VA Long-Term Care
Changes In Service Delivery Raise Important Questions Gao ID: GAO-04-425T January 28, 2004The Department of Veterans Affairs (VA) is likely to see a significant increase in long-term care need over the next decade. The number of veterans most in need of longterm care services--those 85 years old and older--is expected to increase from about 870,000 to 1.3 million over this period. Many of these veterans will rely on VA to provide or pay for nursing home care or noninstitutional services that may help them remain at home and, for some, delay or prevent the need for nursing home care. VA operates its own nursing home care units in 132 locations. VA also pays for nursing home care under contract in non-VA nursing homes--referred to as community nursing homes. In addition, VA pays part of the cost of care for veterans at state veterans' nursing homes and also pays a portion of the construction costs for some state veterans' nursing homes. Congress has expressed concerns about recent trends in VA long-term care service delivery and how VA plans to meet the nursing home care needs and related longterm care needs of veterans as the elderly population most in need of long-term care increases. GAO was asked to determine for fiscal years 1998 through 2003 (1) how VA nursing home workload has changed and (2) how VA noninstitutional long-term care workload has changed.
Recent trends in VA nursing home care and noninstitutional service delivery raise important questions, particularly whether access to services is sufficient to meet the needs of a rapidly growing elderly veteran population. VA's overall nursing home workload--average daily census--was 33,214 in fiscal year 2003, 1 percent below its fiscal year 1998 workload. The workload was below the fiscal year 1998 level each year, decreasing by as much as 8 percent below the fiscal year 1998 level in fiscal year 2000. VA's use of nursing home care by setting also changed over the 6-year period. First, the percentage of workload in state veterans' nursing homes increased as the number of state veterans' nursing homes receiving VA payments increased. Second, the percentage of workload in VA's own nursing homes declined, in part, because VA decreased the number of long-stay patients and increased the number of short-stay patients it treats in the nursing homes it operates. This is consistent with VA's increased emphasis on post-acute care. Third, the percentage of workload in community nursing homes declined from 17 to 13 percent. VA officials told us that now shorter-term contracts are often used to transition veterans to nursing home care, which is paid for by other payers such as Medicaid. VA's noninstitutional long-term care workload--average daily census--increased by approximately 75 percent from fiscal years 1998 through 2003. Workload increased by 4,655 during this period to 10,892, reflecting a change in VA's approach to care which includes meeting more long-term care need through noninstitutional services. Most of the growth in noninstitutional workload came from VA's greater use of contract skilled home health care, which includes medical services provided to veterans at home, and homemaker/home health aide such as grooming and meal preparation.
GAO-04-425T, VA Long-Term Care: Changes In Service Delivery Raise Important Questions
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Testimony:
Before the Committee on Veterans' Affairs, House of Representatives:
United States General Accounting Office:
GAO:
For Release on Delivery Expected at 12:00 noon EST Wednesday, January
28, 2004:
VA LONG-TERM CARE:
Changes In Service Delivery Raise Important Questions:
Statement of Cynthia A. Bascetta Director, Health Care--Veterans'
Health and Benefits Issues:
GAO-04-425T:
GAO Highlights:
Highlights of GAO-04-425T, a testimony before the Committee on
Veterans' Affairs, House of Representatives
Why GAO Did This Study:
The Department of Veterans Affairs (VA) is likely to see a significant
increase in long-term care need over the next decade. The number of
veterans most in need of long-term care services”those 85 years old
and older”is expected to increase from about 870,000 to 1.3 million
over this period. Many of these veterans will rely on VA to provide or
pay for nursing home care or noninstitutional services that may help
them remain at home and, for some, delay or prevent the need for
nursing home care. VA operates its own nursing home care units in 132
locations. VA also pays for nursing home care under contract in non-VA
nursing homes”referred to as community nursing homes. In addition, VA
pays part of the cost of care for veterans at state veterans‘ nursing
homes and also pays a portion of the construction costs for some state
veterans‘ nursing homes.
