oversight

VA Long-Term Care: Service Gaps and Facility Restrictions Limit Veterans' Access to Noninstitutional Care

Published by the Government Accountability Office on 2003-05-09.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States General Accounting Office

GAO          Report to Congressional Requesters




May 2003
             VA LONG-TERM
             CARE

             Service Gaps and
             Facility Restrictions
             Limit Veterans’ Access
             to Noninstitutional
             Care




GAO-03-487
                                               May 2003


                                               VA LONG-TERM CARE

                                               Service Gaps and Facility Restrictions
Highlights of GAO-03-487, a report to
Congressional Requesters                       Limit Veterans’ Access to
                                               Noninstitutional Care


With the aging of the veteran                  Veterans’ access to the six noninstitutional services we reviewed is limited
population, the Department of                  by service gaps and facility restrictions. Of VA’s 139 facilities, 126 do not
Veterans Affairs (VA) is likely to             offer all six of these servicesadult day health care, geriatric evaluation,
see a significant increase in                  respite care, home-based primary care, homemaker/home health aide, and
demand for long-term care. In
response to recent GAO findings
                                               skilled home health care. Veterans have the least access to respite care,
that variation exists in availability          which is not offered at 106 facilities. By contrast, skilled home health care is
of noninstitutional services across            not offered at 7 facilities. Veterans’ access is more limited than these
VA, GAO was asked to update and                numbers suggest, however, because even when facilities offer these services
expand its previous work to                    they often do so in only part of the geographic area they serve. In fact, for
determine (1) whether veterans’                four of the six services the majority of facilities either do not offer the
access to six noninstitutional                 service or do not provide access to all veterans living in their geographic
services is limited by service                 service area. Veterans’ access may be further limited by restrictions that
availability and restrictions on use           individual facilities set for use of services they offer. For example, at least 9
and (2) if access is limited, what             facilities limit veterans’ eligibility to receive noninstitutional services based
factors contribute to limited                  on their level of disability related to military service, which conflicts with
access. GAO surveyed VA’s 139
medical facilities, visited 4 of them
                                               VA’s eligibility standards. Further, restrictions placed by many facilities on
and updated information collected              the number of veterans who can receive noninstitutional services have
from a fifth facility visited during           resulted in veterans at 57 of VA’s 139 facilities being placed on waiting lists
earlier work, and interviewed                  for noninstitutional services.
headquarters and field officials.
                                               Noninstitutional Long-Term Care Services Not Available to All Veterans, Based on
                                               Geographic Areas, at VA’s 139 Facilities as of Fall 2002


GAO is recommending that VA:

• ensure that facilities follow VA’s
eligibility standards when
determining veteran eligibility for
noninstitutional long-term care
services, and

• refine current performance
measures to help ensure that all VA
facilities provide veterans with
access to required noninstitutional
services.
                                               VA’s lack of emphasis on increasing access to noninstitutional long-term
VA concurred with the                          care services has contributed to service gaps and individual facility
recommendations.                               restrictions that limit access to care. Without emphasis from VA
                                               headquarters on the provision of noninstitutional services, field officials
                                               faced with competing priorities have chosen to use available resources to
                                               address other priorities. While VA has implemented a performance measure
www.gao.gov/cgi-bin/getrpt?GAO-03-487.         for fiscal year 2003 that encourages networks to increase veterans’ use of
                                               five of the six noninstitutional services, it does not require networks to
To view the full report, including the scope
and methodology, click on the link above.      ensure that all facilities provide veterans access to noninstitutional services.
For more information, contact Cynthia A.
Bascetta at (202) 512-7101.
Contents


Letter                                                                                              1
                       Results in Brief                                                             3
                       Background                                                                   4
                       Veterans’ Access Is Limited by Gaps in Service Availability and
                         Facility Restrictions on Service Use                                       7
                       Lack of Emphasis, Inadequate Guidance, and Other Factors
                         Contribute to Limited Access                                             12
                       Conclusions                                                                16
                       Recommendations for Executive Action                                       16
                       Agency Comments                                                            17

Appendix I             VA Noninstitutional Long-Term Care Services in
                       Our Review                                                                 18



Appendix II            Scope and Methodology                                                      19



Appendix III           Availability and Utilization of Six Noninstitutional
                       Long-Term Care Services by VA Medical Facility or
                       Health Care System                                                         22



Appendix IV            Comments From the Department of Veterans Affairs                           27



Appendix V             GAO Contact and Staff Acknowledgments                                      28
                       GAO Contact                                                                28
                       Acknowledgments                                                            28

Related GAO Products                                                                              29



Tables
                       Table 1: VA Long-Term Care Workload and Expenditures, by Care
                                Setting, Fiscal Year 2002                                           6




                       Page i                           GAO-03-487 VA Noninstitutional Long-Term Care
          Table 2: Noninstitutional Services in Our Review Offered by the
                   Five VA Facilities We Visited                                                    20
          Table 3: Availability and Utilization of Six Noninstitutional Long-
                   Term Care Services at VA Medical Facilities (July 2002)                          22


Figures
          Figure 1: Noninstitutional Long-Term Care Services at VA’s 139
                   Medical Facilities                                                                8
          Figure 2: Noninstitutional Long-Term Care Services, Based on
                   Geographic Areas, at VA’s 139 Medical Facilities                                  9




          Abbreviations

          HCS               health care system
          VA                Department of Veterans Affairs




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          Page ii                                  GAO-03-487 VA Noninstitutional Long-Term Care
United States General Accounting Office
Washington, DC 20548




                                   May 9, 2003

                                   The Honorable Bob Graham
                                   Ranking Minority Member
                                   Committee on Veterans’ Affairs
                                   United States Senate

                                   The Honorable Lane Evans
                                   Ranking Minority Member
                                   Committee on Veterans’ Affairs
                                   House of Representatives

                                   The Honorable John D. Rockefeller IV
                                   United States Senate

                                   The Department of Veterans Affairs (VA) spent about $23 billion on health
                                   care in fiscal year 2002, including about $3.3 billion on long-term care.
                                   Demand for VA long-term care is likely to increase significantly during the
                                   next decade. Because of the aging of the veteran population, VA estimates
                                   that the number of veterans age 85 and older—those most in need of long-
                                   term care—will more than double, from about 640,000 currently to about
                                   1.3 million in 2012. Due to changes in VA’s eligibility standards more older
                                   veterans will be eligible to receive VA health care, including long-term care
                                   services.

                                   In recent years, VA has increased the proportion of its long-term care
                                   spending on care in noninstitutional settings, such as veterans’ own
                                   homes. This is consistent with the preference of many veterans and others
                                   to receive care in their homes or in other settings, such as adult day health
                                   care centers, that are less restrictive than institutions. For example, some
                                   veterans receive assistance in their homes with bathing and dressing
                                   provided by home health aides. However, VA has traditionally provided
                                   the bulk of veterans’ long-term care in institutional settings, such as
                                   nursing homes, which is reflected in VA’s spending for long-term care
                                   services. In fiscal year 2001, more than 90 percent of VA’s long-term care
                                   spending was for institutional long-term care.

