VA Long-Term Care
Oversight of Nursing Home Program Impeded by Data Gaps Gao ID: GAO-05-65 November 10, 2004The Department of Veterans Affairs (VA) operates a $2.3 billion nursing home program that provides or pays for veterans' care in three settings: VA nursing homes, community nursing homes, and state veterans' nursing homes. The Veterans Millennium Health Care and Benefits Act (Millennium Act) of 1999 and VA policy require that VA provide nursing home care to veterans with a certain eligibility. Congress has expressed a need for additional data to conduct oversight of VA's nursing home program. Specifically, for all VA nursing home settings in fiscal year 2003, GAO was asked to report on (1) VA spending to provide or pay for nursing home care, (2) VA workload provided or paid for, (3) the percentage of nursing home care that is long and short stay, and (4) the percentage of veterans receiving care required by the Millennium Act or VA policy.
In fiscal year 2003, VA spent 73 percent of its nursing home resources on VA nursing homes--almost $1.7 billion of about $2.3 billion--and the remaining 27 percent on community and state veterans' nursing homes. Half of VA's average daily nursing home workload of 33,214 in fiscal year 2003 was for state veterans' nursing homes, even though this setting accounted for 15 percent of VA's overall nursing home expenditures. In large part, this is because VA pays about one-third of the cost of care in state veterans' nursing homes. Community nursing homes and VA nursing homes accounted for 13 and 37 percent of the workload, respectively. About one-third of nursing home care in VA nursing homes in fiscal year 2003 was long-stay care (90 days or more). Long-stay services include those needed by veterans who cannot be cared for at home because of severe, chronic physical or mental impairments such as the inability to independently eat or the need for supervision because of dementia. The other two-thirds was short-stay care (less than 90 days), which includes services such as postacute care needed for recuperation from a stroke. VA lacks similar data for community and state veterans' nursing homes. About one-fourth of veterans who received care in VA nursing homes in fiscal year 2003 were served because the Millennium Act or VA policy requires that VA provide or pay for nursing home care of veterans with a certain eligibility. All other veterans received care at VA's discretion. VA lacks data on comparable eligibility status for community and state veterans' nursing homes even though these settings combined accounted for 63 percent of VA's overall workload. Gaps in data on length of stay and eligibility in these two settings impede program oversight.
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Report to the Chairman, Committee on Veterans' Affairs, House of
Representatives:
United States Government Accountability Office:
GAO:
November 2004:
VA Long-Term Care:
Oversight of Nursing Home Program Impeded by Data Gaps:
GAO-05-65:
GAO Highlights:
Highlights of GAO-05-65, a report to the Chairman, Committee on
Veterans‘ Affairs, House of Representatives:
Why GAO Did This Study:
The Department of Veterans Affairs (VA) operates a $2.3 billion nursing
home program that provides or pays for veterans‘ care in three
settings: VA nursing homes, community nursing homes, and state
veterans‘ nursing homes. The Veterans Millennium Health Care and
Benefits Act (Millennium Act) of 1999 and VA policy require that VA
provide nursing home care to veterans with a certain eligibility.
The Committee has expressed a need for additional data to conduct
oversight of VA‘s nursing home program. Specifically, for all VA
nursing home settings in fiscal year 2003, GAO was asked to report on
(1) VA spending to provide or pay for nursing home care, (2) VA
workload provided or paid for, (3) the percentage of nursing home care
that is long and short stay, and (4) the percentage of veterans
receiving care required by the Millennium Act or VA policy.
What GAO Found:
In fiscal year 2003, VA spent 73 percent of its nursing home resources
on VA nursing homes”almost $1.7 billion of about $2.3 billion”and the
remaining 27 percent on community and state veterans‘ nursing homes.
Half of VA‘s average daily nursing home workload of 33,214 in fiscal
year 2003 was for state veterans‘ nursing homes, even though this
setting accounted for 15 percent of VA‘s overall nursing home
expenditures. In large part, this is because VA pays about one-third
of the cost of care in state veterans‘ nursing homes. Community nursing
homes and VA nursing homes accounted for 13 and 37 percent of the
workload, respectively.
About one-third of nursing home care in VA nursing homes in fiscal year
2003 was long-stay care (90 days or more). Long-stay services include
those needed by veterans who cannot be cared for at home because of
severe, chronic physical or mental impairments such as the inability
to independently eat or the need for supervision because of dementia.
The other two-thirds was short-stay care (less than 90 days), which
includes services such as postacute care needed for recuperation from a
stroke. VA lacks similar data for community and state veterans‘ nursing
homes.
About one-fourth of veterans who received care in VA nursing homes in
fiscal year 2003 were served because the Millennium Act or VA policy
requires that VA provide or pay for nursing home care of veterans with
a certain eligibility. All other veterans received care at VA‘s
discretion. VA lacks data on comparable eligibility status for
community and state veterans‘ nursing homes even though these settings
combined accounted for 63 percent of VA‘s overall workload. Gaps in
data on length of stay and eligibility in these two settings impede
program oversight.
Data Gaps on Length of Stay and Eligibility for VA‘s Nursing Home
Program, Fiscal Year 2003:
[See PDF for image]
Note: The workload measure is average daily census, which represents
the total number of days of nursing home care divided by the number of
days in the year.
[End of figure]
What GAO Recommends:
To help ensure more complete data for program monitoring and
congressional oversight, GAO recommends that VA collect data on
veterans‘ length of stay and eligibility for community nursing homes
and state veterans‘ nursing homes comparable to data VA collects for VA
nursing homes. VA stated that it concurred in principle with GAO‘s
recommendations and will work to reduce data gaps GAO identified.
However, VA did not indicate specific plans to collect the data GAO
recommended.
www.gao.gov/cgi-bin/getrpt?GAO-05-65.
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]
Contents:
Letter:
Results in Brief:
Background:
VA Spent Almost Three-Quarters of Its Nursing Home Resources on Care
for Veterans in VA Nursing Homes, but Expenditures Varied Widely by
Network:
State Veterans' Nursing Homes Provided Half of VA's Overall Nursing
Home Workload, but Networks' Use of Nursing Home Care Setting Varied:
About One-Third of VA Nursing Home Care Is Long Stay, but VA Lacks
Comparable Information for Other Nursing Home Settings:
About One-Fourth of Veterans Who Received Care in VA Nursing Homes Are
Required to Be Served by the Millennium Act or VA Policy, but VA Lacks
Comparable Information for Other Settings:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Changes in Percentage of Nursing Home Expenditures by
Setting and Network, Fiscal Years 1998 and 2003:
Appendix III: Changes in Percentage of Nursing Home Workload by Setting
and Network, Fiscal Years 1998 and 2003:
Appendix IV: Comments from the Department of Veterans Affairs:
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Related GAO Products:
Figures:
Figure 1: Percentage of Nursing Home Expenditures by Setting, Fiscal
Years 1998 and 2003:
Figure 2: Percentage of Nursing Home Expenditures by Setting and
Network, Fiscal Year 2003:
Figure 3: Percentage of VA Nursing Home Workload by Setting, Fiscal
Years 1998 and 2003:
Figure 4: Percentage of Nursing Home Workload by Setting and Network,
Fiscal Year 2003:
Figure 5: Percentage of Long-and Short-Stay Care in VA Nursing Homes,
Fiscal Years 1998 and 2003:
Figure 6: Percentage of Long-and Short-Stay Care in VA Nursing Homes by
Network, Fiscal Year 2003:
Figure 7: Percentage of Veterans Receiving VA Nursing Home Care as
Required by Millennium Act or VA's Policy on Nursing Home Eligibility
by Network, Fiscal Year 2003:
Abbreviations:
VA: Department of Veterans Affairs:
VHA: Veterans Health Administration:
United States Government Accountability Office:
Washington, DC 20548:
November 10, 2004:
The Honorable Christopher H. Smith:
Chairman:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Chairman:
The Department of Veterans Affairs (VA) operates a $2.3 billion nursing
home program that provides or pays for veterans' care in VA's 21 health
care networks.[Footnote 1] Meeting veterans' nursing home care needs is
a key issue for VA because it has a large elderly veteran population,
many of whom are in need of such care. In 2003, 38 percent of the
veteran population was over the age of 65 compared to 12 percent for
the overall population. VA provides or pays for veterans' care in three
nursing home settings. VA operates its own nursing homes and also pays
for nursing home care under contract in non-VA nursing homes--referred
to as community nursing homes. In addition, VA pays part of the cost of
care for veterans at state veterans' nursing homes and also pays a
portion of the construction costs for some state veterans' nursing
homes. To enhance access to veterans needing nursing home care across
VA's health care system, an independent commission recommended in
February 2004 that VA develop a strategic plan for long-term care that
includes policies and strategies for the delivery of nursing home
care.[Footnote 2]
In November 1999, the Congress passed the Veterans Millennium Health
Care and Benefits Act (Millennium Act),[Footnote 3] which required that
through December 31, 2003, VA provide nursing home care to those
veterans with a service-connected disability rated at 70 percent or
greater,[Footnote 4] those requiring nursing home care because of a
condition related to their military service who do not have a service-
connected disability rating of 70 percent or greater, and those who
were admitted to VA nursing homes on or before the effective date of
the act. Subsequent law extended these provisions through December 31,
2008.[Footnote 5] In addition, VA's policy on nursing home eligibility
required that networks provide nursing home care to veterans with 60
percent service-connected disability ratings who also meet other
criteria.[Footnote 6] For all other veterans enrolled in its system,
VA's policy on nursing home eligibility is to provide nursing home care
in VA nursing homes and contract community nursing homes on a
discretionary basis depending on available resources, with certain
patients having higher priority, including veterans who require
postacute care after a hospital episode. Veterans can also choose to
seek care in state veterans' nursing homes and if admitted, VA pays a
portion of the cost to treat them.