This Committee has expressed concerns about recent trends in VA long-
term care service delivery and how VA plans to meet the nursing home
care needs and related long-term care needs of veterans as the elderly
population most in need of long-term care increases. GAO was asked to
determine for fiscal years 1998 through 2003 (1) how VA nursing home
workload has changed and (2) how VA noninstitutional long-term care
workload has changed.
What GAO Found:
Recent trends in VA nursing home care and noninstitutional service
delivery raise important questions, particularly whether access to
services is sufficient to meet the needs of a rapidly growing elderly
veteran population. VA's overall nursing home workload”average daily
census”was 33,214 in fiscal year 2003, 1 percent below its fiscal year
1998 workload. The workload was below the fiscal year 1998 level each
year, decreasing by as much as 8 percent below the fiscal year 1998
level in fiscal year 2000. VA‘s use of nursing home care by setting
also changed over the 6-year period. First, the percentage of workload
in state veterans‘ nursing homes increased as the number of state
veterans‘ nursing homes receiving VA payments increased. Second, the
percentage of workload in VA‘s own nursing homes declined, in part,
because VA decreased the number of long-stay patients and increased
the number of short-stay patients it treats in the nursing homes it
operates. This is consistent with VA‘s increased emphasis on post-
acute care. Third, the percentage of workload in community nursing
homes declined from 17 to 13 percent. VA officials told us that now
shorter-term contracts are often used to transition veterans to
nursing home care, which is paid for by other payers such as Medicaid.
Percentage of Nursing Home Workload By Setting, Fiscal Years 1998 and
2003:
[See PDF for image]
Note: The workload measure is average daily census, which represents
the total number of days of nursing home care provided in a year
divided by the number of days in the year.
[End of figure]
VA's noninstitutional long-term care workload”average daily census”
increased by approximately 75 percent from fiscal years 1998 through
2003. Workload increased by 4,655 during this period to 10,892,
reflecting a change in VA‘s approach to care which includes meeting
more long-term care need through noninstitutional services. Most of
the growth in noninstitutional workload came from VA‘s greater use of
contract skilled home health care, which includes medical services
provided to veterans at home, and homemaker/home health aide such as
grooming and meal preparation.
www.gao.gov/cgi-bin/getrpt?GAO-04-425T.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Cynthia A. Bascetta
at (202) 512-7101.
[End of section]
Mr. Chairman and Members of the Committee:
We are pleased to be here today to discuss veterans' use of long-term
care services, which include nursing home care and noninstitutional
services provided or paid for by the Department of Veterans Affairs
(VA). Concern with meeting veterans' long-term care needs is increasing
as the number of veterans most in need of these services--those 85
years old and older--is expected to increase from about 870,000 this
year to 1.3 million over the next decade. Many of these veterans will
seek assistance from VA to provide or pay for nursing home care or a
range of noninstitutional services that may help them remain at home
and, for some, delay or prevent the need for nursing home care.
To provide assistance to veterans with chronic illness or physical or
mental disability, VA provides a continuum of institutional and
noninstitutional long-term care services. VA provides care that its own
employees deliver and contracts with other health care providers to
deliver care. VA operates its own nursing home care units in 132
locations and also pays for nursing home care under contract in non-VA
nursing homes--referred to as community nursing homes. In addition, VA
pays part of the cost of care for veterans at state veterans' nursing
homes and also pays a portion of the construction costs for some state
veterans' nursing homes. VA also provides noninstitutional services to
veterans in their own homes or in community settings using both its own
employees and through contracts with other providers.
This Committee has expressed concerns about recent trends in VA long-
term care service delivery and how VA plans to meet the nursing home
care needs and related long-term care needs of veterans as the elderly
population most in need of long-term care increases. To assist the
Committee in its oversight responsibilities in this area, you asked us
to determine for fiscal years 1998 through 2003 (1) how VA nursing home
workload has changed and (2) how VA noninstitutional long-term care
workload has changed.
