VA Long-Term Care: Oversight of Nursing Home Program Impeded by  
Data Gaps (10-NOV-04, GAO-05-65).				 
                                                                 
The Department of Veterans Affairs (VA) operates a $2.3 billion  
nursing home program that provides or pays for veterans' care in 
three settings: VA nursing homes, community nursing homes, and	 
state veterans' nursing homes. The Veterans Millennium Health	 
Care and Benefits Act (Millennium Act) of 1999 and VA policy	 
require that VA provide nursing home care to veterans with a	 
certain eligibility. Congress has expressed a need for additional
data to conduct oversight of VA's nursing home program. 	 
Specifically, for all VA nursing home settings in fiscal year	 
2003, GAO was asked to report on (1) VA spending to provide or	 
pay for nursing home care, (2) VA workload provided or paid for, 
(3) the percentage of nursing home care that is long and short	 
stay, and (4) the percentage of veterans receiving care required 
by the Millennium Act or VA policy.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-65						        
    ACCNO:   A13433						        
  TITLE:     VA Long-Term Care: Oversight of Nursing Home Program     
Impeded by Data Gaps						 
     DATE:   11/10/2004 
  SUBJECT:   Health care personnel				 
	     Health care services				 
	     Nursing homes					 
	     Veterans benefits					 
	     Veterans hospitals 				 
	     Health care costs					 
	     Health statistics					 
	     Statistical data					 
	     Work measurement					 

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GAO-05-65

United States Government Accountability Office

GAO Report to the Chairman, Committee on Veterans' Affairs, House of
Representatives

November 2004

VA LONG-TERM CARE

             Oversight of Nursing Home Program Impeded by Data Gaps

GAO-05-65

[IMG]

November 2004

VA LONG-TERM CARE

Oversight of Nursing Home Program Impeded by Data Gaps

                                 What GAO Found

In fiscal year 2003, VA spent 73 percent of its nursing home resources on
VA nursing homes-almost $1.7 billion of about $2.3 billion-and the
remaining 27 percent on community and state veterans' nursing homes.

Half of VA's average daily nursing home workload of 33,214 in fiscal year
2003 was for state veterans' nursing homes, even though this setting
accounted for 15 percent of VA's overall nursing home expenditures. In
large part, this is because VA pays about one-third of the cost of care in
state veterans' nursing homes. Community nursing homes and VA nursing
homes accounted for 13 and 37 percent of the workload, respectively.

About one-third of nursing home care in VA nursing homes in fiscal year
2003 was long-stay care (90 days or more). Long-stay services include
those needed by veterans who cannot be cared for at home because of
severe, chronic physical or mental impairments such as the inability to
independently eat or the need for supervision because of dementia. The
other two-thirds was short-stay care (less than 90 days), which includes
services such as postacute care needed for recuperation from a stroke. VA
lacks similar data for community and state veterans' nursing homes.

About one-fourth of veterans who received care in VA nursing homes in
fiscal year 2003 were served because the Millennium Act or VA policy
requires that VA provide or pay for nursing home care of veterans with a
certain eligibility. All other veterans received care at VA's discretion.
VA lacks data on comparable eligibility status for community and state
veterans' nursing homes even though these settings combined accounted for
63 percent of VA's overall workload. Gaps in data on length of stay and
eligibility in these two settings impede program oversight.

Data Gaps on Length of Stay and Eligibility for VA's Nursing Home Program,
Fiscal Year 2003

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

                 United States Government Accountability Office

Contents

    Letter                                                                  1 
                                   Results in Brief                         3 
                                      Background                            5 
              VA Spent Almost Three-Quarters of Its Nursing Home Resources 

on Care for Veterans in VA Nursing Homes, but Expenditures

Varied Widely by Network 7 State Veterans' Nursing Homes Provided Half of
VA's Overall Nursing Home Workload, but Networks' Use of Nursing Home Care
Setting Varied 10 About One-Third of VA Nursing Home Care Is Long Stay,
but VA

Lacks Comparable Information for Other Nursing Home Settings 14 About
One-Fourth of Veterans Who Received Care in VA Nursing Homes Are Required
to Be Served by the Millennium Act or VA Policy, but VA Lacks Comparable
Information for Other Settings 18

Conclusions 20 Recommendations for Executive Action 21 Agency Comments and
Our Evaluation 21

Appendix I Objectives, Scope, and Methodology

Appendix II	Changes in Percentage of Nursing Home Expenditures by Setting
and Network, Fiscal Years 1998 and 2003 26

Appendix III	Changes in Percentage of Nursing Home Workload by Setting and
Network, Fiscal Years 1998 and 2003

        Appendix IV Comments from the Department of Veterans Affairs 30

Appendix V GAO Contact and Staff Acknowledgments 34

GAO Contact 34 Acknowledgments 34

                            Related GAO Products 35

Figures

Figure 1: Percentage of Nursing Home Expenditures by Setting, Fiscal Years
1998 and 2003 8 Figure 2: Percentage of Nursing Home Expenditures by
Setting and Network, Fiscal Year 2003 9 Figure 3: Percentage of VA Nursing
Home Workload by Setting, Fiscal Years 1998 and 2003 11 Figure 4:
Percentage of Nursing Home Workload by Setting and Network, Fiscal Year
2003 13 Figure 5: Percentage of Long- and Short-Stay Care in VA Nursing
Homes, Fiscal Years 1998 and 2003 15 Figure 6: Percentage of Long- and
Short-Stay Care in VA Nursing Homes by Network, Fiscal Year 2003 16

Figure 7: Percentage of Veterans Receiving VA Nursing Home Care as
Required by Millennium Act or VA's Policy on Nursing Home Eligibility by
Network, Fiscal Year 2003 19

Abbreviations

VA Department of Veterans Affairs VHA Veterans Health Administration

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United States Government Accountability Office Washington, DC 20548

November 10, 2004

The Honorable Christopher H. Smith
Chairman
Committee on Veterans' Affairs
House of Representatives

Dear Mr. Chairman:

The Department of Veterans Affairs (VA) operates a $2.3 billion nursing
home program that provides or pays for veterans' care in VA's 21 health
care networks.1 Meeting veterans' nursing home care needs is a key issue
for VA because it has a large elderly veteran population, many of whom
are in need of such care. In 2003, 38 percent of the veteran population
was
over the age of 65 compared to 12 percent for the overall population. VA
provides or pays for veterans' care in three nursing home settings. VA
operates its own nursing homes 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. To enhance access to
veterans needing nursing home care across VA's health care system, an
independent commission recommended in February 2004 that VA develop
a strategic plan for long-term care that includes policies and strategies
for
the delivery of nursing home care.2

In November 1999, the Congress passed the Veterans Millennium Health
Care and Benefits Act (Millennium Act),3 which required that through
December 31, 2003, VA provide nursing home care to those veterans with a

1VA's national health care system consists of 21 regional health care
networks. These networks have budget and management responsibilities that
include allocating budgetary resources for VA nursing homes.

