Veterans' Health Care: VA's Approaches to Meeting Veterans' Home Health
Care Needs (Letter Report, 03/15/96, GAO/HEHS-96-68).

Pursuant to a congressional request, GAO provided information on how the
Department of Veterans Affairs (VA) meets veterans' home health care
needs, focusing on: (1) the characteristics and services of the home
health care programs VA uses; (2) the available data describing program
costs; and (3) how VA ensures that veterans receive quality home care
services.

GAO found that: (1) most veterans receive home health care services from
community-based providers through either the VA fee-based program or
Medicare's home health care benefit; (2) most veterans in these programs
receive short-term home health care services for acute medical
conditions, while some veterans receive long-term care for chronic
conditions; (3) VA provides in-home physician, nursing, social work, and
dietician services to veterans with chronic conditions through its
Hospital-Based Home Care (HBHC) program; (4) VA makes decisions about
using HBHC programs based on its perception of relative costs, since
comparable cost data are not available; (5) HBHC program costs are based
on data developed by hospitals that support the programs, while VA
reported fee-based program costs represent payments made to providers
and exclude certain administrative costs; (6) VA monitors the quality of
care provided by HBHC programs more directly than it does
community-based care; and (7) licensing and certification assessments of
community-based providers provide VA assurance that care is provided by
qualified sources, but VA is ultimately responsible for ensuring the
quality of care in its programs.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-96-68
     TITLE:  Veterans' Health Care: VA's Approaches to Meeting Veterans' 
             Home Health Care Needs
      DATE:  03/15/96
   SUBJECT:  Home health care services
             Health services administration
             Veterans benefits
             Health care programs
             Health care cost control
             Quality assurance
             Long-term care
             Patient care services
             Community health services
IDENTIFIER:  Medicare Program
             VA Hospital-Based Home Care Program
             Community Health Accreditation Program
             
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Cover
================================================================ COVER


Report to the Ranking Minority Member, Committee on Veterans'
Affairs,
U.S.  Senate

March 1996

VETERANS' HEALTH CARE - VA'S
APPROACHES TO MEETING VETERANS'
HOME HEALTH CARE NEEDS

GAO/HEHS-96-68

Veterans' Home Health Care

(101454)


Abbreviations
=============================================================== ABBREV

  CHAP - Community Health Accreditation Program
  HBHC - Hospital-Based Home Care
  HCFA - Health Care Financing Administration
  JCAHO - Joint Commission on Accreditation of Healthcare
     Organizations
  VA - Department of Veterans Affairs

Letter
=============================================================== LETTER


B-257587

March 15, 1996

The Honorable John D.  Rockefeller, IV
Ranking Minority Member
Committee on Veterans' Affairs
United States Senate

Dear Senator Rockefeller: 

In fiscal year 1994, the Department of Veterans Affairs (VA) provided
or facilitated the delivery of home health care services to more than
40,000 veterans at a cost of $64 million to VA and millions more to
Medicare.  By providing veterans with home health care services, VA
allows these veterans to continue living at home and in their
community, rather than caring for them in an institutional setting. 
Veterans may need home health care for a variety of reasons:  Older
veterans may have chronic medical conditions, such as heart disease,
and need periodic attention to remain living at home.  Others may be
discharged from VA medical centers following treatment for illness or
injury and continue to need such care as the changing of dressings or
administration of medications.  The number of veterans needing home
health care is expected to grow as the veteran population ages and as
VA more quickly discharges patients from its hospitals to reduce the
costs of hospitalization. 

Because of your interest in this important service for veterans, you
asked us to develop information on how VA meets veterans' home health
care needs.  We are providing information on (1) the characteristics
and services of the home health care programs VA uses, (2) the
available data describing program costs, and (3) how VA ensures that
veterans receive quality home health care services. 

We did our work at 3 of VA's 173 hospitals, in Boston and West
Roxbury, Massachusetts, and in Tampa, Florida.  As part of our work,
we visited 30 veterans in their homes to understand better how home
health care services are provided.  Additionally, we sent a
questionnaire to 158 VA medical centers\1 and 7 other VA health care
facilities asking for information on how they provide and evaluate
home health care services for veterans.  (See app.  I for more detail
on our methodology.) We performed this review from May 1994 to
December 1995 in accordance with generally accepted government
auditing standards. 


--------------------
\1 Several medical centers have more than one hospital. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

VA's efforts to meet veterans' home health care needs focus on
providing long-term services to address veterans' chronic medical
conditions as well as shorter-term services to address their acute
medical conditions.  VA's Hospital-Based Home Care (HBHC) program
most often provides primary care to those with chronic conditions. 
Under HBHC, VA staff provide in-home physician, nursing, social work,
and dietician services to veterans who often need such services for a
year or longer.  Veterans requiring short-term, skilled care, often
following a stay in a VA hospital for an acute medical condition,
generally receive services from community-based providers.  VA either
arranges for Medicare to pay for eligible veterans to receive home
care from community-based providers or, under its fee-based program,
pays community-based providers itself to provide care to those who
are not eligible for Medicare. 