My testimony today is based on our ongoing review of long-term care
workload for this Committee.[Footnote 1] For this review, we measured
nursing home workload as defined by average daily census, which
reflects the average number of veterans receiving nursing home care on
any given day during the course of the year. We also measured
noninstitutional workload using average daily census; however, the
number of veterans receiving these services may be less than workload
because a veteran may receive more than one service in a day. We
analyzed data on nursing home workload that VA provided to determine
how workload had changed from fiscal years 1998 through 2003. We also
verified VA's nursing home workload numbers based on contacts with
officials from VA's 21 health care networks and VA headquarters. To
determine how noninstitutional long-term care workload has changed
during this period, we analyzed data on visits for six noninstitutional
services which VA either provides directly or pays for others to
provide: home-based primary care, adult day health care, homemaker/home
health aide, skilled home health care, home respite care, and home
hospice care. We also interviewed VA officials at headquarters and
obtained information from the networks to better understand the reasons
for changes in nursing home workload during this period. In doing our
work, we tested the reliability of the data and determined they were
adequate for our purposes. We did our work in accordance with generally
accepted government auditing standards from January 2003 through
January 2004.
In summary, recent trends in VA nursing home and noninstitutional
service delivery raise important questions, particularly whether access
to services is sufficient to meet the needs of a rapidly growing
elderly veteran population. VA's overall nursing home workload---
average daily census---was 33,214 in fiscal year 2003, 1 percent below
its fiscal year 1998 workload. The workload was below the fiscal year
1998 level each year, decreasing by as much as 8 percent below the
fiscal year 1998 level in fiscal year 2000. Fourteen of 21 networks
experienced declines in nursing home workload during this period.
Moreover, VA's use of the three nursing home settings changed over this
6-year period. First, the percentage of workload met in state veterans'
nursing homes increased from 43 to 50 percent as the number of state
veterans' nursing homes receiving VA payment increased. The percentage
of workload met in state veterans' nursing homes increased in 19 of
VA's 21 health care networks. Second, the percentage of workload in
VA's own nursing homes declined from 40 to 37 percent. Thirteen
networks provided a smaller percentage of workload in VA-operated homes
during this period. The percentage of workload provided in VA-operated
homes declined, in part, because VA decreased the number of long-stay
patients and increased the number of short-stay patients it treats in
its own nursing homes. This is consistent with VA's policy to give
priority to post-acute patients and certain other nursing home
patients. VA generally provides long-term nursing home care as
resources permit. Third, the percentage of workload in community
nursing homes declined from 17 to 13 percent. Seventeen networks
reduced the percentage of their nursing home workload provided in
community nursing homes during this period.
VA's noninstitutional long-term care workload---average daily census--
-increased by approximately 75 percent from fiscal years 1998 through
2003. Workload increased by 4,655 during this period to 10,892,
reflecting a change in VA's approach to care which includes meeting
more long-term care need through noninstitutional services. Most of the
growth in noninstitutional workload came from VA's greater use of
contract skilled home health care, which includes medical services
provided to veterans at home, and homemaker/home health aide services
such as grooming and meal preparation. These services are most likely
to help veterans prevent or delay the need for nursing home care.
Background:
Meeting veterans' long-term care needs has become a more pressing issue
as the veteran population ages. The elderly veteran population most in
need of long-term care--those 85 years and older---grew dramatically
from about 387,000 to about 764,000, an increase of about 100 percent
from fiscal years 1998 to 2003. (See fig. 1.):
Figure 1: Growth in Veteran Population, 85 Years and Older, Fiscal
Years 1998 Through 2003:
[See PDF for image]
[End of figure]
Over the past two decades the provision of long-term care has been
shifting away from institutions and nursing homes towards more
noninstitutional long-term care services in VA and in other programs.
In recognition of this change in approach to how long-term care is
provided, the Federal Advisory Committee on the Future of VA Long-Term
Care recommended, in 1998, that VA update its long-term care policy by
meeting the growing demand for long-term care through significant
expansion of its capacity to provide home and community-based services-
-also known as noninstitutional long-term care services--while
maintaining its nursing home capacity at the 1998 level.[Footnote 2]
VA provides a continuum of noninstitutional long-term care services to
provide care to veterans needing assistance. Long-term care provided in
noninstitutional settings---including services provided in veterans'
homes and community-based services such as adult day health care
centers---is preferred by many veterans. Noninstitutional 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 noninstitutional long-term care services
directly or through other providers with which VA contracts. (See table
1 for the noninstitutional long-term care services in our review.):
Table 1: Selected VA Noninstitutional Long-Term Care Services:
VA noninstitutional long-term care service: Home-based primary care;
Definition: Primary health care, delivered by a physician-directed
interdisciplinary team of staff including nurses to homebound (often
bedbound) veterans for whom visits to an outpatient clinic are not
practical; Source of care: VA providers.