2The independent commission is called the Capital Asset Realignment for
Enhanced Services Commission. This Commission reviewed proposals by VA
regarding realignment and allocation of capital assets, such as health
care facilities, to better meet the demand for veterans' health care
services into the future.

3Pub. L. No. 106-117, 113 Stat. 1545 (1999).

service-connected disability rated at 70 percent or greater,4 those
requiring nursing home care because of a condition related to their
military service who do not have a service-connected disability rating of
70 percent or greater, and those who were admitted to VA nursing homes on
or before the effective date of the act. Subsequent law extended these
provisions through December 31, 2008.5 In addition, VA's policy on nursing
home eligibility required that networks provide nursing home care to
veterans with 60 percent service-connected disability ratings who also
meet other criteria.6 For all other veterans enrolled in its system, VA's
policy on nursing home eligibility is to provide nursing home care in VA
nursing homes and contract community nursing homes on a discretionary
basis depending on available resources, with certain patients having
higher priority, including veterans who require postacute care after a
hospital episode. Veterans can also choose to seek care in state veterans'
nursing homes and if admitted, VA pays a portion of the cost to treat
them.

The Committee has expressed a need for additional data in order to conduct
oversight of VA's nursing home program, especially in light of the large
elderly veteran population. These data needs have focused on the total
amount of resources spent to deliver nursing home care in VA nursing
homes, community nursing homes, and state veterans' nursing homes and the
amount of nursing home care provided with these resources. The Committee
has also expressed a need for data on the percentage of veterans in VA's
nursing home program that received longand short-stay nursing home care.
Long-stay care patients cannot be cared for at home because of severe,
chronic physical or mental limitations. In addition, the Committee has
expressed a need for data on the percentage of veterans in VA's nursing
home program that are required to be served based on the Millennium Act or
VA policy.

For all nursing home settings in VA's program in fiscal year 2003, this
report provides information on (1) VA spending to provide or pay for

4A service-connected disability is an injury or disease that was incurred
or aggravated while on active duty. VA classifies veterans with
service-connected disabilities according to the extent of their
disability. These classifications are expressed in terms of
percentages--for example, the most severely disabled such veteran would be
classified as having a serviceconnected disability of 100 percent.
Percentages are assigned in increments of 10 percent.

5The Veterans Health Care, Capital Asset, and Business Improvement Act of
2003, Pub. L. No. 108-170, S: 106 (b), 117 Stat. 2042, 2046 extended this
provision of the Millennium Act.

6These veterans must also be classified as unemployable or Permanent and
Total Disabled (P&T).

nursing home care, (2) VA workload provided or paid for, (3) the
percentage of nursing home care that is long and short stay, and (4) the
percentage of veterans receiving care that are required to be served by
the Millennium Act or VA policy. To place this information in context, we
supplement our findings with information for fiscal year 1998.7

To perform our work, we reviewed documents and analyzed VA data on the
amount of nursing home expenditures and workload, the percentage of
long-and short-stay care, and the eligibility status of veterans based on
the Millennium Act or VA's policy on nursing home eligibility. In our
calculation of expenditures, we included direct expenditures by VA to
provide or pay for nursing home care plus costs to administer the program
at the VA medical center. For this review, we measured nursing home
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 used VA data to estimate the number of VA nursing
home long stays, defined as 90 days or more, and short stays, defined as
less than 90 days. To determine the eligibility status of veterans we used
VA data to estimate veterans' eligibility for VA nursing home care based
on the Millennium Act or VA policy. In doing our work, we tested the
reliability of the data and determined they were adequate for our
purposes. For a complete description of our scope and methodology, see
appendix I. We conducted our review from January 2003 through November
2004 in accordance with generally accepted government auditing standards.

In fiscal year 2003, VA nursing homes accounted for almost $1.7 billion,
or about three-quarters of the approximately $2.3 billion VA spent to
provide or pay for veterans to receive nursing home care. In contrast,
state veterans' nursing homes and community nursing homes accounted for
the remaining 27 percent or $624 million spent by VA on nursing home care.
Since fiscal year 1998, the percentage of expenditures for VA nursing
homes and state veterans' nursing homes has increased while the percentage
for community nursing homes has decreased. VA's 21 health care networks
vary widely in the percentage of resources spent on each nursing home care
setting, although all networks spent a larger percentage of their
resources on VA nursing homes.

7We do not present data on eligibility for fiscal year 1998 because the
Millennium Act was not enacted until fiscal year 2000.

Results in Brief

State veterans' nursing homes accounted for half of VA's overall nursing
home workload-average daily census-in fiscal year 2003, even though this
setting accounted for only 15 percent of overall nursing home
expenditures. In fiscal year 2003, state veterans' nursing homes delivered
care to 16,639 of the 33,214 veterans served on a daily basis. In
contrast, VA used its nursing homes to provide 37 percent and paid for
community nursing homes to provide 13 percent of its overall workload in
that year. The percentage of workload served is higher than the percentage
of expenditures in state veterans' nursing homes, in part, because VA pays
on average about one-third of the costs for care veterans receive in state
veterans' nursing homes, compared to the full cost in other settings.
Since fiscal year 1998, VA's use of nursing homes by setting has changed.
The percentage of workload met in state veterans' nursing homes increased,
while the percentage of workload met in VA nursing homes and community
nursing homes declined. Although state veterans' nursing homes predominate
overall, VA's networks vary widely in the percentage of workload met in
different nursing home settings.

About one-third of the care VA provided in VA nursing homes was long stay
in fiscal year 2003, but VA lacks comparable information for community
nursing homes and state veterans' nursing homes. Long-stay care (90 days
or more) includes services needed by veterans who cannot be cared for at
home because of severe, chronic physical or mental limitations such as the
inability to independently eat or the need for supervision because of
dementia or other conditions. About two-thirds of VA nursing home care was
short-stay care (less than 90 days), which includes services such as
postacute care needed for recuperation from a stroke or hip replacement.
Since fiscal year 1998, the use of long-stay care in VA nursing homes has
declined while the use of short-stay care has increased. VA does not
collect and report comparable information on the length of stay for
veterans in community nursing homes and state veterans' nursing homes.

About one-fourth of veterans who received care in VA nursing homes in
fiscal year 2003 were required to be served by the Millennium Act or VA's
policy on nursing home eligibility. In contrast, about three-quarters of
veterans in VA nursing homes received such care on a discretionary basis
depending on available resources. VA does not collect and report
comparable information on eligibility status for community nursing homes
and state veterans' nursing homes even though these settings combined
accounted for 63 percent of VA's overall workload. Although VA officials
told us that medical center officials may know the eligibility status of
the veterans they pay for in community nursing homes and state veterans'

nursing homes, VA does not have the information at either the nationwide
or the network level.

To help ensure that VA can provide adequate program monitoring and
planning for nursing home care and to provide a better basis for
congressional oversight, we are recommending that VA collect data on
veterans' length of stay and eligibility for community nursing homes and
state veterans' nursing homes comparable to data VA currently collects for
its nursing homes.

