VA Long-Term Care: Changes In Service Delivery Raise Important	 
Questions (28-JAN-04, GAO-04-425T).				 
                                                                 
The Department of Veterans Affairs (VA) is likely to see a	 
significant increase in long-term care need over the next decade.
The number of veterans most in need of longterm care		 
services--those 85 years old and older--is expected to increase  
from about 870,000 to 1.3 million over this period. Many of these
veterans will rely on VA to provide or pay for nursing home care 
or noninstitutional services that may help them remain at home	 
and, for some, delay or prevent the need for nursing home care.  
VA operates its own nursing home care units in 132 locations. VA 
also pays for nursing home care under contract in non-VA nursing 
homes--referred to as community nursing homes. In addition, VA	 
pays part of the cost of care for veterans at state veterans'	 
nursing homes and also pays a portion of the construction costs  
for some state veterans' nursing homes. Congress has expressed	 
concerns about recent trends in VA long-term care service	 
delivery and how VA plans to meet the nursing home care needs and
related longterm care needs of veterans as the elderly population
most in need of long-term care increases. GAO was asked to	 
determine for fiscal years 1998 through 2003 (1) how VA nursing  
home workload has changed and (2) how VA noninstitutional	 
long-term care workload has changed.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-425T					        
    ACCNO:   A09175						        
  TITLE:     VA Long-Term Care: Changes In Service Delivery Raise     
Important Questions						 
     DATE:   01/28/2004 
  SUBJECT:   Comparative analysis				 
	     Long-term care					 
	     Nursing homes					 
	     Veterans						 
	     Veterans benefits					 
	     Workloads						 

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GAO-04-425T

United States General Accounting Office

GAO Testimony

Before the Committee on Veterans' Affairs, House of Representatives

For Release on Delivery Expected at 12:00 noon EST

Wednesday, January 28, 2004

VA LONG-TERM CARE

             Changes In Service Delivery Raise Important Questions

Statement of Cynthia A. Bascetta Director, Health Care-Veterans' Health and
Benefits Issues

GAO-04-425T

Highlights of GAO-04-425T, a testimony before the Committee on Veterans'
Affairs, House of Representatives

The Department of Veterans Affairs (VA) is likely to see a significant
increase in long-term care need over the next decade. The number of
veterans most in need of longterm care services-those 85 years old and
older-is expected to increase from about 870,000 to 1.3 million over this
period. Many of these veterans will rely on VA to provide or pay for
nursing home care or noninstitutional services that may help them remain
at home and, for some, delay or prevent the need for nursing home care. VA
operates its own nursing home care units in 132 locations. VA also pays
for nursing home care under contract in non-VA nursing homes-referred to
as community nursing homes. In addition, VA pays part of the cost of care
for veterans at state veterans' nursing homes and also pays a portion of
the construction costs for some state veterans' nursing homes.

This Committee has expressed concerns about recent trends in VA long-term
care service delivery and how VA plans to meet the nursing home care needs
and related longterm care needs of veterans as the elderly population most
in need of long-term care increases. GAO was asked to determine for fiscal
years 1998 through 2003 (1) how VA nursing home workload has changed and
(2) how VA noninstitutional long-term care workload has changed.

www.gao.gov/cgi-bin/getrpt?GAO-04-425T.

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.

January 28, 2004

VA LONG-TERM CARE

Changes In Service Delivery Raise Important Questions

Recent trends in VA nursing home care and noninstitutional service
delivery raise important questions, particularly whether access to
services is sufficient to meet the needs of a rapidly growing elderly
veteran population. VA's overall nursing home workload-average daily
census-was 33,214 in fiscal year 2003, 1 percent below its fiscal year
1998 workload. The workload was below the fiscal year 1998 level each
year, decreasing by as much as 8 percent below the fiscal year 1998 level
in fiscal year 2000. VA's use of nursing home care by setting also changed
over the 6-year period. First, the percentage of workload in state
veterans' nursing homes increased as the number of state veterans' nursing
homes receiving VA payments increased. Second, the percentage of workload
in VA's own nursing homes declined, in part, because VA decreased the
number of long-stay patients and increased the number of short-stay
patients it treats in the nursing homes it operates. This is consistent
with VA's increased emphasis on post-acute care. Third, the percentage of
workload in community nursing homes declined from 17 to 13 percent. VA
officials told us that now shorter-term contracts are often used to
transition veterans to nursing home care, which is paid for by other
payers such as Medicaid.