VA noninstitutional long-term care service: Homemaker/home health aide;
Definition: Personal care, such as grooming, housekeeping, and meal
preparation services, provided in the home to veterans who would
otherwise need nursing home care; Source of care: Contracted
providers.
VA noninstitutional long-term care service: Adult day health care;
Definition: Health maintenance and rehabilitative services provided to
frail elderly veterans in an outpatient setting during part of the
day; Source of care: VA and contracted providers.
VA noninstitutional long-term care service: Skilled home health care;
Definition: Medical services provided to veterans at home; Source of
care: Contracted providers.
VA noninstitutional long-term care service: Home respite care;
Definition: Services provided at home to temporarily relieve the
veteran's caregiver from the burden of caring for a chronically
disabled veteran; Source of care: Contracted providers.
VA noninstitutional long-term care service: Home hospice care;
Definition: Services provided at home to veterans whose primary goal of
treatment is comfort rather than cure for an advanced disease that is
life-limiting; Source of care: Contracted providers.
Source: VA.
[End of table]
Veterans can also receive nursing home care and noninstitutional
services financed by sources other than VA, including Medicaid and
Medicare, private health or long-term care insurance, or self-financed.
States design and administer Medicaid programs that include coverage
for nursing home care and home and community-based services. Medicare
primarily covers acute care health costs and therefore limits its
nursing home coverage to short-term stays following hospitalization.
Medicare also pays for home health care. State Medicaid programs are
the principal funders of nursing home and home health care services,
besides patients self-financing their care. We have estimated that
private insurance pays for about 11 percent of nursing home and home
health care expenditures.[Footnote 3]
Nursing Home Workload Declined Slightly And Use Of Nursing Home Care By
Setting Changed:
VA's overall nursing home workload---average daily census---was 33,214
in fiscal year 2003, slightly below its fiscal year 1998 workload.
However, the workload was below the fiscal year 1998 level each year,
reaching its lowest level in fiscal year 2000. Over the last 6 years,
VA's use of nursing homes by setting changed. These changes in workload
and use of different settings to provide nursing home care varied by
network.
Nursing Home Workload Declined Slightly from Fiscal Year 1998 through
Fiscal Year 2003:
VA's nursing home workload was 33,214 in fiscal year 2003, 1 percent
below its fiscal year 1998 workload. (See table 2.) Nursing home
workload varied over this period but was consistently below the fiscal
year 1998 level, decreasing by as much as 8 percent in fiscal year 2000
from its fiscal year 1998 level. The distribution of the nursing home
workload among the three nursing home settings shifted during this
period. From fiscal years 1998 through 2003, workload in the nursing
homes VA operates declined by 1,014. In addition, workload in community
nursing homes declined by 1,434. In contrast, workload in state
veterans' homes increased by 2,032.
Table 2: Change in Nursing Home Workload Provided or Paid for by VA in
Fiscal Years 1998-2003:
Type of nursing home: VA-operated nursing homes;
1998: 13,387;
1999: 12,614;
2000: 11,841;
2001: 11,727;
2002: 12,035;
2003: 12,373;
Change 1998-2003: -1,014.
Type of nursing home: Community nursing homes;
1998: 5,636;
1999: 4,575;
2000: 3,799;
2001: 4,163;
2002: 4,080;
2003: 4,202;
Change 1998-2003: -1,434.
Type of nursing home: State veterans' nursing homes;
1998: 14,607;
1999: 15,046;
2000: 15,259;
2001: 15,533;
2002: 15,985;
2003: 16,639;
Change 1998-2003: 2,032.