In commenting on a draft of this report, VA stated that it concurred in
principle with our recommendations. VA stated that it will continue its
efforts to reduce data gaps in the community nursing home and state
veterans home programs, but VA did not indicate specific plans to collect
data on length of stay and eligibility for its long-term care planning
process. Moreover, VA stated that data other than eligibility and length
of stay, such as age and disability, are most crucial for its long-term
care strategic planning and program oversight. We disagree with VA's
position that eligibility and length-of-stay data are not considered most
crucial and are concerned about VA's lack of specificity regarding its
intent to utilize these data. While factors such as age and disability are
generally recognized as important in projecting veterans' overall need for
nursing home care, VA needs veterans' eligibility status and length of
stay to determine what portion of the overall need VA will meet nationally
and in individual communities. Eligibility data are crucial because VA
needs to know who it is required to serve based on the Millennium Act or
VA policy and what proportion of veterans it will serve on a discretionary
basis. In addition, length-of-stay data are crucial because VA needs to
know the type of nursing home care, short and long stay, that will be
needed by the veterans it serves in each of its three nursing home
settings.

                                   Background

VA operates its nursing homes in 132 locations, which are located
throughout VA's 21 health care networks. Almost all of these nursing homes
are attached or in close proximity to a VA medical center. According to VA
policy, VA staff at these facilities determine whether the veteran has a
clinical need for nursing home care based on a comprehensive
interdisciplinary clinical assessment. The interdisciplinary teams
determining clinical need for nursing home care could include personnel
such as the nursing home director, a social worker, nurse, physical
therapist, and gerontologist. The care provided to veterans at a VA
nursing home could include a range of services, including short-term
postacute care needed to recover from a condition such as a stroke to

longer-term care required by veterans who cannot be cared for at home
because of severe, chronic physical or mental limitations.

VA may also refer patients to receive nursing home care under contract
from non-VA nursing homes located in the community-referred to as
community nursing homes. In fiscal year 2003, VA purchased care from
community nursing homes in one of two ways. VA contracted with most
nursing homes through the local VA medical center. In addition, VA also
contracted with some community nursing homes under its Regional Community
Nursing Home initiative, in which nursing home chains in single or
multiple states contract directly with VA headquarters for services at
their nursing homes. In fiscal year 2003, VA contracted with 1,723 nursing
homes through its medical centers and with 508 more nursing homes under
its Regional Community Nursing Home initiative.8

Veterans may also choose to seek care in state veterans' nursing homes. In
fiscal year 2003, 109 state veterans' nursing homes located in 44 states
and Puerto Rico received VA payment to provide care. VA may refer patients
to these nursing homes for care, but does not control the admission
process. Veterans are admitted based on eligibility criteria established
by the states. For state veterans' nursing homes to participate in VA's
program, however, VA requires that at least 75 percent of the residents be
veterans in most cases.9 State veterans' nursing homes may also provide
nursing home care to certain nonveterans, such as spouses of residents who
are veterans. 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.10 In fiscal
year 2003, VA paid $56.24 per day for veterans in these state veterans'
nursing homes and

8VA discontinued its Regional Community Nursing Home initiative and
reverted these contracts to contracts through its medical centers in
fiscal year 2004.

9If a state veterans' home received a construction grant from VA, at least
75 percent of its residents must be veterans in order to participate in
the VA per-diem program. If the state veterans' home did not receive a
construction grant from VA, VA requires that more than 50 percent of the
residents be veterans. See 38 CFR S: 51.210 (d)(2003).

10The daily amount paid per veteran in recognized state veterans' homes is
the per diem rate established under 38 U.S.C. S:1741, for nursing home
care.

VA Spent Almost Three-Quarters of Its Nursing Home Resources on Care for
Veterans in VA Nursing Homes, but Expenditures Varied Widely by Network

awarded $174 million in grants to 16 states for renovations of existing
facilities or construction of new state veterans' homes.11

Veterans can also receive nursing home care financed by sources other than
VA, including Medicaid and Medicare, private health or long-term care
insurance, or self-financed.12 States design and administer Medicaid
programs that include coverage for long-term nursing home care to assist
with daily activities such as eating and bathing. Medicare primarily
covers acute care health costs and therefore limits its nursing home
coverage to short stays requiring skilled nursing home care following
hospitalization. State Medicaid programs are the principal funders of
nursing homes, besides patients self-financing their care. Private health
insurance pays for about 11 percent of nursing home and home health care
expenditures.13

VA nursing homes accounted for almost three-quarters of VA's overall
nursing home expenditures, or about $1.7 billion, in fiscal year 2003.
Care in state veterans' nursing homes accounted for 15 percent of nursing
home expenditures, or about $352 million. Care in community nursing homes
accounted for the lowest percentage of overall nursing home expenditures
at 12 percent, or about $272 million. Overall, VA spent approximately $2.3
billion to provide or pay for nursing home care in VA nursing homes,
community nursing homes, and state veterans' nursing homes in fiscal year
2003.

In contrast to fiscal year 1998, in fiscal year 2003 the percentage of
expenditures from community nursing homes declined, whereas the percentage
of expenditures for care in VA nursing homes and state

11These grants include resources for construction and renovation of state
veterans' nursing homes that provide services in addition to or other than
nursing home care. Some state veterans' nursing homes include-or consist
solely of-domiciliaries, which are facilities for the care of veterans who
do not require hospital or nursing home care but are unable to live
independently because of medical or psychiatric disabilities. A small
number of state veterans' nursing homes also offer hospital care or adult
day health care.

12VA is not authorized, in most cases, to bill and collect payments from
Medicare and Medicaid nor can VA bill other insurers for health care
conditions that are related to military service. However, a veteran's
eligibility to participate in VA's nursing home program does not prohibit
a veteran from using these financing sources of nursing home care outside
of VA's health care system, if eligible.

13See GAO, Long-Term Care: Aging Baby Boom Generation Will Increase Demand
and Burden on Federal and State Budgets, GAO-02-544T (Washington, D.C.:
Mar. 21, 2002).

veterans' nursing homes increased. (See fig. 1.) For example, 70 percent
of nursing home expenditures were accounted for by VA nursing homes in
fiscal year 1998 as compared to 73 percent in 2003. Moreover, the
percentage of community nursing home expenditures was 17 percent in 1998
as compared to 12 percent in 2003. During the same years, VA's overall
nursing home expenditures increased by about a third, growing from about
$1.7 billion to approximately $2.3 billion.

Figure 1: Percentage of Nursing Home Expenditures by Setting, Fiscal Years
1998 and 2003

1998 Nursing home expenditures: total $1.7 billion

VA nursing VA nursing homes homes

Community	Community nursing homes

State veterans' nursing homes nursing homes

Source: GAO analysis of VA data.

