VA Long-Term Care: More Accurate Measure of Home-Based Primary	 
Care Workload Is Needed (08-SEP-04, GAO-04-913).		 
                                                                 
The Department of Veterans Affairs (VA) provides a variety of	 
long-term care services that includes nursing home care and	 
noninstitutional care provided in community-based settings or in 
the homes of veterans. One important noninstitutional service is 
home-based primary care, which uses a multidisciplinary team	 
approach involving VA health care providers and others such as	 
social workers to treat veterans who are homebound. As part of	 
GAO's work for the Committee on Veterans' Affairs, House of	 
Representatives, to assess how VA meets veterans' long-term care 
needs, GAO reviewed how VA measures workload for home-based	 
primary care and five other noninstitutional services.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-913 					        
    ACCNO:   A12103						        
  TITLE:     VA Long-Term Care: More Accurate Measure of Home-Based   
Primary Care Workload Is Needed 				 
     DATE:   09/08/2004 
  SUBJECT:   Home health care services				 
	     Long-term care					 
	     Performance measures				 
	     Veterans						 
	     Work measurement					 
	     Data collection					 
	     Data integrity					 

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GAO-04-913

                 United States Government Accountability Office

GAO

Report to the Secretary of Veterans

                                    Affairs

September 2004

VA LONG-TERM CARE

      More Accurate Measure of Home-Based Primary Care Workload Is Needed

                                       a

GAO-04-913

Highlights of GAO-04-913, a report to the Secretary of Veterans Affairs

The Department of Veterans Affairs (VA) provides a variety of longterm
care services that includes nursing home care and noninstitutional care
provided in community-based settings or in the homes of veterans. One
important noninstitutional service is homebased primary care, which uses a
multidisciplinary team approach involving VA health care providers and
others such as social workers to treat veterans who are homebound. As part
of GAO's work for the Committee on Veterans' Affairs, House of
Representatives, to assess how VA meets veterans' long-term care needs,
GAO reviewed how VA measures workload for homebased primary care and five
other noninstitutional services.

GAO recommends that VA measure and report the amount of homebased primary
care services veterans receive by using visits. VA agreed that a more
accurate measure of home-based primary care is needed but did not concur
with GAO's recommendation. However, VA plans to establish a combination of
workload measures for home-based primary care and other long-term care
programs in fiscal year 2005, including visits, which will be responsive
to GAO's recommendation.

www.gao.gov/cgi-bin/getrpt?GAO-04-913.

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.

September 2004

VA LONG-TERM CARE

More Accurate Measure of Home-Based Primary Care Workload Is Needed

The amount of home-based primary care veterans receive is not accurately
reflected in VA's workload measurement for that service. VA measures
home-based primary care workload using the number of days a veteran is
enrolled in the program rather than the number of visits the veteran
received. For example, if a veteran was enrolled in VA's home-based
primary care program for 1 week, and received two visits from VA providers
that week, VA would calculate the workload using 7 days, rather than two
visits. As a result, using enrolled days as the workload unit of measure
overstates the amount of home-based primary care actually received by
veterans. In fiscal year 2003, VA reported an average daily workload for
home-based primary care of 8,370 using enrolled days; in contrast, GAO
determined that using the number of visits results in a workload of 944.
In addition, VA's measurement of home-based primary care using enrolled
days is inconsistent with the way it measures workload for the other
noninstitutional long-term care services GAO reviewed. VA measures
workload for these other services using the number of visits a veteran
received. As a result, VA's workload total for home-based primary care
overstates that service's use compared to other noninstitutional services
VA provides.

VA Noninstitutional Long-Term Care Workload, Fiscal Year 2003

Workload (average daily census) 10,000

8,370

8,000

6,000

4,000

2,000

0 Home-based Skilled Homemaker/ Adult day Home Home primary care home home
health health care hospice care respite care health care aide

Enrolled days

Visits

Source: VA data and GAO analysis of VA data.

Note: VA reports all noninstitutional care workload measures except
home-based primary care in visits.