Total;
1998: 33,630;
1999: 32,235;
2000: 30,899;
2001: 31,423;
2002: 32,100;
2003: 33,214;
Change 1998-2003: -416.
Source: VA.
Note: The workload measure is average daily census, which represents
the total number of days of nursing home care provided in a year
divided by the number of days in the year.
[End of table]
Although VA nursing home workload did not change greatly from fiscal
years 1998 through fiscal year 2003, some networks experienced
significant increases or decreases. Fourteen of VA's 21 networks had
lower nursing home workloads in fiscal year 2003 than in fiscal year
1998 for all three settings combined. (See fig. 2.) Network 5
(Baltimore) had the largest decline in workload--19 percent. Seven
networks' nursing home workloads grew during this period. Network 17
(Dallas) had the largest increase in nursing home workload--42 percent.
Figure 2: Change in Nursing Home Workload by VA Network, Fiscal Years
1998-2003:
[See PDF for image]
Note: Nursing home workload is measured using average daily census
combined for VA-operated nursing homes, community nursing homes, and
state veterans' nursing homes. Average daily census represents the
total number of days of nursing home care provided in a year divided by
the number of days in the year. VA merged networks 13 and 14 into
network 23 in January 2002.
[End of figure]
Use of Nursing Home Care Setting Changed from Fiscal Year 1998 through
2003:
VA's use of nursing home care among the three settings changed from
fiscal years 1998 through 2003. The percentage of workload met in state
veterans' nursing homes increased from 43 to 50 percent. (See fig. 3.)
This increase is attributable in large part to 18 more state veterans'
nursing homes receiving payment from VA to provide such care. By fiscal
year 2003, 109 state veterans' nursing homes received VA payment to
provide this care. VA is authorized to pay for about two-thirds of the
costs of construction of state veterans' nursing homes and pays about a
third of the costs per day to provide care to veterans in these homes.
Figure 3: Percentage of Nursing Home Workload By Setting, Fiscal Years
1998 and 2003:
[See PDF for image]
Note: The workload measure is average daily census, which represents
the total number of days of nursing home care provided in a year
divided by the number of days in the year.
[End of figure]
The percentage of workload provided in state veterans' nursing homes
increased in 19 of VA's 21 health care networks. Network 17 (Dallas)
had the largest increase in the percentage of workload provided by
state veterans' nursing homes. The percentage of nursing home care
provided by state veterans' nursing homes in this network increased
from 0 to 30 percent during this period after the opening of four state
veterans' nursing homes in Texas. By contrast, the percentage of
workload provided by state veterans' nursing homes declined in 2
networks: Network 5 (Baltimore) by 3 percent and Network 21 (San
Francisco) by 2 percent.
The percentage of nursing home workload provided in VA's own nursing
homes declined from 40 to 37 percent during this period. Thirteen
networks provided a smaller percentage of nursing home care in VA-
operated nursing homes in fiscal year 2003 than in fiscal year 1998.
Network 17 (Dallas) had the largest decrease in the percentage of
workload provided by VA-operated nursing homes, declining from 68
percent to 49 percent during this period. This resulted because the
state veterans' nursing home workload increased substantially. By
contrast, the percentage of care provided in VA-operated homes
increased in 8 networks. Network 5 (Baltimore) had the largest
increase, growing from 50 percent in fiscal year 1998 to 64 percent in
fiscal year 2003. In Network 21 (San Francisco), the percentage of care
in VA-operated nursing homes increased by 7 percent and in the
remaining 6 networks the percentage of care in VA-operated nursing
homes increased 3 percent or less.
Our analysis of length-of stay trends in VA-operated nursing homes
shows that the decline in the number of veterans with long stays--90
days or more--largely explains the decline in nursing home workload
during this period. The number of long-stay veterans declined from
about 14,200 in fiscal year 1998 to about 12,700 in fiscal year 2002,
the most recent year for which data are available.[Footnote 4] At the
same time the number of short-stay veterans---those with stays of less
than 90 days---increased from about 26,700 to about 32,200. However,
the increase in short-stay patients was not large enough to offset the
decline in workload resulting from the decrease in long-stay patients.