The percentage of nursing home expenditures for care in each nursing home
setting varied widely by network in fiscal year 2003. (See fig. 2.) All
networks spent the largest percentage of their resources on VA nursing
homes. The percentage of expenditures for VA nursing homes ranged from a
low of 47 percent in Network 19 (Denver) to a high of 88 percent in
Network 6 (Durham). Further, the percentage of overall nursing home
expenditures accounted for by community and state veterans' nursing homes
also varied widely across the networks. For example, the percentage of
expenditures for community nursing homes ranged from a low of 2 percent in
Network 3 (Bronx) to a high of 28 percent in Network 20 (Portland).

Figure 2: Percentage of Nursing Home Expenditures by Setting and Network,
Fiscal Year 2003

Network

6 (Durham)

4 (Pittsburgh)

2 (Albany)

5 (Baltimore)

21 (San Francisco)

3 (Bronx)

10 (Cincinnati)

8 (Bay Pines)

17 (Dallas)

18 (Phoenix)

7 (Atlanta)

22 (Long Beach)

11 (Ann Arbor)

12 (Chicago)

1 (Boston)

16 (Jackson)

15 (Kansas City)

23 (Minneapolis)

9 (Nashville)

20 (Portland)

19 (Denver) 0 20 40 60 80 100 Percentage

VA nursing homes State veterans' nursing homes Community nursing homes
Source: GAO analysis of VA data.

Note: In January 2002 VA merged networks 13 and 14 to form a single
network, Network 23 (Minneapolis). A network's total percentage may not
equal 100 because of rounding.

State Veterans' Nursing Homes Provided Half of VA's Overall Nursing Home
Workload, but Networks' Use of Nursing Home Care Setting Varied

A comparison of how networks' percentage of expenditures on each nursing
home setting changed in fiscal year 2003 as compared to fiscal year 1998
showed that networks' changes were consistent with the VAwide changes.14
In fiscal year 2003, the percentage of expenditures for VA nursing homes
increased in 15 of the 21 health care networks as compared to fiscal year
1998. Similar to the overall trend, the percentage of expenditures for
state veterans' nursing homes increased in 17 of 21 networks, whereas the
percentage of expenditures for community nursing homes decreased in 17 of
21 networks. The largest shift in the percentage of expenditures for the
three settings occurred in Network 19 (Denver). In this network, the
percentage of expenditures for VA nursing homes declined from 75 to 47
percent because of a nursing home closure during this period. For more
detailed information on the percent change in nursing home expenditures
for each setting and network in fiscal years 1998 and 2003, see appendix
II.

State veterans' nursing homes accounted for half of VA's overall nursing
home workload-measured by average daily census-in fiscal year 2003, even
though they accounted for only 15 percent of expenditures. In large part
this is because VA pays a per-diem rate for care in state veterans'
nursing homes that, on average, accounts for about one-third of the cost
to provide veterans nursing home care in this setting. The remaining
payments made to state veterans' nursing homes come from a number of other
sources including Medicaid, Medicare, private health insurance, and
patients self-financing their care. VA nursing homes provided the next
largest percentage of nursing home workload, 37 percent in fiscal year
2003. Community nursing homes provided 13 percent of overall nursing home
workload. Overall, VA provided or paid for 33,214 patients to receive
nursing home care daily in VA nursing homes, community nursing homes, and
state veterans' nursing homes in fiscal year 2003.

Since fiscal year 1998, VA has increased its use of state veterans'
nursing homes and decreased the use of VA nursing homes and community
nursing homes. Overall, workload in VA's nursing home program was 33,214
in fiscal year 2003, about 1 percent below its fiscal year 1998 workload.
The percentage of nursing home workload provided in state

14For the purposes of our analysis we treated networks 13 and 14 as one
network in fiscal year 1998 to compare with Network 23 (Minneapolis) in
2003, which now includes the regions previously served by networks 13 and
14.

veterans' nursing homes increased from 43 to 50 percent. In contrast, the
percentage of workload provided in VA nursing homes and community nursing
homes declined. (See fig. 3.)

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

1998 Nursing home workload: total 33,630 2003 Nursing home workload: total
33,214

                         State veterans' nursing homes

VA nursing homes

                         State veterans' nursing homes

VA nursing homes

Community nursing homes Community nursing homes

                        Source: GAO analysis of VA data.

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 increase in the percentage of nursing home workload provided in state
veterans' nursing homes resulted from a number of factors. States, with
the assistance of construction grants from VA, built 17 new state
veterans' nursing homes, increasing the number of beds available during
this period. The increasing percentage of state veterans' nursing home
workload also occurred as a result of declines in workload in VA nursing
homes and community nursing homes due to changes in VA's use of these
settings. In VA nursing homes, VA officials attributed some of the
decreases in nursing home workload to an increased emphasis on postacute
patients with short lengths of stay. Moreover, VA officials told us that
they are providing contract community nursing home care to fewer veterans
and paying for shorter contracts than in the past. The number of patients
VA served in this setting declined from 28,893 to 14,032 during this
period.15 Network officials also told us that contracts for community
nursing home care are often now 30 days or less and are used primarily to

15These patient numbers are based on discharges and a single patient may
be admitted more than once in the same fiscal year.

transition veterans to nursing home care, which is paid for by other
payers such as Medicaid.

Although state veterans' nursing homes predominate overall, networks vary
widely in the percentage of workload met in different nursing home
settings. For example, networks varied in their use of state veterans'
nursing homes ranging from a low of 22 percent in Network 8 (Bay Pines) to
a high of 71 percent in Network 15 (Kansas City). (See fig. 4.) This
variation is due, in part, to the available bed capacity of state
veterans' nursing homes in these networks. In 2003, Network 15 (Kansas
City) had 1,509 state veterans' nursing home beds compared to 420 beds in
Network 8 (Bay Pines). However, wide network variation also existed in the
percentage of networks' workloads accounted for by VA nursing homes and
community nursing homes.

Figure 4: Percentage of Nursing Home Workload by Setting and Network,
Fiscal Year 2003

Network 15 (Kansas City)

23 (Minneapolis)

16 (Jackson)

3 (Bronx)

19 (Denver)

1 (Boston)

9 (Nashville)

7 (Atlanta)

12 (Chicago)

20 (Portland)

11 (Ann Arbor)

4 (Pittsburgh)

18 (Phoenix)

10 (Cincinnati)

2 (Albany)

17 (Dallas)

21 (San Francisco)

5 (Baltimore)

6 (Durham)

22 (Long Beach)

8 (Bay Pines) 0 20 40 60 80 100 Percentage

State veterans' nursing homes VA nursing homes Community nursing homes
Source: GAO analysis of VA data.

Note: In January 2002 VA merged networks 13 and 14 to form a single
network, Network 23 (Minneapolis). A network's total percentage may not
equal 100 because of rounding.