Contents

     Letter                                                                 1 
                                    Results in Brief                        2 
                                       Background                           3 
                VA's Workload Measurement for Home-Based Primary Care Does 
                  Not Accurately Reflect the Amount of Care Received by    
                                        Veterans                            4 
                                       Conclusions                          5 
                           Recommendation for Executive Action              6 
                           Agency Comments and Our Evaluation               6 
Appendix I             Comments from the Department of Veterans Affairs 

Table

Table 1: Selected VA Noninstitutional Long-Term Care Services

Figure

Figure 1: VA Noninstitutional Long-Term Care Workload, Fiscal Year 2003

Abbreviation

                       VA Department of Veterans Affairs

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United States Government Accountability Office Washington, DC 20548

September 8, 2004

The Honorable Anthony J. Principi Secretary of Veterans Affairs

Dear Mr. Secretary:

The Department of Veterans Affairs (VA) provides a continuum of longterm
care services that includes nursing home care and noninstitutional
services provided in community-based settings or in the homes of veterans.
One important noninstitutional service VA provides is homebased primary
care, which uses a multidisciplinary team approach involving VA health
care providers and others such as social workers to treat veterans who are
homebound. Concerns about meeting veterans' long-term care needs in both
institutional and noninstitutional settings have increased in part because
the veteran population is aging. The number of veterans 85 years old and
older, who are most in need of longterm care, is expected to increase from
about 870,000 to 1.3 million over the next decade. Through its
noninstitutional long-term care program, VA provides or pays for services
that may help veterans remain at home and delay, or prevent, their need
for nursing home care. As part of our work for the Committee on Veterans'
Affairs, House of Representatives, to assess how VA met or addressed its
long-term care workload needs from fiscal years 1998 through 2003, we
reviewed how VA measures this workload for home-based primary care and
other services.1

To conduct our review, we assessed veteran patient workload data for
fiscal years 1998 through 2003. Because VA did not change how it measured
workload for the noninstitutional services we reviewed from fiscal years
1998 through 2003, we focused on fiscal year 2003 for this report. We
obtained data from VA on workload and information about how it is measured
and we analyzed these data for six noninstitutional longterm care
services: (1) home-based primary care, (2) adult day health care, (3)
homemaker/home health aide, (4) skilled home health care, (5) home

1See GAO, VA Long-Term Care: Changes In Service Delivery Raise Important
Questions, GAO-04-425T (Washington, D.C.: Jan. 28, 2004).

Results in Brief

respite care, and (6) home hospice care.2 In doing our work, we tested the
reliability of the data and determined they were adequate for our
purposes. We conducted our review from January 2003 through August 2004 in
accordance with generally accepted government auditing standards.

VA's workload measurement of home-based primary care services does not
accurately reflect the amount of care veterans receive. VA measures
home-based primary care workload using the number of days a veteran is
enrolled in the program rather than the number of visits received by a
veteran. For example, if a veteran was enrolled in VA's home-based primary
care program for 1 week, and received two visits from VA providers that
week, VA would calculate the workload using 7 days, rather than two
visits. As a result, the use of enrolled days as the unit of measure for
home-based primary care overstates the services actually received by
veterans. Specifically, VA reported an average daily workload for
homebased primary care of 8,370 using enrolled days in fiscal year 2003;
in contrast, we determined that using the number of visits results in a
workload of 944. In addition, VA's measurement of home-based primary care
using enrolled days is inconsistent with the way VA measures workload for
the five other noninstitutional long-term care services we reviewed. For
these other services, VA measures workload using the number of visits a
veteran received. Because the number of visits is a more accurate measure
of the home-based primary care services veterans receive than enrolled
days, we are recommending that VA use visits to measure and report the
amount of home-based primary care services veterans receive.

In commenting on a draft of this report, VA agreed that a more accurate
measure of home-based primary care is needed but did not concur with our
recommendation. However, VA plans to establish a combination of workload
measures for home-based primary care and other long-term care programs in
fiscal year 2005, including visits, which will be responsive to our
recommendation. This will provide useful information to Congress and other
stakeholders for assessing the amount of home-based primary care services
veterans receive from VA.

