VA Long-Term Care
More Accurate Measure of Home-Based Primary Care Workload Is Needed Gao ID: GAO-04-913 September 8, 2004The Department of Veterans Affairs (VA) provides a variety of long-term care services that includes nursing home care and noninstitutional care provided in community-based settings or in the homes of veterans. One important noninstitutional service is home-based primary care, which uses a multidisciplinary team approach involving VA health care providers and others such as social workers to treat veterans who are homebound. As part of GAO's work for the Committee on Veterans' Affairs, House of Representatives, to assess how VA meets veterans' long-term care needs, GAO reviewed how VA measures workload for home-based primary care and five other noninstitutional services.
The amount of home-based primary care veterans receive is not accurately reflected in VA's workload measurement for that service. VA measures home-based primary care workload using the number of days a veteran is enrolled in the program rather than the number of visits the veteran received. For example, if a veteran was enrolled in VA's home-based primary care program for 1 week, and received two visits from VA providers that week, VA would calculate the workload using 7 days, rather than two visits. As a result, using enrolled days as the workload unit of measure overstates the amount of home-based primary care actually received by veterans. In fiscal year 2003, VA reported an average daily workload for home-based primary care of 8,370 using enrolled days; in contrast, GAO determined that using the number of visits results in a workload of 944. In addition, VA's measurement of home-based primary care using enrolled days is inconsistent with the way it measures workload for the other noninstitutional long-term care services GAO reviewed. VA measures workload for these other services using the number of visits a veteran received. As a result, VA's workload total for home-based primary care overstates that service's use compared to other noninstitutional services VA provides.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-04-913, VA Long-Term Care: More Accurate Measure of Home-Based Primary Care Workload Is Needed
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Report to the Secretary of Veterans Affairs:
United States Government Accountability Office:
GAO:
September 2004:
VA Long-Term Care:
More Accurate Measure of Home-Based Primary Care Workload Is Needed:
GAO-04-913:
GAO Highlights:
Highlights of GAO-04-913, a report to the Secretary of Veterans
Affairs:
Why GAO Did This Study:
The Department of Veterans Affairs (VA) provides a variety of long-
term care services that includes nursing home care and noninstitutional
care provided in community-based settings or in the homes of veterans.
One important noninstitutional service is home-based primary care,
which uses a multidisciplinary team approach involving VA health care
providers and others such as social workers to treat veterans who are
homebound. As part of GAO‘s work for the Committee on Veterans‘
Affairs, House of Representatives, to assess how VA meets veterans‘
long-term care needs, GAO reviewed how VA measures workload for home-
based primary care and five other noninstitutional services.
What GAO Found:
The amount of home-based primary care veterans receive is not
accurately reflected in VA‘s workload measurement for that service. VA
measures home-based primary care workload using the number of days a
veteran is enrolled in the program rather than the number of visits the
veteran received. For example, if a veteran was enrolled in VA‘s home-
based primary care program for 1 week, and received two visits from VA
providers that week, VA would calculate the workload using 7 days,
rather than two visits. As a result, using enrolled days as the
workload unit of measure overstates the amount of home-based primary
care actually received by veterans. In fiscal year 2003, VA reported
an average daily workload for home-based primary care of 8,370 using
enrolled days; in contrast, GAO determined that using the number of
visits results in a workload of 944. In addition, VA‘s measurement of
home-based primary care using enrolled days is inconsistent with the
way it measures workload for the other noninstitutional long-term care
services GAO reviewed. VA measures workload for these other services
using the number of visits a veteran received. As a result, VA‘s
workload total for home-based primary care overstates that service‘s
use compared to other noninstitutional services VA provides.
VA Noninstitutional Long-Term Care Workload, Fiscal Year 2003:
[See PDF for image]
Note: VA reports all noninstitutional care workload measures except
home-based primary care in visits.
[End of figure]
What GAO Recommends:
GAO recommends that VA measure and report the amount of home-based
primary care services veterans receive by using visits. VA agreed that
a more accurate measure of home-based primary care is needed but did
not concur with GAO‘s recommendation. However, VA plans to establish a
combination of workload measures for home-based primary care and other
long-term care programs in fiscal year 2005, including visits, which
will be responsive to GAO‘s recommendation.
www.gao.gov/cgi-bin/getrpt?GAO-04-913.
