VA Health Care: More Outpatient Rehabilitation Services for Blind
Veterans Could Better Meet Their Needs (22-JUL-04, GAO-04-996T). 
                                                                 
In fiscal year 2003, the Department of Veterans Affairs (VA)	 
estimated that about 157,000 veterans were legally blind, and	 
about 44,000 of these veterans were enrolled in VA health care.  
The Chairman of the Subcommittee on Health, House Veterans'	 
Affairs Committee, and the Ranking Minority Member, Senate	 
Veterans' Affairs Committee expressed concerns about VA's	 
rehabilitation services for blind veterans. GAO reviewed (1) the 
availability of VA outpatient blind rehabilitation services, (2) 
whether legally blind veterans benefit from VA and non-VA	 
outpatient services, and (3) what factors affect VA's ability to 
increase veterans' access to blind rehabilitation outpatient	 
services. GAO reviewed VA's blind rehabilitation policies;	 
interviewed officials from VA, the Blinded Veterans Association, 
state and private nonprofit agencies, and visited five Blind	 
Rehabilitation Centers (BRC).					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-996T					        
    ACCNO:   A11070						        
  TITLE:     VA Health Care: More Outpatient Rehabilitation Services  
for Blind Veterans Could Better Meet Their Needs		 
     DATE:   07/22/2004 
  SUBJECT:   Education or training				 
	     Health care facilities				 
	     Health care programs				 
	     Health care services				 
	     Medical fees					 
	     Patient care services				 
	     Veterans						 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-04-996T

                 United States Government Accountability Office

GAO Testimony

Before the Committee on Veterans' Affairs, House of Representatives

For Release on Delivery

Expected at 9:30 a.m. EDT VA HEALTH CARE

Thursday, July 22, 2004

  More Outpatient Rehabilitation Services for Blind Veterans Could Better Meet
                                  Their Needs

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

GAO-04-996T

Highlights of GAO-04-996T, a report to the Committee on Veterans' Affairs,
House of Representatives

In fiscal year 2003, the Department of Veterans Affairs (VA) estimated
that about 157,000 veterans were legally blind, and about 44,000 of these
veterans were enrolled in VA health care. The Chairman of the Subcommittee
on Health, House Veterans' Affairs Committee, and the Ranking Minority
Member, Senate Veterans' Affairs Committee expressed concerns about VA's
rehabilitation services for blind veterans. GAO reviewed (1) the
availability of VA outpatient blind rehabilitation services, (2) whether
legally blind veterans benefit from VA and non-VA outpatient services, and
(3) what factors affect VA's ability to increase veterans' access to blind
rehabilitation outpatient services. GAO reviewed VA's blind rehabilitation
policies; interviewed officials from VA, the Blinded Veterans Association,
state and private nonprofit agencies, and visited five Blind
Rehabilitation Centers (BRC).

GAO recommends that the Secretary of Veterans Affairs direct the Under
Secretary for Health to issue, as soon as possible in fiscal year 2005, a
uniform standard of care policy that ensures that a broad range of
inpatient and outpatient blind rehabilitation services are more widely
available to legally blind veterans. In commenting on a draft of this
testimony, VA concurred with our recommendation.

www.gao.gov/cgi-bin/getrpt?GAO-04-996T.

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.

July 22, 2004

VA HEALTH CARE

More Outpatient Rehabilitation Services for Blind Veterans Could Better Meet
Their Needs

VA provides three types of blind rehabilitation outpatient training
services. These services, which are available at a small number of VA
locations, range from short-term programs provided in VA facilities to
services provided in the veteran's own home. They are Visual Impairment
Services Outpatient Rehabilitation, Visual Impairment Center to Optimize
Remaining Sight, and Blind Rehabilitation Outpatient Specialists.

Locations of VA Outpatient Blind Rehabilitation Services, May 2004

Source: VA.

VA reported to GAO that some legally blind veterans could benefit from
increased access to outpatient blind rehabilitation services. When VA
reviewed all of the veterans who, as of March 31, 2004, were on the
waiting list for admission to the five BRCs GAO visited, VA officials
reported that 315 out of 1,501 of them, or 21 percent, could potentially
be better served through access to outpatient blind rehabilitation
services, if such services were available.