Percentage of Nursing Home Workload By Setting, Fiscal Years 1998 and 2003

Note: The workload measure is average daily census, which represents the
total number of days of nursing home care provided in a year divided by
the number of days in the year.

VA's noninstitutional long-term care workload-average daily census-
increased by approximately 75 percent from fiscal years 1998 through 2003.
Workload increased by 4,655 during this period to 10,892, reflecting a
change in VA's approach to care which includes meeting more long-term care
need through noninstitutional services. Most of the growth in
noninstitutional workload came from VA's greater use of contract skilled
home health care, which includes medical services provided to veterans at
home, and homemaker/home health aide such as grooming and meal
preparation.

Mr. Chairman and Members of the Committee:

We are pleased to be here today to discuss veterans' use of long-term care
services, which include nursing home care and noninstitutional services
provided or paid for by the Department of Veterans Affairs (VA). Concern
with meeting veterans' long-term care needs is increasing as the number of
veterans most in need of these services-those 85 years old and older-is
expected to increase from about 870,000 this year to 1.3 million over the
next decade. Many of these veterans will seek assistance from VA to
provide or pay for nursing home care or a range of noninstitutional
services that may help them remain at home and, for some, delay or prevent
the need for nursing home care.

To provide assistance to veterans with chronic illness or physical or
mental disability, VA provides a continuum of institutional and
noninstitutional long-term care services. VA provides care that its own
employees deliver and contracts with other health care providers to
deliver care. VA operates its own nursing home care units in 132 locations
and also pays for nursing home care under contract in non-VA nursing
homes-referred to as community nursing homes. In addition, VA pays part of
the cost of care for veterans at state veterans' nursing homes and also
pays a portion of the construction costs for some state veterans' nursing
homes. VA also provides noninstitutional services to veterans in their own
homes or in community settings using both its own employees and through
contracts with other providers.

This Committee has expressed concerns about recent trends in VA longterm
care service delivery and how VA plans to meet the nursing home care needs
and related long-term care needs of veterans as the elderly population
most in need of long-term care increases. To assist the Committee in its
oversight responsibilities in this area, you asked us to determine for
fiscal years 1998 through 2003 (1) how VA nursing home workload has
changed and (2) how VA noninstitutional long-term care workload has
changed.

My testimony today is based on our ongoing review of long-term care
workload for this Committee.1 For this review, we measured nursing home

1We reported preliminary findings on nursing home workload in a testimony
to this Committee on May 8, 2003. U.S. General Accounting Office,
Department of Veterans Affairs: Key Management Challenges in Health and
Disability Programs GAO-03-756T (Washington, D.C.: May 8, 2003).

workload as defined by average daily census, which reflects the average
number of veterans receiving nursing home care on any given day during the
course of the year. We also measured noninstitutional workload using
average daily census; however, the number of veterans receiving these
services may be less than workload because a veteran may receive more than
one service in a day. We analyzed data on nursing home workload that VA
provided to determine how workload had changed from fiscal years 1998
through 2003. We also verified VA's nursing home workload numbers based on
contacts with officials from VA's 21 health care networks and VA
headquarters. To determine how noninstitutional longterm care workload has
changed during this period, we analyzed data on visits for six
noninstitutional services which VA either provides directly or pays for
others to provide: home-based primary care, adult day health care,
homemaker/home health aide, skilled home health care, home respite care,
and home hospice care. We also interviewed VA officials at headquarters
and obtained information from the networks to better understand the
reasons for changes in nursing home workload during this period. In doing
our work, we tested the reliability of the data and determined they were
adequate for our purposes. We did our work in accordance with generally
accepted government auditing standards from January 2003 through January
2004.