VA data portray the costs of VA's HBHC and fee-based programs
differently.  For example, VA's fee-based program cost figures
represent payments made to community-based providers but exclude
administrative and other costs associated with patients; HBHCs' cost
figures, on the other hand, include administrative costs.  Lacking
useful cost data, VA hospital administrators are making decisions
about whether or not to have an HBHC program on the basis of their
perceptions of the relative costs of VA's HBHC and community-based
programs. 

Regardless of which home health care program is used, VA monitors the
quality of care provided, but it monitors care provided by its HBHC
programs more directly than it does the community-based care. 
Nevertheless, licensing and certification assessments of
community-based providers give VA some assurance that veterans
receive care from qualified home health care providers.  In addition,
Medicare has primary responsibility for ensuring that community-based
providers provide quality care to Medicare-eligible veterans for whom
VA arranges such care. 


   BACKGROUND
------------------------------------------------------------ Letter :2

VA arranges for the delivery of home health care services to veterans
through two methods.  Under its HBHC programs, teams of VA hospital
staff deliver primary care services directly to veterans in their
homes.  Under VA's second method, community-based providers deliver
home health care services to veterans.  VA pays for these
community-based provider services through its fee-based home health
services program unless the veteran is covered by Medicare's home
health care benefit.  Generally, for these veterans, VA hospital
staff facilitate the delivery of these services and Medicare pays for
them. 

Begun in July 1972, VA's HBHC program consists of individual HBHC
programs affiliated with hospitals and medical centers around the
country.  HBHC is an extended care program designed to meet the
long-term care needs of veterans who have chronic multiple medical
and psychosocial problems, a terminal illness, or a need for
post-hospital rehabilitation or monitoring.  The objectives of the
program are to provide primary care services to homebound patients in
their homes; create a therapeutic and safe home environment; support
the caregiver--the veteran's spouse, other family member, or
friend--in caring for the patient; reduce the need for, and provide
an alternative to, hospitalization or other institutionalization;
promote timely discharge of patients from hospitals or nursing homes;
and provide an academic and clinical setting for students of the
health professions.  Veterans may or may not be charged a fee for
HBHC services, depending upon their eligibility for outpatient
services.  In fiscal year 1994, VA served 9,953 veterans under this
program. 

VA's fee-based home health services program pays community-based
providers to provide home health care services to veterans who
received inpatient care for an acute condition at a medical center
and have been discharged.  It also pays for skilled medical treatment
for other veterans entitled to VA medical care.  Whether veterans are
charged fees for services under this program depends upon their
eligibility for outpatient services.  In fiscal year 1994, VA served
12,800 patients under this program. 

In addition to the veterans receiving hospital-based and fee-based
care, VA facilities referred at least 19,000 Medicare-eligible
veterans to Medicare-certified health care agencies in fiscal year
1994. 

For hospitals with an HBHC program, the decision about whether a
patient receives HBHC or community-based care is made by hospital
staff on the basis of such factors as the patient's medical condition
and the types of services needed.  If HBHC would best meet the
patient's needs, staff would try to use that program to provide home
health care.  If the hospital does not have an HBHC or if staff
determine that community-based care would meet the veteran's needs,
the next step is determined by the veteran's Medicare eligibility. 
Generally, if a veteran's care would not be covered by Medicare, VA
will pay for a veteran's home health care services under the
fee-based program.  VA staff facilitate the delivery of home health
care to veterans with Medicare coverage by referring them to
community-based providers with the understanding that Medicare will
pay for their services.  However, VA continues to provide all medical
care follow-up, drugs, and supplies that are not paid for by
Medicare. 


   CHARACTERISTICS AND SERVICES OF
   VA'S HBHC PROGRAMS
------------------------------------------------------------ Letter :3

VA hospitals are not required to have HBHC programs, and most do not. 
In fiscal year 1995, VA operated 74 HBHC programs:  73 of its 173
hospitals had an HBHC program, and one additional program was
operated by an outpatient clinic.  A VA hospital can operate an HBHC
program if it meets certain criteria and receives VA approval.  For
example, guidance from VA's Central Office requires hospitals to
demonstrate that they discharge a required number of veterans with
specified medical conditions and that they have staff to provide
services to the veterans once they are discharged.  Hospitals may
also terminate their HBHC programs in response to other demands on
their staff and budget.  Between fiscal years 1990 and 1995, the
number of programs increased from 72 to 74, with five VA hospitals
initiating HBHC programs and three terminating their programs during
this time. 

HBHC patients tend to be chronically ill and in need of long-term
care, although some may be terminally ill or need short-term care
following hospitalization.  In fiscal year 1994, half of the HBHC
programs reported to VA that their patients had an average age of 71
years or less.  There is no limit on how long veterans may stay in
the program.  During fiscal year 1994, half the questionnaire
respondents that had an HBHC program indicated that their patients
stayed in the program an average of 7 months or less.  As of March
31, 1995, about 44 percent of the patients had been in the program 1
year or longer. 

