation of veterans with particular geriatric
needs, generally provided by VA through one of two services: (1) geriatric
evaluation and management, 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 health care, delivered by a VA
physician- directed interdisciplinary team of VA staff including nurses
and other healthcare professionals to homebound (often bedbound) veterans
for whom return to an outpatient clinic is not practical.

 Homemaker/ home health aide: personal care, such as grooming,
housekeeping, and meal preparation services, provided in the home to
veterans who would otherwise need nursing home care. It does not

include skilled professional services.

 Respite care: services provided to temporarily relieve the veteran*s
caregiver from the burden of caring for a chronically ill and severely
disabled veteran in the home. Noninstitutional settings for respite care
include veterans* own homes.

 Skilled home health care: medical services provided to veterans at home
by non- VA health care providers. Appendix I: VA Noninstitutional Long-
Term

Care Services in Our Review

Appendix II: Scope and Methodology Page 19 GAO- 03- 487 VA
Noninstitutional Long- Term Care We reviewed the Department of Veterans
Affairs* (VA) provision of six noninstitutional long- term care services
in order to update and expand our

previous work to determine (1) whether veterans* access to six
noninstitutional services is limited by service availability and
restrictions on use and (2) if access is limited, what factors contribute
to limited access. The six services we reviewed include the three services
VA chose to require all facilities to provide to meet the Millennium Act
requirements* adult day health care, noninstitutional geriatric
evaluation, and noninstitutional respite care* and three additional
noninstitutional services* home- based primary care, skilled home health
care, and homemaker/ home health aide.

To determine if veterans* access to the six noninstitutional long- term
care services is limited and if it is limited, to what extent, we sent an
electronic mail survey to VA*s 139 medical facilities in September 2002.
We asked

facilities to indicate which of the six services they offered and, for
each service they offered, asked them to provide the number of veterans
currently receiving or authorized to receive the service and the number of
veterans who received the service during July 2002. 1 The month of July
2002 was chosen because workload data were likely to be available at the

time the survey was completed by VA staff. We also asked facilities to
indicate whether each offered service was available to veterans living in
all parts of their geographic service areas. We compared these survey data
to the data we obtained in our fall 2001 survey of VA long- term care
services

to determine the extent to which availability had changed since that
survey. We also compared our current survey results to information
provided by VA headquarters, and where we noted differences we contacted
facility officials to clarify their survey responses.

To determine the factors that contribute to limited access to the six
noninstitutional long- term care services we asked survey respondents to
indicate the reasons why their facilities do not offer certain services
and what factors influence the number of veterans using the services they
do offer. We also conducted telephone interviews of officials in each of
VA*s 21 network offices to assess the role each network plays in deciding
what noninstitutional services network facilities will offer and what
criteria facilities will use in allocating services.

1 The utilization data provided by VA facilities does not represent an
unduplicated count of veterans in these settings because some veterans may
receive more than one noninstitutional service. Appendix II: Scope and
Methodology

Appendix II: Scope and Methodology Page 20 GAO- 03- 487 VA
Noninstitutional Long- Term Care To augment information collected through
our survey and telephone interviews, we visited four VA medical facilities
to interview VA officials and clinicians on veteran demand for
noninstitutional services and reasons

for variation in access to the six noninstitutional services. We also
updated information we collected from a site we visited during our earlier
work on VA*s noninstitutional services. 2 As shown in table 2, the five
facilities included in this report* Albany, New York; Memphis, Tennessee;
Richmond, Virginia; Tucson, Arizona; and Walla Walla, Washington reflect
differences in the number and type of noninstitutional long- term care
services offered. Table 2: Noninstitutional Services in Our Review Offered
by the Five VA Facilities We Visited

VA facility Number of services in our review offered at the time

of our visit Home- based primary care

Homemaker/ home health

aide Skilled home health care Adult day

health care Geriatric evaluation Respite care

Albany, New York 5 X X X X X Memphis, Tennessee 4 X X X X Richmond,
Virginia 2 X X Tucson, Arizona 6 X X X X X X Walla Walla, Washington 2 X X
Source: GAO.

We selected the Memphis and Tucson VA facilities to visit because each
offered at least four of the six services and had similar numbers of
veterans enrolled. However, the number of veterans using their services

differed substantially, which allowed us to explore the reasons for
observed differences in service utilization. The Albany facility offered
five of the six services and is located in a network that has extensive

noninstitutional service offerings. In contrast, the Richmond and Walla
Walla facilities were selected because they each offered two services;
further, we selected the Walla Walla facility because it is located in a
sparsely populated area. We met with officials in VA*s Geriatrics and
Extended Care Strategic Healthcare Group and obtained documents on VA*s
noninstitutional longterm

care services, including service descriptions, policies, guidance, and 2
GAO- 02- 652T.

Appendix II: Scope and Methodology Page 21 GAO- 03- 487 VA
Noninstitutional Long- Term Care other information. In addition, we
interviewed the Deputy Under Secretary for Health for Operations and
Management to determine the level of oversight that this office provides
regarding the noninstitutional long- term

care services offered by VA facilities, including the implementation and
tracking of network performance measures related to noninstitutional care.