This results because multiple short-stay patients are required to
generate the same workload as a single long-stay patient. For example,
a single long-stay patient in a nursing home for 12 months creates a
workload of an average daily census of 1 over a year. By contrast, 12
short-stay patients staying in a nursing home for one month each
creates the same average daily census.
Among VA's networks, 16 had declines in the number of long-stay
patients in VA-operated homes during this period. Five networks,
however, had increases in the number of long-stay patients: Network 1
(Boston), Network 5 (Baltimore), Network 7 (Atlanta), Network 12
(Chicago) and Network 21 (San Francisco).
VA officials attribute some of the changes in nursing home workload in
VA-operated facilities to an increased emphasis on short-term, post-
acute rehabilitation care. VA's policy is to provide nursing home care
in its own nursing homes as a priority to post-acute patients, patients
who cannot be adequately cared for in community nursing homes or in
noninstitutional settings, and those patients who can be cared for more
efficiently in VA's own nursing homes. In addition, VA may provide
nursing home care, to the extent resources are available, to other
patients who need long-term care for chronic disabilities. Consistent
with VA's policy, the proportion of discharged veterans whose length of
stays were less than 90 days in VA-operated nursing homes increased
from 74 to 81 percent from fiscal years 1998 through 2003. This is
similar to lengths of stay provided in facilities certified by
Medicare---but not Medicaid---that provide post-acute skilled nursing
home care.[Footnote 5] About 81 percent of discharged patients in these
certified Medicare facilities had length of stays of less than 90 days
in fiscal year 1999.[Footnote 6]
The percentage of workload in community nursing homes declined from 17
to 13 percent from fiscal year 1998 through fiscal year 2003. This
decline occurred because VA reduced the number of patients served and
the number of days paid for under contract in this setting. The number
of patients in these settings declined from 28,893 to 14,032 during
this period.[Footnote 7] Some VA officials told us that in the past VA
used community nursing homes for more patients and for longer-term
contracts than currently. VA officials told us that now shorter-term
contracts are often used to transition veterans to nursing home care,
which is paid by other payers such as Medicaid. For example, some
network officials told us that contracts for community nursing home
care are often 30 days or less.
Of the 21 networks, 17 reduced the percentage of nursing home workload
provided in community nursing homes during this period. Four networks
reduced the percentage of nursing home care provided in community
nursing homes by about 11 percent: Network 4 (Pittsburgh), Network 5
(Baltimore), Network 6 (Durham), and Network 17 (Dallas). By contrast,
the percentage of workload provided in community nursing homes
increased in 4 networks. The percentage of nursing home care provided
in community nursing homes in Network 19 (Denver) increased by about 10
percent. The percentage of nursing home care provided in community
nursing homes among the other 3 networks---Network 23 (Minneapolis),
Network 20 (Portland), and Network 18 (Phoenix)---increased 3 percent
or less.
VA Noninstitutional Long-Term Care Workload Increased:
VA's noninstitutional long-term care workload---average daily census--
-for the six services in our review increased by approximately 75
percent from fiscal years 1998 through 2003. Workload increased by
4,655 during this period to 10,892. (See table 3.) Much of this growth
came from increases in skilled home health and homemaker/home health
aide care--services that are most likely to help veterans prevent or
delay the need for nursing home care. One of the services that grew
most rapidly was skilled home health care which increased by 127
percent during this period. Although noninstitutional long-term care
workload increased, all veterans may not have access to these services
because there are limitations in the availability of these services. We
previously reported a number of limitations in access to
noninstitutional services that veterans experienced in the fall of
2002. At that time some facilities did not offer some of these
noninstitutional services at all, or offered them only in certain parts
of the geographic area they served.[Footnote 8] For example, more than
half of VA's 139 medical facilities did not provide home-based primary
care or adult day health care in the fall of 2002.[Footnote 9]
Table 3: Change in Noninstitutional Long-Term Care Workload Provided or
Paid for by VA in Fiscal Years 1998-2003:
Type of noninstitutional service: Home-based primary care;
1998: 923;
1999: 964;
2000: 890;
2001: 908;
2002: 903;
2003: 944;
Change 1998-2003: 21.