                                   In November 1999, the Congress passed the Veterans Millennium Health
                                   Care and Benefits Act (Millennium Act),1 which required that VA provide


                                   1
                                    Pub. L. No. 106-117, 113 Stat. 1545 (1999).


                                   Page 1                                    GAO-03-487 VA Noninstitutional Long-Term Care
veterans access to three servicesadult day health care, geriatric
evaluation, and respite care. VA chose to meet the Millennium Act
requirements by issuing a directive in October 2001 requiring that facilities
provide adult day health care, noninstitutional geriatric evaluation, and
noninstitutional respite care to veterans in need of such services.2

In April 2002, at the request of the Senate Committee on Veterans’ Affairs,
we testified on variation in the availability of VA’s noninstitutional long-
term care services.3 Your offices expressed concern that this variation
could mean that some veterans did not have access to noninstitutional
services because of gaps in service availability and because of the
restrictions that some facilities might place on veterans’ use of these
services, such as limiting the amount of service a veteran may receive. To
address these concerns, you asked us to update and expand our previous
work4 to determine (1) whether veterans’ access to six noninstitutional
services is limited by service availability and restrictions on use and (2) if
access is limited, what factors contribute to limited access. The six
noninstitutional services you asked us to examine are the three that VA
requires as a result of the Millennium Act adult day health care, geriatric
evaluation, and respite careand three additional noninstitutional
services—home-based primary care, skilled home health care, and
homemaker/home health aide. See appendix I for information on these six
noninstitutional long-term care services.

To do our work, we surveyed each of VA’s 139 medical facilities to obtain
data on the types of services offered and the number of veterans receiving
the six noninstitutional long-term care services,5 and where access to
services was limited, we identified the reasons why services were limited.
We compared these survey data to the data we obtained in our fall 2001
survey of VA long-term care services to determine the extent to which



2
 The act requires that VA provide noninstitutional extended care services to enrolled
veterans until December 31, 2003.
3
 U.S. General Accounting Office, VA Long-Term Care: The Availability of Noninstitutional
Services Is Uneven, GAO-02-652T (Washington, D.C.: Apr. 25, 2002).
4
U.S. General Accounting Office, 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.: Mar. 29, 2002).
5
 Although VA has 172 medical centers, in some instances 2 or more medical centers have
consolidated into health care systems. Counting health care systems and individual medical
centers that are not part of a health care system as single facilities, VA has 139 facilities.




Page 2                                    GAO-03-487 VA Noninstitutional Long-Term Care
                   availability had changed since that survey. To gain an understanding of
                   facilities’ noninstitutional long-term care operations we also interviewed
                   VA officials in headquarters and in each of VA’s 21 network offices,6 visited
                   4 VA medical facilities—located in Memphis, Tennessee; Richmond,
                   Virginia; Tucson, Arizona; and Walla Walla, Washingtonand updated
                   information collected from a fifth facility in Albany, New York, which we
                   visited for our previous report on noninstitutional services. These five
                   facilities were chosen based on variation in both the number and type of
                   noninstitutional services they offered. In addition, we evaluated directives
                   and regulations and other guidance related to these six noninstitutional
                   services issued by VA headquarters, networks, and individual facilities.
                   For a complete description of our scope and methodology, see appendix
                   II. Our work was conducted from June 2002 through April 2003 in
                   accordance with generally accepted government auditing standards.


                   Veterans’ access to the six noninstitutional long-term care services in our
Results in Brief   study is limited by the lack of service availability and restrictions on their
                   use. Of VA’s 139 facilities, 126 do not offer all six of the services. Veterans
                   have the least access to noninstitutional respite care, which is not offered
                   by 106 VA facilities. By contrast, skilled home health care is not offered at
                   7 facilities. Furthermore, veterans’ access to care is more limited than
                   these numbers suggest, because even when facilities offer these services
                   they often do so in only parts of the geographic area they serve. In fact, for
                   four of the six servicesnoninstitutional respite care, home-based
                   primary care, adult day health care, and noninstitutional geriatric
                   evaluationthe majority of facilities either do not offer the service or do
                   not offer the service in the entire geographic area they serve. Veterans’
                   access may be further limited by restrictions that individual facilities set
                   for use of services they offer. For example, 9 facilities, in conflict with
                   VA’s eligibility standards, limited veterans’ access to noninstitutional
                   services based on their level of disability related to military service.
                   Further, restrictions placed by many facilities on the number of veterans
                   who can receive noninstitutional services have resulted in veterans at 57
                   of VA’s 139 facilities being placed on waiting lists for noninstitutional
                   services.




                   6
                    VA originally created 22 networks, but in January 2002 VA merged 2 networks into a single
                   network, leaving the agency with 21 networks.




                   Page 3                                  GAO-03-487 VA Noninstitutional Long-Term Care
             VA’s lack of emphasis on increasing access to noninstitutional long-term
             care services and a lack of guidance on the provision of these services
             have contributed to service gaps and individual facility restrictions. VA
             headquarters has not emphasized increasing access to these services by
             establishing measurable performance goals as it has for other priorities
             such as maintaining workloads in VA nursing homes. Without such
             performance measures, field officials faced with competing priorities have
             chosen to use available resources to address other priorities. VA has
             implemented a performance measure for fiscal year 2003 that encourages
             networks to increase veterans’ use of five of the six noninstitutional
             services, but it does not require networks to ensure that all network
             facilities provide veterans access to noninstitutional services. Moreover,
             VA has not provided facilities with adequate guidance on the provision of
             noninstitutional respite care, even though most have had little experience
             in providing the service. Some networks and facilities are confused about
             how to provide the service and as a result some are not providing the
             service. VA has also not provided adequate guidance on which
             noninstitutional services are required. In particular, VA has not specified
             whether the home health services requirement includes one, all, or some
             combination of home-based primary care, homemaker/home health aide,
             and skilled home health care. In the absence of VA headquarters guidance
             on what home health services are required, VA facilities vary in their
             interpretations of what services they must provide.

             To help ensure that veterans have access to noninstitutional long-term
             care services and that such services are offered uniformly throughout VA,
             we are recommending that VA take actions to increase emphasis on
             provision of these services, provide adequate guidance on their provision,
             and ensure that VA’s eligibility standards are used to determine eligibility.
             VA concurred with our recommendations, discussed preliminary actions it
             plans to take, and stated that it will provide a detailed action plan to
             implement our recommendations after this report is issued.


             Changes in VA’s eligibility standards have resulted in an increase in the
Background   number of veterans who are eligible to receive VA health care, including
             noninstitutional long-term care services. The Veterans’ Health Care
             Eligibility Reform Act of 19967 authorized VA to provide health care
             services not previously available to veterans without service-connected


             7
             Pub. L. No. 104-262 §§ 101, 104, 110 Stat. 3178-79, 3182-83 (1996).




             Page 4                                   GAO-03-487 VA Noninstitutional Long-Term Care
disabilities or low incomes.8 As required by the act and due to an
anticipated increase in demand for VA health care from these changes in
eligibility, VA established an enrollment system to manage veterans’
access to care. This system includes eight priority categories for
enrollment, with higher priority given to veterans with service-connected
disabilities, lower incomes, or other recognized statuses such as former
prisoners of war. If sufficient resources are not available to provide care
that is timely and acceptable in quality for all priority groups, the act
requires VA to limit enrollment nationally, consistent with the eight
priority groups. If needed, enrollment restrictions would begin with the
lowest priority category. On January 17, 2003, VA announced that it would
no longer enroll priority 8 veterans, those in the lowest priority category,
for the duration of the year.9

VA long-term care includes a continuum of services for the delivery of care
to veterans needing assistance due to chronic illness or physical or mental
disability. Assistance with veterans’ needs takes many forms and is
provided in varied settings, including institutional care in nursing homes
or in noninstitutional settings preferred by many veterans, including in-
home care services and community-based services such as adult day
health care centers. Long-term care also includes respite care services that
temporarily relieve a veteran’s caregiver from the burden of caring for a
chronically ill and disabled veteran in the home. VA offers long-term care
services directly or through other providers with which VA contracts.