In summary, recent trends in VA nursing home and noninstitutional service
delivery raise important questions, particularly whether access to
services is sufficient to meet the needs of a rapidly growing elderly
veteran population. VA's overall nursing home workload--average daily
census-was 33,214 in fiscal year 2003, 1 percent below its fiscal year
1998 workload. The workload was below the fiscal year 1998 level each
year, decreasing by as much as 8 percent below the fiscal year 1998 level
in fiscal year 2000. Fourteen of 21 networks experienced declines in
nursing home workload during this period. Moreover, VA's use of the three
nursing home settings changed over this 6-year period. First, the
percentage of workload met in state veterans' nursing homes increased from
43 to 50 percent as the number of state veterans' nursing homes receiving
VA payment increased. The percentage of workload met in state veterans'
nursing homes increased in 19 of VA's 21 health care networks. Second, the
percentage of workload in VA's own nursing homes declined from 40 to 37
percent. Thirteen networks provided a smaller percentage of workload in
VA-operated homes during this period. The percentage of workload provided
in VA-operated homes declined, in part, because VA decreased the number of
long-stay patients and increased the number of short-stay patients it
treats in its own nursing homes. This is consistent with VA's policy to
give priority to post-acute patients and certain other

nursing home patients. VA generally provides long-term nursing home care
as resources permit. Third, the percentage of workload in community
nursing homes declined from 17 to 13 percent. Seventeen networks reduced
the percentage of their nursing home workload provided in community
nursing homes during this period.

VA's noninstitutional long-term care workload--average daily
census-increased by approximately 75 percent from fiscal years 1998
through 2003. Workload increased by 4,655 during this period to 10,892,
reflecting a change in VA's approach to care which includes meeting more
long-term care need through noninstitutional services. Most of the growth
in noninstitutional workload came from VA's greater use of contract
skilled home health care, which includes medical services provided to
veterans at home, and homemaker/home health aide services such as grooming
and meal preparation. These services are most likely to help veterans
prevent or delay the need for nursing home care.

Background 	Meeting veterans' long-term care needs has become a more
pressing issue as the veteran population ages. The elderly veteran
population most in need of long-term care-those 85 years and older--grew
dramatically from about 387,000 to about 764,000, an increase of about 100
percent from fiscal years 1998 to 2003. (See fig. 1.)

Figure 1: Growth in Veteran Population, 85 Years and Older, Fiscal Years
1998 Through 2003

Veteran population 900,000

800,000 763,956

700,000

600,000

500,000

400,000

300,000

200,000

100,000

0 1998 1999 2000 2001 2002 2003

Fiscal years

Source: GAO analysis of VA data.

Over the past two decades the provision of long-term care has been
shifting away from institutions and nursing homes towards more
noninstitutional long-term care services in VA and in other programs. In
recognition of this change in approach to how long-term care is provided,
the Federal Advisory Committee on the Future of VA Long-Term Care
recommended, in 1998, that VA update its long-term care policy by meeting
the growing demand for long-term care through significant expansion of its
capacity to provide home and community-based services-also known as
noninstitutional long-term care services-while maintaining its nursing
home capacity at the 1998 level.2

VA provides a continuum of noninstitutional long-term care services to
provide care to veterans needing assistance. Long-term care provided in
noninstitutional settings--including services provided in veterans' homes
and community-based services such as adult day health care centers--is
preferred by many veterans. Noninstitutional care also includes respite
care services that temporarily relieve a veteran's caregiver from the

2VA 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).

burden of caring for a chronically ill and disabled veteran in the home.
VA offers noninstitutional long-term care services directly or through
other providers with which VA contracts. (See table 1 for the
noninstitutional long-term care services in our review.)

         Table 1: Selected VA Noninstitutional Long-Term Care Services

VA noninstitutional long

term care service Definition

Source of care

                           Primary health care, delivered by a                
Home-based primary care physician-directed interdisciplinary  VA providers
                           team of staff                         
                           including nurses to homebound (often  
                           bedbound) veterans for whom visits to 
                                            an                   
                           outpatient clinic are not practical.  
                           Personal care, such as grooming,                   
                           housekeeping, and meal preparation    Contracted
    Homemaker/home health  services,                             
                           provided in the home to veterans who               
            aide             would otherwise need nursing home    providers
                                           care.                 
                           Health maintenance and rehabilitative              
                           services provided to frail elderly       VA and
    Adult day health care  veterans in                           
                           an outpatient setting during part of   contracted  
                                         the day.                
                                                                  providers   
     Skilled home health   Medical services provided to veterans Contracted   
            care                         at home.                
                                                                  providers   
                           Services provided at home to                       
                           temporarily relieve the veteran's     Contracted
      Home respite care    caregiver from the                    
                            burden of caring for a chronically    providers   
                                     disabled veteran.           
                           Services provided at home to veterans              
                           whose primary goal of treatment is    Contracted
      Home hospice care    comfort                               
                             rather than cure for an advanced                 
                              disease that is life-limiting.      providers

Source: VA.