Type of noninstitutional service: Adult day health care[A];
1998: 1,023;
1999: 1,215;
2000: 1,106;
2001: 1,201;
2002: 1,310;
2003: 1,220;
Change 1998-2003: 197.
Type of noninstitutional service: Homemaker/home health aide;
1998: 2,385;
1999: 3,141;
2000: 3,080;
2001: 3,824;
2002: 4,180;
2003: 4,317;
Change 1998-2003: 1,932.
Type of noninstitutional service: Skilled home health care;
1998: 1,906;
1999: 2,148;
2000: 2,555;
2001: 3,273;
2002: 3,851;
2003: 4,332;
Change 1998-2003: 2,426.
Type of noninstitutional service: Home respite care;
1998: [B];
1999: [B];
2000: [B];
2001: [B];
2002: [B];
2003: 2;
Change 1998-2003: 2.
Type of noninstitutional service: Home hospice care;
1998: [B];
1999: [B];
2000: [B];
2001: [B];
2002: [B];
2003: 77;
Change 1998-2003: 77.
Type of noninstitutional service: Total[C];
1998: 6,237;
1999: 7,468;
2000: 7,631;
2001: 9,206;
2002: 10,244;
2003: 10,892;
Change 1998-2003: 4,655.
Source: VA and GAO analysis of VA data.
Note: Workload is measured by average daily census which represents the
total number of visits of noninstitutional care provided in a year
divided by the number of days in the year. The average daily census
calculation for adult day health care uses 251 rather than 365 days
because this service is not always provided 7 days a week.
[A] Numbers include contracted adult day health care and VA-provided
adult day health care.
[B] Data not available.
[C] Total workload is not a measure of unique patients daily because
the same patient may receive more than one service in the same day.
[End of table]
The noninstitutional workload numbers for home-based primary care in
table 3 are different from those reported by VA in its appropriations
submissions to Congress and in recent VA testimony.[Footnote 10] In its
reports on noninstitutional workload, VA has measured home-based
primary care services using enrolled days---the number of days a
veteran is enrolled to receive a service---rather than the number of
home-based primary care visits a veteran receives. However, VA has
measured use of the other noninstitutional services in visits.
Therefore, to ensure comparability across services, we used visits as
the workload measure for home-based primary care. As a result, our
workload total for home-based primary care is smaller than the number
VA reports because veterans do not typically receive a home-based
primary care visit for each day in which they are enrolled in home-
based primary care. Specifically, we report the 2002 home-based primary
care workload as 903 while VA has reported it as 8,081. Our consistent
measure of all services in visits results in a lower total
noninstitutional workload than that reported by VA.
Concluding Observations:
Over the last 6 years, the veteran population most in need of long-term
care has grown dramatically. During this period, VA's use of nursing
home care by setting has changed so that state veterans' nursing homes
now provide one-half of all nursing home workload provided or paid for
by VA. At the same time, VA decreased the workload it serves in its own
nursing homes consistent with VA's policy to emphasize short-stay,
post-acute care in its own nursing homes. VA also used community
nursing home care less as it transitioned more veterans who needed such
care to care paid for by other payers such as Medicaid. In addition, VA
increased the long-term care workload provided in noninstitutional
settings.
These trends over the last 6 years raise important questions for how VA
is meeting current long-term care need and what it may need to do to
meet future long-term care need.
* What does the significant variation in nursing home workload change
among the networks over this 6-year period mean for meeting veterans'
long-term care needs in different parts of the country?
* What are the implications for access, quality, and costs of VA's
significant shift to using state veterans' nursing homes to provide
one-half of its nursing home care?
* How has VA's increased emphasis on post-acute care in its own nursing
homes affected its ability to continue providing long-term care in its
nursing homes for veterans with chronic disabilities?
* To what extent does total VA long-term care workload---composed of a
fairly constant nursing home workload and a rapidly expanding but
smaller noninstitutional workload---meet the needs of a rapidly growing
elderly veteran population?