Appendix III: Availability and Utilization of Six Noninstitutional Long-
Term Care Services by VA Medical Facility or Health Care System

Page 22 GAO- 03- 487 VA Noninstitutional Long- Term Care Table 3 provides
information on the availability and utilization of the six
noninstitutional long- term care services reported by VA*s 139 medical

facilities and health care systems for the month of July 2002. 1 Table 3:
Availability and Utilization of Six Noninstitutional Long- Term Care
Services at VA Medical Facilities (July 2002) Number of veterans receiving
service a VA medical facility or health care system (HCS) Home- based

primary care Homemaker/

home health aide Skilled home health care Adult day

health care Geriatric evaluation Respite care Network 1 (Boston) Bedford
13 35 * 27 22 Boston HCS 107 65 96 20 Connecticut HCS 132 53 77 22 115
Manchester 44 19 26 7 Northampton 101 48 26 Providence 55 14 52 8 Togus 86
500 1 6 White River Junction b 12 49 45 26 Network 2 (Albany) Albany 159
62 22 107 613 Bath 177 115 14 0

Canandaigua 132 186 33 15 Syracuse 273 147 37 45 216 Western New York HCS
263 285 68 120 26 Network 3 (Bronx) Bronx 120 15 21 93 Hudson Valley HCS
71 48 6 3 New Jersey HCS 132 262 45 6 Northport 47 64 32 12 49 New York
Harbor HCS 210 219 16 156 1,136 Network 4 (Pittsburgh) Altoona b 12 Butler
36 123 58 Clarksburg 176 23 6 Coatesville 80 0 24 Erie 84 16 3 2 Lebanon 2
7 67 Philadelphia 16 17 905 Pittsburgh HCS 133 129 87 51 16 1 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. Appendix III: Availability and Utilization of

Six Noninstitutional Long- Term Care Services by VA Medical Facility or
Health Care System

Appendix III: Availability and Utilization of Six Noninstitutional Long-
Term Care Services by VA Medical Facility or Health Care System

Page 23 GAO- 03- 487 VA Noninstitutional Long- Term Care Number of
veterans receiving service a VA medical facility or health care system
(HCS) Home- based

primary care Homemaker/

home health aide Skilled home health care Adult day

health care Geriatric evaluation Respite care

Wilkes- Barre 30 99 1 76 Wilmington 25 4 5 Network 5 (Baltimore)
Martinsburg 73 16 Maryland HCS 220 273 52 287 12 3 Washington, DC 125 120
6 85 292 Network 6 (Durham) Asheville 35 90 22 61 26 61 Beckley 10 Durham
47 37 130 97 1 Fayetteville (NC) 19 18 11 17 Hampton 27 29 13 0 Richmond
101 0 1,800 Salem 40 13 71 3

Salisbury 35 100 11 Network 7 (Atlanta) Atlanta 90 51 52 7 550 7 Augusta
53 195 88 2 56 Birmingham 94 4 62 0 27 4 Central Alabama HCS 135 57 48 257
Charleston 96 57 92 6 169 10 Columbia (SC) 35 53 82 20 Dublin 68 127
Tuscaloosa 94 15 Network 8 (Bay Pines) Bay Pines b 123 83 44 23 857 Miami
b 224 75 54 32 397 N. Florida/ S. Georgia HCS b 248 270 30 9 647 San Juan
193 0 2 569 Tampa b 163 39 155 300 West Palm Beach 42 23 2 Network 9
(Nashville) Huntington 60 49 Lexington 23 32 53 52 1 Louisville 29 469 46
Memphis b 112 73 227 560 Mountain Home 158 42 14 15 Tennessee Valley HCS
216 129 13 * Network 10 (Cincinnati) Chillicothe 186 102 3 Cincinnati 22
60 71 26 Cleveland 249 378 26 9 288

Appendix III: Availability and Utilization of Six Noninstitutional Long-
Term Care Services by VA Medical Facility or Health Care System

Page 24 GAO- 03- 487 VA Noninstitutional Long- Term Care Number of
veterans receiving service a VA medical facility or health care system
(HCS) Home- based

primary care Homemaker/

home health aide Skilled home health care Adult day

health care Geriatric evaluation Respite care

Columbus 44 13 25 Dayton 53 275 179 37 42 Network 11 (Ann Arbor) Ann Arbor
88 13 54 0 Battle Creek 120 107 22 31 1 Danville 96 117 * 40 0 Detroit 100
29 100 1 5 Indianapolis 111 109 49 20 48 0

Northern Indiana HCS 96 180 87 1 4 Saginaw 31 15 2 8 2 Network 12
(Chicago) Chicago HCS b 94 30 52 36 12 Hines 183 64 90 45 133 Iron
Mountain 12 15 0 Madison 21 * 5 18 Milwaukee 146 30 23 60 60 North Chicago
144 1 19 Tomah 5 1 Network 15 (Kansas City) Columbia (MO) 134 55 18 0 3