Veterans can also receive nursing home care and noninstitutional services
financed by sources other than VA, including Medicaid and Medicare,
private health or long-term care insurance, or self-financed. States
design and administer Medicaid programs that include coverage for nursing
home care and home and community-based services. Medicare primarily covers
acute care health costs and therefore limits its nursing home coverage to
short-term stays following hospitalization. Medicare also pays for home
health care. State Medicaid programs are the principal funders of nursing
home and home health care services, besides patients self-financing their
care. We have estimated that private insurance pays for about 11 percent
of nursing home and home health care expenditures.3

3See U.S. General Accounting Office, Long-Term Care: Aging Baby Boom
Generation Will Increase Demand and Burden on Federal and State Budgets
GAO-02-544T (Washington, D.C.: March 21, 2002).

  Nursing Home Workload Declined Slightly And Use Of Nursing Home Care By
  Setting Changed

VA's overall nursing home workload--average daily census--was 33,214 in
fiscal year 2003, slightly below its fiscal year 1998 workload. However,
the workload was below the fiscal year 1998 level each year, reaching its
lowest level in fiscal year 2000. Over the last 6 years, VA's use of
nursing homes by setting changed. These changes in workload and use of
different settings to provide nursing home care varied by network.

Nursing Home Workload Declined Slightly from Fiscal Year 1998 through
Fiscal Year 2003

VA's nursing home workload was 33,214 in fiscal year 2003, 1 percent below
its fiscal year 1998 workload. (See table 2.) Nursing home workload varied
over this period but was consistently below the fiscal year 1998 level,
decreasing by as much as 8 percent in fiscal year 2000 from its fiscal
year 1998 level. The distribution of the nursing home workload among the
three nursing home settings shifted during this period. From fiscal years
1998 through 2003, workload in the nursing homes VA operates declined by
1,014. In addition, workload in community nursing homes declined by 1,434.
In contrast, workload in state veterans' homes increased by 2,032.

Table 2: Change in Nursing Home Workload Provided or Paid for by VA in
Fiscal Years 1998-2003

    Type of nursing home   1998   1999   2000   2001   2002    2003    Change 
                                                                    1998-2003 
    VA-operated nursing   13,387 12,614 11,841 11,727 12,035 12,373    -1,014 
           homes                                                    
     Community nursing    5,636  4,575  3,799  4,163  4,080   4,202    -1,434 
           homes                                                    
      State veterans'     14,607 15,046 15,259 15,533 15,985 16,639     2,032 
       nursing homes                                                
           Total          33,630 32,235 30,899 31,423 32,100 33,214      -416 

Source: VA.

Note: The workload measure is average daily census, which represents the
total number of days of nursing home care provided in a year divided by
the number of days in the year.

Although VA nursing home workload did not change greatly from fiscal years
1998 through fiscal year 2003, some networks experienced significant
increases or decreases. Fourteen of VA's 21 networks had lower nursing
home workloads in fiscal year 2003 than in fiscal year 1998 for all three
settings combined. (See fig. 2.) Network 5 (Baltimore) had the largest
decline in workload-19 percent. Seven networks' nursing home workloads
grew during this period. Network 17 (Dallas) had the largest increase in
nursing home workload-42 percent.

Figure 2: Change in Nursing Home Workload by VA Network, Fiscal Years 1998-2003

Percentage

                                   42 -17 -19

y)1 (Boston)2 (Alban

ur3 (Bronx)4 (Pittsb

gh)5 (Baltimore)6 (Durham)7 (Atlanta)8 (Bay Pines)9 (Nashville)10
(Cincinnati)11 (Ann Arbor)12 (Chicago)

15 (Kansas City)16 (Jackson) 17 (Dallas)18 (Phoenix)19 (Denver)

or

21 (San Francisco)22 (Long Beac

                                     tland)

h)

23 (Minneapolis)

                                     20 (P

Workload change from fiscal years 1998 to 2003 Source: GAO analysis of VA
data.