VA provides most of its long-term care to veterans in institutional settings,
such as VA nursing homes or state-owned veterans’ homes rather than in
noninstitutional settings. In fiscal year 2002, VA served about 36 percent of
its long-term care workload, or average daily census, in noninstitutional
settings (see table 1). That same year noninstitutional care accounted for 9
percent of VA’s long-term care expenditures. In contrast, noninstitutional



8
 A service-connected disability is an injury or disease that was incurred or aggravated while
on active military 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 service-connected disability of 100 percent. Percentages are assigned in
increments of 10 percent.
9
 Priority 8 veterans are primarily veterans with no service-connected disabilities who have
incomes above established limits for geographic regions set by the U.S. Department of
Housing and Urban Development to reflect regional costs of living. Priority 8 veterans
enrolled prior to January 17, 2003, remain enrolled to receive VA health care benefits.




Page 5                                   GAO-03-487 VA Noninstitutional Long-Term Care
care accounted for about 29 percent of Medicaid’s long-term care
expenditures in fiscal year 2001, the most recent year for which data are
available.10

Table 1: VA Long-Term Care Workload and Expenditures, by Care Setting, Fiscal
Year 2002
                                                                a
 Long-term care setting               Average daily census                    Total expenditures
 Institutional                                       43,363                       $2,979,156,000
 Noninstitutional                                    24,126                          283,098,000
 Total                                               67,489                       $3,262,254,000

Source: VA.
a
 The average daily census represents the total number of days of inpatient care for institutional care
and the total number of outpatient encounters for noninstitutional care, each divided by the number of
days in the year. Thus, the figures represent VA’s workload during the year and not an unduplicated
count of veterans in these settings because some veterans receive more than one service.


VA has delegated decision making regarding financing and service delivery
for long-term care and other health care services to its 21 health care
networks. VA allocates resources for health care to each of the 21
networks primarily through the Veterans Equitable Resource Allocation
system, in which networks are funded through a formula reflecting the
number and types of veterans receiving care in the network, including
those receiving long-term care.11 In turn, VA’s networks have budget and
management responsibilities that include allocating resources received
from headquarters to facilities within their networks—including resources
used to provide long-term care services.




10
 Medicaid, the joint federal-state health-financing program for low-income individuals, is
the nation’s largest funding source for long-term care. In fiscal year 2001, Medicaid
expenditures on long-term care totaled $75.3 billion.
11
 For more information on VA’s resource allocation system see U.S. General Accounting
Office, VA Health Care: Allocation Changes Would Better Align Resources with Workload,
GAO-02-338 (Washington, D.C.: Feb. 28, 2002).




Page 6                                       GAO-03-487 VA Noninstitutional Long-Term Care
                            Veterans’ access to the six noninstitutional services in our reviewadult
Veterans’ Access Is         day health care, geriatric evaluation, respite care, home-based primary
Limited by Gaps in          care, homemaker/home health aide, and skilled home health care—is
                            limited due to gaps in availability and facility restrictions on use of the
Service Availability        services. Of VA’s 139 facilities, 126 do not offer all six noninstitutional
and Facility                services. Facilities that do offer a service do not always offer the service to
Restrictions on             veterans in the entire geographic area the facility serves. Further, veterans’
                            access to the six noninstitutional services may be limited by restrictions
Service Use                 that individual VA facilities place on service use. Some of these facility
                            restrictions conflict with VA eligibility standards which state that most
                            services are to be available to all enrolled veterans regardless of priority
                            group. The restrictions include providing services only to certain veterans
                            or limiting the number of veterans who can use services at any one time.


Access to Care Is Limited   Access to care is limited because many VA facilities do not offer the six
by Service Gaps Across VA   noninstitutional services in our review. Of VA’s 139 facilities, 126 did not
                            offer all of the six noninstitutional services in fall 2002, a pattern similar to
                            that in fall 2001. (See fig. 1.) The least commonly available service of the
                            six we reviewed in 2001 and 2002 was noninstitutional respite care. This
                            service was not available at 110 of VA’s 139 facilities in fall 2001, and as of
                            fall 2002, noninstitutional respite care was not available at 106 of VA’s 139
                            facilities. In contrast, the most widely available service we reviewed was
                            skilled home health care, which was offered at all but 7 facilities. For a
                            complete list of the services each VA facility reported offering, see
                            appendix III.




                            Page 7                              GAO-03-487 VA Noninstitutional Long-Term Care
Figure 1: Noninstitutional Long-Term Care Services at VA’s 139 Medical Facilities

VA facilities
140


120


100


 80


 60


 40


 20


  0
       2001 2002          2001 2002      2001 2002     2001 2002       2001 2002       2001 2002
      Respite care        Home-based      Geriatric     Adult day     Homemaker/      Skilled home
                          primary care   evaluation    health care    home health      health care
                                                                         aide
                Offered

                Not offered

 Source: GAO.

Note: Includes services provided directly by facilities or through contracts with other providers as of
fall 2001 and fall 2002.


Veterans’ access to these services is further limited because among
facilities that offer services, many do so in only parts of the geographic
area they serve. Our fall 2002 survey showed that for four of the six
services noninstitutional respite care, home-based primary care, adult
day health care, and noninstitutional geriatric evaluationthe majority of
the facilities either did not offer the service or did not offer the service in
the entire geographic area they serve. As shown in figure 2, 42 facilities did
not offer adult day health care and an additional 76 facilities did not offer
it in their entire geographic service area. As a result, where veterans live in
a facility’s geographic service area sometimes determines whether they
can access the services offered by the facility. The remaining 21 facilities
reported that they offered adult day health care in all parts of their
geographic service areas.




Page 8                                           GAO-03-487 VA Noninstitutional Long-Term Care
Figure 2: Noninstitutional Long-Term Care Services, Based on Geographic Areas, at
VA’s 139 Medical Facilities


VA facilities
140


 120


 100


     80


     60


     40


     20


      0
          Respite care     Home-based          Geriatric       Adult day      Homemaker/       Skilled home
                           primary care       evaluation      health care   home health aide    health care
                 Offered in entire geographic area

                 Offered but not in entire geographic area

                 Not offered
 Source: GAO.

Note: Includes services provided directly by facilities or through contracts with other providers as of
fall 2002.