The Committee has expressed a need for additional data in order to
conduct oversight of VA's nursing home program, especially in light of
the large elderly veteran population. These data needs have focused on
the total amount of resources spent to deliver nursing home care in VA
nursing homes, community nursing homes, and state veterans' nursing
homes and the amount of nursing home care provided with these
resources. The Committee has also expressed a need for data on the
percentage of veterans in VA's nursing home program that received long-
and short-stay nursing home care. Long-stay care patients cannot be
cared for at home because of severe, chronic physical or mental
limitations. In addition, the Committee has expressed a need for data
on the percentage of veterans in VA's nursing home program that are
required to be served based on the Millennium Act or VA policy.
For all nursing home settings in VA's program in fiscal year 2003, this
report provides information on (1) VA spending to provide or pay for
nursing home care, (2) VA workload provided or paid for, (3) the
percentage of nursing home care that is long and short stay, and (4)
the percentage of veterans receiving care that are required to be
served by the Millennium Act or VA policy. To place this information in
context, we supplement our findings with information for fiscal year
1998.[Footnote 7]
To perform our work, we reviewed documents and analyzed VA data on the
amount of nursing home expenditures and workload, the percentage of
long-and short-stay care, and the eligibility status of veterans based
on the Millennium Act or VA's policy on nursing home eligibility. In
our calculation of expenditures, we included direct expenditures by VA
to provide or pay for nursing home care plus costs to administer the
program at the VA medical center. For this review, we measured nursing
home workload as defined by average daily census, which reflects the
average number of veterans receiving nursing home care on any given day
during the course of the year. We used VA data to estimate the number
of VA nursing home long stays, defined as 90 days or more, and short
stays, defined as less than 90 days. To determine the eligibility
status of veterans we used VA data to estimate veterans' eligibility
for VA nursing home care based on the Millennium Act or VA policy. In
doing our work, we tested the reliability of the data and determined
they were adequate for our purposes. For a complete description of our
scope and methodology, see appendix I. We conducted our review from
January 2003 through November 2004 in accordance with generally
accepted government auditing standards.
Results in Brief:
In fiscal year 2003, VA nursing homes accounted for almost $1.7
billion, or about three-quarters of the approximately $2.3 billion VA
spent to provide or pay for veterans to receive nursing home care. In
contrast, state veterans' nursing homes and community nursing homes
accounted for the remaining 27 percent or $624 million spent by VA on
nursing home care. Since fiscal year 1998, the percentage of
expenditures for VA nursing homes and state veterans' nursing homes has
increased while the percentage for community nursing homes has
decreased. VA's 21 health care networks vary widely in the percentage
of resources spent on each nursing home care setting, although all
networks spent a larger percentage of their resources on VA nursing
homes.
State veterans' nursing homes accounted for half of VA's overall
nursing home workload--average daily census--in fiscal year 2003, even
though this setting accounted for only 15 percent of overall nursing
home expenditures. In fiscal year 2003, state veterans' nursing homes
delivered care to 16,639 of the 33,214 veterans served on a daily
basis. In contrast, VA used its nursing homes to provide 37 percent and
paid for community nursing homes to provide 13 percent of its overall
workload in that year. The percentage of workload served is higher than
the percentage of expenditures in state veterans' nursing homes, in
part, because VA pays on average about one-third of the costs for care
veterans receive in state veterans' nursing homes, compared to the full
cost in other settings. Since fiscal year 1998, VA's use of nursing
homes by setting has changed. The percentage of workload met in state
veterans' nursing homes increased, while the percentage of workload met
in VA nursing homes and community nursing homes declined. Although
state veterans' nursing homes predominate overall, VA's networks vary
widely in the percentage of workload met in different nursing home
settings.
About one-third of the care VA provided in VA nursing homes was long
stay in fiscal year 2003, but VA lacks comparable information for
community nursing homes and state veterans' nursing homes. Long-stay
care (90 days or more) includes services needed by veterans who cannot
be cared for at home because of severe, chronic physical or mental
limitations such as the inability to independently eat or the need for
supervision because of dementia or other conditions. About two-thirds
of VA nursing home care was short-stay care (less than 90 days), which
includes services such as postacute care needed for recuperation from a
stroke or hip replacement. Since fiscal year 1998, the use of long-stay
care in VA nursing homes has declined while the use of short-stay care
has increased. VA does not collect and report comparable information on
the length of stay for veterans in community nursing homes and state
veterans' nursing homes.
About one-fourth of veterans who received care in VA nursing homes in
fiscal year 2003 were required to be served by the Millennium Act or
VA's policy on nursing home eligibility. In contrast, about three-
quarters of veterans in VA nursing homes received such care on a
discretionary basis depending on available resources. VA does not
collect and report comparable information on eligibility status for
community nursing homes and state veterans' nursing homes even though
these settings combined accounted for 63 percent of VA's overall
workload. Although VA officials told us that medical center officials
may know the eligibility status of the veterans they pay for in
community nursing homes and state veterans' nursing homes, VA does not
have the information at either the nationwide or the network level.
To help ensure that VA can provide adequate program monitoring and
planning for nursing home care and to provide a better basis for
congressional oversight, we are recommending that VA collect data on
veterans' length of stay and eligibility for community nursing homes
and state veterans' nursing homes comparable to data VA currently
collects for its nursing homes.
In commenting on a draft of this report, VA stated that it concurred in
principle with our recommendations. VA stated that it will continue its
efforts to reduce data gaps in the community nursing home and state
veterans home programs, but VA did not indicate specific plans to
collect data on length of stay and eligibility for its long-term care
planning process. Moreover, VA stated that data other than eligibility
and length of stay, such as age and disability, are most crucial for
its long-term care strategic planning and program oversight. We
disagree with VA's position that eligibility and length-of-stay data
are not considered most crucial and are concerned about VA's lack of
specificity regarding its intent to utilize these data. While factors
such as age and disability are generally recognized as important in
projecting veterans' overall need for nursing home care, VA needs
veterans' eligibility status and length of stay to determine what
portion of the overall need VA will meet nationally and in individual
communities. Eligibility data are crucial because VA needs to know who
it is required to serve based on the Millennium Act or VA policy and
what proportion of veterans it will serve on a discretionary basis. In
addition, length-of-stay data are crucial because VA needs to know the
type of nursing home care, short and long stay, that will be needed by
the veterans it serves in each of its three nursing home settings.
Background:
VA operates its nursing homes in 132 locations, which are located
throughout VA's 21 health care networks. Almost all of these nursing
homes are attached or in close proximity to a VA medical center.
According to VA policy, VA staff at these facilities determine whether
the veteran has a clinical need for nursing home care based on a
comprehensive interdisciplinary clinical assessment. The
interdisciplinary teams determining clinical need for nursing home care
could include personnel such as the nursing home director, a social
worker, nurse, physical therapist, and gerontologist. The care provided
to veterans at a VA nursing home could include a range of services,
including short-term postacute care needed to recover from a condition
such as a stroke to longer-term care required by veterans who cannot be
cared for at home because of severe, chronic physical or mental
limitations.
VA may also refer patients to receive nursing home care under contract
from non-VA nursing homes located in the community--referred to as
community nursing homes. In fiscal year 2003, VA purchased care from
community nursing homes in one of two ways. VA contracted with most
nursing homes through the local VA medical center. In addition, VA also
contracted with some community nursing homes under its Regional
Community Nursing Home initiative, in which nursing home chains in
single or multiple states contract directly with VA headquarters for
services at their nursing homes. In fiscal year 2003, VA contracted
with 1,723 nursing homes through its medical centers and with 508 more
nursing homes under its Regional Community Nursing Home
initiative.[Footnote 8]
Veterans may also choose to seek care in state veterans' nursing homes.
In fiscal year 2003, 109 state veterans' nursing homes located in 44
states and Puerto Rico received VA payment to provide care. VA may
refer patients to these nursing homes for care, but does not control
the admission process. Veterans are admitted based on eligibility
criteria established by the states. For state veterans' nursing homes
to participate in VA's program, however, VA requires that at least 75
percent of the residents be veterans in most cases.[Footnote 9] State
veterans' nursing homes may also provide nursing home care to certain
nonveterans, such as spouses of residents who are veterans. VA is
authorized to pay for about two-thirds of the costs of construction of
state veterans' nursing homes and pays about a third of the costs per
day to provide care to veterans in these homes.[Footnote 10] In fiscal
year 2003, VA paid $56.24 per day for veterans in these state veterans'
nursing homes and awarded $174 million in grants to 16 states for
renovations of existing facilities or construction of new state
veterans' homes.[Footnote 11]
Veterans can also receive nursing home care financed by sources other
than VA, including Medicaid and Medicare, private health or long-term
care insurance, or self-financed.[Footnote 12] States design and
administer Medicaid programs that include coverage for long-term
nursing home care to assist with daily activities such as eating and
bathing. Medicare primarily covers acute care health costs and
therefore limits its nursing home coverage to short stays requiring
skilled nursing home care following hospitalization. State Medicaid
programs are the principal funders of nursing homes, besides patients
self-financing their care. Private health insurance pays for about 11
percent of nursing home and home health care expenditures.[Footnote 13]
VA Spent Almost Three-Quarters of Its Nursing Home Resources on Care
for Veterans in VA Nursing Homes, but Expenditures Varied Widely by
Network:
VA nursing homes accounted for almost three-quarters of VA's overall
nursing home expenditures, or about $1.7 billion, in fiscal year 2003.