Note: Nursing home workload is measured using average daily census
combined for VA-operated nursing homes, community nursing homes, and state
veterans' nursing homes. Average daily census represents the total number
of days of nursing home care provided in a year divided by the number of
days in the year. VA merged networks 13 and 14 into network 23 in January
2002.

Use of Nursing Home Care Setting Changed from Fiscal Year 1998 through
2003

VA's use of nursing home care among the three settings changed from fiscal
years 1998 through 2003. The percentage of workload met in state veterans'
nursing homes increased from 43 to 50 percent. (See fig. 3.) This increase
is attributable in large part to 18 more state veterans' nursing homes
receiving payment from VA to provide such care. By fiscal year 2003, 109
state veterans' nursing homes received VA payment to provide this care. VA
is authorized to pay for about two-thirds of the costs of

construction of state veterans' nursing homes and pays about a third of
the costs per day to provide care to veterans in these homes.

Figure 3: Percentage of Nursing Home Workload By Setting, Fiscal Years
1998 and 2003

Note: The workload measure is average daily census, which represents the
total number of days of nursing home care provided in a year divided by
the number of days in the year.

The percentage of workload provided in state veterans' nursing homes
increased in 19 of VA's 21 health care networks. Network 17 (Dallas) had
the largest increase in the percentage of workload provided by state
veterans' nursing homes. The percentage of nursing home care provided by
state veterans' nursing homes in this network increased from 0 to 30
percent during this period after the opening of four state veterans'
nursing homes in Texas. By contrast, the percentage of workload provided
by state veterans' nursing homes declined in 2 networks: Network 5
(Baltimore) by 3 percent and Network 21 (San Francisco) by 2 percent.

The percentage of nursing home workload provided in VA's own nursing homes
declined from 40 to 37 percent during this period. Thirteen networks
provided a smaller percentage of nursing home care in VAoperated nursing
homes in fiscal year 2003 than in fiscal year 1998. Network 17 (Dallas)
had the largest decrease in the percentage of

workload provided by VA-operated nursing homes, declining from 68 percent
to 49 percent during this period. This resulted because the state
veterans' nursing home workload increased substantially. By contrast, the
percentage of care provided in VA-operated homes increased in 8 networks.
Network 5 (Baltimore) had the largest increase, growing from 50 percent in
fiscal year 1998 to 64 percent in fiscal year 2003. In Network 21 (San
Francisco), the percentage of care in VA-operated nursing homes increased
by 7 percent and in the remaining 6 networks the percentage of care in
VA-operated nursing homes increased 3 percent or less.

Our analysis of length-of stay trends in VA-operated nursing homes shows
that the decline in the number of veterans with long stays-90 days or
more-largely explains the decline in nursing home workload during this
period. The number of long-stay veterans declined from about 14,200 in
fiscal year 1998 to about 12,700 in fiscal year 2002, the most recent year
for which data are available.4 At the same time the number of short-stay
veterans--those with stays of less than 90 days--increased from about
26,700 to about 32,200. However, the increase in short-stay patients was
not large enough to offset the decline in workload resulting from the
decrease in long-stay patients. This results because multiple short-stay
patients are required to generate the same workload as a single long-stay
patient. For example, a single long-stay patient in a nursing home for 12
months creates a workload of an average daily census of 1 over a year. By
contrast, 12 short-stay patients staying in a nursing home for one month
each creates the same average daily census.

Among VA's networks, 16 had declines in the number of long-stay patients
in VA-operated homes during this period. Five networks, however, had
increases in the number of long-stay patients: Network 1 (Boston), Network
5 (Baltimore), Network 7 (Atlanta), Network 12 (Chicago) and Network 21
(San Francisco).