In order to qualify for HBHC services, veterans

  must be homebound;

  should have a caregiver--such as a spouse, family member,
     significant other, or friend--to assist with their care;

  must live within a defined geographic area--usually a 30- mile
     radius of the hospital;

  must generally only need services Monday through Friday during
     normal working hours; and

  must be entitled to VA medical care. 

Under the HBHC program, an interdisciplinary team of VA hospital
staff delivers primary care services to veterans in their homes.  A
typical program consists of several nurses, a social worker, a
coordinator, a clerk, and the part-time services of a physician and
dietician.  Some programs also have a physical therapist,
occupational therapist, or home health technician. 

Skilled nursing is the predominant service of HBHC programs:  99
percent of the HBHC programs report providing this service.\2 Skilled
nursing includes such activities as changing dressings, teaching
patients how to manage their medical problems, administering
medications, and drawing blood samples for laboratory analysis. 
Nursing services are provided in accordance with the patient's plan
of care. 

HBHC social workers provide psychosocial services, such as counseling
and resolution of social and emotional problems that affect treatment
or impede medical recovery.  Ninety-six percent of the HBHC programs
provide these services to veterans in their homes, according to
questionnaire respondents from hospitals with HBHC programs. 

HBHC physicians usually work in the programs on a part-time basis and
have primary medical responsibility for all HBHC patients.  Their
responsibilities include identifying the patients' medical problems,
defining the medical management of the problems, and determining
whether to admit HBHC patients to the medical center.  Approximately
80 percent of the respondents said their HBHC program provides
physician services in veterans' homes. 

Dietician services are another important component of HBHC programs,
with almost 9 out of every 10 programs reporting that their
dieticians make home visits.  HBHC dieticians assess patients'
nutritional needs over time in relation to changes in their
condition.  They also teach patients and their caregivers how to
adapt and modify their food preparation practices. 

Responses to our questionnaire showed that most HBHC programs in
fiscal year 1995 did not provide skilled physical, occupational, or
speech therapy; home health aide services; or pharmacy services to
veterans in their homes. 

In fiscal year 1994, VA reported expenditures of $36.6 million on
this program. 


--------------------
\2 We did not determine how frequently veterans used services
provided under the home health care approaches used by VA. 


   CHARACTERISTICS AND SERVICES OF
   THE COMMUNITY-BASED PROGRAMS
------------------------------------------------------------ Letter :4

Most veterans receive home health care services from community-based
providers through either VA's fee-based program or Medicare's home
health care benefit.  These veterans tend to need short-term home
health care associated with an acute medical condition, although some
have longer-term needs.  Many of the services commonly provided by
the fee-based program and Medicare are the same, but more types of
services are generally available to veterans covered by Medicare. 


      VA'S FEE-BASED PROGRAM
---------------------------------------------------------- Letter :4.1

Nearly all VA hospitals used the fee-based program in fiscal year
1995 to purchase skilled home health care services from
community-based providers.  Most veterans in this program receive
short-term home health care services to address acute medical
conditions, such as hip fractures or surgical wounds.  Some veterans,
however, receive long-term home health care services to address
chronic conditions, as in the case of a patient with Parkinson's
disease, for example, who has an ongoing need for skilled services,
such as intramuscular injections. 

Half of our questionnaire respondents reported that their fee-based
patients in fiscal year 1994 had an average age of 61 years or less. 
VA will authorize payment to community providers for a maximum of 12
months following a veteran's hospital discharge, and reauthorization
can be extended upon the approval of a VA physician.  During fiscal
year 1994, half of our questionnaire respondents indicated that their
fee-based patients had an average length of stay in the program of 90
days or less. 

To qualify for this program, veterans must be entitled to VA medical
care.  Veterans are not required, however, as in the HBHC program, to
have a caregiver at home, live within a certain distance of the
hospital, or generally need services only during certain hours of the
work week. 

Skilled nursing is the predominant service covered by the fee-based
program.  Nearly all respondents to our questionnaire said that they
usually purchase skilled nursing services for veterans. 

Physical, occupational, and speech therapy services are each
purchased for patients in the fee-based program in over half of the
medical centers, according to questionnaire respondents.  Physical
therapists work with patients to improve their capacity to perform
simple daily activities, and occupational therapists assess patients'
rehabilitation needs, develop plans of care, and provide training. 
Speech therapists help patients such as stroke victims improve their
ability to communicate. 

The fee-based program also covers the services of physicians and
psychologists.  However, only about one-fifth or fewer of the
respondents said that they usually purchase these services under the
fee-based program. 

Although VA cannot use fee-based program funds for home health aide
services, 22 percent of the respondents said they provide this
service to veterans in that program.\3

Medical centers can pay for these services through VA's
Homemaker/Home Health Aide program.\4

In fiscal year 1994, VA reported payments of $27.3 million on
fee-based home health care services. 


--------------------
\3 Under its Spinal Cord Injury program, VA may pay for home health
aides who provide bowel and bladder care for quadriplegic veterans. 