About One-Third of VA Nursing Home Care Is Long Stay, but VA Lacks
Comparable Information for Other Nursing Home Settings

Changes in networks' delivery of nursing home care among the three nursing
home settings were consistent with VA-wide changes between fiscal year
1998 and 2003. The percentage of workload provided in state veterans'
nursing homes increased in 19 of VA's 21 health care networks. Similar to
the overall trend, the percentage of workload met in community nursing
homes declined in 17 networks and declined in 13 networks for VA nursing
homes. The largest shift in the percentage of workload for the three
settings occurred in Network 17 (Dallas). In this network, the percentage
of workload for state veterans' nursing homes increased from 0 to 30
percent because Texas opened up four state veterans' nursing homes during
this period. For more detailed information on the percent change in
nursing home workload for each setting and network in fiscal years 1998
and 2003, see appendix III.

About one-third of the care VA provided in VA nursing homes was long stay
in fiscal year 2003. The use of long-stay nursing home care (90 days or
more) includes services needed when a person has a physical or mental
disability that cannot be cared for at home. For example, veterans needing
long-stay care may have difficulty performing some activities of daily
living without assistance, such as bathing, dressing, toileting, eating,
and moving from one location to another. They may have mental impairments,
such as Alzheimer's disease or dementia, that necessitate supervision to
avoid harm to themselves or others or require assistance with tasks such
as taking medications. The remainder, or two-thirds of VA nursing home
care, was short-stay care (less than 90 days) in this setting. VA's use of
shortstay care includes nursing home services such as postacute care
required for recuperation from a stroke or hip replacement. VA officials
also told us that this care could include a number of other services such
as the delivery of complex medical services such as chemotherapy, the
treatment of wounds such as pressure ulcers, and end-of-life care. VA's
use of shortstay care is similar to services provided by Medicare, which
provides short-term coverage, whereas VA's use of long-stay care is
similar to services provided by Medicaid, which provides long-term
coverage for nursing home care.16

Since fiscal year 1998, VA has decreased its use of long-stay care and
increased its use of short-stay nursing home care. Specifically, the

16Medicare covers skilled nursing facility stays for up to 100 days (per
spell of illness), whereas Medicaid has no length-of-stay limits.

percentage of nursing home care that was long stay has declined from 43 to
34 percent between fiscal years 1998 and 2003. (See fig. 5.) In contrast,
the percentage of short stays provided in this setting increased from 57
to 66 percent during the same period. This shift in the amount of
short-stay care is consistent with VA's policy on nursing home eligibility
that sets a higher priority on serving veterans who require short-stay
postacute care.

Figure 5: Percentage of Long- and Short-Stay Care in VA Nursing Homes,
Fiscal Years 1998 and 2003

1998 Nursing home stays: 47,074 2003 Nursing home stays: 53,075

Long stay (90 days or more)

Source: GAO analysis of VA data.

Note: Nursing home stays are episodes of care where veterans receive
nursing home services in a VA nursing home. Nursing home stays do not
reflect the total number of individual veterans treated in a VA nursing
home because some veterans had multiple nursing home stays in a given
fiscal year.

Networks vary widely, however, in the percentage of VA nursing home care
that is long stay. The percentage of long stays in VA nursing homes ranged
from a low of 17 percent in Network 20 (Portland) to a high of 55 percent
in Network 7 (Atlanta). (See fig. 6.) Network 20 (Portland) officials told
us that the focus of their VA nursing homes has changed from long-stay
care to short-stay transitional and rehabilitative care and as a result
they are serving more veterans with shorter lengths of stay. By contrast,
Network 7 (Atlanta) officials told us that several of their nursing homes
provide services that are consistent with long-stay nursing home care such
as providing assistance to veterans who have difficulty performing some
activities of daily living such as the inability to independently eat.

Figure 6: Percentage of Long- and Short-Stay Care in VA Nursing Homes by
Network, Fiscal Year 2003

Network

20 (Portland)

15 (Kansas City)

18 (Phoenix)

23 (Minneapolis)

21 (San Francisco)

22 (Long Beach)

5 (Baltimore)

10 (Cincinnati)

2 (Albany)

8 (Bay Pines)

12 (Chicago)

4 (Pittsburgh)

17 (Dallas)

1 (Boston)

9 (Nashville)

11 (Ann Arbor)

6 (Durham)

19 (Denver)

16 (Jackson)

3 (Bronx)

7 (Atlanta)

0 20 40 60 80 100

Percentage

Short stay (less than 90 days) Long stay (90 days or more)

                        Source: GAO analysis of VA data.

Note: In January 2002 VA merged networks 13 and 14 to form a single
network, Network 23 (Minneapolis).

VA lacks information on the amount of long-and short-stay nursing home
care veterans receive in community and state veterans' nursing homes
preventing it from strategically planning how best to use these nursing
home settings at the national and network levels to enhance access to
nursing home services. VA officials told us that while some of these data
may be available at certain facilities because the facilities collect them
for their own purposes, VA does not require state veterans' nursing homes
and community nursing homes to provide billing or other information that
identifies individual veterans on which length of stay could be
calculated. VA collects information on the payments made to community
nursing homes and state veterans' nursing homes, but does not collect the
days of care a veteran receives or other individual information. VA
officials told us that they receive and pay individual claims for some
veterans in community nursing homes, but that in other cases VA pays for
care provided by community nursing homes based on invoices, which
aggregate information on the number of patients being treated by a nursing
home.

VA officials told us that they are in the initial planning stages of
redesigning a payment system to collect information by individual veteran
in community nursing homes, but that the implementation of such a system
could take several years. Once completed, VA officials expect the new
system to collect and report data on the total number of days individual
veterans receive in community nursing homes. VA does not currently have
plans to collect such data for state veterans' nursing homes, but is
exploring doing so.

About One-Fourth of Veterans Who Received Care in VA Nursing Homes Are
Required to Be Served by the Millennium Act or VA Policy, but VA Lacks
Comparable Information for Other Settings

In fiscal year 2003, about 26 percent of veterans who received care in VA
nursing homes are required to be served by the Millennium Act or VA's
policy on nursing home eligibility. Of these veterans, about 21 percent
are being treated under the Millennium Act because they have a
serviceconnected disability rating of 70 percent or greater. The act also
required that VA continue to treat veterans who had been receiving nursing
home care in VA facilities at the time the law was enacted about 4
percent of the veterans receiving care in fiscal year 2003 fell into this
category.17 Further, 1 percent of veterans in VA nursing homes are
required to be served based solely on VA's policy on nursing home
eligibility that extended required coverage to veterans with a 60 percent
serviceconnected disability rating who also met other criteria.

However, the vast majority of veterans-about 74 percent in fiscal year
2003-received VA nursing home care as a discretionary benefit based on
available budgetary resources. VA's policy on nursing home eligibility
directs that for these veterans VA nursing homes admit, as a priority,
patients who meet certain clinical and programmatic criteria: patients
requiring nursing home care after a hospital episode, patients who VA
determines cannot be adequately cared for in community nursing homes or
home-and community-based care, and those patients who can be cared for
more efficiently in VA nursing homes.