VA officials attribute some of the changes in nursing home workload in
VA-operated facilities to an increased emphasis on short-term, post-acute
rehabilitation care. VA's policy is to provide nursing home care in its
own nursing homes as a priority to post-acute patients, patients who
cannot be adequately cared for in community nursing homes or in
noninstitutional

4This calculation requires complete data for the first 3 months of a
fiscal year to determine if some patients in a prior fiscal year were in a
VA-operated nursing home for 90 or more days. Data for the first 3 months
of fiscal year 2004 were not available when we did our calculations. As a
result, we provide our analysis for fiscal year 2002.

settings, and those patients who can be cared for more efficiently in VA's
own nursing homes. In addition, VA may provide nursing home care, to the
extent resources are available, to other patients who need long-term care
for chronic disabilities. Consistent with VA's policy, the proportion of
discharged veterans whose length of stays were less than 90 days in
VAoperated nursing homes increased from 74 to 81 percent from fiscal years
1998 through 2003. This is similar to lengths of stay provided in
facilities certified by Medicare--but not Medicaid--that provide
post-acute skilled nursing home care.5 About 81 percent of discharged
patients in these certified Medicare facilities had length of stays of
less than 90 days in fiscal year 1999.6

The percentage of workload in community nursing homes declined from 17 to
13 percent from fiscal year 1998 through fiscal year 2003. This decline
occurred because VA reduced the number of patients served and the number
of days paid for under contract in this setting. The number of patients in
these settings declined from 28,893 to 14,032 during this period.7 Some VA
officials told us that in the past VA used community nursing homes for
more patients and for longer-term contracts than currently. VA officials
told us that now shorter-term contracts are often used to transition
veterans to nursing home care, which is paid by other payers such as
Medicaid. For example, some network officials told us that contracts for
community nursing home care are often 30 days or less.

Of the 21 networks, 17 reduced the percentage of nursing home workload
provided in community nursing homes during this period. Four networks
reduced the percentage of nursing home care provided in community nursing
homes by about 11 percent: Network 4 (Pittsburgh), Network 5 (Baltimore),
Network 6 (Durham), and Network 17 (Dallas). By contrast, the percentage
of workload provided in community nursing homes increased in 4 networks.
The percentage of nursing home care provided in community nursing homes in
Network 19 (Denver) increased by about 10 percent. The percentage of
nursing home care provided in community nursing homes among the other 3
networks-- Network 23 (Minneapolis),

5Some nursing home facilities are certified only by Medicare to provide
skilled nursing home care. Others are certified by both Medicare and
Medicaid.

6See A. Jones, The National Nursing Home Survey: 1999 Summary. National
Center for Health Statistics, Vital Health Stat 13(152), 2002.

7These patient numbers are based on discharges and are not unduplicated
because a single patient may be admitted more than once in the same fiscal
year.

  VA Noninstitutional Long-Term Care Workload Increased

Network 20 (Portland), and Network 18 (Phoenix)--increased 3 percent or
less.

VA's noninstitutional long-term care workload--average daily census-for
the six services in our review increased by approximately 75 percent from
fiscal years 1998 through 2003. Workload increased by 4,655 during this
period to 10,892. (See table 3.) Much of this growth came from increases
in skilled home health and homemaker/home health aide care- services that
are most likely to help veterans prevent or delay the need for nursing
home care. One of the services that grew most rapidly was skilled home
health care which increased by 127 percent during this period. Although
noninstitutional long-term care workload increased, all veterans may not
have access to these services because there are limitations in the
availability of these services. We previously reported a number of
limitations in access to noninstitutional services that veterans
experienced in the fall of 2002. At that time some facilities did not
offer some of these noninstitutional services at all, or offered them only
in certain parts of the geographic area they served.8 For example, more
than half of VA's 139 medical facilities did not provide home-based
primary care or adult day

9

health care in the fall of 2002.

8U.S. General Accounting Office, VA Long-Term Care: Veterans' Access to
Noninstitutional Care Is Limited by Service Gaps and Facility Restrictions
GAO-03-815T (Washington, D.C.: May 22, 2003), and 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).

9We reported on 139 medical facilities, even though VA had 172 medical
centers, because in some instances 2 or more medical centers had
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 had 139 facilities.

Table 3: Change in Noninstitutional Long-Term Care Workload Provided or
Paid for by VA in Fiscal Years 1998-2003

Type of noninstitutional service

1998 1999 2000 2001 2002 2003 Change 1998-2003

     Home-based primary care      923  964    890    908     903  944   
     aAdult day health care     1,023 1,215  1,106  1,201 1,310  1,220  
Homemaker/home health aide   2,385 3,141  3,080  3,824 4,180  4,317  1,932 
    Skilled home health care    1,906 2,148  2,555  3,273 3,851  4,332  2,426 
        Home respite care           b      b      b     b      b   2    
        Home hospice care           b      b      b     b      b   77   
             Totalc             6,237 7,468  7,631  9,206 10,244 10,892 4,655 

Source: VA and GAO analysis of VA data.