Care in state veterans' nursing homes accounted for 15 percent of
nursing home expenditures, or about $352 million. Care in community
nursing homes accounted for the lowest percentage of overall nursing
home expenditures at 12 percent, or about $272 million. Overall, VA
spent approximately $2.3 billion to provide or pay for nursing home
care in VA nursing homes, community nursing homes, and state veterans'
nursing homes in fiscal year 2003.
In contrast to fiscal year 1998, in fiscal year 2003 the percentage of
expenditures from community nursing homes declined, whereas the
percentage of expenditures for care in VA nursing homes and state
veterans' nursing homes increased. (See fig. 1.) For example, 70
percent of nursing home expenditures were accounted for by VA nursing
homes in fiscal year 1998 as compared to 73 percent in 2003. Moreover,
the percentage of community nursing home expenditures was 17 percent in
1998 as compared to 12 percent in 2003. During the same years, VA's
overall nursing home expenditures increased by about a third, growing
from about $1.7 billion to approximately $2.3 billion.
Figure 1: Percentage of Nursing Home Expenditures by Setting, Fiscal
Years 1998 and 2003:
[See PDF for image]
[End of figure]
The percentage of nursing home expenditures for care in each nursing
home setting varied widely by network in fiscal year 2003. (See fig.
2.) All networks spent the largest percentage of their resources on VA
nursing homes. The percentage of expenditures for VA nursing homes
ranged from a low of 47 percent in Network 19 (Denver) to a high of 88
percent in Network 6 (Durham). Further, the percentage of overall
nursing home expenditures accounted for by community and state
veterans' nursing homes also varied widely across the networks. For
example, the percentage of expenditures for community nursing homes
ranged from a low of 2 percent in Network 3 (Bronx) to a high of 28
percent in Network 20 (Portland).
Figure 2: Percentage of Nursing Home Expenditures by Setting and
Network, Fiscal Year 2003:
[See PDF for image]
Note: In January 2002 VA merged networks 13 and 14 to form a single
network, Network 23 (Minneapolis). A network's total percentage may not
equal 100 because of rounding.
[End of figure]
A comparison of how networks' percentage of expenditures on each
nursing home setting changed in fiscal year 2003 as compared to fiscal
year 1998 showed that networks' changes were consistent with the VA-
wide changes.[Footnote 14] In fiscal year 2003, the percentage of
expenditures for VA nursing homes increased in 15 of the 21 health care
networks as compared to fiscal year 1998. Similar to the overall trend,
the percentage of expenditures for state veterans' nursing homes
increased in 17 of 21 networks, whereas the percentage of expenditures
for community nursing homes decreased in 17 of 21 networks. The largest
shift in the percentage of expenditures for the three settings occurred
in Network 19 (Denver). In this network, the percentage of expenditures
for VA nursing homes declined from 75 to 47 percent because of a
nursing home closure during this period. For more detailed information
on the percent change in nursing home expenditures for each setting and
network in fiscal years 1998 and 2003, see appendix II.
State Veterans' Nursing Homes Provided Half of VA's Overall Nursing
Home Workload, but Networks' Use of Nursing Home Care Setting Varied:
State veterans' nursing homes accounted for half of VA's overall
nursing home workload--measured by average daily census--in fiscal year
2003, even though they accounted for only 15 percent of expenditures.
In large part this is because VA pays a per-diem rate for care in state
veterans' nursing homes that, on average, accounts for about one-third
of the cost to provide veterans nursing home care in this setting. The
remaining payments made to state veterans' nursing homes come from a
number of other sources including Medicaid, Medicare, private health
insurance, and patients self-financing their care. VA nursing homes
provided the next largest percentage of nursing home workload, 37
percent in fiscal year 2003. Community nursing homes provided 13
percent of overall nursing home workload. Overall, VA provided or paid
for 33,214 patients to receive nursing home care daily in VA nursing
homes, community nursing homes, and state veterans' nursing homes in
fiscal year 2003.
Since fiscal year 1998, VA has increased its use of state veterans'
nursing homes and decreased the use of VA nursing homes and community
nursing homes. Overall, workload in VA's nursing home program was
33,214 in fiscal year 2003, about 1 percent below its fiscal year 1998
workload. The percentage of nursing home workload provided in state
veterans' nursing homes increased from 43 to 50 percent. In contrast,
the percentage of workload provided in VA nursing homes and community
nursing homes declined. (See fig. 3.)
Figure 3: Percentage of VA Nursing Home Workload by Setting, Fiscal
Years 1998 and 2003:
[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 increase in the percentage of nursing home workload provided in
state veterans' nursing homes resulted from a number of factors.
States, with the assistance of construction grants from VA, built 17
new state veterans' nursing homes, increasing the number of beds
available during this period. The increasing percentage of state
veterans' nursing home workload also occurred as a result of declines
in workload in VA nursing homes and community nursing homes due to
changes in VA's use of these settings. In VA nursing homes, VA
officials attributed some of the decreases in nursing home workload to
an increased emphasis on postacute patients with short lengths of stay.
Moreover, VA officials told us that they are providing contract
community nursing home care to fewer veterans and paying for shorter
contracts than in the past. The number of patients VA served in this
setting declined from 28,893 to 14,032 during this period.[Footnote 15]
Network officials also told us that contracts for community nursing
home care are often now 30 days or less and are used primarily to
transition veterans to nursing home care, which is paid for by other
payers such as Medicaid.
Although state veterans' nursing homes predominate overall, networks
vary widely in the percentage of workload met in different nursing home
settings. For example, networks varied in their use of state veterans'
nursing homes ranging from a low of 22 percent in Network 8 (Bay Pines)
to a high of 71 percent in Network 15 (Kansas City). (See fig. 4.) This
variation is due, in part, to the available bed capacity of state
veterans' nursing homes in these networks. In 2003, Network 15 (Kansas
City) had 1,509 state veterans' nursing home beds compared to 420 beds
in Network 8 (Bay Pines). However, wide network variation also existed
in the percentage of networks' workloads accounted for by VA nursing
homes and community nursing homes.
Figure 4: Percentage of Nursing Home Workload by Setting and Network,
Fiscal Year 2003:
[See PDF for image]
Note: In January 2002 VA merged networks 13 and 14 to form a single
network, Network 23 (Minneapolis). A network's total percentage may not
equal 100 because of rounding.
[End of figure]
Changes in networks' delivery of nursing home care among the three
nursing home settings were consistent with VA-wide changes between
fiscal year 1998 and 2003. The percentage of workload provided in state
veterans' nursing homes increased in 19 of VA's 21 health care
networks. Similar to the overall trend, the percentage of workload met
in community nursing homes declined in 17 networks and declined in 13
networks for VA nursing homes. The largest shift in the percentage of
workload for the three settings occurred in Network 17 (Dallas). In
this network, the percentage of workload for state veterans' nursing
homes increased from 0 to 30 percent because Texas opened up four state
veterans' nursing homes during this period. For more detailed
information on the percent change in nursing home workload for each
setting and network in fiscal years 1998 and 2003, see appendix III.
About One-Third of VA Nursing Home Care Is Long Stay, but VA Lacks
Comparable Information for Other Nursing Home Settings:
About one-third of the care VA provided in VA nursing homes was long
stay in fiscal year 2003. The use of long-stay nursing home care (90
days or more) includes services needed when a person has a physical or
mental disability that cannot be cared for at home. For example,
veterans needing long-stay care may have difficulty performing some
activities of daily living without assistance, such as bathing,
dressing, toileting, eating, and moving from one location to another.
They may have mental impairments, such as Alzheimer's disease or
dementia, that necessitate supervision to avoid harm to themselves or
others or require assistance with tasks such as taking medications. The
remainder, or two-thirds of VA nursing home care, was short-stay care
(less than 90 days) in this setting. VA's use of short-stay care
includes nursing home services such as postacute care required for
recuperation from a stroke or hip replacement. VA officials also told
us that this care could include a number of other services such as the
delivery of complex medical services such as chemotherapy, the
treatment of wounds such as pressure ulcers, and end-of-life care. VA's
use of short-stay care is similar to services provided by Medicare,
which provides short-term coverage, whereas VA's use of long-stay care
is similar to services provided by Medicaid, which provides long-term
coverage for nursing home care.[Footnote 16]
Since fiscal year 1998, VA has decreased its use of long-stay care and
increased its use of short-stay nursing home care. Specifically, the
percentage of nursing home care that was long stay has declined from 43
to 34 percent between fiscal years 1998 and 2003. (See fig. 5.) In
contrast, the percentage of short stays provided in this setting
increased from 57 to 66 percent during the same period. This shift in
the amount of short-stay care is consistent with VA's policy on nursing
home eligibility that sets a higher priority on serving veterans who
require short-stay postacute care.