The percentage of veterans receiving VA nursing home care as required by
the Millennium Act or VA's policy on nursing home eligibility varied
widely across networks in fiscal year 2003. The percentage of veterans
receiving this care ranged from a low of 20 percent in Network 15 (Kansas
City) and Network 11 (Ann Arbor) to a high of 39 percent in Network 1
(Boston). (See fig. 7.) However, most networks were grouped closer to the
lower range. Fifteen of VA's 21 health care networks had percentages of 26
percent or less. According to VA officials, the percentage of veterans
that are required to be treated may be lower in some networks because
networks may choose to pay for these veterans to receive care in community
nursing homes. In contrast, some networks may prefer to treat these
patients in VA nursing homes. For example, officials from Network 3
(Bronx), a network with the second highest percentage at 37 percent, told
us that they prefer to treat these types of veterans in VA nursing homes
because they have sufficient bed capacity.

17This category excludes veterans who were also eligible for nursing home
care based on their service-connected rating and other statuses.

Figure 7: Percentage of Veterans Receiving VA Nursing Home Care as
Required by Millennium Act or VA's Policy on Nursing Home Eligibility by
Network, Fiscal Year 2003

Network

15 (Kansas City)

11 (Ann Arbor)

5 (Baltimore)

10 (Cincinnati)

9 (Nashville)

2 (Albany)

23 (Minneapolis)

18 (Phoenix)

20 (Portland)

21 (San Francisco)

12 (Chicago)

22 (Long Beach)

17 (Dallas)

16 (Jackson)

4 (Pittsburgh)

8 (Bay Pines)

7 (Atlanta)

6 (Durham)

19 (Denver)

3 (Bronx)

1 (Boston) 0 20 40 60 80 100 Percentage

Not required by Millennium Act or VA policy Required by Millennium Act or
VA policy Source: GAO analysis of VA data.

Note: In January 2002 VA merged networks 13 and 14 to form a single
network, Network 23 (Minneapolis).

VA lacks comparable information for community nursing homes or state
veterans' nursing homes on the percentage of veterans that are required to
be served based on the Millennium Act or VA's policy on nursing home
eligibility even though these settings combined accounted for 63 percent
of VA's overall nursing home workload. The lack of such data prevents VA
from strategically planning how best to use these nursing home settings at
the national and network levels to enhance access to nursing home
services. VA officials told us that while some of these data on
eligibility status may be available at certain facilities because the
facilities collect them for their own purposes, VA does not require that
this information be collected and reported to headquarters. VA does not
collect information by individual on all payments made to community
nursing homes and state veterans' nursing homes. As a result, VA cannot
match individual veterans' data from their payment system with data it
currently collects on eligibility to determine the eligibility status of
all veterans receiving contract care in community nursing homes and state
veterans' nursing homes. VA officials told us this type of analysis could
be done if a new information system for collecting contract payments is
designed and implemented to collect and report such information.

Conclusions 	Gaps in nursing home data impede VA's ability to monitor and
strategically plan for the nursing home care VA pays for nationally and at
the network level. The workload in state veterans' nursing homes and
community nursing homes has grown to 63 percent of VA's overall nursing
home workload. However, VA does not have data on length of stay and the
eligibility status of veterans receiving care in these settings as it has
for VA nursing homes. As a result, VA cannot strategically plan how best
to serve veterans it is required to serve, including those who have a 70
percent or greater service-connected disability rating, or other veterans
receiving care on a discretionary basis; nor can VA strategically plan how
best to use the nursing home settings to provide long-and short-stay
nursing home care nationally or in individual networks. Equally important,
the lack of such data and assessments hampers congressional oversight of
strategic options available to VA in its nursing home care planning and
its progress in meeting veterans' needs.

Recommendations for To help ensure that VA can provide adequate program
monitoring and planning for nursing home care and to improve the
completeness of data Executive Action needed for congressional oversight,
we recommend that the Secretary of Veterans Affairs direct the Under
Secretary for Health to take two actions:

o  	For community nursing homes and state veterans' nursing homes, collect
and report data on the number of veterans who have long and short stays,
comparable to data VA currently collects on VA nursing homes.

o  For community nursing homes and state veterans' nursing homes, collect

Agency Comments
and Our Evaluation

and report data on the number of veterans in these homes that VA is
required to serve based on the requirements of the Millennium Act or VA's
policy on nursing home eligibility, comparable to data VA currently
collects on VA nursing homes.

We provided a draft of this report to VA for comment. In commenting on the
draft, VA stated that it concurred in principle with our recommendations.
VA stated that it will continue its efforts to reduce data gaps in the
community nursing home and state veterans home programs, but VA did not
indicate specific plans to collect data on length of stay and eligibility
for its long-term care planning process. Moreover, VA stated that data
other than eligibility and length of stay, such as age and disability, are
most crucial for its long-term care strategic planning and program
oversight. We disagree with VA's position that eligibility and
length-of-stay data are not considered most crucial and are concerned
about VA's lack of specificity regarding its intent to utilize these data.
While factors such as age and disability are generally recognized as
important in projecting need for nursing home care, VA needs data on
veterans' eligibility status and length of stay to determine what portion
of the overall veteran need for nursing home care VA will meet nationally
and in individual communities. Because VA is required to serve veterans
that meet the requirements of the Millennium Act or VA policy, VA needs to
project the number of these veterans seeking nursing home care from VA and
determine the number of other veterans it will also serve on a
discretionary basis after meeting this need. To strategically plan and
provide the type of service needed in the future, VA must also project
what proportion of veterans with different eligibility statuses will need
short-stay or long-stay nursing home care. VA needs to use this
information to determine if the nursing home care it currently pays for in
VA nursing homes, contract community nursing homes, and state veterans'
nursing homes is appropriately located and provides the type of nursing
home care needed by veterans.

VA also noted that it is narrowing information gaps on both veterans'
eligibility status and length of stay for veterans in its community and
state veterans' nursing home programs by using data extracted from various
sources to estimate these numbers. However, VA did not provide these data
for our review. Given that the combined workload in these settings
accounted for 63 percent of VA's overall nursing home workload in fiscal
year 2003, we believe that complete information on veterans' eligibility
status and length of stay for veterans in these settings is crucial for
both strategic planning and program oversight.

VA noted that one of our statements-that about one-fourth of veterans
receiving nursing home care are entitled to such care under the
requirements of the Millennium Act-could be misinterpreted to imply that
some of these "mandatory" veterans are being displaced by veterans
receiving discretionary care. We did not imply this relationship, nor did
our work examine this particular issue.

We are sending copies of this report to the Secretary of Veterans Affairs
and appropriate congressional committees. The report is available at no
charge on GAO's Web site at http://www.gao.gov. We will also make copies
available to others on request.

If you or your staff have any questions about this report, please call me
at (202) 512-7101. Another contact and key contributors are listed in
appendix V.