Note: Workload is measured by average daily census which represents the
total number of visits of noninstitutional care provided in a year divided
by the number of days in the year. The average daily census calculation
for adult day health care uses 251 rather than 365 days because this
service is not always provided 7 days a week.

a

Numbers include contracted adult day health care and VA-provided adult day
health care.

b Data not available.

c

Total workload is not a measure of unique patients daily because the same
patient may receive more than one service in the same day.

The noninstitutional workload numbers for home-based primary care in table
3 are different from those reported by VA in its appropriations
submissions to Congress and in recent VA testimony.10 In its reports on
noninstitutional workload, VA has measured home-based primary care
services using enrolled days--the number of days a veteran is enrolled to
receive a service--rather than the number of home-based primary care
visits a veteran receives. However, VA has measured use of the other
noninstitutional services in visits. Therefore, to ensure comparability
across services, we used visits as the workload measure for home-based
primary care. As a result, our workload total for home-based primary care
is smaller than the number VA reports because veterans do not typically
receive a home-based primary care visit for each day in which they are
enrolled in home-based primary care. Specifically, we report the 2002
home-based primary care workload as 903 while VA has reported it as

10House Subcommittee on Health, Committee on Veterans' Affairs, Statement
of the Under Secretary for Health, Department of Veterans Affairs, VA's
Long-Term Care Programs, 108th Congress, 1st session, May 22, 2003,
Department of Veterans Affairs FY 2004 Budget Submission: Medical Programs
Volume 2 of 5 Final (Washington, D.C.: March 2003), 2148, and Department
of Veterans Affairs FY 2002 Budget Submission: Medical Programs Volume 2
of 6 (Washington, D.C.: April 2001), 2-101.

Concluding Observations

8,081. Our consistent measure of all services in visits results in a lower
total noninstitutional workload than that reported by VA.

Over the last 6 years, the veteran population most in need of long-term
care has grown dramatically. During this period, VA's use of nursing home
care by setting has changed so that state veterans' nursing homes now
provide one-half of all nursing home workload provided or paid for by VA.
At the same time, VA decreased the workload it serves in its own nursing
homes consistent with VA's policy to emphasize short-stay, post-acute care
in its own nursing homes. VA also used community nursing home care less as
it transitioned more veterans who needed such care to care paid for by
other payers such as Medicaid. In addition, VA increased the long-term
care workload provided in noninstitutional settings.

These trends over the last 6 years raise important questions for how VA is
meeting current long-term care need and what it may need to do to meet
future long-term care need.

o  	What does the significant variation in nursing home workload change
among the networks over this 6-year period mean for meeting veterans'
long-term care needs in different parts of the country?

o  	What are the implications for access, quality, and costs of VA's
significant shift to using state veterans' nursing homes to provide
one-half of its nursing home care?

o  	How has VA's increased emphasis on post-acute care in its own nursing
homes affected its ability to continue providing long-term care in its
nursing homes for veterans with chronic disabilities?

o  	To what extent does total VA long-term care workload--composed of a
fairly constant nursing home workload and a rapidly expanding but smaller
noninstitutional workload--meet the needs of a rapidly growing elderly
veteran population?

The continuing rapid rise in the veteran population likely to be in
greatest need of long-term care--those 85 years and older--poses a major
challenge for VA health care. Answers to these four questions can help
policymakers, VA, and its stakeholders better understand the best ways to
meet VA's long-term care challenge. We look forward to continuing to work
with you on these significant issues.

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

Contact and For further information regarding this testimony, please
contact me at

Acknowledgments 	(202) 512-7101. Individuals making key contributions to
this testimony include James C. Musselwhite, Thomas A. Walke, and Pamela
A. Dooley.

Related GAO Products

VA Long-Term Care: Veterans' Access to Noninstitutional Care Is Limited by
Service Gaps and Facility Restrictions. GAO-03-815T. Washington, D.C.: May
22, 2003.

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.

Medicare: Utilization of Home Health Care by State. GAO-02-782R.
Washington, D.C.: May 23, 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.

VA Long-Term Care: Oversight of Community Nursing Homes Needs
Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001.

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