\4 Through the Homemaker/Home Health Aide program, VA hospitals can
spend up to 15 percent of their Community Nursing Home program funds
on homemakers and home health aides for veterans residing at home. 
This includes veterans in the fee-based and HBHC programs.  During
fiscal year 1995, 122 medical centers participated in this program. 
Expenditures totaled approximately $15 million, or about 4 percent of
the Community Nursing Home budget. 


      MEDICARE'S HOME HEALTH CARE
      BENEFIT
---------------------------------------------------------- Letter :4.2

Most respondents to our questionnaire indicated that they refer
veterans covered by Medicare's home health care benefit to
community-based providers.  Most people who receive Medicare home
health care benefits do so for services associated with an acute
medical condition, often following hospitalization.  Since 1989,
however, Medicare has been providing more long-term home health care
services to chronically disabled elderly beneficiaries.  VA officials
told us that Medicare-eligible veterans follow the same basic
pattern, with most receiving short-term home health care services
around an acute medical condition requiring hospitalization.  We were
unable to determine how long veterans referred by VA hospitals
received Medicare-funded home health care.  However, in 1992, about
three-quarters of the general Medicare population that used the home
health care benefit received services for fewer than 120 days; the
average duration of services for these beneficiaries was 42 days. 

To qualify for Medicare home health care coverage, beneficiaries must
be eligible for Medicare (almost all elderly and some disabled
people), homebound, in need of skilled nursing or therapy services on
a part-time or intermittent basis, and under the care of a physician
who prepares and periodically reviews their care plan.  The VA
physician usually fulfills Medicare's physician requirement for
veterans discharged from a VA hospital.  Unlike the HBHC program,
Medicare does not require beneficiaries to have a caregiver at home
or live within a certain radius of the hospital that discharged them. 

Skilled nursing and home health aide services--along with physical
therapy, occupational therapy, speech therapy, and medical social
services--are the home health care services that VA usually
facilitates for veterans covered by Medicare.  Approximately 70
percent or more of the respondents to our questionnaire indicated
that they facilitate the delivery of these services. 

Physician, dietician, and pharmacy services are not covered under
Medicare's home health care benefit.  However, physician services are
covered by other parts of the Medicare program; pharmacy and
dietician services may be covered by Medicare under some
circumstances. 

Medicare, and not VA, pays for community-based providers to deliver
home health care services to veterans covered by Medicare's home
health care benefit.  VA incurs some administrative costs in
referring patients to Medicare, as well as the costs of VA
physicians' developing and reviewing plans of care, but VA does not
separately identify these costs. 


   COST DATA FOR VA'S HOME HEALTH
   CARE PROGRAMS PORTRAYED
   DIFFERENTLY
------------------------------------------------------------ Letter :5

Data on the costs of VA's home health care programs are reported
differently, both among HBHCs and between HBHCs and fee-based
programs.  As a result, to the extent that VA administrators make
decisions about whether to have an HBHC program on the basis of the
relative costs of HBHCs and fee-based programs, they do so on the
basis of their perceptions of cost rather than comparable data. 

HBHC program costs are based on data developed by the hospitals that
support the programs.  VA Central Office officials told us that
hospitals have wide latitude in deciding which costs to charge to
their HBHC programs.  This results in different cost charges among
the 74 HBHC programs.  For example, some HBHC programs include costs
of librarians or chaplains, while others include costs of
anesthesiologists or optometrists.  In addition, hospitals commonly
charge costs to their HBHC programs for certain administrative
support functions, such as costs for a portion of one
full-time-equivalent staff person in the Office of the Chief of
Staff.  One hospital, for example, charged $8,600 for support from
the Chief of Staff's Office in fiscal year 1994.  However, we found
another case in which a hospital charged $80,500 for approximately 2
full-time-equivalent staff from the Chief of Staff's Office.  A VA
Central Office official agreed that a charge this high was an error. 
Central Office officials further stated that they discuss
questionable charges that appear in VA's cost reports with hospital
staff but that it is up to the hospitals to appropriately allocate
costs. 

VA's reported costs of its fee-based program, on the other hand,
represent payments made to community-based providers but exclude
costs such as program administration and other indirect costs
associated with caring for veterans in this program.  For example,
costs for staff who administer the program are included in the
operating costs of the hospitals where the staff work and are not
identified as a cost of the fee-based program.  In addition,
approximately 70 percent of our questionnaire respondents stated that
they case-manage fee-based patients, yet costs associated with case
management are not included in the fee-based program. 

Since VA reports the costs of its programs differently, VA hospital
officials are left to make decisions on whether or not to have an
HBHC program based on their perceptions of the relative cost of HBHC
and fee-based programs.  These perceptions vary widely.  For example,
about 3 years ago, the Tampa HBHC program began treating patients who
previously would have received fee-based care.  One reason for doing
so was to reduce the costly fee-based payments for nursing services. 
The Kansas City Missouri hospital, on the other hand, terminated its
HBHC program in 1994 and referred some of its HBHC patients to
community-based providers.  A former HBHC official told us that
hospital administrators believed that it was less costly to pay for
community-based services than for an HBHC program. 