Figure 5: Percentage of Long-and Short-Stay Care in VA Nursing Homes,
Fiscal Years 1998 and 2003:
[See PDF for image]
Note: Nursing home stays are episodes of care where veterans receive
nursing home services in a VA nursing home. Nursing home stays do not
reflect the total number of individual veterans treated in a VA nursing
home because some veterans had multiple nursing home stays in a given
fiscal year.
[End of figure]
Networks vary widely, however, in the percentage of VA nursing home
care that is long stay. The percentage of long stays in VA nursing
homes ranged from a low of 17 percent in Network 20 (Portland) to a
high of 55 percent in Network 7 (Atlanta). (See fig. 6.) Network 20
(Portland) officials told us that the focus of their VA nursing homes
has changed from long-stay care to short-stay transitional and
rehabilitative care and as a result they are serving more veterans with
shorter lengths of stay. By contrast, Network 7 (Atlanta) officials
told us that several of their nursing homes provide services that are
consistent with long-stay nursing home care such as providing
assistance to veterans who have difficulty performing some activities
of daily living such as the inability to independently eat.
Figure 6: Percentage of Long-and Short-Stay Care in VA Nursing Homes by
Network, Fiscal Year 2003:
[See PDF for image]
Note: In January 2002 VA merged networks 13 and 14 to form a single
network, Network 23 (Minneapolis).
[End of figure]
VA lacks information on the amount of long-and short-stay nursing home
care veterans receive in community and state veterans' nursing homes
preventing it from strategically planning how best to use these nursing
home settings at the national and network levels to enhance access to
nursing home services. VA officials told us that while some of these
data may be available at certain facilities because the facilities
collect them for their own purposes, VA does not require state
veterans' nursing homes and community nursing homes to provide billing
or other information that identifies individual veterans on which
length of stay could be calculated. VA collects information on the
payments made to community nursing homes and state veterans' nursing
homes, but does not collect the days of care a veteran receives or
other individual information. VA officials told us that they receive
and pay individual claims for some veterans in community nursing homes,
but that in other cases VA pays for care provided by community nursing
homes based on invoices, which aggregate information on the number of
patients being treated by a nursing home.
VA officials told us that they are in the initial planning stages of
redesigning a payment system to collect information by individual
veteran in community nursing homes, but that the implementation of such
a system could take several years. Once completed, VA officials expect
the new system to collect and report data on the total number of days
individual veterans receive in community nursing homes. VA does not
currently have plans to collect such data for state veterans' nursing
homes, but is exploring doing so.
About One-Fourth of Veterans Who Received Care in VA Nursing Homes Are
Required to Be Served by the Millennium Act or VA Policy, but VA Lacks
Comparable Information for Other Settings:
In fiscal year 2003, about 26 percent of veterans who received care in
VA nursing homes are required to be served by the Millennium Act or
VA's policy on nursing home eligibility. Of these veterans, about 21
percent are being treated under the Millennium Act because they have a
service-connected disability rating of 70 percent or greater. The act
also required that VA continue to treat veterans who had been receiving
nursing home care in VA facilities at the time the law was enacted
ĉabout 4 percent of the veterans receiving care in fiscal year 2003
fell into this category.[Footnote 17] Further, 1 percent of veterans in
VA nursing homes are required to be served based solely on VA's policy
on nursing home eligibility that extended required coverage to veterans
with a 60 percent service-connected disability rating who also met
other criteria.
However, the vast majority of veterans--about 74 percent in fiscal year
2003--received VA nursing home care as a discretionary benefit based on
available budgetary resources. VA's policy on nursing home eligibility
directs that for these veterans VA nursing homes admit, as a priority,
patients who meet certain clinical and programmatic criteria: patients
requiring nursing home care after a hospital episode, patients who VA
determines cannot be adequately cared for in community nursing homes or
home-and community-based care, and those patients who can be cared for
more efficiently in VA nursing homes.
The percentage of veterans receiving VA nursing home care as required
by the Millennium Act or VA's policy on nursing home eligibility varied
widely across networks in fiscal year 2003. The percentage of veterans
receiving this care ranged from a low of 20 percent in Network 15
(Kansas City) and Network 11 (Ann Arbor) to a high of 39 percent in
Network 1 (Boston). (See fig. 7.) However, most networks were grouped
closer to the lower range. Fifteen of VA's 21 health care networks had
percentages of 26 percent or less. According to VA officials, the
percentage of veterans that are required to be treated may be lower in
some networks because networks may choose to pay for these veterans to
receive care in community nursing homes. In contrast, some networks may
prefer to treat these patients in VA nursing homes. For example,
officials from Network 3 (Bronx), a network with the second highest
percentage at 37 percent, told us that they prefer to treat these types
of veterans in VA nursing homes because they have sufficient bed
capacity.
Figure 7: Percentage of Veterans Receiving VA Nursing Home Care as
Required by Millennium Act or VA's Policy on Nursing Home Eligibility
by Network, Fiscal Year 2003:
[See PDF for image]
Note: In January 2002 VA merged networks 13 and 14 to form a single
network, Network 23 (Minneapolis).
[End of figure]
VA lacks comparable information for community nursing homes or state
veterans' nursing homes on the percentage of veterans that are required
to be served based on the Millennium Act or VA's policy on nursing home
eligibility even though these settings combined accounted for 63
percent of VA's overall nursing home workload. The lack of such data
prevents VA from strategically planning how best to use these nursing
home settings at the national and network levels to enhance access to
nursing home services. VA officials told us that while some of these
data on eligibility status may be available at certain facilities
because the facilities collect them for their own purposes, VA does not
require that this information be collected and reported to
headquarters. VA does not collect information by individual on all
payments made to community nursing homes and state veterans' nursing
homes. As a result, VA cannot match individual veterans' data from
their payment system with data it currently collects on eligibility to
determine the eligibility status of all veterans receiving contract
care in community nursing homes and state veterans' nursing homes. VA
officials told us this type of analysis could be done if a new
information system for collecting contract payments is designed and
implemented to collect and report such information.
Conclusions:
Gaps in nursing home data impede VA's ability to monitor and
strategically plan for the nursing home care VA pays for nationally and
at the network level. The workload in state veterans' nursing homes and
community nursing homes has grown to 63 percent of VA's overall nursing
home workload. However, VA does not have data on length of stay and the
eligibility status of veterans receiving care in these settings as it
has for VA nursing homes. As a result, VA cannot strategically plan how
best to serve veterans it is required to serve, including those who
have a 70 percent or greater service-connected disability rating, or
other veterans receiving care on a discretionary basis; nor can VA
strategically plan how best to use the nursing home settings to provide
long-and short-stay nursing home care nationally or in individual
networks. Equally important, the lack of such data and assessments
hampers congressional oversight of strategic options available to VA in
its nursing home care planning and its progress in meeting veterans'
needs.
Recommendations for Executive Action:
To help ensure that VA can provide adequate program monitoring and
planning for nursing home care and to improve the completeness of data
needed for congressional oversight, we recommend that the Secretary of
Veterans Affairs direct the Under Secretary for Health to take two
actions:
* For community nursing homes and state veterans' nursing homes,
collect and report data on the number of veterans who have long and
short stays, comparable to data VA currently collects on VA nursing
homes.
* For community nursing homes and state veterans' nursing homes,
collect and report data on the number of veterans in these homes that
VA is required to serve based on the requirements of the Millennium Act
or VA's policy on nursing home eligibility, comparable to data VA
currently collects on VA nursing homes.
Agency Comments and Our Evaluation:
We provided a draft of this report to VA for comment. In commenting on
the draft, VA stated that it concurred in principle with our
recommendations. VA stated that it will continue its efforts to reduce
data gaps in the community nursing home and state veterans home
programs, but VA did not indicate specific plans to collect data on
length of stay and eligibility for its long-term care planning process.
Moreover, VA stated that data other than eligibility and length of
stay, such as age and disability, are most crucial for its long-term
care strategic planning and program oversight. We disagree with VA's
position that eligibility and length-of-stay data are not considered
most crucial and are concerned about VA's lack of specificity regarding
its intent to utilize these data. While factors such as age and
disability are generally recognized as important in projecting need for
nursing home care, VA needs data on veterans' eligibility status and
length of stay to determine what portion of the overall veteran need
for nursing home care VA will meet nationally and in individual
communities. Because VA is required to serve veterans that meet the
requirements of the Millennium Act or VA policy, VA needs to project
the number of these veterans seeking nursing home care from VA and
determine the number of other veterans it will also serve on a
discretionary basis after meeting this need. To strategically plan and
provide the type of service needed in the future, VA must also project
what proportion of veterans with different eligibility statuses will
need short-stay or long-stay nursing home care. VA needs to use this
information to determine if the nursing home care it currently pays for
in VA nursing homes, contract community nursing homes, and state
veterans' nursing homes is appropriately located and provides the type
of nursing home care needed by veterans.