GAO also identified two factors that may affect the expansion of VA's
outpatient blind rehabilitation services. The first involves VA's
longstanding position that training for legally blind veterans is best
provided in a comprehensive inpatient setting. The second reported factor
is VA's method of allocating funds for medical care. VA is currently
working to develop an allocation amount that would better reflect the cost
of providing blind rehabilitation services on an outpatient basis.

Mr. Chairman and Members of the Committee:

I am pleased to be here today to discuss the health care rehabilitation
services the Department of Veterans Affairs (VA) provides to legally blind
veterans. In fiscal year 2003, VA estimated that about 157,000 veterans
were legally blind,1 and about 44,000 of these veterans were enrolled in
VA health care. Since the 1940s, the demographics of VA's blind veteran
population have changed from young veterans totally blind as a result of
traumatic injury to primarily older veterans whose legal blindness is
caused by age-related eye diseases.

You expressed concern that VA has not updated its delivery of care options
for blind rehabilitation programs by offering, in addition to inpatient
services, a range of outpatient services closer to where veterans live.2
To determine how VA serves the needs of legally blind veterans and what
role outpatient training services could play, we reviewed (1) the
availability of VA outpatient blind rehabilitation services, (2) whether
legally blind veterans benefit from VA and non-VA outpatient services, and
(3) what factors affect VA's ability to increase veterans' access to blind
rehabilitation outpatient services.

To address these issues, we met with officials from VA's Rehabilitative
Strategic Health Care Group, including the Blind Rehabilitation Service
Program Office (program office). We also met with VA's directors for
ophthalmology and optometry. We reviewed applicable policies and
procedures regarding VA's blind rehabilitation services, its strategic
plan for blind rehabilitation, and its planning documents for special
disability populations. To determine what blind rehabilitation services
were available to veterans, we visited five medical centers offering blind
rehabilitation services and met with Blind Rehabilitation Center (BRC)
officials as well as case managers and rehabilitation specialists who work

1VA defines "legal blindness" as when the patient's best-corrected central
visual acuity, with ordinary glasses or contact lenses, is 20/200 or less
in the better eye (measured by the Snellen Visual Acuity Chart), or when
the field of useful vision is 20 degrees or less in the better eye. For
example, a legally blind person can read only the big "E" on the eye chart
or sees as if looking through a paper towel tube.

2This work was requested by the Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, House of Representatives and the Ranking
Minority Member, Committee on Veterans' Affairs, United States Senate.

with legally blind veterans.3 We asked BRC officials and case managers to
evaluate veterans on the waiting lists for admission to these BRCs as of
March 31, 2004, to identify those who could potentially be better served
through access to outpatient blind rehabilitation services, if such
services were available. We also interviewed case managers who were
located at medical centers without a BRC and representatives of the
Blinded Veterans Association to gain their perspectives on the types of
care that would benefit legally blind veterans. In addition, we met with
officials from state and private nonprofit agencies in Arizona, Illinois,
and Washington to learn about the blind rehabilitation programs they offer
older citizens.4 Our review was conducted from September 2003 through July
2004 in accordance with generally accepted government auditing standards.

In summary, VA provides three types of blind rehabilitation outpatient
training services, but they are available only in a few VA locations.
These services range from short-term programs provided in VA facilities to
services provided in the veteran's own home. VA also believes that some
legally blind veterans could benefit from increased access to outpatient
blind rehabilitation services. In fact, VA officials reported to us that
21 percent of veterans on the waiting lists for admission to the five BRCs
we visited could potentially be better served through access to outpatient
blind rehabilitation services, if such services were available. Finally,
two factors affect the expansion of VA's outpatient blind rehabilitation
services. The first involves VA's long-standing position that training for
legally blind veterans should be provided in a comprehensive inpatient
setting. This delivery model has not kept pace with VA's overall health
care strategy that reduces its reliance on inpatient care and emphasizes
more outpatient care. The second reported factor affecting the use of
outpatient blind rehabilitation services is its method of allocating funds
for medical care. VA's Visual Impairment Advisory Board (VIAB) believes
that the funds allocated for basic outpatient care for legally blind
veterans do not cover the cost of providing blind rehabilitation
outpatient services. The VIAB is currently working with VA's Office of
Finance and Allocation

3We visited the BRCs located in Tucson, Arizona; West Palm Beach, Florida;
Augusta, Georgia; Hines, Illinois; and American Lake, Washington. These
BRCs were selected based on differences in geographic location and the
number of beds available at the BRC.

