VA Long-Term Care: Veterans' Access to Noninstitutional Care Is  
Limited by Service Gaps and Facility Restrictions (22-MAY-03,	 
GAO-03-815T).							 
                                                                 
With the aging of the veteran population, the Department of	 
Veterans Affairs (VA) is likely to see a significant increase in 
long-term care need. VA uses noninstitutional long-term care	 
services, such as home health care and adult day health care, and
institutional care to meet this need. GAO identified limits in	 
veterans' access to six noninstitutional long-term care services 
and factors that contribute to these limitations in its report VA
Long-Term Care: Service Gaps and Facility Restrictions Limit	 
Veterans' Access to Noninstitutional Care (GAO-03-487, May 9,	 
2003). The report is based, in part, on a survey of all 139 VA	 
facilities. Today's testimony discusses conclusions and 	 
highlights recommendations GAO made in the report to improve	 
access to VA noninstitutional long-term care services.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-815T					        
    ACCNO:   A06967						        
  TITLE:     VA Long-Term Care: Veterans' Access to Noninstitutional  
Care Is Limited by Service Gaps and Facility Restrictions	 
     DATE:   05/22/2003 
  SUBJECT:   Home health care services				 
	     Long-term care					 
	     Veterans benefits					 

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GAO-03-815T

Testimony Before the Subcommittee on Health, Committee on Veterans*
Affairs, House of Representatives

United States General Accounting Office

GAO For Release on Delivery Expected at 1: 30 p. m. Thursday, May 22, 2003
VA LONG- TERM CARE

Veterans* Access to Noninstitutional Care Is Limited by Service Gaps and
Facility Restrictions

Statement of Cynthia A. Bascetta Director, Health Care* Veterans*

Health and Benefits Issues

GAO- 03- 815T

Veterans* access to the six noninstitutional services GAO 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. Many facilities restrict the number of
veterans who receive services resulting 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. Faced with competing priorities
and little guidance from headquarters, field officials 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 longterm care need. VA uses noninstitutional long-
term care services, such as home health care and adult day health care,
and

institutional care to meet this need. GAO identified limits in veterans*
access to six noninstitutional longterm care services and factors that
contribute to these limitations in its

report VA Long- Term Care: Service Gaps and Facility Restrictions Limit
Veterans* Access to Noninstitutional Care

(GAO- 03- 487, May 9, 2003). The report is based, in part, on a survey of
all 139 VA facilities. Today*s testimony discusses conclusions

and highlights recommendations GAO made in the report to improve access to
VA noninstitutional longterm care services.

In its report GAO recommended 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- 815T. To view the full product,
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- 815T, a testimony

before the Subcommittee on Health, Committee on Veterans* Affairs, House
of Representatives

May 22, 2003

VA LONG- TERM CARE

Veterans* Access to Noninstitutional Care Is Limited by Service Gaps and
Facility Restrictions

Page 1 GAO- 03- 815T

Mr. Chairman and Members of the Subcommittee: We are pleased to be here
today to discuss the Department of Veterans Affairs (VA) noninstitutional
long- term care services and how veterans* access to these services could
be improved. Meeting the long- term care needs of veterans is growing in
importance as the number of veterans most in need of these services* those
85 years old and older* is expected to increase from 640,000 to 1.3
million by 2012. To provide assistance to

veterans with chronic illness or physical or mental disability, VA
provides a continuum of noninstitutional and institutional services.
Noninstitutional services are provided to veterans in their own homes or
in community settings, and include specific services to meet the
requirements of the Veterans Millennium Health Care and Benefits Act. 1 VA
provides noninstitutional services directly through its own employees and
by contracting for services. In fiscal year 2002, VA spent

approximately $283 million on noninstitutional long- term care services
and served an average daily census of about 24,000 veterans. By contrast,
VA spent nearly $3 billion on institutional long- term care provided in
nursing homes and other settings and had an average daily census of more
than 43,000 veterans.