VA may also arrange for veterans to access three noninstitutional long-
term care services from non-VA sources even though VA does not pay for
these services. The Millennium Act and VA policy allow facilities to make
available to veterans the services required as a result of the Millennium
Actadult day health care, noninstitutional respite care, and
noninstitutional geriatric evaluationthrough other providers or payers
while still overseeing the care delivered using a case management
approach.12 However, VA headquarters has neither issued guidance on the
use of case management to meet this requirement under the Millennium
Act nor has it monitored the extent to which facilities use this option.
Further, the use of case management by VA to make these three services



12
 Case management includes assessment of the veteran’s care needs, care planning and
implementation, referral coordination, monitoring, and periodic reassessment of the
veteran’s care needs.




Page 9                                                GAO-03-487 VA Noninstitutional Long-Term Care
                                  available to veterans is limited by the eligibility of veterans for these other
                                  sources of care. That is, if veterans are not eligible for other sources of
                                  care, such as Medicaid and Medicare, and VA does not provide the service,
                                  then veterans will likely not have access to the three services.


Veterans’ Access to Care Is       Access to care is further limited by the restrictions that some facilities
Further Limited by                place on the six noninstitutional services in our review. These restrictions
Individual Facility               include (1) limiting services to veterans with certain levels of service-
                                  connected disability, (2) limiting the amount of service that veterans can
Restrictions                      receive, and (3) establishing a maximum number of veterans who can
                                  receive a service at any time.

Some Facilities Limit Access to   We found that nine VA facilities imposed their own eligibility restrictions
Services Based on Veterans’       on access to noninstitutional services based on veterans’ service-
Service-Connected Disability      connected disabilities. We identified five of these nine facilities through
Levels                            comments facilities made in our survey, although we did not
                                  systematically ask facilities this question in our survey. Because we did
                                  not systematically ask in our survey, it is possible that additional facilities
                                  may impose similar eligibility restrictions. Other VA facilities may have
                                  also instituted similar restrictions on access. These restrictions conflict
                                  with VA eligibility standards and result in inequitable access for veterans
                                  enrolled at these facilities. VA’s eligibility standards state that most
                                  services are to be available to all enrolled veterans, regardless of priority
                                  group.13

                                  In our survey of VA’s 139 facilities, 5 facilities provided additional
                                  comments indicating that they limit certain services—including adult day
                                  health care, homemaker/home health aide, skilled home health, and
                                  respite care—to veterans with service-connected disabilities. Four of the
                                  5 facilities limit services to veterans with service-connected disabilities of
                                  70 percent or greater. In addition, one of the facilities we visited provides
                                  homemaker/home health aide services to veterans with service-connected
                                  disabilities of 70 percent or greater. Another facility we visited provides
                                  the service primarily to veterans with service-connected disabilities of 70
                                  percent or greater or veterans with service-connected disabilities of at
                                  least 60 percent for a single condition; other veterans may receive the


                                  13
                                   Although VA issued a regulation on September 17, 2002, granting priority for
                                  appointments to veterans with service-connected disabilities of at least 50 percent and
                                  veterans needing care for a service-connected disability, the regulation does not change
                                  other veterans’ eligibility to receive services.




                                  Page 10                                  GAO-03-487 VA Noninstitutional Long-Term Care
                                service, but only for 6 months. In addition, one network official told us
                                that 2 facilities in his network limit homemaker/home health aide services
                                to veterans with service-connected disabilities of 70 percent or greater
                                because under the Millennium Act VA must pay for nursing home care
                                when such veterans need it.14 According to this official, because
                                homemaker/home health aide services can keep veterans in their own
                                homes rather than in nursing homes, providing the service to such
                                veterans can delay the need for nursing home care and the resultant
                                financial obligation for the facilities.

Access Is also Limited by       The amount of service veterans receive may depend on which facility
Restrictions on the Amount of   provides their care. Facilities vary in the limits they set. Some facilities
Services Provided               restrict the amount of a noninstitutional service a veteran can receive once
                                the veteran has been authorized to receive care. For example, a network
                                official told us that one network facility offers veterans up to 24 hours per
                                week of homemaker/home health aide services while a facility official in
                                another network told us their facility provides no more than 10 hours per
                                week. A facility we visited in another network does not place any
                                restrictions on the amount of homemaker/home health aide services
                                provided.

                                Facility officials noted that they can serve more veterans if they limit the
                                amount of service provided to each veteran. One facility we contacted
                                provided veterans no more than 2 days per week of adult day health care.
                                Because of this restriction, veterans whose medical needs require more
                                adult day health care pay for the service themselves, find another payer
                                such as Medicaid, or forego the additional service. At another facility we
                                visited, veterans without service-connected disabilities were limited to 2
                                full days or 3 half days per week regardless of medical need. In 1998, this
                                facility also reduced the number of homemaker/home health aide hours
                                provided each week from 21 to 8 in order to increase the number of
                                veterans who could be provided the service. At both facilities, officials
                                emphasized that the purpose of limits on the amount of service provided
                                was to increase the number of veterans who could receive at least some of
                                the service.




                                14
                                 The Millennium Act requires that VA provide nursing home care to any veteran who needs
                                such care and who has a service-connected disability of 70 percent or greater, or to any
                                veteran needing such care specifically for a service-connected disability, even if the
                                disability is less than 70 percent.




                                Page 11                                GAO-03-487 VA Noninstitutional Long-Term Care
Access at Many Facilities Is   In our survey of VA facilities, 57 of 139 facilities reported maintaining a list
Restricted by Limits on the    of veterans waiting for at least one of the services in our review. These
Number of Veterans Served      facilities told us in effect that they are not meeting all their veterans’ needs
                               for noninstitutional services. Many facilities place limits on the total
                               number of veterans they serve by establishing a budget cap—the
                               maximum number of veterans who can receive a particular service at any
                               time. For three of the six services in our study—home-based primary care,
                               homemaker/home health aide, and noninstitutional geriatric evaluation—
                               most facilities reported in our survey that despite offering the service, they
                               were currently unable to provide services to additional veterans within
                               their budget caps. Additional veterans needing services would have to wait
                               until space or resources became available.


                               A lack of VA emphasis on increasing access to noninstitutional long-term
Lack of Emphasis,              care services, inadequate VA guidance on providing these services, and
Inadequate Guidance,           other factors have contributed to limited access for veterans. VA had not
                               provided measurable standards for the provision of these services until
and Other Factors              fiscal year 2003 or oversight to monitor their provision as it has for high-
Contribute to Limited          priority services. VA guidance on the provision of noninstitutional long-
Access                         term care services has left unclear to some facilities how one service is to
                               be defined and provided and whether some of the services in our review
                               are a part of what VA requires be made available to veterans who need
                               them. Other factors, such as availability of contractors to provide a
                               service, also contribute to the lack of access for specific services.


VA Has Not Emphasized          VA network and facility officials told us that VA headquarters has not
Increased Access to            emphasized increased access to noninstitutional long-term care services
Noninstitutional Long-         but emphasized other priorities. As a result, these officials said they use
                               their resources for the priorities VA headquarters emphasizes rather than
Term Care Services             noninstitutional services. For example, officials in 9 of VA’s 21 networks
                               told us that VA headquarters’ emphasis on the performance measure that
                               requires networks to maintain workload in VA nursing homes has led them
                               to devote resources to nursing home care that they might otherwise have
                               used to provide noninstitutional services. One network director told us
                               that the “pressure” from VA headquarters to maintain nursing home
                               utilization is much greater than that to offer noninstitutional services. In
                               another network, an official at a VA facility not offering three of the
                               services in our study told us that these services were “victims of
                               competition for resources.” In other words, the facility had not funded
                               these three noninstitutional services because facility officials had chosen
                               to devote resources to other services. Another network director told us


                               Page 12                            GAO-03-487 VA Noninstitutional Long-Term Care
                           that, if forced to choose between funding different services, the network
                           would allocate resources to services included in a performance measure.