Sincerely yours,

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

Appendix I: Objectives, Scope, and Methodology

We reviewed the Department of Veterans Affairs' (VA) nursing home program
for fiscal year 2003 for VA nursing homes, community nursing homes, and
state veterans' nursing homes to determine (1) VA spending to provide or
pay for nursing home care, (2) VA workload provided or paid for, (3) the
percentage of nursing home care that is long and short stay, and (4) the
percentage of veterans receiving care that are required to be served by
the Millennium Act or VA policy. To place this information in context, you
asked us to supplement our findings with information for fiscal year 1998.

To address the first two objectives, we obtained data on nursing home
workload and expenditures at the network level for fiscal years 1998 and
2003 from several VA headquarters offices. VA's Geriatrics and Extended
Care Strategic Healthcare Group provided us workload data for VA nursing
homes and community nursing homes, as reported in VA's Automated
Management Information System. This group also gave us workload data from
monthly reports completed by state veterans' nursing homes that were
maintained at the VA medical centers. These data are used by the
Geriatrics and Extended Care office to provide per diem grants to state
veterans' homes. The Office of the Chief Financial Officer for the
Veterans Health Administration (VHA) provided us expenditure data from
VA's Cost Distribution Report for the nursing home care provided or paid
for by VA.

To do our analysis, we used average daily census as a measure of workload.
Average daily census is the total number of days of nursing home care
provided in a year divided by the number of days in the year. For VA
nursing home expenditures, we included the direct costs used to provide
nursing home care plus other facility costs associated with operating the
nursing home. VA nursing home expenditures excluded depreciation as well
as VA headquarters and network administrative costs. To calculate
community nursing home expenditures, we included all contract payments
made to community nursing homes plus additional facility expenditures
required to directly support the program at the local VA medical center.
To calculate state veterans' home expenditures, we included per diem
payments made to state veterans' nursing homes plus additional facility
expenditures required to directly support the program at local VA medical
centers. Expenditures for state veterans' homes did not include
construction grants.

To determine the percentage of long and short stays in VA nursing homes in
fiscal years 1998 and 2003, we obtained data on length of stay from VHA's
Extended Care Patient Treatment Files. The Patient Treatment Files

Appendix I: Objectives, Scope, and Methodology

include nursing home discharges for veterans who were discharged from a VA
nursing home during a fiscal year, and current resident files for veterans
who were not discharged by the end of a fiscal year. Using length of
nursing home stay, we classified stays of 90 days or more as long stays
and stays of less than 90 days as short stays. Length of stay is
calculated as the number of days in a nursing home between the admission
and discharge days and was given a minimum value of 1. The number of days
absent from the nursing home, such as for a hospital stay, was subtracted
from the length of stay. Because current residents were not discharged
within the fiscal year, we calculated their lengths of stay by looking
ahead into the next fiscal year. That is, we matched current residents
with discharges in the next fiscal year to determine whether their stays
were short or long. A current resident who was admitted on the last day of
the fiscal year, for example, but was discharged after 90 days into the
next fiscal year, was classified as having a long stay. If the same
resident was discharged within 90 days of the next fiscal year, then the
stay was classified as short. We classified nursing home stays as long for
current residents who were not discharged in the next fiscal year. Our
analysis for long-and short-stay care was based on nursing home stays
rather than individual veterans because some veterans had multiple nursing
home stays.

To determine the percentage of veterans in VA nursing homes receiving care
that are required to be served by the Millennium Act or VA policy, we
obtained individual data on eligibility for veterans enrolled in VA's
health care system. VHA's Office of Policy and Planning provided us these
data in an enrollment file for fiscal year 2003. We merged these data with
the discharge and current resident files from VHA's Extended Care Patient
Treatment Files in order to calculate the percentage of veterans receiving
nursing home care that are required to be served in fiscal year 2003. Our
analyses on eligibility are based on individual veterans rather than
nursing home stays; because some veterans had multiple nursing home stays
in a given year, we retained veterans' first nursing home stay and
eliminated other stays in that year. We used a variable from VA's
enrollment file that measures service-connected disability rating. In
addition, we used variables from the file that measure whether the veteran
is unemployable and whether the veteran is considered permanent and total
disabled, based on disabilities not related to military service.

We included the following categories of veterans in our calculation to
determine the percentage of veterans receiving nursing home care required
to be served by the Millennium Act or VA's policy on nursing home
eligibility: (1) veterans who had a service-connected disability rating

Appendix I: Objectives, Scope, and Methodology

of 70 percent or more; (2) veterans who were admitted to a VA nursing home
on or before November 30, 1999; and (3) veterans who had a
serviceconnected disability rating of 60 percent and who were also
unemployable or permanent and total disabled. We did not include in our
estimate veterans VA is required to serve who need nursing home care
because of a service-connected disability, but who do not have a
service-connected disability rating of 70 percent or more. VA did not have
data on these veterans, but a VA official estimated that this group is
very small based on conversations with facility staff.

To supplement our knowledge of the type of nursing home care provided in
VA networks, we visited two networks and five nursing homes. In Network 5
(Baltimore) we visited Washington, D.C.; Martinsburg, West Virginia; and
Baltimore, Maryland. In Network 23 (Minneapolis) we visited St. Cloud,
Minnesota; and Minneapolis, Minnesota. We selected these two networks
because they were in different geographic regions and had variation in the
types of care offered in their facilities. Within each network, we chose
one nursing home that provided more long-stay nursing home care and
another that provided more short-stay care.

We assessed the reliability of workload and expenditure data in VA's
nursing home program, VHA's enrollment data file, and VHA's Extended Care
Patient Treatment Files in several ways. First, we performed tests of data
elements. For example, we examined the range of values for length of stay
to determine whether these data were complete and reasonable. Second, we
reviewed existing information about the data elements. For example, we
obtained and reviewed information from VHA on data elements we used from
VHA's Extended Care Patient Treatment Files. Third, we interviewed agency
officials knowledgeable about the data in our analyses and knowledgeable
about VA's nursing home program. For example, we sent network-specific
nursing home workload and expenditure data provided to us by VA
headquarters to each of VA's 21 health care networks through electronic
mail in December 2003. Network officials reported whether these data were
accurate and indicated where they found discrepancies. Through discussions
with VA headquarters and network officials we resolved the discrepancies.
We determined that the data we used in our analyses were sufficiently
reliable for the purposes of this report.

We performed our review from January 2003 to November 2004 in accordance
with generally accepted government auditing standards.