VA also noted that it is narrowing information gaps on both veterans'
eligibility status and length of stay for veterans in its community and
state veterans' nursing home programs by using data extracted from
various sources to estimate these numbers. However, VA did not provide
these data for our review. Given that the combined workload in these
settings accounted for 63 percent of VA's overall nursing home workload
in fiscal year 2003, we believe that complete information on veterans'
eligibility status and length of stay for veterans in these settings is
crucial for both strategic planning and program oversight.
VA noted that one of our statements--that about one-fourth of veterans
receiving nursing home care are entitled to such care under the
requirements of the Millennium Act--could be misinterpreted to imply
that some of these "mandatory" veterans are being displaced by veterans
receiving discretionary care. We did not imply this relationship, nor
did our work examine this particular issue.
We are sending copies of this report to the Secretary of Veterans
Affairs and appropriate congressional committees. The report is
available at no charge on GAO's Web site at http://www.gao.gov. We will
also make copies available to others on request.
If you or your staff have any questions about this report, please call
me at (202) 512-7101. Another contact and key contributors are listed
in appendix V.
Sincerely yours,
Signed by:
Cynthia A. Bascetta:
Director, Health Care--Veterans' Health and Benefits Issues:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
We reviewed the Department of Veterans Affairs' (VA) nursing home
program for fiscal year 2003 for VA nursing homes, community nursing
homes, and state veterans' nursing homes to determine (1) VA spending
to provide or pay for nursing home care, (2) VA workload provided or
paid for, (3) the percentage of nursing home care that is long and
short stay, and (4) the percentage of veterans receiving care that are
required to be served by the Millennium Act or VA policy. To place this
information in context, you asked us to supplement our findings with
information for fiscal year 1998.
To address the first two objectives, we obtained data on nursing home
workload and expenditures at the network level for fiscal years 1998
and 2003 from several VA headquarters offices. VA's Geriatrics and
Extended Care Strategic Healthcare Group provided us workload data for
VA nursing homes and community nursing homes, as reported in VA's
Automated Management Information System. This group also gave us
workload data from monthly reports completed by state veterans' nursing
homes that were maintained at the VA medical centers. These data are
used by the Geriatrics and Extended Care office to provide per diem
grants to state veterans' homes. The Office of the Chief Financial
Officer for the Veterans Health Administration (VHA) provided us
expenditure data from VA's Cost Distribution Report for the nursing
home care provided or paid for by VA.
To do our analysis, we used average daily census as a measure of
workload. Average daily census is the total number of days of nursing
home care provided in a year divided by the number of days in the year.
For VA nursing home expenditures, we included the direct costs used to
provide nursing home care plus other facility costs associated with
operating the nursing home. VA nursing home expenditures excluded
depreciation as well as VA headquarters and network administrative
costs. To calculate community nursing home expenditures, we included
all contract payments made to community nursing homes plus additional
facility expenditures required to directly support the program at the
local VA medical center. To calculate state veterans' home
expenditures, we included per diem payments made to state veterans'
nursing homes plus additional facility expenditures required to
directly support the program at local VA medical centers. Expenditures
for state veterans' homes did not include construction grants.
To determine the percentage of long and short stays in VA nursing homes
in fiscal years 1998 and 2003, we obtained data on length of stay from
VHA's Extended Care Patient Treatment Files. The Patient Treatment
Files include nursing home discharges for veterans who were discharged
from a VA nursing home during a fiscal year, and current resident files
for veterans who were not discharged by the end of a fiscal year. Using
length of nursing home stay, we classified stays of 90 days or more as
long stays and stays of less than 90 days as short stays. Length of
stay is calculated as the number of days in a nursing home between the
admission and discharge days and was given a minimum value of 1. The
number of days absent from the nursing home, such as for a hospital
stay, was subtracted from the length of stay. Because current residents
were not discharged within the fiscal year, we calculated their lengths
of stay by looking ahead into the next fiscal year. That is, we matched
current residents with discharges in the next fiscal year to determine
whether their stays were short or long. A current resident who was
admitted on the last day of the fiscal year, for example, but was
discharged after 90 days into the next fiscal year, was classified as
having a long stay. If the same resident was discharged within 90 days
of the next fiscal year, then the stay was classified as short. We
classified nursing home stays as long for current residents who were
not discharged in the next fiscal year. Our analysis for long-and
short-stay care was based on nursing home stays rather than individual
veterans because some veterans had multiple nursing home stays.
To determine the percentage of veterans in VA nursing homes receiving
care that are required to be served by the Millennium Act or VA policy,
we obtained individual data on eligibility for veterans enrolled in
VA's health care system. VHA's Office of Policy and Planning provided
us these data in an enrollment file for fiscal year 2003. We merged
these data with the discharge and current resident files from VHA's
Extended Care Patient Treatment Files in order to calculate the
percentage of veterans receiving nursing home care that are required to
be served in fiscal year 2003. Our analyses on eligibility are based on
individual veterans rather than nursing home stays; because some
veterans had multiple nursing home stays in a given year, we retained
veterans' first nursing home stay and eliminated other stays in that
year. We used a variable from VA's enrollment file that measures
service-connected disability rating. In addition, we used variables
from the file that measure whether the veteran is unemployable and
whether the veteran is considered permanent and total disabled, based
on disabilities not related to military service.
We included the following categories of veterans in our calculation to
determine the percentage of veterans receiving nursing home care
required to be served by the Millennium Act or VA's policy on nursing
home eligibility: (1) veterans who had a service-connected disability
rating of 70 percent or more; (2) veterans who were admitted to a VA
nursing home on or before November 30, 1999; and (3) veterans who had a
service-connected disability rating of 60 percent and who were also
unemployable or permanent and total disabled. We did not include in our
estimate veterans VA is required to serve who need nursing home care
because of a service-connected disability, but who do not have a
service-connected disability rating of 70 percent or more. VA did not
have data on these veterans, but a VA official estimated that this
group is very small based on conversations with facility staff.
To supplement our knowledge of the type of nursing home care provided
in VA networks, we visited two networks and five nursing homes. In
Network 5 (Baltimore) we visited Washington, D.C; Martinsburg, West
Virginia; and Baltimore, Maryland. In Network 23 (Minneapolis) we
visited St. Cloud, Minnesota; and Minneapolis, Minnesota. We selected
these two networks because they were in different geographic regions
and had variation in the types of care offered in their facilities.
Within each network, we chose one nursing home that provided more long-
stay nursing home care and another that provided more short-stay care.
We assessed the reliability of workload and expenditure data in VA's
nursing home program, VHA's enrollment data file, and VHA's Extended
Care Patient Treatment Files in several ways. First, we performed tests
of data elements. For example, we examined the range of values for
length of stay to determine whether these data were complete and
reasonable. Second, we reviewed existing information about the data
elements. For example, we obtained and reviewed information from VHA on
data elements we used from VHA's Extended Care Patient Treatment Files.
Third, we interviewed agency officials knowledgeable about the data in
our analyses and knowledgeable about VA's nursing home program. For
example, we sent network-specific nursing home workload and expenditure
data provided to us by VA headquarters to each of VA's 21 health care
networks through electronic mail in December 2003. Network officials
reported whether these data were accurate and indicated where they
found discrepancies. Through discussions with VA headquarters and
network officials we resolved the discrepancies. We determined that the
data we used in our analyses were sufficiently reliable for the
purposes of this report.
We performed our review from January 2003 to November 2004 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Changes in Percentage of Nursing Home Expenditures by
Setting and Network, Fiscal Years 1998 and 2003:
Network: 1 (Boston);
Fiscal year 1998 total expenditures: $109,377,623;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 53%;
* Community nursing homes: 31%;
* State veterans‘ nursing homes: 16%;
Fiscal year 2003 total expenditures: $136,122,953;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 65%;
* Community nursing homes: 16%;
* State veterans‘ nursing homes: 19%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 12%;
* Community nursing homes: -15%;
* State veterans‘ nursing homes: 3%.
Network: 2 (Albany);
Fiscal year 1998 total expenditures: $63,014,011;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 82%;
* Community nursing homes: 12%;
* State veterans‘ nursing homes: 6%;
Fiscal year 2003 total expenditures: $74,077,560;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 85%;
* Community nursing homes: 8%;
* State veterans‘ nursing homes: 7%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 3%;
* Community nursing homes: -4%;
* State veterans‘ nursing homes: 1%.
Network: 3 (Bronx);
Fiscal year 1998 total expenditures: $124,045,443;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 76%;
* Community nursing homes: 12%;
* State veterans‘ nursing homes: 12%;
Fiscal year 2003 total expenditures: $152,483,201;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 82%;
* Community nursing homes: 2%;
* State veterans‘ nursing homes: 16%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 6%;
* Community nursing homes: -10%;
* State veterans‘ nursing homes: 4%.
Network: 4 (Pittsburgh);
Fiscal year 1998 total expenditures: $137,687,784;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 73%;
* Community nursing homes: 16%;
* State veterans‘ nursing homes: 11%;
Fiscal year 2003 total expenditures: $180,292,753;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 85%;
* Community nursing homes: 3%;
* State veterans‘ nursing homes: 12%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 11%;
* Community nursing homes: -12%;
* State veterans‘ nursing homes: 1%.