Respondents to our questionnaire also expressed very different views
regarding costs and why they either have or do not have an HBHC
program.  Over three-fourths of the questionnaire respondents with an
HBHC program stated that one reason their medical center has an HBHC
program is that it is less costly than purchasing fee-based services. 
Conversely, approximately half of the respondents without an HBHC
program said that one reason they do not have an HBHC program is that
it would be more costly than community-based care purchased under the
fee-based program. 

Respondents to our questionnaire also expressed very different views
on whether HBHC was more cost effective as compared with
community-based care.  In this instance, cost-effectiveness refers
not only to the actual costs incurred in treating a veteran but also
to the effectiveness of the care.  For example, who has fewer
hospital admissions and shorter hospital stays:  HBHC patients
receiving primary care services or patients receiving skilled
services from community-based providers?  About 40 percent of our
respondents said they had no basis to judge whether HBHC was more or
less cost effective than community-based care.  The remaining
respondents were evenly divided on which method of providing home
health care to veterans was the more cost effective. 


   QUALITY ASSURANCE APPROACHES
   FOR VA PROGRAMS AND MEDICARE
------------------------------------------------------------ Letter :6

VA monitors the quality of care provided by its home health care
programs, but it is more directly involved in monitoring the care its
own employees provide, through HBHC, than the care delivered by
community-based providers.  Licensing and certification assessments
of community-based providers conducted by independent organizations
provide VA some assurance that veterans in the fee-based program and
those covered by Medicare's home health care benefit receive care
from qualified home health care providers.\5 HBHC programs are
assessed by outside organizations as well, but in addition, they use
case management and quality indicators to evaluate the care they
deliver.\6 Medical centers are less likely to use these additional
means to monitor the quality of care delivered by community-based
providers. 

Medicare has the primary responsibility for ensuring that quality
care is furnished under its home health care benefit.  Medicare
requires community-based providers to have internal quality assurance
programs.  Moreover, Medicare requires VA physicians referring
patients to prepare and review plans of care. 


--------------------
\5 We did not review individual state licensing requirements, which
vary by state, or compare them with Medicare's certification
requirements. 

\6 We did not determine the extent to which community-based providers
case manage their patients or use quality indicators to evaluate the
care they deliver. 


      ASSESSMENT OF HBHC AND
      COMMUNITY-BASED PROVIDERS
---------------------------------------------------------- Letter :6.1

All HBHC programs are accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) and are subject to
a performance review every 3 years.  JCAHO staff apply standards
contained in their Accreditation Manual for Home Care to evaluate how
well the home health care provider assessed the patient's service
needs, planned for the patient's care, and monitored the patient's
response to the care provided.  Before 1995, JCAHO's reviews did not
measure actual outcomes of care but instead focused on processes and
the capacity of a provider to deliver quality care.  JCAHO's 1995
standards, however, place more emphasis on outcomes of care. 

Community-based home health care providers that are certified to
treat Medicare beneficiaries are assessed at least once every 15
months by a state survey agency (usually a component of the state
health department), by JCAHO, or by the National League for Nursing's
Community Health Accreditation Program (CHAP).  These surveys are
intended to ensure that Medicare beneficiaries receive care from
qualified home health care providers.  State survey agencies, under
contract with the Health Care Financing Administration (HCFA), which
administers Medicare, survey community-based providers\7 to determine
if they meet Medicare's conditions of participation.  These
conditions cover such topics as acceptance of patients, medical
supervision, and skilled nursing services.  Survey staff visit home
health care providers and examine organizational, functional,
personnel, and patient records and visit with patients in their homes
to evaluate the quality and scope of services provided.  Home health
care providers that meet JCAHO's or CHAP's standards are also deemed
to have met Medicare's conditions of participation.  Thus, veterans
in HBHC programs and those receiving home health care services
covered by Medicare are assured of receiving care from
Medicare-certified providers. 

Most, but not all, fee-based patients also receive care from
Medicare-certified providers.  About 83 percent of the respondents to
our questionnaire said they purchase care from Medicare-certified
providers most, almost all, or all of the time for their fee-based
patients.  For example, the three hospitals we visited use only
Medicare-certified home health care providers.  These hospitals
select the providers on the basis of factors such as which providers
serve the area where the veteran needing home health care lives,
whether the provider is Medicare-certified, and whether the
hospital's past experience with the provider has been positive. 
However, fee-based patients who are paralyzed do not always receive
care from Medicare-certified providers because the fee-based program
allows family members who have been trained and certified by VA to
deliver bowel and bladder care to quadriplegic veterans.  Also, a VA
Central Office official told us that there are not enough
Medicare-certified providers in some areas of the country. 


--------------------
\7 At the end of 1994, the number of Medicare-certified home health
care providers totaled 7,864. 