My remarks are based on a recent report and other issued work. 2 We
surveyed each of VA*s 139 medical facilities to obtain data on the
availability of six noninstitutional long- term care services, 3 and
identified any limits in access and reasons for these limitations. These
services included three VA provides to meet the requirements of the
Millennium Act* adult day health care, noninstitutional geriatric
evaluation, and noninstitutional respite care* in addition to home- based
primary care,

1 In November 1999, the Congress passed the Veterans Millennium Health
Care and Benefits Act, which required that VA provide 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 U. S. General Accounting Office, VA Long- Term Care: Service Gaps and
Facility Restrictions Limit Veterans* Access to Noninstitutional Care,
GAO- 03- 487 (Washington, D. C.: May 9, 2003). Also see Related GAO
Products. 3 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 2 GAO- 03- 815T

skilled home health care, and homemaker/ home health aide. We also
interviewed VA officials and examined documents related to these issues.

In summary, we found that veterans* access to the six noninstitutional
services we reviewed is limited by the lack of service availability and
restrictions on their use. Of VA*s 139 facilities, 126 do not offer all
six 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 by 7 facilities but is provided by the remaining 132.
Veterans* access to care is more limited, however, because even when
facilities offer these services they often do so in only parts of the
geographic area they serve. More than half of VA facilities do not offer
four of the six services noninstitutional respite care, home- based
primary care, adult day health care, and noninstitutional geriatric
evaluation at all, or only offer such services in parts of the geographic
areas they serve. Veterans* access may be further limited by restrictions
that individual

facilities place on the services they offer. For example, we found that 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. In addition, restrictions placed by many
facilities on the

number of veterans who can receive these noninstitutional services have
resulted in veterans at 57 of VA*s 139 facilities being placed on waiting
lists for noninstitutional services.

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 noninstitutional respite care 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,

Page 3 GAO- 03- 815T

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. Specifically, we are recommending that VA (1)
ensure that facilities follow VA*s eligibility standards when determining
veteran eligibility for noninstitutional long- term care services, (2)
define and provide guidance on noninstitutional respite care, (3) specify
in VA policy whether homebased primary care, homemaker/ home health aide,
and skilled home health care are to be available to all enrolled veterans,
and (4) 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 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.

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 4 authorized VA to provide health care
services not previously available to veterans without service- connected
disabilities or low incomes. 5 As required by the act and due to an
anticipated increase in demand for VA health care from these changes in
eligibility, VA has 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

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

Page 4 GAO- 03- 815T

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. 6 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 home and community- based noninstitutional care. Long- term care also
includes respite care services that temporarily relieve a caregiver from
the burden of caring for a chronically ill and disabled veteran in the
home.

VA*s long- term care infrastructure, including nursing homes it operates,
was developed when the concentration of veteran population was distributed
differently by region. When VA developed its long- term care
infrastructure, it relied more on nursing home care and less on home and
community- based services than current practice. To help update VA*s long-
term care policy, the Federal Advisory Committee on the Future of VA Long-
Term Care recommended in 1998 that VA meet the growing demand for long-
term care by greatly expanding home and communitybased service capacity
while maintaining its nursing home capacity at the level of that time. 7
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, including resources used for long- term care. 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.

6 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. 7 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).

Page 5 GAO- 03- 815T

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 they
serve. 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.

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 with
little progress

made in expanding the availability of services from 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 facilities in fall 2001, and as of fall 2002, noninstitutional respite
care was not available at 106 facilities. In contrast, the most widely
available service we reviewed was skilled home health care, which was
offered at all but 7 facilities. 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 6 GAO- 03- 815T

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 one or more of the services or did not
offer them 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 adult day health care in their entire geographic
service area. As a result, where veterans live in a facility*s geographic
service area determined whether they had access to 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 7 GAO- 03- 815T

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.

The Millennium Act and VA policy also 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. 8 In these
cases, VA could arrange for these services from non- VA sources but would
not pay for them. 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 benefit of VA case management in assisting veterans to access
these three services is limited to those veterans who have some other
sources to pay for the care. That is, if veterans are not eligible for
care

8 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 8 GAO- 03- 815T

covered by another payer, such as Medicaid, or cannot pay themselves, case
management assistance is not likely to result in access to the three
services.