Eastern Kansas HCS 61 54 6 18 Kansas City 64 16 3 Marion 31 215 Poplar
Bluff 38 22 St. Louis 75 78 30 10 * Wichita b 35 40 9 Network 16 (Jackson)
Alexandria 15 21 7 Central Arkansas HCS b 187 145 31 73 719 Fayetteville
(AR) 3 Gulf Coast HCS 75 51 134 195 Houston 92 36 60 6 333 Jackson 35 115
28 Muskogee b 8 38 New Orleans 82 12 35 Oklahoma City 32 34 160 11 * *
Shreveport 64 33 80 Network 17 (Dallas) Central Texas HCS 97 23 2 18 0
North Texas HCS b 195 98 39 18 62 South Texas HCS 189 128 57 44 418

Appendix III: Availability and Utilization of Six Noninstitutional Long-
Term Care Services by VA Medical Facility or Health Care System

Page 25 GAO- 03- 487 VA Noninstitutional Long- Term Care Number of
veterans receiving service a VA medical facility or health care system
(HCS) Home- based

primary care Homemaker/

home health aide Skilled home health care Adult day

health care Geriatric evaluation Respite care Network 18 (Phoenix)
Albuquerque b 96 168 3 135 Amarillo b 82 Big Spring El Paso b 3 1

Phoenix 75 57 250 * Prescott 6 72 38 * Tucson 163 128 156 39 25 8

Network 19 (Denver) Cheyenne 107 1 Denver 76 134 66 61 122 14 Fort Lyon 85
165 0 Grand Junction b 6 Montana HCS Salt Lake City b 127 115 98 83
Sheridan 25 5 2 Network 20 (Portland) Alaska HCS 15 87 Boise 45 43 5
Portland 119 26 68 94 Puget Sound HCS 149 125 19 35 144 0

Roseburg 25 17 Spokane 28 11 12 10 Walla Walla b 14 * White City
Domiciliary 29 * 76 60 3

Network 21 (San Francisco) Central California HCS b 52 18 19 38 Honolulu b
65 11 4 2 75 Northern California HCS 185 78 69 6 Palo Alto 115 29 48 15 90
10 Reno 83 83 83 9 35 0 San Francisco 99 69 40 8 80 Network 22 (Long
Beach) Greater Los Angeles HCS 245 95 12 57 123 Loma Linda 90 210 25 Long
Beach 115 119 Southern Nevada HCS 33 34 0

San Diego 77 40 15 50 80 Network 23 (Minneapolis) c Black Hills HCS 105
101 1 Central Iowa HCS 49 17 66 Fargo 69 240 2

Appendix III: Availability and Utilization of Six Noninstitutional Long-
Term Care Services by VA Medical Facility or Health Care System

Page 26 GAO- 03- 487 VA Noninstitutional Long- Term Care Number of
veterans receiving service a VA medical facility or health care system
(HCS) Home- based

primary care Homemaker/

home health aide Skilled home health care Adult day

health care Geriatric evaluation Respite care

Iowa City 182 302 85 352 4 Minneapolis 116 200 130 200 44 0 Nebraska/
Western Iowa HCS 94 82 7 36 1

Sioux Falls 51 50 2 16 St. Cloud 76 105 87 12 1 Source: GAO.

Notes: Responses to our surveys were submitted September through November
2002. Facility cells that are empty indicate that a facility did not
report offering the service at the time of our survey. A dash indicates
that a facility reported offering the service but did not report the
service*s July 2002 utilization. a Services include those provided
directly by VA staff or through contracts. b Facility reported using only
a volunteer service to provide noninstitutional respite care to veterans.
We did not include volunteer respite care services in our number of
facilities offering noninstitutional respite care. c Network 23 was
created when Networks 13 and 14 were merged into a single network in
January 2002. VA currently has 21 networks.

Appendix IV: Comments From the Department of Veterans Affairs Page 27 GAO-
03- 487 VA Noninstitutional Long- Term Care Appendix IV: Comments From the
Department of Veterans Affairs

Appendix V: GAO Contact and Staff Acknowledgments Page 28 GAO- 03- 487 VA
Noninstitutional Long- Term Care James C. Musselwhite, (202) 512- 7259

In addition to the contact named above Pamela Dooley, Steve Gaty, Marcia
Mann, and Kristin Wilson made key contributions to this report. Appendix
V: GAO Contact and Staff Acknowledgments

GAO Contact Acknowledgments

Related GAO Products Page 29 GAO- 03- 487 VA Noninstitutional Long- Term
Care Long- Term Care: Availability of Medicaid Home and Community Services
for Elderly Individuals Varies Considerably. GAO- 02- 1121. Washington, D.
C.: September 26, 2002. VA Long- Term Care: The Availability of
Noninstitutional Services Is Uneven. GAO- 02- 652T. Washington, D. C.:
April 25, 2002.

VA Long- Term Care: Implementation of Certain Millennium Act Provisions Is
Incomplete, and Availability of Noninstitutional Services Is Uneven. GAO-
02- 510R. Washington, D. C.: March 29, 2002.

Veterans* Affairs: Observations on Selected Features of the Proposed
Veterans* Millennium Health Care Act. GAO/ T- HEHS- 99- 125. Washington,
D. C.: May 19, 1999. Related GAO Products (290194)

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