      CASE MANAGEMENT
---------------------------------------------------------- Letter :6.2

VA's programs also employ case management to ensure quality care. 
Case management, in general, involves coordinating the services
needed by and provided to a patient.  Case management may address
only a veteran's health needs or the total needs of a veteran and his
or her family.  Similarly, case management may be limited to the
process of arranging initial services or may be an ongoing process
for the duration of an illness.  Not everyone discharged to home
health care from a hospital needs case management; some veterans and
their families may act as their own case managers.  When case
management is appropriate, it is seen as important to the adequacy of
the home health care veterans receive:  68 percent of the
questionnaire respondents said that case management greatly improves
the adequacy of care patients receive. 

The way in which a veteran's care is managed by VA may differ
somewhat depending upon the program that is providing for the
veteran's services.  Nearly all (96 percent) of the respondents with
HBHC programs said that they typically case manage patients and that
nurses are usually the primary case managers.  For veterans receiving
fee-based services, most respondents (73 percent) said the VA
physician who orders the home health care reviews the provider's
periodic reports on the patient's health status most, almost all, or
all of the time, and 62 percent said someone (most often a nurse)
serves as a case manager for patients.  For veterans receiving care
paid for by Medicare, about the same number of respondents (72
percent) said the VA physician who orders the home health care
reviews the provider's periodic reports most, almost all, or all of
the time, but fewer (49 percent) said that someone (usually a nurse)
case manages the patient's care. 

Respondents also described different primary functions of case
managers in the different programs, as shown in table 1.  Nearly all
respondents with an HBHC program said that their case managers
performed the primary functions listed in the table, while
respondents without an HBHC program indicated that their case
managers were much less likely to perform these functions.  The
greatest difference among respondents was that evaluating the
patient's home environment was much less likely to be a primary
function of the community-based program case manager than it was to
be a function of the HBHC case manager. 



                                Table 1
                
                Primary Functions of VA Case Managers in
                  the HBHC and Fee-Based Programs and
                  Under the Medicare Home Health Care
                                Benefit


                                                          Fee-  Medica
                                                  HBHC   based      re
                                                progra  progra  benefi
Case management function                             m       m       t
----------------------------------------------  ------  ------  ------
Participate with provider staff in initially        90      46      44
 assessing needs of patients
Coordinate development, evaluation, and review      94      53      43
 of patient care plans
Evaluate patient's home environment                 85      21      14
Evaluate ability of caregiver to meet the care      90      39      34
 needs of the patient
Monitor and manage the overall delivery of          92      43      32
 care to patient
Review and assess periodically the medical          92      54      41
 condition of the patient with provider staff
----------------------------------------------------------------------
The HBHC and community-based programs we visited replicated the
difference in primary case management functions described in the
questionnaires.  Case management at the Boston and Tampa HBHC
programs involves each of the six functions cited in table 1.  For
example, each program holds team meetings at least weekly to discuss
veterans' status and needs.  The Boston, Tampa, and West Roxbury
hospitals also case manage patients in their community-based
programs, but the management is not as extensive as that conducted by
HBHC programs.  For example, case management at West Roxbury is
limited to defining a plan of care and arranging for the veteran to
receive it.  At the Tampa hospital, case managers participate with
community provider staff in assessing the care needs of patients,
coordinate development of patient care plans, and periodically review
patients' medical conditions with community provider staff.  However,
case managers at Tampa do not have the primary functions of directly
monitoring and managing the overall delivery of home health care
services provided patients under the fee-based or Medicare programs
or, for those patients covered by Medicare, directly evaluating the
patient's home environment and ability of the caregiver to meet the
care needs of patients. 

Our discussions with medical center staff in the three locations we
visited suggest some additional reasons why the primary functions of
case management in the community-based programs may differ from those
in HBHC.  First, case managers for veterans receiving community-based
care may also be responsible for a variety of other functions,
leaving less time to devote to case management.  For example, a Tampa
medical center nurse who manages veterans' cases in the fee-based and
Medicare programs told us that she coordinates services for two other
sets of veterans as well:  those that need hospice services and those
that are in contract nursing homes.  None of the HBHC case managers
we spoke to told us that they had similar responsibilities for
veterans outside of the HBHC program.  Second, medical center case
managers may be responsible for arranging home health care services
for a large number of veterans as compared with the number of
veterans managed by HBHC case managers, which would also leave them
less time to devote to case management functions.  The two nurse case
managers at the Boston medical center, for example, referred 1,074
veterans to community providers in fiscal year 1994.  In contrast,
Boston's three HBHC case managers were responsible for case managing
and providing care to 112 veterans that same year. 


      QUALITY INDICATORS
---------------------------------------------------------- Letter :6.3

Another way VA assesses veterans' care is by monitoring performance
indicators that VA believes are related to the quality of care
provided.  For example, if a provider frequently used by a VA
hospital has high rates of patient deaths or patients' being
readmitted to the hospital, visiting an emergency room, falling,
having impaired skin integrity, or getting an infection, this may
reflect a problem with the care being provided.  Patient satisfaction
is also useful as a way of assessing the quality of care.  For
example, one HBHC program we visited set a standard that at least 90
percent of its veterans would be satisfied with their care, as
measured by a patient satisfaction survey.  In the fourth quarter of
fiscal year 1994, 99.5 percent of the veterans surveyed said that
they were satisfied with their care.  Indicators such as these are
useful to assess performance, identify problems, develop corrective
actions, and monitor the effectiveness of the changes made. 