Network: 5 (Baltimore);
Fiscal year 1998 total expenditures: $40,103,045;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 70%;
* Community nursing homes: 20%;
* State veterans‘ nursing homes: 9%;
Fiscal year 2003 total expenditures: $64,659,735;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 85%;
* Community nursing homes: 9%;
* State veterans‘ nursing homes: 6%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 14%;
* Community nursing homes: -11%;
* State veterans‘ nursing homes: -3%.
Network: 6 (Durham);
Fiscal year 1998 total expenditures: $81,293,363;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 82%;
* Community nursing homes: 15%;
* State veterans‘ nursing homes: 3%;
Fiscal year 2003 total expenditures: $110,469,579;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 88%;
* Community nursing homes: 6%;
* State veterans‘ nursing homes: 6%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 6%;
* Community nursing homes: -9%;
* State veterans‘ nursing homes: 3%.
Network: 7 (Atlanta);
Fiscal year 1998 total expenditures: $79,392,405;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 60%;
* Community nursing homes: 18%;
* State veterans‘ nursing homes: 23%;
Fiscal year 2003 total expenditures: $140,447,102;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 74%;
* Community nursing homes: 8%;
* State veterans‘ nursing homes: 18%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 15%;
* Community nursing homes: -10%;
* State veterans‘ nursing homes: -5%.
Network: 8 (Bay Pines);
Fiscal year 1998 total expenditures: $88,228,833;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 83%;
* Community nursing homes: 15%;
* State veterans‘ nursing homes: 2%;
Fiscal year 2003 total expenditures: $157,002,146;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 79%;
* Community nursing homes: 16%;
* State veterans‘ nursing homes: 5%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -4%;
* Community nursing homes: [A]%;
* State veterans‘ nursing homes: 3%.
Network: 9 (Nashville);
Fiscal year 1998 total expenditures: $54,466,227;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 58%;
* Community nursing homes: 25%;
* State veterans‘ nursing homes: 16%;
Fiscal year 2003 total expenditures: $63,764,289;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 53%;
* Community nursing homes: 24%;
* State veterans‘ nursing homes: 23%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -5%;
* Community nursing homes: -2%;
* State veterans‘ nursing homes: 6%.
Network: 10 (Cincinnati);
Fiscal year 1998 total expenditures: $71,896,679;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 74%;
* Community nursing homes: 18%;
* State veterans‘ nursing homes: 7%;
Fiscal year 2003 total expenditures: $97,699,712;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 81%;
* Community nursing homes: 9%;
* State veterans‘ nursing homes: 9%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 7%;
* Community nursing homes: -9%;
* State veterans‘ nursing homes: 2%.
Network: 11 (Ann Arbor);
Fiscal year 1998 total expenditures: $77,163,729;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 72%;
* Community nursing homes: 12%;
* State veterans‘ nursing homes: 16%;
Fiscal year 2003 total expenditures: $101,393,221;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 74%;
* Community nursing homes: 10%;
* State veterans‘ nursing homes: 16%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 2%;
* Community nursing homes: -2%;
* State veterans‘ nursing homes: a%.
Network: 12 (Chicago);
Fiscal year 1998 total expenditures: $103,315,242;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 65%;
* Community nursing homes: 18%;
* State veterans‘ nursing homes: 17%;
Fiscal year 2003 total expenditures: $138,884,538;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 73%;
* Community nursing homes: 10%;
* State veterans‘ nursing homes: 17%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 8%;
* Community nursing homes: -8%;
* State veterans‘ nursing homes: a%.
Network: 15 (Kansas City);
Fiscal year 1998 total expenditures: $62,283,391;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 59%;
* Community nursing homes: 18%;
* State veterans‘ nursing homes: 23%;
Fiscal year 2003 total expenditures: $86,113,975;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 59%;
* Community nursing homes: 10%;
* State veterans‘ nursing homes: 31%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: a%;
* Community nursing homes: -8%;
* State veterans‘ nursing homes: 8%.
Network: 16 (Jackson);
Fiscal year 1998 total expenditures: $101,425,232;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 61%;
* Community nursing homes: 14%;
* State veterans‘ nursing homes: 25%;
Fiscal year 2003 total expenditures: $144,733,884;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 61%;
* Community nursing homes: 10%;
* State veterans‘ nursing homes: 29%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: a%;
* Community nursing homes: -4%;
* State veterans‘ nursing homes: 4%.
Network: 17 (Dallas);
Fiscal year 1998 total expenditures: $57,124,099;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 82%;
* Community nursing homes: 18%;
* State veterans‘ nursing homes: 0[B]%;
Fiscal year 2003 total expenditures: $93,214,744;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 78%;
* Community nursing homes: 14%;
* State veterans‘ nursing homes: 9%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -4%;
* Community nursing homes: -5%;
* State veterans‘ nursing homes: 9%.
Network: 18 (Phoenix);
Fiscal year 1998 total expenditures: $57,216,391;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 74%;
* Community nursing homes: 17%;
* State veterans‘ nursing homes: 9%;
Fiscal year 2003 total expenditures: $81,963,959;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 75%;
* Community nursing homes: 14%;
* State veterans‘ nursing homes: 11%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: a%;
* Community nursing homes: -3%;
* State veterans‘ nursing homes: 3%.
Network: 19 (Denver);
Fiscal year 1998 total expenditures: $51,508,938;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 75%;
* Community nursing homes: 9%;
* State veterans‘ nursing homes: 16%;
Fiscal year 2003 total expenditures: $50,110,475;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 47%;
* Community nursing homes: 26%;
* State veterans‘ nursing homes: 28%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -28%;
* Community nursing homes: 17%;
* State veterans‘ nursing homes: 12%.
Network: 20 (Portland);
Fiscal year 1998 total expenditures: $60,569,408;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 59%;
* Community nursing homes: 27%;
* State veterans‘ nursing homes: 14%;
Fiscal year 2003 total expenditures: $87,791,970;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 53%;
* Community nursing homes: 28%;
* State veterans‘ nursing homes: 19%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -6%;
* Community nursing homes: a%;
* State veterans‘ nursing homes: 5%.
Network: 21 (San Francisco);
Fiscal year 1998 total expenditures: $77,213,692;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 72%;
* Community nursing homes: 21%;
* State veterans‘ nursing homes: 7%;
Fiscal year 2003 total expenditures: $116,215,532;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 82%;
* Community nursing homes: 13%;
* State veterans‘ nursing homes: 5%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 10%;
* Community nursing homes: -8%;
* State veterans‘ nursing homes: -1%.
Network: 22 (Long Beach);
Fiscal year 1998 total expenditures: $78,414,772;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 73%;
* Community nursing homes: 24%;
* State veterans‘ nursing homes: 3%;
Fiscal year 2003 total expenditures: $105,809,650;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 74%;
* Community nursing homes: 23%;
* State veterans‘ nursing homes: 3%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 1%;
* Community nursing homes: -1%;
* State veterans‘ nursing homes: c%.
Network: 23 (Minneapolis);
Fiscal year 1998 total expenditures: $107,175,837;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 65%;
* Community nursing homes: 8%;
* State veterans‘ nursing homes: 27%;
Fiscal year 2003 total expenditures: $138,156,457;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 59%;
* Community nursing homes: 11%;
* State veterans‘ nursing homes: 30%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -6%;
* Community nursing homes: 3%;
* State veterans‘ nursing homes: 3%.
Network: Total;
Fiscal year 1998 total expenditures: $1,682,916,144;
Fiscal year 1998 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 70%;
* Community nursing homes: 17%;
* State veterans‘ nursing homes: 13%;
Fiscal year 2003 total expenditures: $2,321,407,435;
Fiscal year 2003 percentage of total expenditures in each nursing home
setting:
* VA nursing homes: 73%;
* Community nursing homes: 12%;
* State veterans‘ nursing homes: 15%;
Change in percentage of expenditures by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 3%;
* Community nursing homes: -6%;
* State veterans‘ nursing homes: 2%.
[End of table]
[End of section]
Appendix III: Changes in Percentage of Nursing Home Workload by Setting
and Network, Fiscal Years 1998 and 2003:
Network: 1 (Boston);
Fiscal year 1998 total workload: 2,291;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 27%;
* Community nursing homes: 20%;
* State veterans‘ nursing homes: 53%;
Fiscal year 2003 total workload: 2,131;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 29%;
* Community nursing homes: 14%;
* State veterans‘ nursing homes: 57%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 2%;
* Community nursing homes: -7%;
* State veterans‘ nursing homes: 5%.
Network: 2 (Albany);
Fiscal year 1998 total workload: 910;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 58%;
* Community nursing homes: 14%;
* State veterans‘ nursing homes: 28%;
Fiscal year 2003 total workload: 759;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 55%;
* Community nursing homes: 11%;
* State veterans‘ nursing homes: 35%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -3%;
* Community nursing homes: -4%;
* State veterans‘ nursing homes: 7%.
Network: 3 (Bronx);
Fiscal year 1998 total workload: 2,240;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 44%;
* Community nursing homes: 9%;
* State veterans‘ nursing homes: 47%;
Fiscal year 2003 total workload: 2,006;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 38%;
* Community nursing homes: 2%;
* State veterans‘ nursing homes: 60%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -6%;
* Community nursing homes: -7%;
* State veterans‘ nursing homes: 13%.