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's Workload Measurement for Home-Based Primary Care Does Not
Accurately Reflect the Amount of Care Received by Veterans:
Conclusions:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Comments from the Department of Veterans Affairs:
Table:
Table 1: Selected VA Noninstitutional Long-Term Care Services:
Figure:
Figure 1: VA Noninstitutional Long-Term Care Workload, Fiscal Year
2003:
Abbreviation:
VA: Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
September 8, 2004:
The Honorable Anthony J. Principi:
Secretary of Veterans Affairs:
Dear Mr. Secretary:
The Department of Veterans Affairs (VA) provides a continuum of long-
term care services that includes nursing home care and noninstitutional
services provided in community-based settings or in the homes of
veterans. One important noninstitutional service VA provides is home-
based primary care, which uses a multidisciplinary team approach
involving VA health care providers and others such as social workers to
treat veterans who are homebound. Concerns about meeting veterans'
long-term care needs in both institutional and noninstitutional
settings have increased in part because the veteran population is
aging. The number of veterans 85 years old and older, who are most in
need of long-term care, is expected to increase from about 870,000 to
1.3 million over the next decade. Through its noninstitutional long-
term care program, VA provides or pays for services that may help
veterans remain at home and delay, or prevent, their need for nursing
home care. As part of our work for the Committee on Veterans' Affairs,
House of Representatives, to assess how VA met or addressed its long-
term care workload needs from fiscal years 1998 through 2003, we
reviewed how VA measures this workload for home-based primary care and
other services.[Footnote 1]
To conduct our review, we assessed veteran patient workload data for
fiscal years 1998 through 2003. Because VA did not change how it
measured workload for the noninstitutional services we reviewed from
fiscal years 1998 through 2003, we focused on fiscal year 2003 for this
report. We obtained data from VA on workload and information about how
it is measured and we analyzed these data for six noninstitutional
long-term care services: (1) home-based primary care, (2) adult day
health care, (3) homemaker/home health aide, (4) skilled home health
care, (5) home respite care, and (6) home hospice care.[Footnote 2] In
doing our work, we tested the reliability of the data and determined
they were adequate for our purposes. We conducted our review from
January 2003 through August 2004 in accordance with generally accepted
government auditing standards.
Results in Brief:
VA's workload measurement of home-based primary care services does not
accurately reflect the amount of care veterans receive. VA measures
home-based primary care workload using the number of days a veteran is
enrolled in the program rather than the number of visits received by a
veteran. For example, if a veteran was enrolled in VA's home-based
primary care program for 1 week, and received two visits from VA
providers that week, VA would calculate the workload using 7 days,
rather than two visits. As a result, the use of enrolled days as the
unit of measure for home-based primary care overstates the services
actually received by veterans. Specifically, VA reported an average
daily workload for home-based primary care of 8,370 using enrolled days
in fiscal year 2003; in contrast, we determined that using the number
of visits results in a workload of 944. In addition, VA's measurement
of home-based primary care using enrolled days is inconsistent with the
way VA measures workload for the five other noninstitutional long-term
care services we reviewed. For these other services, VA measures
workload using the number of visits a veteran received. Because the
number of visits is a more accurate measure of the home-based primary
care services veterans receive than enrolled days, we are recommending
that VA use visits to measure and report the amount of home-based
primary care services veterans receive.
In commenting on a draft of this report, VA agreed that a more accurate
measure of home-based primary care is needed but did not concur with
our recommendation. However, VA plans to establish a combination of
workload measures for home-based primary care and other long-term care
programs in fiscal year 2005, including visits, which will be
responsive to our recommendation. This will provide useful information
to Congress and other stakeholders for assessing the amount of home-
based primary care services veterans receive from VA.
Background:
VA provides noninstitutional services as an important part of its
continuum of long-term care. VA provides these services to veterans in
their own homes or in community settings using both its own employees
and other providers available through contracts. Veterans may prefer
such services, which allow them to remain in their homes or in other
settings that are less restrictive than institutions. We reviewed six
of the noninstitutional services that VA provides or pays for. (See
table 1.) VA reported workload measures for these noninstitutional care
services in appropriations requests and testimony to Congress.[Footnote
3]
Table 1: Selected VA Noninstitutional Long-Term Care Services:
Service: Home-based primary care;
Description: Primary health care, delivered by a physician-directed
interdisciplinary team of staff including nurses, to homebound (often
bedbound) veterans for whom visits to an outpatient clinic are not
practical;
Care providers: VA providers.
Service: Homemaker/home health aide;
Description: Personal care, such as grooming, housekeeping, and meal
preparation services, provided in the home to veterans who would
otherwise need nursing home care;
Care providers: Contracted providers.
Service: Adult day health care;
Description: Health maintenance and rehabilitative services provided
to frail elderly veterans in an outpatient setting during part of the
day;
Care providers: VA and contracted providers.
Service: Skilled home health care;
Description: Medical services provided to veterans at home;
Care providers: Contracted providers.
Service: Home respite care;
Description: Services provided at home to temporarily relieve the
veteran's caregiver from the burden of caring for a chronically
disabled veteran in the home;
Care providers: Contracted providers.