                           One way VA emphasizes services is through performance measures, which
                           VA establishes to monitor network officials’ progress toward meeting
                           certain VA strategic goals, such as increasing veteran access to services.
                           VA has demonstrated that requiring network officials to meet measurable
                           performance standards can promote change. For example, since their
                           inception in fiscal year 1996 VA performance measures have included a
                           measure for providing immunizations to prevent pneumonia to veterans
                           age 65 and older and those at high risk of the disease. VA increased the
                           percentage of veterans in this population who received the immunization
                           from 26 percent in fiscal year 1996 to 81 percent in fiscal year 2002.

                           In October 2002, VA introduced a performance measure for
                           noninstitutional long-term care which requires all networks to provide
                           noninstitutional services to a portion of their enrolled veterans needing
                           such services14.4 percent in fiscal year 2003 and 16 percent in fiscal
                           year 2006.15 The fiscal year 2003 goal for this measure will require the
                           majority of networks to increase utilization of their noninstitutional
                           services. The performance measure includes five of the services in our
                           review but does not include noninstitutional geriatric evaluation.
                           However, the performance measure does not require networks to ensure
                           that veterans can access noninstitutional long-term care services at all
                           network facilities. Instead, network targets can be achieved in the current
                           performance measure if networks increase utilization at facilities that
                           already offer noninstitutional services.


VA Has Provided            VA headquarters has provided inadequate guidance to networks and
Inadequate Guidance on     facilities on the provision of noninstitutional respite care to address
the Provision of           confusion in the field about what this service is and how it should be
                           provided. This confusion exists, in part, because VA has limited
Noninstitutional Respite   experience with noninstitutional respite care and VA traditionally
Care                       provided respite care in institutions such as nursing homes.
                           Noninstitutional respite care, by contrast, is provided only in
                           noninstitutional settings, such as a veteran’s own home.




                           15
                            According to VA, when it plans for noninstitutional services it assumes that the vast
                           majority of veterans will choose to use their Medicare benefits for home health care.




                           Page 13                                  GAO-03-487 VA Noninstitutional Long-Term Care
                       Although noninstitutional respite care has been required by VA for over a
                       year, VA has not issued adequate guidance on the provision of
                       noninstitutional respite care and VA staff told us they were unsure how to
                       develop a noninstitutional respite care service. VA issued a directive in
                       October 2001 that requires all facilities to provide noninstitutional respite
                       care to veterans in need of the service yet it inadequately defines
                       noninstitutional respite care and does not provide facilities with
                       information regarding how to provide the service. For example, the
                       directive states that noninstitutional respite care may be provided in a
                       home or other noninstitutional settings. However, it does not specify
                       which noninstitutional settings may be used for the purpose of respite
                       care. In fact, officials in 6 of the 21 networks we contacted indicated that
                       there was confusion in their networks about how to establish
                       noninstitutional respite care programs and 1 of these networks reported
                       this was the reason facilities in the network were not providing the
                       service. Further, in our survey, six facilities reported that they offer
                       noninstitutional respite care in community nursing homes, which are
                       institutional settings, thus not meeting the requirement for noninstitutional
                       respite care. VA headquarters officials said they are developing a
                       handbook that will define and provide guidance on the provision of
                       noninstitutional respite care.


VA Guidance Does Not   VA requires that facilities offer a home health service benefit as part of
Specify Which Home     VA’s medical benefits package.16 VA headquarters officials told us that the
Health Services Are    home services benefit includes home-based primary care,
                       homemaker/home health aide, and skilled home health care. However, VA
Required               policy does not specify whether one, some combination, or all three home
                       health services are required under the home health services benefit.
                       Currently 138 out of VA’s 139 facilities offer at least one of these three
                       home health services, 59 facilities offer two of the three services, and 66
                       facilities offer all three. Without clear guidance to facilities on what
                       services they must make available in order to fulfill the home health
                       services benefit, facilities vary in their interpretation of what is included in
                       the benefit and headquarters cannot ensure that veterans have access to
                       the services to which they are entitled.

                       Because facilities and networks vary in their interpretation of what is
                       included in the home health services benefit, facilities do not uniformly


                       16
                         The medical benefits package is the set of services to be available to all enrolled veterans.




                       Page 14                                    GAO-03-487 VA Noninstitutional Long-Term Care
                            offer the same home health services. For example, at one facility we
                            visited, an official told us that the facility interpreted the home health
                            services benefit to mean that veterans must have access to skilled home
                            health care—which the facility made available to all veterans. The facility
                            restricted veterans’ access to its homemaker/home health aide and home-
                            based primary care services because facility officials did not believe these
                            services were required under the home health benefit. Similarly, in another
                            network an official told us that the network interpreted the home health
                            services benefit to include all three home care serviceshome-based
                            primary care, homemaker/home health aide, and skilled home health care.
                            As a result, access to these three services varies according to facility
                            interpretation of what is required. Without clear guidance to facilities on
                            what services they must make available in order to fulfill the home health
                            care services requirement, headquarters cannot ensure that veterans have
                            access to the home health services to which they are entitled and veterans
                            are likely to experience variation in the benefits package.


Other Factors Limit the     Other factors limiting access to services include lack of contractors,
Availability of             difficulty hiring needed staff, and limitations imposed due to distances VA
Noninstitutional Services   staff can travel. The lack of contractors is particularly important in adult
                            day health care, where 62 facilities that either did not provide adult day
                            health care at all or only did so in parts of their geographic service areas
                            reported that they experienced difficulty in finding local contractors to
                            provide the service. In addition, 63 facilities cited insufficient facility staff
                            as the reason for not offering geriatric evaluation or only offering it to a
                            portion of their geographic service area. Officials in VA headquarters told
                            us that many facilities have been unable to recruit clinically trained
                            geriatric staff, such as geriatricians and geriatric nurse practitioners,
                            needed to operate this service.

                            For home-based primary care, 94 facilities that did not offer the service at
                            all or did not do so in all parts of their geographic service area reported
                            that they did not do so because many veterans live outside of the facility’s
                            home-based primary care service area. VA guidance limits the service to
                            veterans who live within a locally established radius of the facility because




                            Page 15                             GAO-03-487 VA Noninstitutional Long-Term Care
                      home-based primary care staff travel from the facility to veterans’ homes
                      to deliver care.17


                      Veterans’ access to the six noninstitutional long-term care services we
Conclusions           reviewed is limited and highly variable across the country. Extensive gaps
                      in services exist at many facilities either because they do not offer the
                      services or do not offer it in all parts of their service areas. Moreover,
                      individual facility restrictions on veterans’ use of services means that
                      access may be further restricted. These include facility restrictions based
                      on veterans’ levels of service-connected disability that are inconsistent
                      with VA eligibility standards. Facility restrictions have resulted in waiting
                      lists for services at many facilities. The end result is that veterans’ access
                      to these services is often limited or nonexistent based on where they live.