4We selected these states because they were in the same geographic
location as three of the BRCs we visited.

Resource Center5 to develop an allocation amount that would better reflect
the cost of providing blind rehabilitation services on an outpatient
basis, which could provide an incentive to expand this care. We are
recommending that VA take action to ensure that a broad range of inpatient
and outpatient blind rehabilitation services is more widely available to
legally blind veterans.

Background 	In 1944, President Franklin D. Roosevelt made a commitment
that no servicemen blinded in combat in World War II would be returned to
their homes without adequate training to meet the problems imposed by
their blindness, according to VA. From 1944 to 1947, the Army and Navy
provided this rehabilitation training. In 1947, responsibility for this
training was transferred to VA, and in 1948, VA opened its first BRC to
provide comprehensive inpatient care to legally blind veterans.

In 1956, blind rehabilitation services were expanded to include veterans
whose legal blindness was not service-connected. Because of this
expansion, the demographics of VA's blind veteran population shifted
toward predominately older veterans whose legal blindness was caused by
age-related eye diseases. Expanded eligibility also caused an increase in
demand for services. VA responded to this demand by opening 9 additional
BRCs in the United States and Puerto Rico for a total of 10 facilities
with 241 authorized beds. (See table 1.) As of May 5 2004, VA reported
that there were 2,127 legally blind veterans waiting for admission to
BRCs.6

5The Allocation Resource Center is responsible for developing,
implementing, and maintaining management information systems that provide
data for the Veterans Health Administration's budget process.

6See U.S. General Accounting Office, VA Needs to Improve Accuracy of
Reported Wait Times for Blind Rehabilitation Services, GAO-04-949
(Washington, D.C.: July 22, 2004).

Table 1: Location of VA's Blind Rehabilitation Centers, the Year Each Was
Opened, and the Number of Authorized and Staffed Beds, as of May 2004

                                     Bedsa

                              Location  Year Opened    Authorized     Staffed 
             American Lake, Washington           1971            15 
                      Augusta, Georgia           1996            15 
                   Birmingham, Alabama           1982            32 
                       Hines, Illinois           1948            34 
                 Palo Alto, California           1967            32 
                 San Juan, Puerto Rico           1986            12 
                       Tucson, Arizona           1994            34 
                           Waco, Texas           1974            15 
               West Haven, Connecticut           1969            34 
              West Palm Beach, Florida           2000            18 
                                 Total                          241       218 

Source: VA.

aAuthorized beds are the total bed capacity of the BRC. Staffed beds are
the beds available for admission of patients. According to VA's Capacity
Report for 2003, the number of staffed beds may be less than authorized
beds because the local medical center may have eliminated staff positions,
imposed a hiring freeze, or experienced difficulties in recruiting
qualified personnel.

In fiscal year 2003, VA estimated that about 157,000 veterans were legally
blind,7 with more than 60 percent age 75 or older. About 44,000 legally
blind veterans were enrolled in VA health care. VA estimated that through
2022, the number of legally blind veterans would remain stable. (See fig.
1.)

7All legally blind veterans are given priority 4 status and currently are
eligible to enroll in VA health care.

Figure 1: Estimated Age Distribution of Legally Blind Veterans, Fiscal
Years 2003, 2012, and 2022

Number of legally blind veterans

120,000

100,000

80,000

60,000

40,000

20,000

0 <55 55-64 65-74 >=75 Age of legally blind veterans

2003

2012

2022

Source: Atlanta VA Rehabilitation Research and Development Center.

The National Institutes of Health (NIH) considers the increase in
agerelated eye diseases to be an emerging major public health problem.
According to NIH, the four leading diseases that cause age-related legal
blindness are cataract, glaucoma, macular degeneration, and diabetic
retinopathy, each affecting vision differently. (See fig. 2 for
illustrations of how each disease affects vision.) Cataract is a clouding
of the eye's normally clear lens. Most cataracts appear with advancing
age, and by age 80, more than half of all Americans develop them. Glaucoma
causes gradual damage to the optic nerve-the nerve to the eye-that results
in decreasing peripheral vision. It is estimated that as many as 4 million
Americans have glaucoma. Macular degeneration results in the loss of
central visual clarity and contrast sensitivity. It is the most common
cause of legal blindness in older Americans and rarely affects those under
the age of 60. Diabetic retinopathy is a common complication of diabetes
impairing vision over time. It results in the loss of visual clarity,
peripheral vision, and color and contrast sensitivity. It also increases
the eye's

sensitivity to glare. Nearly half of all diabetics will develop some
degree of diabetic retinopathy, and the risk increases with veterans' age
and the length of time they have had diabetes.