Some facilities limit access to services based on veterans*
serviceconnected disability levels. For example, we found that nine VA
facilities imposed their own eligibility restrictions on access to
noninstitutional services based on veterans* service- connected
disabilities. Because we did not systematically ask in our survey if
facilities had restrictions based on service- connected disabilities, it
is possible that additional facilities may impose similar eligibility
restrictions. Such 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. 9 Many facilities
also limit the number of veterans who may receive a

service at a particular time. As a result, when more veterans need service
than the established facility limit, these veterans have to wait for
service until space or resources become available. In our survey, 57 of
VA*s 139 facilities reported that veterans are on waiting lists for one or
more of the six noninstitutional services we reviewed as a result of
restrictions placed on the number of veterans who may receive a service.

We are recommending that VA ensure that its facilities follow VA*s
eligibility standards when determining eligibility for noninstitutional
longterm care services. The examples we found clearly point out the need
for VA to take such action to ensure that facilities follow VA eligibility
standards so that similarly situated veterans have access to similar care
across the country. VA concurred with this recommendation and stated that
the Veterans Health Administration will add eligibility sections in each
new directive and handbook concerning Home and Community Based Care
Programs. In addition, VA stated that it will provide a detailed action
plan to implement this and other recommendations we made on VA*s

noninstitutional long- term care services. 9 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

Page 9 GAO- 03- 815T

A lack of VA emphasis on increasing access to noninstitutional long- term
care services and inadequate VA guidance on providing these services have
contributed to limited access for veterans. Until fiscal year 2003 VA had
not provided measurable standards for the provision of these services or
oversight to monitor their provision as it had for high- priority
services. VA guidance on the provision of noninstitutional long- term care
services has left unclear to some facilities how noninstitutional respite
care service is to be defined and provided and whether all of the home
health services in our review are a part of what VA requires be made
available to veterans

who need them. 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 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 veterans* 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 has included a performance 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 such veterans who received the immunization from 26 percent in fiscal
year 1996 to 81 percent in fiscal year 2002. Lack of Emphasis and

Inadequate Guidance Contribute to Limited Access

VA Has Not Emphasized Increased Access to Noninstitutional LongTerm Care
Services

Page 10 GAO- 03- 815T

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. 10
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 have
access to noninstitutional long- term care services at all network
facilities. Instead, network performance targets can be achieved if
networks increase utilization at facilities that already offer

noninstitutional services. We are recommending that VA refine current
performance measures to help ensure that all VA facilities provide
veterans with access to required noninstitutional services. Without
refinements that include individual

facility performance, existing measures will not hold networks accountable
for providing required services at each facility. VA concurred with this
recommendation and stated that the Veterans Health Administration will
develop performance measures to underscore the

importance VA places on its noninstitutional long- term care programs. In
addition, VA stated that it will provide a detailed action plan to
implement this and other recommendations we made on VA*s noninstitutional
longterm care 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.

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

10 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 11 GAO- 03- 815T

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 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.

We are recommending that VA define and provide guidance on
noninstitutional respite care so that facilities can be clear on what
noninstitutional respite care is and how and where it is to be provided.
VA concurred with this recommendation and stated that it will provide a
detailed action plan to implement this and other recommendations we made
on VA*s noninstitutional long- term care services.

VA requires that facilities offer a home health services benefit as part
of its medical benefits package. 11 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.

11 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 12 GAO- 03- 815T

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

We are recommending that VA 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. VA concurred with this
recommendation and VA stated that it will provide a detailed action plan
to implement this and other recommendations we made on VA*s
noninstitutional long- term care services.

Mr. Chairman, this concludes my prepared remarks. I will be pleased to
answer any questions you or other members of the subcommittee may have.

For further information regarding this testimony, please contact me at
(202) 512- 7101. James C. Musselwhite also contributed to this testimony.
Contact and Acknowledgements

Page 13 GAO- 03- 815T

VA Long- Term Care: Service Gaps and Facility Restrictions Limit Veterans*
Access to Noninstitutional Care. GAO- 03- 487. Washington, D. C.: May 9,
2003. Department of Veterans Affairs: Key Management Challenges in Health

and Disability Programs. GAO- 03- 756T. Washington, D. C.: May 8, 2003.
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

(290292)

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