                      Shortfalls and unevenness in veterans’ access to noninstitutional long-term
                      care services have resulted because VA headquarters has not provided
                      adequate guidance and emphasis on making these services available. VA
                      has not provided sufficient guidance to clear up confusion at facilities as
                      to how noninstitutional respite care services are provided or to make clear
                      which home health services facilities must provide. As a result, facilities
                      vary in their interpretation of which services to provide, creating
                      unevenness in their availability. Furthermore, VA has not sufficiently
                      emphasized the importance of providing these services to encourage
                      networks and facilities to make them a priority in their overall service
                      continuum. In particular, VA has not developed a performance measure
                      that would help ensure the provision of these services consistently across
                      VA facilities.


                      To increase access to noninstitutional long-term care services and make
Recommendations for   access more even across networks and facilities, we recommend that the
Executive Action      Secretary of Veterans Affairs direct the Under Secretary for Health to:

                  •   ensure that facilities follow VA’s eligibility standards when determining
                      veteran eligibility for noninstitutional long-term care services;
                  •   define and provide guidance on noninstitutional respite care;



                      17
                        At two facilities we visited where home-based primary care is offered, officials told us
                      that veterans would likely be provided home health care through a contract service if they
                      lived outside of each facility’s home-based primary care service area.




                      Page 16                                  GAO-03-487 VA Noninstitutional Long-Term Care
                  •   specify in VA policy whether home-based primary care, homemaker/home
                      health aide, and skilled home health care are to be available to all enrolled
                      veterans; and
                  •   refine current performance measures to help ensure that all VA facilities
                      provide veterans with access to required noninstitutional services.

                      In commenting on a draft of our report, VA agreed with our findings and
Agency Comments       conclusions and concurred with our recommendations. VA stated that it
                      will add eligibility sections in each new directive and handbook it issues
                      concerning noninstitutional long-term care programs and develop
                      performance measures to underscore the importance VA places on its
                      noninstitutional long-term care programs. VA, however, did not provide
                      details on how it plans to address our recommendations, but instead
                      stated that it will provide a detailed action plan to implement our
                      recommendations in response to the issuance of this report. VA’s written
                      comments are in appendix IV.


                      As agreed with your office, unless you publicly announce its contents
                      earlier, we will plan no further distribution of this report until 30 days after
                      its date. At that time, we will send copies to interested congressional
                      committees and other parties. We also will make copies available to others
                      upon request. In addition, the report is available at no charge on the GAO
                      Web site at http://www.gao.gov. If you or your staffs have any questions
                      about this report, please call me at (202) 512-7101. Another contact and
                      key contributors are listed in appendix V.




                      Cynthia A. Bascetta
                      Director, Health Care—Veterans’
                       Health and Benefits Issues




                      Page 17                            GAO-03-487 VA Noninstitutional Long-Term Care
                 Appendix I: VA Noninstitutional Long-Term
Appendix I: VA Noninstitutional Long-Term
                 Care Services in Our Review



Care Services in Our Review

             •   Adult day health care: health maintenance and rehabilitative services
                 provided to frail elderly veterans in an outpatient setting during part of the
                 day.

             •   Geriatric evaluation: evaluation of veterans with particular geriatric needs,
                 generally provided by VA through one of two services: (1) geriatric
                 evaluation and management, in which interdisciplinary health care teams
                 of geriatric specialists evaluate and manage frail elderly veterans, and (2)
                 geriatric primary care, in which outpatient primary care, including medical
                 and nursing services, preventive health care services, health education,
                 and specialty referral, is provided to geriatric veterans.

             •   Home-based primary care: primary health care, delivered by a VA
                 physician-directed interdisciplinary team of VA staff including nurses and
                 other healthcare professionals to homebound (often bedbound) veterans
                 for whom return to an outpatient clinic is not practical.

             •   Homemaker/home health aide: personal care, such as grooming,
                 housekeeping, and meal preparation services, provided in the home to
                 veterans who would otherwise need nursing home care. It does not
                 include skilled professional services.

             •   Respite care: services provided to temporarily relieve the veteran’s
                 caregiver from the burden of caring for a chronically ill and severely
                 disabled veteran in the home. Noninstitutional settings for respite care
                 include veterans’ own homes.

             •   Skilled home health care: medical services provided to veterans at home
                 by non-VA health care providers.




                 Page 18                                GAO-03-487 VA Noninstitutional Long-Term Care
              Appendix II: Scope and Methodology
Appendix II: Scope and Methodology


              We reviewed the Department of Veterans Affairs’ (VA) provision of six
              noninstitutional long-term care services in order to update and expand our
              previous work to determine (1) whether veterans’ access to six
              noninstitutional services is limited by service availability and restrictions
              on use and (2) if access is limited, what factors contribute to limited
              access. The six services we reviewed include the three services VA chose
              to require all facilities to provide to meet the Millennium Act
              requirements—adult day health care, noninstitutional geriatric evaluation,
              and noninstitutional respite care—and three additional noninstitutional
              services—home-based primary care, skilled home health care, and
              homemaker/home health aide.

              To determine if veterans’ access to the six noninstitutional long-term care
              services is limited and if it is limited, to what extent, we sent an electronic
              mail survey to VA’s 139 medical facilities in September 2002. We asked
              facilities to indicate which of the six services they offered and, for each
              service they offered, asked them to provide the number of veterans
              currently receiving or authorized to receive the service and the number of
              veterans who received the service during July 2002.1 The month of July
              2002 was chosen because workload data were likely to be available at the
              time the survey was completed by VA staff. We also asked facilities to
              indicate whether each offered service was available to veterans living in all
              parts of their geographic service areas. We compared these survey data to
              the data we obtained in our fall 2001 survey of VA long-term care services
              to determine the extent to which availability had changed since that
              survey. We also compared our current survey results to information
              provided by VA headquarters, and where we noted differences we
              contacted facility officials to clarify their survey responses.

              To determine the factors that contribute to limited access to the six
              noninstitutional long-term care services we asked survey respondents to
              indicate the reasons why their facilities do not offer certain services and
              what factors influence the number of veterans using the services they do
              offer. We also conducted telephone interviews of officials in each of VA’s
              21 network offices to assess the role each network plays in deciding what
              noninstitutional services network facilities will offer and what criteria
              facilities will use in allocating services.



              1
               The utilization data provided by VA facilities does not represent an unduplicated count of
              veterans in these settings because some veterans may receive more than one
              noninstitutional service.




              Page 19                                  GAO-03-487 VA Noninstitutional Long-Term Care
                                           Appendix II: Scope and Methodology




                                           To augment information collected through our survey and telephone
                                           interviews, we visited four VA medical facilities to interview VA officials
                                           and clinicians on veteran demand for noninstitutional services and reasons
                                           for variation in access to the six noninstitutional services. We also updated
                                           information we collected from a site we visited during our earlier work on
                                           VA’s noninstitutional services.2 As shown in table 2, the five facilities
                                           included in this report—Albany, New York; Memphis, Tennessee;
                                           Richmond, Virginia; Tucson, Arizona; and Walla Walla,
                                           Washingtonreflect differences in the number and type of
                                           noninstitutional long-term care services offered.