Figure 2: Vision and Vision Loss Due to Age-Related Eye Diseases

      Source: National Eye Institute, U.S. National Institutes of Health.

To assist legally blind veterans, VA established Visual Impairment
Services Team (VIST) coordinators who act as case managers and are
responsible for coordinating all medical services for these veterans,
including obtaining medical examinations and arranging for blind
rehabilitation services. There are about 170 VIST coordinators, who are
located at VA medical centers that have at least 100 enrolled legally
blind veterans. VIST coordinators are also responsible for certain
administrative services such as reviewing the veteran's compensation and
pension benefits. Almost all of VA's blind rehabilitation services for
veterans are provided through comprehensive inpatient care at BRCs, where
veterans are trained to use their remaining vision8 and other senses, as
well as adaptive devices such as canes, to help compensate for impaired
vision. VA offers both basic and computer training. (See table 2 for
examples of the types of skills taught during basic and computer
training.)

8About 85 percent of those who are legally blind have some usable vision.

 Table 2: Examples of Training Courses Offered at Blind Rehabilitation Centers

Basic training

                           Examples of skills taught

Visual skills  o  	Maximizing remaining vision through the use of
alternative scanning or viewing techniques

o  	Using magnification devices or closed circuit televisions to read or
write

Orientation and mobility  o  Moving around the home

o  Traveling through different environments

o  	Using adaptive devices, such as telescopic devices for reading street
signs

Living skills  o  Cooking and eating

o  Doing laundry or changing light bulbs

o  Typing or keyboarding

Manual skills  o  Using hand and power tools

o  Problem solving and organization of work

Leisure skills  o  Going to sporting events

o  Playing golf or fishing

o  Developing a hobby, such as woodworking

Adjustment counseling  o  	Using counseling, therapy, and social
interaction with others who have similar visual impairments to learn to
adjust to blindness

Computer training Examples of skills taught

Computer skills  o  Operating a computer

o  Searching the Internet

o  Sending, receiving, and reading e-mail

Source: VA Blind Rehabilitation Service.

In fiscal years 2002 and 2003, VA spent over $56 million each year for
inpatient training at BRCs. During this same time period, VA spent less
than $5 million each year to provide outpatient rehabilitation training
for legally blind veterans.

  Blind Rehabilitation Outpatient Services Are Available in Few VA Locations

VA offers three types of blind rehabilitation outpatient services to
legally blind veterans,9 but these services are available in few VA
locations. The three types of services include Visual Impairment Services
Outpatient Rehabilitation (VISOR), Visual Impairment Center to Optimize
Remaining Sight (VICTORS), and Blind Rehabilitation Outpatient Specialists
(BROS). The services range from short-term outpatient programs provided in
VA facilities to home-based services. Figure 3 identifies the locations
throughout the United States and Puerto Rico where these services are
offered.10

9Some VA low vision eye clinics also provide limited outpatient
rehabilitation training to legally blind veterans whose remaining vision
can be enhanced through the use of magnification devices. However, while
VA has overall workload data for its eye clinics, it cannot disaggregate
the data to identify how much low vision training is provided to legally
blind veterans.

10All of VA's outpatient programs also treat low vision veterans in
addition to those veterans who are legally blind. VA defines low vision as
when the patient has significant uncorrectable visual impairments of 20/70
up to, but not including, 20/200.

admission to a BRC or to veterans who do not want to attend a BRC.
Veterans who participate in this program are housed in hoptel beds11
within the medical facility. In fiscal year 2003, 54 veterans attended the
VISOR program; about 20 to 30 percent of these veterans were legally
blind. According to a VISOR official, there is no waiting list for this
program and the local medical center provides the necessary funding for
it.