2Combining workload for each of these services is not a measure of the
number of unique veterans receiving these services because a patient may
receive more than one noninstitutional long-term care service in the same
day.

Background 	VA provides noninstitutional services as an important part of
its continuum of long-term care. VA provides these services to veterans in
their own homes or in community settings using both its own employees and
other providers available through contracts. Veterans may prefer such
services, which allow them to remain in their homes or in other settings
that are less restrictive than institutions. We reviewed six of the
noninstitutional services that VA provides or pays for. (See table 1.) VA
reported workload measures for these noninstitutional care services in
appropriations requests and testimony to Congress.3

Table 1: Selected VA Noninstitutional Long-Term Care Services

Service Description Care providers

Home-based primary Primary health care, delivered by a VA providers

care 	physician-directed interdisciplinary team of staff including nurses,
to homebound (often bedbound) veterans for whom visits to an outpatient
clinic are 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.

Contracted providers

 Adult day health care Health maintenance and rehabilitative VA and contracted

services provided to frail elderly veterans in an outpatient setting
during part of the day.

                                   providers

Skilled home health care	Medical services provided to veterans at
Contracted home. providers

Home respite care 	Services provided at home to temporarily Contracted
relieve the veteran's caregiver from the providers burden of caring for a
chronically disabled veteran in the home.

3House Committee on Veterans' Affairs, Statement of the Under Secretary
for Health, Department of Veterans Affairs, VA's Long-Term Care Programs,
108th Congress, 2nd session, January 28, 2004; House 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,
Fiscal Year 2004 Budget Submission: Medical Programs Volume 2 of 5 Final
(Washington, D.C.: March 2003), 2-148; and Department of Veterans Affairs,
Fiscal Year 2002 Budget Submission: Medical Programs, Volume 2 of 6
(Washington, D.C.: April 2001), 2-101.

Service Description Care providers

Home hospice care 	Services provided at home to veterans Contracted whose
primary goal of treatment is providers comfort rather than cure for an
advanced disease that is life-limiting.

VA's Workload Measurement for Home-Based Primary Care Does Not Accurately
Reflect the Amount of Care Received by Veterans

Source: VA.

VA's workload measurement for home-based primary care does not accurately
reflect the amount of care received by veterans. VA measures home-based
primary care workload using the number of days the veteran is enrolled in
the program to receive these services, including weekends. Veterans do
not, however, typically receive a home-based primary care visit every day
they are enrolled in the program. For example, if a veteran was enrolled
in VA's home-based primary care program for 1 week, and received two
visits from VA providers that week, VA would calculate the workload using
7 days, rather than two visits. VA officials told us that VA used the
number of enrolled days to measure access to home-based primary care.
While the number of enrolled days may provide a measure of access it does
not provide an accurate measure of the services veterans receive.
Measuring workload on the basis of number of visits veterans receive is a
more accurate measure of VA's provision of this service.

To more accurately reflect the services veterans received, we measured
VA's workload for home-based primary care using number of visits as the
unit of measure. Using this method, we determined that the average daily
workload for VA's home-based primary care in fiscal year 2003 was 944. VA,
however, reported an average daily workload for home-based primary care
that year of 8,370 based on enrolled days. The use of enrolled days as a
workload measure overstates the amount of home-based primary care services
veterans received by a factor of 9 to 1.

Moreover, the way VA measures home-based primary care workload is
inconsistent with the way it measures workload for the five other
noninstitutional long-term care services we reviewed.4 For these other
services, VA measures workload using the number of visits a veteran
received from a health care provider rather than the number of days the
veteran was enrolled in the program. In fiscal year 2003, VA's use of

4VA refers to measures of workload for the six services we reviewed as
average daily census.

enrolled days to measure home-based primary care workload resulted in that
service having the largest workload (46 percent) in comparison to the five
other noninstitutional services. In contrast, when using visits to measure
the home-based primary care workload, home-based primary care constituted
9 percent of all noninstitutional care services and its workload was
smaller than the workload for homemaker/home health aide, adult day health
care, or skilled home health care. (See fig. 1.)