As table 2 shows, more medical centers track selected quality
indicators for their HBHC programs than for their community-based
programs.\8 We did not ask how often the community-based providers
themselves track these indicators for their patients. 



                                Table 2
                
                Quality Indicators Used in VA's HBHC and
                 Fee-Based Programs and for Medicare's
                        Home Health Care Benefit


                                                          Fee-  Medica
                                                  HBHC   based      re
                                                progra  progra  benefi
                                                     m       m       t
----------------------------------------------  ------  ------  ------
Patient deaths                                      70      31      29
Visits to the medical center's emergency            52      22      18
 department
Visits to other hospitals' emergency                41      14      10
 departments
Hospital readmissions                               66      36      31
Falls                                               89      15      14
Impaired skin integrity                             70      22      24
Infection rates                                     93      17      13
Patient satisfaction                                97      62      59
----------------------------------------------------------------------
Although VA hospitals less often track these quality indicators for
community-based providers and patients receiving their care from
those providers, they do take other steps to ensure that veterans in
community-based programs receive quality care.  Eighty percent of
questionnaire respondents stated that they have periodic telephone or
personal contacts with provider staff most, almost all, or all of the
time to discuss the health status of veterans in the fee-based
program, and 65 percent said that they have similar contacts for
veterans that are covered by Medicare's home health care benefit. 
About 80 percent said that they require providers to submit periodic
written reports regarding the health status of veterans in the
fee-based program most, almost all, or all of the time, and about 70
percent said they ask for similar reports for those veterans in the
Medicare program.  Further, VA officials told us that hospitals
evaluate patients' medical conditions when they have an inpatient or
outpatient visit at the hospital. 


--------------------
\8 The table lists only those indicators we included in our
questionnaire; it does not provide a comprehensive list of all
indicators that might be used by a medical center. 


   OBSERVATIONS
------------------------------------------------------------ Letter :7

Because VA's home health care programs provide different arrays of
services to veterans who generally have different home health care
needs and because consistent program cost data are not available, it
is difficult to compare the relative costs of VA's methods of meeting
veterans' home health care needs.  And although VA itself more
directly monitors care provided under its HBHC program, the quality
of care furnished by community-based providers paid for by both VA
and Medicare is evaluated in other ways--including by HCFA as part of
its responsibility for administering the Medicare program. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :8

We obtained comments on a draft of this report from VA officials,
including the Deputy Under Secretary for Health.  The officials noted
that the lack of consistent cost data, in this case for the various
types of home health care provided, is a problem not unique to VA and
is a challenge for all health care providers.  They said that VA, in
making improvements to its financial management and information
systems, is attempting to better identify costs associated with all
of its programs, including each component of its home health care
programs. 

The officials also told us that VA is developing performance measures
that will allow managers at multiple levels to understand and
identify desired program outcomes.  Once these outcomes are in place,
managers will be accountable for meeting them in the most
cost-effective and efficient manner.  VA officials also said that
they intend to do cost-benefit analyses for home health care and
other programs, once enough data are available.  The VA officials
additionally suggested some technical changes, primarily for
clarification, which we incorporated as appropriate. 


---------------------------------------------------------- Letter :8.1

As arranged with your staff, unless you announce its contents
earlier, we plan no further distribution of this report for 7 days
after its issue date.  At that time, we will send copies to the
Secretary of Veterans Affairs, the Senate and House Committees on
Appropriations, and other interested parties.  We will also make
copies available to others upon request. 

This report was prepared under the direction of James Carlan,
Assistant Director, Health Care Delivery and Quality Issues.  If you
or your staff have any questions concerning this report, please
contact Robert Dee, the evaluator-in-charge, at (617) 565-7470. 
Other staff contributing to this report were Sally Coburn, Patricia
Jones, Clarita Mrena, Joan Vogel, and Leonard Hamilton. 

Sincerely yours,

Carlotta C.  Joyner
Associate Director, Health Care Delivery
 and Quality Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

To develop our description of the ways VA provides home health care,
we obtained both nationally descriptive data and additional data at
three locations.  Collecting these data required audit work at VA's
Central Office as well as at the Boston, Massachusetts, and Tampa,
Florida, medical centers and at the West Roxbury division of the
Brockton Medical Center in Massachusetts.  In addition, we reviewed
VA's policies and procedures for operating its HBHC and fee-based
programs as well as Medicare's regulations concerning its home health
care benefit.  We also obtained various VA reports detailing
operations of its HBHC and fee-based programs. 