The continuing rapid rise in the veteran population likely to be in
greatest need of long-term care---those 85 years and older---poses a
major challenge for VA health care. Answers to these four questions can
help policymakers, VA, and its stakeholders better understand the best
ways to meet VA's long-term care challenge. We look forward to
continuing to work with you on these significant issues.
Mr. Chairman, this concludes my prepared remarks. I will be pleased to
answer any questions you or other Members of the Committee may have.
Contact and Acknowledgments:
For further information regarding this testimony, please contact me at
(202) 512-7101. Individuals making key contributions to this testimony
include James C. Musselwhite, Thomas A. Walke, and Pamela A. Dooley.
[End of section]
Related GAO Products:
VA Long-Term Care: Veterans' Access to Noninstitutional Care Is Limited
by Service Gaps and Facility Restrictions. GAO-03-815T. Washington,
D.C.: May 22, 2003.
VA Long-Term Care: Service Gaps and Facility Restrictions Limit
Veterans' Access to Noninstitutional Care. GAO-03-487. Washington,
D.C.: May 9, 2003.
Department of Veterans Affairs: Key Management Challenges in Health and
Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003.
Long-Term Care: Availability of Medicaid Home and Community Services
for Elderly Individuals Varies Considerably. GAO-02-1121. Washington,
D.C.: September 26, 2002.
Medicare: Utilization of Home Health Care by State. GAO-02-782R.
Washington, D.C.: May 23, 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.
VA Long-Term Care: Oversight of Community Nursing Homes Needs
Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001.
FOOTNOTES
[1] We reported preliminary findings on nursing home workload in a
testimony to this Committee on May 8, 2003. U.S. General Accounting
Office, Department of Veterans Affairs: Key Management Challenges in
Health and Disability Programs GAO-03-756T (Washington, D.C.: May 8,
2003).
[2] VA Long-Term Care At The Crossroads: Report of the Federal Advisory
Committee on the Future of VA Long-Term Care (Washington, D.C.: June
1998).
[3] See U.S. General Accounting Office, Long-Term Care: Aging Baby Boom
Generation Will Increase Demand and Burden on Federal and State Budgets
GAO-02-544T (Washington, D.C.: March 21, 2002).
[4] This calculation requires complete data for the first 3 months of a
fiscal year to determine if some patients in a prior fiscal year were
in a VA-operated nursing home for 90 or more days. Data for the first 3
months of fiscal year 2004 were not available when we did our
calculations. As a result, we provide our analysis for fiscal year
2002.
[5] Some nursing home facilities are certified only by Medicare to
provide skilled nursing home care. Others are certified by both
Medicare and Medicaid.
[6] See A. Jones, The National Nursing Home Survey: 1999 Summary.
National Center for Health Statistics, Vital Health Stat 13(152), 2002.
[7] These patient numbers are based on discharges and are not
unduplicated because a single patient may be admitted more than once in
the same fiscal year.
[8] U.S. General Accounting Office, VA Long-Term Care: Veterans' Access
to Noninstitutional Care Is Limited by Service Gaps and Facility
Restrictions GAO-03-815T (Washington, D.C.: May 22, 2003), and U.S.
General Accounting Office, VA Long-Term Care: Service Gaps and Facility
Restrictions Limit Veterans' Access to Noninstitutional Care GAO-03-487
(Washington, D.C.: May 9, 2003).
[9] We reported on 139 medical facilities, even though VA had 172
medical centers, because in some instances 2 or more medical centers
had 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 had 139 facilities.
[10] House Subcommittee on Health, Committee on Veterans' Affairs,
Statement of the Under Secretary for Health, Department of Veterans
Affairs, VA's Long-Term Care Programs, 108th Congress, 1st session, May
22, 2003, Department of Veterans Affairs FY 2004 Budget Submission:
Medical Programs Volume 2 of 5 Final (Washington, D.C.: March 2003), 2-
148, and Department of Veterans Affairs FY 2002 Budget Submission:
Medical Programs Volume 2 of 6 (Washington, D.C.: April 2001), 2-101.