Table 2: Noninstitutional Services in Our Review Offered by the Five VA Facilities We Visited

                    Number of services
                          in our review                   Homemaker/
                     offered at the time Home-based       home health Skilled home         Adult day     Geriatric
 VA facility                 of our visit primary care       aide      health care        health care   evaluation   Respite care
 Albany, New York                      5       X              X             X                  X            X
 Memphis,                              4       X              X             X                               X
 Tennessee
 Richmond,                             2                                        X                           X
 Virginia
 Tucson, Arizona                       6        X              X                X              X            X             X
 Walla Walla,                          2                       X                X
 Washington

Source: GAO.

                                           We selected the Memphis and Tucson VA facilities to visit because each
                                           offered at least four of the six services and had similar numbers of
                                           veterans enrolled. However, the number of veterans using their services
                                           differed substantially, which allowed us to explore the reasons for
                                           observed differences in service utilization. The Albany facility offered five
                                           of the six services and is located in a network that has extensive
                                           noninstitutional service offerings. In contrast, the Richmond and Walla
                                           Walla facilities were selected because they each offered two services;
                                           further, we selected the Walla Walla facility because it is located in a
                                           sparsely populated area.

                                           We met with officials in VA’s Geriatrics and Extended Care Strategic
                                           Healthcare Group and obtained documents on VA’s noninstitutional long-
                                           term care services, including service descriptions, policies, guidance, and



                                           2
                                           GAO-02-652T.




                                           Page 20                                  GAO-03-487 VA Noninstitutional Long-Term Care
Appendix II: Scope and Methodology




other information. In addition, we interviewed the Deputy Under Secretary
for Health for Operations and Management to determine the level of
oversight that this office provides regarding the noninstitutional long-term
care services offered by VA facilities, including the implementation and
tracking of network performance measures related to noninstitutional
care.




Page 21                              GAO-03-487 VA Noninstitutional Long-Term Care
                                          Appendix III: Availability and Utilization of
Appendix III: Availability and Utilization of
                                          Six Noninstitutional Long-Term Care Services
                                          by VA Medical Facility or Health Care System


Six Noninstitutional Long-Term Care Services
by VA Medical Facility or Health Care System
                                          Table 3 provides information on the availability and utilization of the six
                                          noninstitutional long-term care services reported by VA’s 139 medical
                                          facilities and health care systems for the month of July 2002.1

Table 3: Availability and Utilization of Six Noninstitutional Long-Term Care Services at VA Medical Facilities (July 2002)
                                                                                                      a
                                                          Number of veterans receiving service
 VA medical facility or       Home-based         Homemaker/       Skilled home        Adult day              Geriatric
 health care system (HCS)     primary care    home health aide      health care     health care            evaluation    Respite care
 Network 1 (Boston)
 Bedford                                13                   35                   —                 27             22
 Boston HCS                                                 107                   65                96             20
 Connecticut HCS                       132                   53                   77                22            115
 Manchester                             44                   19                   26                 7
 Northampton                                                101                   48                26
 Providence                             55                   14                   52                 8
 Togus                                                       86                  500                 1               6
                      b
 White River Junction                                        12                   49                45              26
 Network 2 (Albany)
 Albany                                159                   62                    22              107            613
 Bath                                  177                  115                                     14                               0
 Canandaigua                           132                  186                                     33             15
 Syracuse                              273                  147                    37               45            216
 Western New York HCS                  263                  285                    68              120             26
 Network 3 (Bronx)
 Bronx                                 120                   15                    21                               93
 Hudson Valley HCS                      71                   48                     6                3
 New Jersey HCS                        132                  262                    45                6
 Northport                              47                   64                    32               12             49
 New York Harbor HCS                   210                  219                    16              156          1,136
 Network 4 (Pittsburgh)
         b
 Altoona                                                                           12
 Butler                                 36                  123                                     58
 Clarksburg                                                 176                    23                6
 Coatesville                                                 80                     0               24
 Erie                                                        84                    16                3                               2
 Lebanon                                                      2                     7                              67
 Philadelphia                                                16                    17                             905
 Pittsburgh HCS                        133                  129                    87               51             16




                                          1
                                           Although VA has 172 medical centers, in some instances 2 or more medical centers have
                                          consolidated into health care systems. Counting health care systems and individual medical
                                          centers that are not part of a health care system as single facilities, VA has 139 facilities.




                                          Page 22                                   GAO-03-487 VA Noninstitutional Long-Term Care
                                        Appendix III: Availability and Utilization of
                                        Six Noninstitutional Long-Term Care Services
                                        by VA Medical Facility or Health Care System




                                                                                               a
                                                        Number of veterans receiving service
VA medical facility or       Home-based        Homemaker/       Skilled home        Adult day         Geriatric
health care system (HCS)     primary care   home health aide      health care     health care       evaluation    Respite care
Wilkes-Barre                                              30               99                1              76
Wilmington                                                25                4                                 5
Network 5 (Baltimore)
Martinsburg                                               73                                  16
Maryland HCS                         220                 273                   52            287            12              3
Washington, DC                       125                 120                    6             85           292
Network 6 (Durham)
Asheville                             35                   90                  22             61            26             61
Beckley                                                                        10
Durham                                47                   37                 130                           97              1
Fayetteville (NC)                                          19                  18             11            17
Hampton                                                    27                  29             13             0
Richmond                                                                      101              0         1,800
Salem                                                      40                  13             71                            3
Salisbury                                                  35                 100             11
Network 7 (Atlanta)
Atlanta                               90                  51                   52              7           550              7
Augusta                               53                 195                   88              2            56
Birmingham                            94                   4                   62              0            27              4
Central Alabama HCS                  135                  57                   48                          257
Charleston                            96                  57                   92              6           169             10
Columbia (SC)                         35                  53                   82             20
Dublin                                                    68                  127
Tuscaloosa                                                94                   15
Network 8 (Bay Pines)
             b
Bay Pines                            123                  83                   44             23           857
       b
Miami                                224                  75                   54             32           397
                         b
N. Florida/S. Georgia HCS            248                 270                   30              9           647
San Juan                             193                   0                    2                          569
         b
Tampa                                163                  39                  155                          300
West Palm Beach                                           42                   23              2
Network 9 (Nashville)
Huntington                                                60                   49
Lexington                             23                  32                   53                           52              1
Louisville                                                29                  469                           46
           b
Memphis                              112                  73                  227                          560
Mountain Home                                            158                   42             14            15
Tennessee Valley HCS                                     216                  129             13            —
Network 10 (Cincinnati)
Chillicothe                                              186                  102              3
Cincinnati                                                22                   60             71            26
Cleveland                            249                 378                   26              9           288




                                        Page 23                                 GAO-03-487 VA Noninstitutional Long-Term Care
                                      Appendix III: Availability and Utilization of
                                      Six Noninstitutional Long-Term Care Services
                                      by VA Medical Facility or Health Care System