We selected the three hospitals we visited to give us examples of
hospitals that have an HBHC program (the medical centers in Boston,
Massachusetts, and Tampa, Florida) and one that does not (West
Roxbury, a division of the Brockton Medical Center).  At these
locations, we interviewed staff and obtained documents about their
programs.  Additionally, we visited 30 veterans in their homes to
understand better how their home health care services were provided;
12 were receiving HBHC services, while 18 were receiving
community-based services.  Of the 12 veterans receiving HBHC
services, 6 were cared for by the Boston HBHC program and 6 by
Tampa's program.  Of the 18 veterans receiving community-based care,
we visited 6 discharged by each of the three VA hospitals.  Seventeen
of the 18 veterans were covered by Medicare's home health care
benefit, and 1 was covered by VA's fee-based program.  During our
visits, a registered nurse on our staff interviewed veterans and
discussed their care and activities, observed their medical
conditions, and reviewed information from their medical files.  We
then discussed our observations with appropriate officials at the
three medical centers. 

To obtain nationally representative data about the three home health
care programs, we sent a detailed questionnaire to 158 VA medical
center directors and 7 other VA health care facilities.  We asked
respondents to answer questions about their HBHC program, if they had
one, and about their community-based program for health care.  The
questions covered general descriptive information, program staffing,
patient admissions and discharges, program services, case management,
quality assurance measures, reasons why they did or did not have an
HBHC program, and other issues.  We pretested the questionnaire at
three medical centers, obtained comments from VA officials, and
revised it accordingly.  A total of 151 medical centers and 6 other
VA health care facilities responded to the questionnaire.  We were
unable to verify independently most of the information provided
through the questionnaire.  However, questionnaire responses from
programs at the three hospitals we visited were consistent with the
information we obtained at those locations.  In addition,
questionnaire responses were consistent with selected aggregate
information provided by the VA Central Office. 


VA MEDICAL CENTERS WITH HBHC
PROGRAMS AND THEIR FISCAL YEAR
1995 STAFFING AUTHORIZATIONS
========================================================== Appendix II

                                        Authorized FY 1995
                                      full-time-equivalent
Medical center location                         staffing\a
----------------------------  ----------------------------
Albany, NY                                            9.70
Albuquerque, NM                                       6.25
Allen Park, MI                                        9.40
Asheville, NC                                         5.00
Atlanta, GA                                           6.85
Baltimore, MD                                        11.00
Batavia, NY                                           7.15
Bay Pines, FL                                         7.20
Birmingham, AL                                        9.80
Boston, MA                                            8.20
Bronx, NY                                             7.00
Buffalo, NY                                          12.90
Brooklyn, NY                                            \b
Butler, PA                                            4.90
Castle Point, NY                                        \c
Charleston, SC                                        3.50
Chicago (Lake Side), IL                               6.75
Chicago (West Side), IL                               7.50
Cleveland, OH                                         7.20
Columbia, MO                                          6.50
Dallas, TX                                            8.00
Danville, IL                                          5.00
Dayton, OH                                            5.00
Denver, CO                                            7.65
Des Moines, IA                                        5.30
Durham, NC                                            8.00
East Orange, NJ                                       5.75
Ft. Wayne, IN                                         3.00
Fresno, CA                                            5.00
Gainesville, FL                                       7.80
Hines, IL                                            14.65
Honolulu, HI                                          5.00
Houston, TX                                           7.75
Indianapolis, IN                                      8.00
Iowa City, IA                                         6.13
Lexington, KY                                         7.75
Little Rock, AR                                      13.50
Long Beach, CA                                        9.70
Madison, WI                                           7.55
Manchester, NH                                        5.50
Martinez, CA                                          8.95
Memphis, TN                                           9.00
Miami, FL                                            11.00
Milwaukee, WI                                         7.75
Minneapolis, MN                                      12.80
New Orleans, LA                                      11.00
New York, NY                                            \b
Newington, CT                                         4.88
North Chicago, IL                                     9.00
Northport, NY                                         7.90
Oklahoma City, OK                                     6.85
Palo Alto, CA                                         7.00
Philadelphia, PA                                        \b
Phoenix, AZ                                           9.60
Pittsburgh, PA                                        9.60
Portland, OR                                          8.00
Providence, RI                                        5.50
Salt Lake City, UT                                    7.73
San Antonio, TX                                       8.00
San Diego, CA                                         8.00
San Francisco, CA                                     5.75
San Juan, PR                                          6.30
Seattle, WA                                           8.25
Sepulveda, CA                                        10.00
Shreveport, LA                                        8.00
St. Louis, MO                                         6.80
Syracuse, NY                                          6.25
Tampa, FL                                             8.27
Tucson, AZ                                            8.00
Washington, DC                                       10.70
West Haven, CT                                        3.75
West Los Angeles, CA                                  4.50
White River Junction, VT                              3.90
Wilkes Barre, PA                                      4.50
----------------------------------------------------------
\a Staff size is based on the HBHC program's full-time-equivalent
employee authorization. 

\b The medical center did not respond to our questionnaire. 

\c Information was not provided on the questionnaire received from
the medical center. 


*** End of document. ***