Appendix II: Changes in Percentage of Nursing Home Expenditures by Setting and
Network, Fiscal Years 1998 and 2003

Fiscal year 1998 percentage of total expenditures in each nursing home
setting

                     Fiscal year 1998               Community           State 
                                                                    veterans' 
       Network                  total  VA nursing    nursing    nursing homes 
                         expenditures    homes        homes     
      1 (Boston)         $109,377,623           53           31 
      2 (Albany)           63,014,011           82           12 
      3 (Bronx)           124,045,443           76           12 
    4 (Pittsburgh)        137,687,784           73           16 
    5 (Baltimore)          40,103,045           70           20 
      6 (Durham)           81,293,363           82           15 
     7 (Atlanta)           79,392,405           60           18 
    8 (Bay Pines)          88,228,833           83           15 
    9 (Nashville)          54,466,227           58           25 
10 (Cincinnati)         71,896,679           74           18 
    11 (Ann Arbor)         77,163,729           72           12 
     12 (Chicago)         103,315,242           65           18 
15 (Kansas City)        62,283,391           59           18 
     16 (Jackson)         101,425,232           61           14 
     17 (Dallas)           57,124,099           82           18            0b 
     18 (Phoenix)          57,216,391           74           17 

          19 (Denver)             51,508,938          75       9           16 
         20 (Portland)            60,569,408          59       27          14 
      21 (San Francisco)          77,213,692          72       21           7 
        22 (Long Beach)           78,414,772          73       24           3 
       23 (Minneapolis)           107,175,837         65       8           27 
             Total              $1,682,916,144        70       17          13 

Source: GAO analysis of VA data.

Note: Changes in percentage of expenditures by setting may not equal the
difference between fiscal years 2003 and 1998 totals because of rounding.

aIncrease was less than 1 percent.

bNetwork 17 (Dallas) had no state veterans' nursing homes in fiscal year
1998.

cDecrease was less than 1 percent.

Appendix II: Changes in Percentage of Nursing Home Expenditures by Setting
and Network, Fiscal Years 1998 and 2003

 Fiscal year 2003 percentage of total expenditures in each nursing home setting

Change in percentage of expenditures by setting, fiscal year 2003 compared
to fiscal year 1998

Fiscal year 2003 total expenditures

                      VA nursing Community State veterans'

VA nursing homes

Community nursing homes

                State veterans' nursing homeshomes nursing homes

nursing homes

       $136,122,953        65       16       19       12       -15    
        74,077,560         85       8        7         3        -4    
       152,483,201         82       2        16        6       -10    
       180,292,753         85       3        12       11       -12    
        64,659,735         85       9        6        14       -11    
       110,469,579         88       6        6         6        -9    
       140,447,102         74       8        18       15       -10    
       157,002,146         79       16       5        -4        a     
        63,764,289         53       24       23       -5        -2    
        97,699,712         81       9        9         7        -9    
       101,393,221         74       10       16        2        -2          a 
       138,884,538         73       10       17        8        -8          a 
        86,113,975         59       10       31        a        -8    
       144,733,884         61       10       29        a        -4    
        93,214,744         78       14       9        -4        -5    
        81,963,959         75       14       11        a        -3    
        50,110,475         47       26       28       -28       17    
        87,791,970         53       28       19       -6        a           5 
       116,215,532         82       13       5        10        -8         -1 
       105,809,650         74       23       3         1        -1          c 
       138,156,457         59       11       30       -6        3           3 
      $2,321,407,435       73       12       15        3        -6          2 

Appendix III: Changes in Percentage of Nursing Home Workload by Setting and
Network, Fiscal Years 1998 and 2003

Fiscal year 1998 percentage of total workload in each nursing home setting

                     Fiscal year                   Community            State 
                         1998                                       veterans' 
       Network      total workload    VA nursing nursing homes  nursing homes 
                                           homes               
      1 (Boston)             2,291            27            20 
      2 (Albany)               910            58            14 
      3 (Bronx)              2,240            44             9 
    4 (Pittsburgh)           2,539            47            16 
    5 (Baltimore)              854            50            20 
      6 (Durham)             1,155            65            20 
     7 (Atlanta)             2,190            33            14 
    8 (Bay Pines)            1,358            69            23 
    9 (Nashville)            1,283            32            21 
10 (Cincinnati)           1,274            52            20 
    11 (Ann Arbor)           1,670            39            13 
     12 (Chicago)            2,225            30            19 
15 (Kansas City)          1,402            27            17 
     16 (Jackson)            2,910            26            13 
     17 (Dallas)               885            68            32             0c 
     18 (Phoenix)              945            47            18 

          19 (Denver)             1,026          38         9              54 
         20 (Portland)            1,196          29         24             47 
       21 (San Francisco)         1,269          49         21             30 
        22 (Long Beach)           1,071          49         36             15 
        23 (Minneapolis)          2,937          27         5              68 
             Total                33,630         40         17             43 

Source: GAO analysis of VA data.

Note: Changes in percentage of workload by setting may not equal the
difference between fiscal years 2003 and 1998 totals because of rounding.
Network totals may not add to national totals due to rounding.

aDecrease was less than 1 percent.

bIncrease was less than 1 percent.

cNetwork 17 (Dallas) had no state veterans' nursing homes in fiscal year
1998.

Appendix III: Changes in Percentage of Nursing Home Workload by Setting
and Network, Fiscal Years 1998 and 2003

Fiscal year 2003 percentage of total workload in each nursing home setting
Change in percentage of workload by setting, fiscal year 2003 compared to fiscal
                                   year 1998

Fiscal year 2003 total workload

VA nursing homes

Community nursing homes

State veterans' nursing homes VA nursing Community State veterans' homes nursing
                              homes nursing homes

       2,131          29          14          57           2          -7      
        759           55          11          35          -3          -4      
       2,006          38           2          60          -6          -7      
       2,314          48           5          46           2          -11     
        695           64           9          27          13          -11     
       1,166          64           9          27           a          -11     
       2,116          36           8          56           3          -6      
       1,617          57          22          22          -12         -2      
       1,189          26          17          56          -6          -4      
       1,124          52          11          37           b          -9      
       1,601          39          11          50           b          -2      
       2,030          33          13          55           2          -7      
       1,714          19          10          71          -8          -7      
       2,929          25           9          66           a          -4      
       1,259          49          21          30          -19         -11     
       1,028          40          19          41          -7           b      

995 22 19 59-15 10

                   1,384 22 25 53-7 1 6 1,225 56 16 287 -5 -2

a

                             1,007 39 36 25 -10 10

b

2,926 23 8 69-3 3

33,214 37 13 50 -3 -4 7

Appendix IV: Comments from the Department of Veterans Affairs

Appendix IV: Comments from the Department of Veterans Affairs

Appendix IV: Comments from the Department of Veterans Affairs

Appendix IV: Comments from the Department of Veterans Affairs

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact James C. Musselwhite, (202) 512-7259

Acknowledgments 	In addition to the contact named above, Cheryl A. Brand,
Pamela A. Dooley, and Thomas A. Walke made key contributions to this
report.

Related GAO Products

VA Long-Term Care: More Accurate Measure of Home-Based Primary Care
Workload Is Needed. GAO-04-913. Washington, D.C.: September 8, 2004.

VA Long-Term Care: Changes in Service Delivery Raise Important Questions.
GAO-04-425T. Washington, D.C.: January 28, 2004.

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.

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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