                                VICTORS Services

VICTORS is a 3- to 7-day outpatient program for veterans in good health
whose vision loss affects their ability to perform activities of daily
living, such as personal grooming and reading mail. The program provides
the veterans with a specialized low vision eye examination, prescriptions
for and training in the use of low vision equipment, and counseling. There
are three VICTORS programs located in VA medical centers in Kansas City,
Missouri; Chicago, Illinois; and Northport, New York. Veterans are housed
in hoptel beds within the medical facility or in nearby hotels. In fiscal
year 2003, VICTORS served over 900 veterans; about 25 to 30 percent of
these veterans were legally blind. According to VICTORS officials, the
wait time for admission to VICTORS varied from about 55 to about 170 days.
The medical center where the program is located funds the services.

                                 BROS Services

BROS are blind rehabilitation outpatient instructors who provide a variety
of short-term services to veterans in their homes and at VA facilities.
BROS train veterans prior to and following their participation in BRC
programs, as well as veterans who cannot or do not choose to attend a BRC.
BROS training addresses veterans' immediate needs, especially those
involving safety issues such as reading prescriptions or simple cooking.
There are 23 BROS throughout VA's health care system, with 7 located in
the VA network that covers Florida and Puerto Rico. In fiscal year 2003,
BROS trained about 2,700 veterans, almost all of whom were legally blind.
Wait time for BROS services varied from about 14 to 28 days according to

11A hoptel is temporary lodging where no medical care is provided.

the BROS we interviewed. BROS are funded by the medical centers where they
are located.12

  Outpatient Services Provide Opportunities to Benefit Veterans

VA officials who provide services to legally blind veterans told us that
some veterans could benefit from increased access to outpatient blind
rehabilitation services. We obtained this information by asking VA to
review all of the veterans who, as of March 31, 2004, were on the waiting
lists for admission to the five BRCs we visited and to determine whether
outpatient services could meet their needs. VA officials reported that 315
out of 1,501 of these veterans, or 21 percent, could potentially be better
served through access to outpatient blind rehabilitation services, if such
services were available. The types of veterans VA believes could
potentially benefit from outpatient services include those who are very
elderly or lack the physical stamina to participate in a comprehensive
28to 42-day BRC program and those who have medical needs that cannot be
provided by the BRC. For example, some BRCs are unable to accept patients
requiring kidney dialysis. In addition, some veterans do not want to leave
their families for long periods of time13 and some legally blind veterans
are primary caretakers for their spouses and are unable to leave their
homes. VA officials also told us that veterans in good health who can
independently perform activities of daily living and require only limited
or specialized training could also be served effectively on an outpatient
basis.

A VA study concluded that there is a need for increased outpatient
services for legally blind veterans. In 1999, VA convened a Blind
Rehabilitation Gold Ribbon Panel to study concerns about the growing
number of legally blind veterans. The panel examined how VA historically
provided blind rehabilitation services and recommended that VA transition
from its primarily inpatient model of care to one that included both

12In connection with VA's fiscal year appropriations for 1995, the Senate
Committee on Appropriations had recommended including $5 million for blind
rehabilitation services to alleviate the lengthy waiting lists for such
services. The conference committee agreed. See S. Rep. No. 103-311 (1994),
H. Conf. Rep. No. 103-715 (1994). In addition to the BROS, these funds
were also used to establish a BRC in Augusta, Georgia, and additional
staff positions for VIST coordinators and computer specialists.

13A 2003 study of 150 veterans located in the southeastern United States
who were recommended for BRC training by their VIST coordinators but who
did not attend, found that 59 percent cited a reluctance to leave home for
an extended period as an important reason for non-participation. Williams,
M., Help-Seeking Behavior as a Predictor of Participation in Department of
Veterans Affairs-Sponsored Visual Impairment Rehabilitation. A
Dissertation (Decatur, GA.; 2003).

inpatient and outpatient services. In 2000, VA established the VIAB to
implement the panel's recommendations. The VIAB drafted guidance for a
uniform standard of care policy for visually impaired veterans throughout
VA's health care system. This guidance outlined a continuum of care to
provide a range of services from basic low vision to comprehensive
inpatient rehabilitation training, including use of more outpatient
services from both VA and non-VA sources. In January 2004, a final draft
of the uniform standard of care policy was forwarded to VA's Health
Systems Committee for approval. The committee believed additional
information was needed for its approval and requested additional analysis
that compared currently available blind rehabilitation services with
anticipated needs. VA plans to complete this analysis in the first quarter
of fiscal year 2005 and then resubmit the uniform standard of care policy
and the additional analysis to the Health Systems Committee. VA officials
were unable to provide a timeframe for the Health Systems Committee's
approval.