Figure 1: VA Noninstitutional Long-Term Care Workload, Fiscal Year 2003

Workload (average daily census) 10,000

8,370

8,000

6,000

4,000

2,000

0 Home-based Skilled Homemaker/ Adult day Home Home

primary care home home health health care hospice care respite care health
care aide

Enrolled days

Visits

Source: VA data and GAO analysis of VA data.

Note: VA reports all noninstitutional care workload measures except
home-based primary care in visits.

Conclusions 	VA's use of enrolled days to measure home-based primary care
workload does not accurately measure the amount of this service that
veterans receive and overstates its usage compared with other
noninstitutional care services. VA reported that in fiscal year 2003 the
average daily workload for home-based primary care, based on enrolled
days, was 8,370. Measured in visits, however, we determined that the
average daily workload for home-based primary care was 944. Inaccurate
measurement and overstated usage of home-based primary care, as reported
by VA, makes it

difficult for decision makers to know the amount of care VA is providing
with the resources it is expending. Using the number of visits instead of
the number of enrolled days to measure home-based primary care workload
would provide a more accurate measure of the amount of homebased primary
care services that veterans receive and would provide a more appropriate
comparison of home-based primary care with other noninstitutional
long-term care services.

Recommendation for Executive Action

Agency Comments and Our Evaluation

Because the number of visits is a more accurate measure of the homebased
primary care services veterans receive than enrolled days, we recommend
that you direct the Under Secretary for Health to use visits to measure
and report the amount of home-based primary care services veterans
receive.

In commenting on a draft of this report, VA agreed that a more accurate
measure of home-based primary care is needed but did not concur with our
recommendation to use visits to measure and report the amount of
home-based primary care services veterans receive. However, VA plans to
establish a combination of workload measures for home-based primary care
and other long-term care programs in fiscal year 2005, including visits,
which will be responsive to our recommendation.

VA stated that it did not concur with our recommendation because using the
number of visits alone, rather than incorporating ancillary work such as
reviewing laboratory and other test results, does not entirely represent
home-based primary care workload. VA stated that it made a deliberate
decision to convert from using the number of visits received to the number
of enrolled days as the primary workload measure because this would
promote more efficient and comprehensive management of the patient
population. However, VA's use of enrolled days as a workload measure for
home-based primary care services provides a misleading picture of VA's
noninstitutional long-term care services. This measure overstates the
amount of services veterans received because VA measures home-based
primary care workload using the number of days the veteran is enrolled in
the program to receive these services, including weekends. Veterans do
not, however, typically receive a home-based primary care visit every day
they are enrolled in the program. Using enrolled days may be useful for
management of a population in need of such services, as VA states, but not
as a measure of the amount of services veterans received.

VA states that in fiscal year 2005 it will begin reporting two other
workload measures in addition to enrolled days, the number of patients
treated and the number of visits veterans receive. We believe that
reporting the number of patients treated will provide useful information
on the number of veterans receiving home-based primary care but still will
not accurately measure the amount of such care veterans receive. We
believe that measuring and reporting the number of visits veterans
receive, as VA said it will do, will be responsive to our recommendation.
This will provide useful information to Congress and other stakeholders
for assessing the amount of home-based primary care services veterans
receive from VA. If VA chooses to also include in its home-based primary
care measure the amount of ancillary work involved in delivering such
care, this could provide a more comprehensive workload measure. However,
based on a discussion with VA officials, VA cannot currently provide data
on the amount of ancillary work involved with delivering home-based
primary care. VA's written comments are in appendix I.

We are sending copies of this report to the House Committee on Veterans'
Affairs; other interested congressional committees; and other interested
parties. This report is also available at no charge on GAO's Web site at
http://www.gao.gov. If you have questions about this report, please
contact me at (202) 512-7101 or James Musselwhite at (202) 512-7259. Also
contributing to this report were Cheryl A. Brand, Janet L. Overton, and
Thomas A. Walke.

Sincerely yours,

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

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