Network: 4 (Pittsburgh);
Fiscal year 1998 total workload: 2,539;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 47%;
* Community nursing homes: 16%;
* State veterans‘ nursing homes: 38%;
Fiscal year 2003 total workload: 2,314;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 48%;
* Community nursing homes: 5%;
* State veterans‘ nursing homes: 46%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 2%;
* Community nursing homes: -11%;
* State veterans‘ nursing homes: 9%.
Network: 5 (Baltimore);
Fiscal year 1998 total workload: 854;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 50%;
* Community nursing homes: 20%;
* State veterans‘ nursing homes: 30%;
Fiscal year 2003 total workload: 695;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 64%;
* Community nursing homes: 9%;
* State veterans‘ nursing homes: 27%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 13%;
* Community nursing homes: -11%;
* State veterans‘ nursing homes: -3%.
Network: 6 (Durham);
Fiscal year 1998 total workload: 1,155;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 65%;
* Community nursing homes: 20%;
* State veterans‘ nursing homes: 15%;
Fiscal year 2003 total workload: 1,166;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 64%;
* Community nursing homes: 9%;
* State veterans‘ nursing homes: 27%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: a%;
* Community nursing homes: -11%;
* State veterans‘ nursing homes: 12%.
Network: 7 (Atlanta);
Fiscal year 1998 total workload: 2,190;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 33%;
* Community nursing homes: 14%;
* State veterans‘ nursing homes: 53%;
Fiscal year 2003 total workload: 2,116;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 36%;
* Community nursing homes: 8%;
* State veterans‘ nursing homes: 56%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 3%;
* Community nursing homes: -6%;
* State veterans‘ nursing homes: 2%.
Network: 8 (Bay Pines);
Fiscal year 1998 total workload: 1,358;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 69%;
* Community nursing homes: 23%;
* State veterans‘ nursing homes: 8%;
Fiscal year 2003 total workload: 1,617;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 57%;
* Community nursing homes: 22%;
* State veterans‘ nursing homes: 22%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -12%;
* Community nursing homes: -2%;
* State veterans‘ nursing homes: 14%.
Network: 9 (Nashville);
Fiscal year 1998 total workload: 1,283;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 32%;
* Community nursing homes: 21%;
* State veterans‘ nursing homes: 47%;
Fiscal year 2003 total workload: 1,189;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 26%;
* Community nursing homes: 17%;
* State veterans‘ nursing homes: 56%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -6%;
* Community nursing homes: -4%;
* State veterans‘ nursing homes: 9%.
Network: 10 (Cincinnati);
Fiscal year 1998 total workload: 1,274;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 52%;
* Community nursing homes: 20%;
* State veterans‘ nursing homes: 28%;
Fiscal year 2003 total workload: 1,124;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 52%;
* Community nursing homes: 11%;
* State veterans‘ nursing homes: 37%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: [B]%;
* Community nursing homes: -9%;
* State veterans‘ nursing homes: 9%.
Network: 11 (Ann Arbor);
Fiscal year 1998 total workload: 1,670;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 39%;
* Community nursing homes: 13%;
* State veterans‘ nursing homes: 49%;
Fiscal year 2003 total workload: 1,601;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 39%;
* Community nursing homes: 11%;
* State veterans‘ nursing homes: 50%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: [B]%;
* Community nursing homes: -2%;
* State veterans‘ nursing homes: 1%.
Network: 12 (Chicago);
Fiscal year 1998 total workload: 2,225;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 30%;
* Community nursing homes: 19%;
* State veterans‘ nursing homes: 50%;
Fiscal year 2003 total workload: 2,030;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 33%;
* Community nursing homes: 13%;
* State veterans‘ nursing homes: 55%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 2%;
* Community nursing homes: -7%;
* State veterans‘ nursing homes: 4%.
Network: 15 (Kansas City);
Fiscal year 1998 total workload: 1,402;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 27%;
* Community nursing homes: 17%;
* State veterans‘ nursing homes: 55%;
Fiscal year 2003 total workload: 1,714;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 19%;
* Community nursing homes: 10%;
* State veterans‘ nursing homes: 71%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -8%;
* Community nursing homes: -7%;
* State veterans‘ nursing homes: 15%.
Network: 16 (Jackson);
Fiscal year 1998 total workload: 2,910;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 26%;
* Community nursing homes: 13%;
* State veterans‘ nursing homes: 61%;
Fiscal year 2003 total workload: 2,929;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 25%;
* Community nursing homes: 9%;
* State veterans‘ nursing homes: 66%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: a%;
* Community nursing homes: -4%;
* State veterans‘ nursing homes: 4%.
Network: 17 (Dallas);
Fiscal year 1998 total workload: 885;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 68%;
* Community nursing homes: 32%;
* State veterans‘ nursing homes: 0[C]%;
Fiscal year 2003 total workload: 1,259;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 49%;
* Community nursing homes: 21%;
* State veterans‘ nursing homes: 30%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -19%;
* Community nursing homes: -11%;
* State veterans‘ nursing homes: 30%.
Network: 18 (Phoenix);
Fiscal year 1998 total workload: 945;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 47%;
* Community nursing homes: 18%;
* State veterans‘ nursing homes: 35%;
Fiscal year 2003 total workload: 1,028;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 40%;
* Community nursing homes: 19%;
* State veterans‘ nursing homes: 41%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -7%;
* Community nursing homes: [B]%;
* State veterans‘ nursing homes: 6%.
Network: 19 (Denver);
Fiscal year 1998 total workload: 1,026;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 38%;
* Community nursing homes: 9%;
* State veterans‘ nursing homes: 54%;
Fiscal year 2003 total workload: 995;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 22%;
* Community nursing homes: 19%;
* State veterans‘ nursing homes: 59%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -15%;
* Community nursing homes: 10%;
* State veterans‘ nursing homes: 5%.
Network: 20 (Portland);
Fiscal year 1998 total workload: 1,196;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 29%;
* Community nursing homes: 24%;
* State veterans‘ nursing homes: 47%;
Fiscal year 2003 total workload: 1,384;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 22%;
* Community nursing homes: 25%;
* State veterans‘ nursing homes: 53%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -7%;
* Community nursing homes: 1%;
* State veterans‘ nursing homes: 6%.
Network: 21 (San Francisco);
Fiscal year 1998 total workload: 1,269;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 49%;
* Community nursing homes: 21%;
* State veterans‘ nursing homes: 30%;
Fiscal year 2003 total workload: 1,225;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 56%;
* Community nursing homes: 16%;
* State veterans‘ nursing homes: 28%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: 7%;
* Community nursing homes: -5%;
* State veterans‘ nursing homes: -2%.
Network: 22 (Long Beach);
Fiscal year 1998 total workload: 1,071;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 49%;
* Community nursing homes: 36%;
* State veterans‘ nursing homes: 15%;
Fiscal year 2003 total workload: 1,007;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 39%;
* Community nursing homes: 36%;
* State veterans‘ nursing homes: 25%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -10%;
* Community nursing homes: a%;
* State veterans‘ nursing homes: 10%.
Network: 23 (Minneapolis);
Fiscal year 1998 total workload: 2,937;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 27%;
* Community nursing homes: 5%;
* State veterans‘ nursing homes: 68%;
Fiscal year 2003 total workload: 2,926;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 23%;
* Community nursing homes: 8%;
* State veterans‘ nursing homes: 69%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -3%;
* Community nursing homes: 3%;
* State veterans‘ nursing homes: [B]%.
Network: Total;
Fiscal year 1998 total workload: 33,630;
Fiscal year 1998 percentage of total workload in each nursing home
setting:
* VA nursing homes: 40%;
* Community nursing homes: 17%;
* State veterans‘ nursing homes: 43%;
Fiscal year 2003 total workload: 33,214;
Fiscal year 2003 percentage of total workload in each nursing home
setting:
* VA nursing homes: 37%;
* Community nursing homes: 13%;
* State veterans‘ nursing homes: 50%;
Change in percentage of workload by setting, fiscal year 2003
compared to fiscal year 1998:
* VA nursing homes: -3%;
* Community nursing homes: -4%;
* State veterans‘ nursing homes: 7%.
[End of table]
[End of section]
Appendix IV: Comments from the Department of Veterans Affairs:
THE SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:
October 5, 2004:
Ms. Cynthia A. Bascetta:
Director:
Health Care Team:
U. S. Government Accountability Office:
441 G Street, NW:
Washington. DC 20540:
Dear Ms. Basceta:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VA LONG TERM CARE,
Oversight of Nursing Home Program Impeded by Data Gaps, (GAO-04-10501.
VA concurs in principle with GAO's recommendations. However. Veterans
Health Administration (VHA) experience demonstrates that the
availability o1 priority data elements other than length of stay (LOS)
and eligibility is far more crucial to VHA's planning process. This is
discussed further in the enclosure.
VA will continue its efforts to reduce data gaps in the community
nursing home and state veteran home programs, although VILA believes it
is generating data that are most crucial to its planning and oversight
efforts. VA appreciates the opportunity to comment on GAO's draft
report.
Sincerely yours.