Some VIST coordinators have already provided outpatient services to
legally blind veterans by referring them to state and private blind
rehabilitation services. For example, in Florida a VIST coordinator
referred veterans to the Lighthouse for the Blind for computer training at
its outpatient facility if they did not live near and did not want to
travel to the BRC. A VIST coordinator in Oklahoma arranged
contractor-provided computer training in the veteran's home for veterans
with a 20 percent or more service-connected disability. The coordinator
issued the computer equipment to a local contractor; the contractor then
set up the equipment in the veteran's home and provided the training.
Another VIST coordinator in North Carolina referred all legally blind
veterans to state service agencies, including veterans waiting for
admission to a BRC. Each county in that state had a social worker for the
blind that referred its citizens to independent living programs for
in-home training in orientation and mobility and living skills. The state
provided this training at no charge to the veteran and VA paid for the
equipment.

Recently, VA has begun to shift computer training from inpatient settings
at BRCs to private sector outpatient settings. VA's goal was to remove
from the BRC waiting list by July 30, 2004, those veterans seeking
admission to a BRC only for computer training. In spring 2004, VA issued
instructions stating that the prosthetic budget of each medical center,
which already paid for computer equipment for legally blind veterans,

would now pay for computer training.14 Additionally, the Blind
Rehabilitation Service Program Office asked BRCs to identify all the
veterans waiting for admission for computer training and refer them back
to their VIST coordinator for local computer training. If BRC and VIST
coordinator staff determined that local computer training was not
available or appropriate for a veteran, they were to provide an
explanation to the program office. On May 5, 2004, 674 veterans were
waiting for admission to a BRC for computer training. As of July 1, 2004,
520 veterans were removed from the BRC waiting list because arrangements
were made for them to receive computer training from non-VA sources or
they no longer wanted the training.

  Factors that Affect Expansion of Blind Rehabilitation Outpatient Services

There are two factors that affect VA's expansion of outpatient services
systemwide. One factor is the agency's long-standing belief that
rehabilitation training for legally blind veterans can be best provided in
a comprehensive inpatient setting. The second reported factor is VA's
method of allocating funds for blind rehabilitation outpatient services,
which provides local medical center management discretion to provide funds
for them.

Some VA officials told us that one factor affecting veterans' access to
outpatient care has been the agency's traditional focus on providing
comprehensive inpatient training at BRCs. VA has historically considered
the BRCs to be an exemplary model of care, and since 1948 BRCs have been
the primary source of care for legally blind veterans. However, this
delivery model has not kept pace with VA's overall health care strategy
that reduces reliance on inpatient care and emphasizes outpatient care.
VA's continued reliance on inpatient blind rehabilitation care is evident
in its recent decision to build two additional BRCs in Long Beach,
California, and Biloxi, Mississippi.15 We have, however, observed some
recent changes that may affect this reliance on inpatient services. For
example, VA has new leadership in its blind rehabilitation program that
has expressed an interest in providing a broad range of inpatient and
outpatient services to meet the training needs of legally blind veterans.
Further, as previously

14According to VA officials, the funds allocated for prosthetics maybe
used only for prosthetic care-e.g. purchase of prosthetic items and
veteran training in the use of these items.

15See Department of Veterans Affairs Capital Asset Realignment for
Enhanced Services (CARES): Secretary of Veterans Affairs CARES Decisions.
(Washington D.C.; May 2004).

discussed, the VIAB's draft continuum of care policy recommends a full
range of blind rehabilitation services, emphasizing more outpatient care,
including VICTORS, VISOR, and BROS.