                                                                                             a
                                                      Number of veterans receiving service
VA medical facility or     Home-based        Homemaker/       Skilled home        Adult day         Geriatric
health care system (HCS)   primary care   home health aide      health care     health care       evaluation    Respite care
Columbus                                                44               13              25
Dayton                              53                 275              179              37               42
Network 11 (Ann Arbor)
Ann Arbor                                               88                   13                           54              0
Battle Creek                       120                 107                   22             31                            1
Danville                            96                 117                   —              40                            0
Detroit                            100                  29                  100              1             5
Indianapolis                       111                 109                   49             20            48              0
Northern Indiana HCS                96                 180                   87              1                            4
Saginaw                                                 31                   15              2             8              2
Network 12 (Chicago)
               b
Chicago HCS                         94                   30                  52             36            12
Hines                              183                   64                  90             45           133
Iron Mountain                                            12                  15              0
Madison                                                  21                  —               5            18
Milwaukee                          146                   30                  23             60            60
North Chicago                      144                                        1             19
Tomah                                                     5                   1
Network 15 (Kansas City)
Columbia (MO)                      134                   55                  18              0                            3
Eastern Kansas HCS                                       61                  54              6            18
Kansas City                                              64                  16              3
Marion                                                   31                 215
Poplar Bluff                                             38                  22
St. Louis                           75                   78                  30             10            —
        b
Wichita                                                  35                  40              9
Network 16 (Jackson)
Alexandria                                              15                   21              7
                      b
Central Arkansas HCS               187                 145                   31             73           719
Fayetteville (AR)                                                             3
Gulf Coast HCS                      75                   51                 134                          195
Houston                             92                   36                  60              6           333
Jackson                                                  35                 115             28
           b
Muskogee                                                                      8             38
New Orleans                         82                                       12             35
Oklahoma City                       32                   34                 160             11            —              —
Shreveport                          64                   33                  80
Network 17 (Dallas)
Central Texas HCS                                       97                   23              2            18              0
                  b
North Texas HCS                    195                  98                   39             18            62
South Texas HCS                    189                 128                   57             44           418




                                      Page 24                                 GAO-03-487 VA Noninstitutional Long-Term Care
                                    Appendix III: Availability and Utilization of
                                    Six Noninstitutional Long-Term Care Services
                                    by VA Medical Facility or Health Care System




                                                                                           a
                                                    Number of veterans receiving service
VA medical facility or     Home-based      Homemaker/       Skilled home        Adult day         Geriatric
health care system (HCS) primary care   home health aide      health care     health care       evaluation    Respite care
Network 18 (Phoenix)
               b
Albuquerque                        96                168                    3                          135
         b
Amarillo                                                                   82
Big Spring
        b
El Paso                                                                     3                            1
Phoenix                            75                 57                  250             —
Prescott                                               6                   72             38            —
Tucson                            163                128                  156             39            25              8
Network 19 (Denver)
Cheyenne                                             107                    1
Denver                             76                134                   66             61           122             14
Fort Lyon                                             85                  165                                           0
                   b
Grand Junction                                                              6
Montana HCS
                 b
Salt Lake City                    127                115                   98                           83
Sheridan                                              25                    5              2
Network 20 (Portland)
Alaska HCS                                            15                   87
Boise                                                 45                   43                            5
Portland                          119                 26                   68                           94
Puget Sound HCS                   149                125                   19             35           144              0
Roseburg                                              25                   17
Spokane                                               28                   11             12                           10
             b
Walla Walla                                           14                   —
White City Domiciliary                                29                   —              76            60              3
Network 21 (San Francisco)
                       b
Central California HCS             52                  18                  19                           38
           b
Honolulu                           65                  11                   4              2            75
Northern California HCS           185                  78                  69              6
Palo Alto                         115                  29                  48             15            90             10
Reno                               83                  83                  83              9            35              0
San Francisco                      99                  69                  40              8            80
Network 22 (Long Beach)
Greater Los Angeles HCS           245                  95                  12             57           123
Loma Linda                                             90                 210             25
Long Beach                        115                                                                  119
Southern Nevada HCS                                                        33                           34              0
San Diego                          77                  40                  15             50            80
                         c
Network 23 (Minneapolis)
Black Hills HCS                                      105                  101                                           1
Central Iowa HCS                   49                 17                   66
Fargo                                                 69                  240              2




                                    Page 25                                 GAO-03-487 VA Noninstitutional Long-Term Care
                                       Appendix III: Availability and Utilization of
                                       Six Noninstitutional Long-Term Care Services
                                       by VA Medical Facility or Health Care System




                                                                                                             a
                                                          Number of veterans receiving service
 VA medical facility or     Home-based           Homemaker/       Skilled home        Adult day                      Geriatric
 health care system (HCS)   primary care      home health aide      health care     health care                    evaluation       Respite care
 Iowa City                                                 182              302              85                           352                  4
 Minneapolis                        116                    200              130             200                            44                  0
 Nebraska/Western Iowa
                                                                94                     82                    7                36                   1
 HCS
 Sioux Falls                                                    51                     50                    2                16
 St. Cloud                                                      76                    105                   87                12                   1

Source: GAO.

                                       Notes: Responses to our surveys were submitted September through November 2002.
                                       Facility cells that are empty indicate that a facility did not report offering the service at the time of our
                                       survey. A dash indicates that a facility reported offering the service but did not report the service’s
                                       July 2002 utilization.
                                       a
                                           Services include those provided directly by VA staff or through contracts.
                                       b
                                        Facility reported using only a volunteer service to provide noninstitutional respite care to veterans.
                                       We did not include volunteer respite care services in our number of facilities offering noninstitutional
                                       respite care.
                                       c
                                       Network 23 was created when Networks 13 and 14 were merged into a single network in January
                                       2002. VA currently has 21 networks.




                                       Page 26                                          GAO-03-487 VA Noninstitutional Long-Term Care
             Appendix IV: Comments From the Department of Veterans Affairs
Appendix IV: Comments From the
Department of Veterans Affairs




             Page 27                               GAO-03-487 VA Noninstitutional Long-Term Care
                  Appendix V: GAO Contact and Staff
Appendix V: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  James C. Musselwhite, (202) 512-7259
GAO Contact
                  In addition to the contact named above Pamela Dooley, Steve Gaty,
Acknowledgments   Marcia Mann, and Kristin Wilson made key contributions to this report.




                  Page 28                             GAO-03-487 VA Noninstitutional Long-Term Care
             Related GAO Products
Related GAO Products


             Long-Term Care: Availability of Medicaid Home and Community Services
             for Elderly Individuals Varies Considerably. GAO-02-1121. Washington,
             D.C.: September 26, 2002.

             VA Long-Term Care: The Availability of Noninstitutional Services Is
             Uneven. GAO-02-652T. Washington, D.C.: April 25, 2002.

             VA Long-Term Care: Implementation of Certain Millennium Act Provisions
             Is Incomplete, and Availability of Noninstitutional Services Is Uneven.
             GAO-02-510R. Washington, D.C.: March 29, 2002.

             Veterans’ Affairs: Observations on Selected Features of the Proposed
             Veterans’ Millennium Health Care Act. GAO/T-HEHS-99-125. Washington,
             D.C.: May 19, 1999.




(290194)
             Page 29                          GAO-03-487 VA Noninstitutional Long-Term Care
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