Signed by:
Anthony J. Principi:
Enclosure:
THE DEPARTMENT OF VETERANS AFFAIRS COMMENTS TO GAO DRAFT REPORT:
VA LONG TERM CARE: Oversight of Nursing Home Program Impeded by Data
Gaps (GAO-04-1050):
To help ensure that VA can provide adequate program monitoring and
planning for nursing home care and to improve the completeness of data
needed for congressional oversight, we recommend that the Secretary of
Veterans Affairs direct the Under Secretary for Health to take two
actions:
* For community nursing homes and state veterans' nursing homes collect
and report data on the number of veterans that have long-and short-
stays, comparable to data VA currently collects on VA nursing homes.
For community nursing homes and state veterans' nursing homes, collect
and report data on the number of veterans in these homes that VA is
required to serve based on the requirements of the Millennium Act of
VA's policy on nursing home eligibility, comparable to data VA
currently collects on VA nursing homes.
Concur in Principle - However, VA believes the availability of other
priority data elements is far more crucial to VA's Long Term Care
strategic planning process.
Over the past year, the Veterans Health Administration (VHA) has
extracted data from various sources to reduce these information gaps in
the Community Nursing Home (CNH) and State Veterans' Home (SVH)
programs. We now have social security information for both these
programs and have length of stay (LOS) and eligibility information for
the CNH program. Additionally, VHA has made progress this year in
narrowing information gaps in CNH and SVH programs. Measuring LOS in
CNH is now achievable and possible in SVH using proxy data. VHA
believes that data integrity in MDS (Minimum Data Set) is highly
variable at this time, however, as consistency in reporting improves,
future information will also improve.
VHA's strategic planning process for nursing home care includes an
actuarial estimate of demand adjusted to reflect policy considerations,
followed by VISN analysis of workload and resource requirements
necessary to meet the demand projections. VHA's projection of demand is
based on the veteran enrollee population, stratified by age, gender,
priority, disability, and marital status elements. Nationally
recognized utilization rates are then applied to these elements to
generate demand projections for nursing home care services. These
projections are then adjusted by known veteran reliance factors,
including priority care status, that best reflect nursing home care
policy. Networks then use the national guidance to develop their own
plans to assess current operating levels versus demand projections and
the potential impact on the three VA sponsored nursing home care
programs. Length of stay is not a particular element of this process.
VHA's most recent modeling effort included the latest available
national long-term care survey information, which includes nursing home
utilization rates and veteran enrollment characteristics.
Additionally, VHA has established a working agreement with the Centers
for Medicare and Medicaid Services for data to be used in a
demonstration project that will link Medicare, Medicaid and VA data for
those veterans with multiple eligibilities. This project, as well as
new data availability, will provide VA with valuable information about
veteran reliance on VA-supported nursing home care. Modeling efforts to
predict future veteran demand for these services will also be improved
as a result of these efforts.
The medical and social needs of our patients, more than their
eligibility status or projected LOS, are the primary drivers of nursing
home placement decisions. For example, a patient requiring skilled
nursing or rehabilitative care following a stroke or surgery, is more
appropriately placed in a VA nursing home care unit or in a community
nursing home that offers the services that the patient requires. A
stable patient who needs only supportive care and who desires to be
close to home may be placed in a community or state home. The LOS and
eligibility status, in these cases, is incidental. Eligibility status
is also incidental, except for the small number of priority 1 a
veterans whose nursing home care is mandatory under the Millennium Act
and VA policy.
GAO cites variability among VISNs in nursing home lengths of stay and
in veteran priorities served. Given the availability of nursing home
care options across the country (Medicare, Medicaid, and others), such
differences are to be expected. GAO notes that one-third of VA nursing
home care was long-stay (90 days or more) in FY 2003. This figure is
based on a count of individual patients. In contrast, calculations
based on the average daily census/patient days of care yield an eighty
percent rate of long stay care in VA units. VA believes this shift is
related to the greater availability of both state veterans' home beds
that offer predominantly long term stays, and home and community based
care, which help delay the need for nursing home care. When nursing
home care is eventually needed, patient stays are normally shorter
because the patient's health status has often deteriorated to the point
that end-of-life care is then indicated.
A final point in response to GAO's report is that GAO states about one-
fourth of veterans receiving nursing home care are entitled to such
care under the requirements of the Millennium Act. Such a statement
could be misinterpreted to imply that some such "mandatory" veterans
are being displaced by veterans receiving discretionary care. GAO has
not provided any evidence of this, nor is VHA aware that this is the
case.
In conclusion, VHA will continue its efforts to reduce data gaps in the
community nursing home and state veterans home programs, although VA
believes VHA is already generating those data that are most crucial to
planning and oversight.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
James C. Musselwhite, (202) 512-7259:
Acknowledgments:
In addition to the contact named above, Cheryl A. Brand, Pamela A.
Dooley, and Thomas A. Walke made key contributions to this report.
[End of section]
Related GAO Products:
VA Long-Term Care: More Accurate Measure of Home-Based Primary Care
Workload Is Needed. GAO-04-913. Washington, D.C.: September 8, 2004.
VA Long-Term Care: Changes in Service Delivery Raise Important
Questions. GAO-04-425T. Washington, D.C.: January 28, 2004.
VA Long-Term Care: Veterans' Access to Noninstitutional Care Is Limited
by Service Gaps and Facility Restrictions. GAO-03-815T. Washington,
D.C.: May 22, 2003.
VA Long-Term Care: Service Gaps and Facility Restrictions Limit
Veterans' Access to Noninstitutional Care. GAO-03-487. Washington,
D.C.: May 9, 2003.
Department of Veterans Affairs: Key Management Challenges in Health and
Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003.
VA Long-Term Care: The Availability of Noninstitutional Services Is
Uneven. GAO-02-652T. Washington, D.C.: April 25, 2002.
VA Long-Term Care: Implementation of Certain Millennium Act Provisions
Is Incomplete, and Availability of Noninstitutional Services Is Uneven.
GAO-02-510R. Washington, D.C.: March 29, 2002.
VA Long-Term Care: Oversight of Community Nursing Homes Needs
Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001.
FOOTNOTES
[1] VA's national health care system consists of 21 regional health
care networks. These networks have budget and management
responsibilities that include allocating budgetary resources for VA
nursing homes.
[2] The independent commission is called the Capital Asset Realignment
for Enhanced Services Commission. This Commission reviewed proposals by
VA regarding realignment and allocation of capital assets, such as
health care facilities, to better meet the demand for veterans' health
care services into the future.
[3] Pub. L. No. 106-117, 113 Stat. 1545 (1999).
[4] A service-connected disability is an injury or disease that was
incurred or aggravated while on active duty. VA classifies veterans
with service-connected disabilities according to the extent of their
disability. These classifications are expressed in terms of
percentages---for example, the most severely disabled such veteran
would be classified as having a service-connected disability of 100
percent. Percentages are assigned in increments of 10 percent.
[5] The Veterans Health Care, Capital Asset, and Business Improvement
Act of 2003, Pub. L. No. 108-170, § 106 (b), 117 Stat. 2042, 2046
extended this provision of the Millennium Act.
[6] These veterans must also be classified as unemployable or Permanent
and Total Disabled (P&T).
[7] We do not present data on eligibility for fiscal year 1998 because
the Millennium Act was not enacted until fiscal year 2000.
[8] VA discontinued its Regional Community Nursing Home initiative and
reverted these contracts to contracts through its medical centers in
fiscal year 2004.
[9] If a state veterans' home received a construction grant from VA, at
least 75 percent of its residents must be veterans in order to
participate in the VA per-diem program. If the state veterans' home did
not receive a construction grant from VA, VA requires that more than 50
percent of the residents be veterans. See 38 CFR § 51.210 (d)(2003).
[10] The daily amount paid per veteran in recognized state veterans'
homes is the per diem rate established under 38 U.S.C. §1741, for
nursing home care.
[11] These grants include resources for construction and renovation of
state veterans' nursing homes that provide services in addition to or
other than nursing home care. Some state veterans' nursing homes
include--or consist solely of--domiciliaries, which are facilities for
the care of veterans who do not require hospital or nursing home care
but are unable to live independently because of medical or psychiatric
disabilities. A small number of state veterans' nursing homes also
offer hospital care or adult day health care.
[12] VA is not authorized, in most cases, to bill and collect payments
from Medicare and Medicaid nor can VA bill other insurers for health
care conditions that are related to military service. However, a
veteran's eligibility to participate in VA's nursing home program does
not prohibit a veteran from using these financing sources of nursing
home care outside of VA's health care system, if eligible.
[13] See GAO, Long-Term Care: Aging Baby Boom Generation Will Increase
Demand and Burden on Federal and State Budgets, GAO-02-544T
(Washington, D.C.: Mar. 21, 2002).
[14] For the purposes of our analysis we treated networks 13 and 14 as
one network in fiscal year 1998 to compare with Network 23
(Minneapolis) in 2003, which now includes the regions previously served
by networks 13 and 14.
[15] These patient numbers are based on discharges and a single patient
may be admitted more than once in the same fiscal year.
[16] Medicare covers skilled nursing facility stays for up to 100 days
(per spell of illness), whereas Medicaid has no length-of-stay limits.
[17] This category excludes veterans who were also eligible for nursing
home care based on their service-connected rating and other statuses.
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