VA blind rehabilitation officials also told us that they believe changes
to VA's resource allocation method could provide an incentive to expand
blind rehabilitation services on an outpatient basis. The VIAB believes
that the funds allocated for basic outpatient care for legally blind
veterans do not cover the cost of providing blind rehabilitation services.
Veterans Integrated Service Networks (networks)16 are allocated funds to
provide basic outpatient care for veterans, which they then allocate to
the medical centers in their regions. Both the networks and the medical
centers have the discretion to prioritize the use of these funds for blind
rehabilitation services or any other medical care. Some networks and
medical centers have made outpatient blind rehabilitation training a
priority and use these funds to provide outpatient services. For example,
the network that covers Florida and Puerto Rico has used its allocations
to fund seven BROS that are located throughout the region to provide
outpatient blind rehabilitation services to legally blind veterans in
their own homes or at VA facilities. Currently, the VIAB is working with
VA's Office of Finance and Allocation Resource Center to develop an
allocation amount that would better reflect the cost of providing blind
rehabilitation services on an outpatient basis, which could in turn,
provide an incentive for networks and medical centers to expand outpatient
rehabilitation services for legally blind veterans.

Conclusions 	Many legally blind veterans have some vision, which
frequently can be enhanced with optical low vision devices and training
that includes learning to perform everyday activities such as cooking,
reading prescription bottles, doing laundry, and paying bills. Since the
1940s, VA's preferred method of providing training to these veterans has
been through inpatient services offered by BRCs. Because of its
predisposition toward inpatient care, VA has developed little capacity to
provide this care on an outpatient basis uniformly throughout the country.
For the last 10 years, VA has been transitioning its overall health care
system from a delivery model based primarily on inpatient care to one
incorporating more outpatient care. Outpatient services for legally blind
veterans, however, have lagged behind this trend. Recently, VA drafted a
uniform standard of

16VA has organized its medical facilities into 21 regional health care
networks.

care policy that recommends a full range of blind rehabilitation services,
emphasizing more outpatient care, including more services provided by
VISOR, VICTORS, and BROS type programs. Making inpatient and outpatient
blind rehabilitation training services available to meet the needs of
legally blind veterans will help ensure that these veterans are provided
with options to receive the right type of care, at the right time, in the
right place.

We are recommending that the Secretary of Veterans Affairs direct the
Under Secretary for Health to issue, as soon as possible in fiscal year
2005, a uniform standard of care policy that ensures that a broad range of
inpatient and outpatient blind rehabilitation services are more widely
available to legally blind veterans.

Recommendations

Agency Comments 	We provided a draft of this testimony to VA for comment.
In oral comments, an official in VA's Office of the Deputy Under Secretary
for Health informed us that VA concurred with our recommendation.

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

Contact and For further information regarding this testimony, please
contact Cynthia A. Bascetta at (202) 512-7101. Michael T. Blair, Jr.,
Cherie Starck, Cynthia Acknowledgments Forbes, and Janet Overton also
contributed to this statement.

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

GAO's Mission	The Government Accountability Office, the audit, evaluation
and investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people. GAO
examines the use of public funds; evaluates federal programs and policies;
and provides analyses, recommendations, and other assistance to help
Congress make informed oversight, policy, and funding decisions. GAO's
commitment to good government is reflected in its core values of
accountability, integrity, and reliability.

Obtaining Copies of The fastest and easiest way to obtain copies of GAO
documents at no cost

is through GAO's Web site (www.gao.gov). Each weekday, GAO postsGAO
Reports and newly released reports, testimony, and correspondence on its
Web site. To Testimony have GAO e-mail you a list of newly posted products
every afternoon, go to

www.gao.gov and select "Subscribe to Updates."

Order by Mail or Phone	The first copy of each printed report is free.
Additional copies are $2 each. A check or money order should be made out
to the Superintendent of Documents. GAO also accepts VISA and Mastercard.
Orders for 100 or more copies mailed to a single address are discounted 25
percent. Orders should be sent to:

U.S. Government Accountability Office 441 G Street NW, Room LM Washington,
D.C. 20548

To order by Phone: 	Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061

  To Report Fraud, Contact:
  Waste, and Abuse in Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: [email protected] Programs Automated answering system: (800)
424-5454 or (202) 512-7470

Congressional 	Gloria Jarmon, Managing Director, [email protected] (202)
512-4400 U.S. Government Accountability Office, 441 G Street NW, Room 7125

Relations Washington, D.C. 20548

Public Affairs Jeff Nelligan, Managing Director, [email protected] (202)
512-4800 U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548
*** End of document. ***