Service: Home hospice care;
Description: Services provided at home to veterans whose primary goal
of treatment is comfort rather than cure for an advanced disease that
is life-limiting;
Care providers: Contracted providers.
Source: VA.
[End of table]
VA's Workload Measurement for Home-Based Primary Care Does Not
Accurately Reflect the Amount of Care Received by Veterans:
VA's workload measurement for home-based primary care does not
accurately reflect the amount of care received by veterans. VA measures
home-based primary care workload using the number of days the veteran
is enrolled in the program to receive these services, including
weekends. Veterans do not, however, typically receive a home-based
primary care visit every day they are enrolled in the program. For
example, if a veteran was enrolled in VA's home-based primary care
program for 1 week, and received two visits from VA providers that
week, VA would calculate the workload using 7 days, rather than two
visits. VA officials told us that VA used the number of enrolled days
to measure access to home-based primary care. While the number of
enrolled days may provide a measure of access it does not provide an
accurate measure of the services veterans receive. Measuring workload
on the basis of number of visits veterans receive is a more accurate
measure of VA's provision of this service.
To more accurately reflect the services veterans received, we measured
VA's workload for home-based primary care using number of visits as the
unit of measure. Using this method, we determined that the average
daily workload for VA's home-based primary care in fiscal year 2003 was
944. VA, however, reported an average daily workload for home-based
primary care that year of 8,370 based on enrolled days. The use of
enrolled days as a workload measure overstates the amount of home-based
primary care services veterans received by a factor of 9 to 1.
Moreover, the way VA measures home-based primary care workload is
inconsistent with the way it measures workload for the five other
noninstitutional long-term care services we reviewed.[Footnote 4] For
these other services, VA measures workload using the number of visits a
veteran received from a health care provider rather than the number of
days the veteran was enrolled in the program. In fiscal year 2003, VA's
use of enrolled days to measure home-based primary care workload
resulted in that service having the largest workload (46 percent) in
comparison to the five other noninstitutional services. In contrast,
when using visits to measure the home-based primary care workload,
home-based primary care constituted 9 percent of all noninstitutional
care services and its workload was smaller than the workload for
homemaker/home health aide, adult day health care, or skilled home
health care. (See fig. 1.)
Figure 1: VA Noninstitutional Long-Term Care Workload, Fiscal Year
2003:
[See PDF for image]
Note: VA reports all noninstitutional care workload measures except
home-based primary care in visits.
[End of figure]
Conclusions:
VA's use of enrolled days to measure home-based primary care workload
does not accurately measure the amount of this service that veterans
receive and overstates its usage compared with other noninstitutional
care services. VA reported that in fiscal year 2003 the average daily
workload for home-based primary care, based on enrolled days, was
8,370. Measured in visits, however, we determined that the average
daily workload for home-based primary care was 944. Inaccurate
measurement and overstated usage of home-based primary care, as
reported by VA, makes it difficult for decision makers to know the
amount of care VA is providing with the resources it is expending.
Using the number of visits instead of the number of enrolled days to
measure home-based primary care workload would provide a more accurate
measure of the amount of home-based primary care services that veterans
receive and would provide a more appropriate comparison of home-based
primary care with other noninstitutional long-term care services.
Recommendation for Executive Action:
Because the number of visits is a more accurate measure of the home-
based primary care services veterans receive than enrolled days, we
recommend that you direct the Under Secretary for Health to use visits
to measure and report the amount of home-based primary care services
veterans receive.
Agency Comments and Our Evaluation:
In commenting on a draft of this report, VA agreed that a more accurate
measure of home-based primary care is needed but did not concur with
our recommendation to use visits to measure and report the amount of
home-based primary care services veterans receive. However, VA plans to
establish a combination of workload measures for home-based primary
care and other long-term care programs in fiscal year 2005, including
visits, which will be responsive to our recommendation.
VA stated that it did not concur with our recommendation because using
the number of visits alone, rather than incorporating ancillary work
such as reviewing laboratory and other test results, does not entirely
represent home-based primary care workload. VA stated that it made a
deliberate decision to convert from using the number of visits received
to the number of enrolled days as the primary workload measure because
this would promote more efficient and comprehensive management of the
patient population. However, VA's use of enrolled days as a workload
measure for home-based primary care services provides a misleading
picture of VA's noninstitutional long-term care services. This measure
overstates the amount of services veterans received because VA measures
home-based primary care workload using the number of days the veteran
is enrolled in the program to receive these services, including
weekends. Veterans do not, however, typically receive a home-based
primary care visit every day they are enrolled in the program. Using
enrolled days may be useful for management of a population in need of
such services, as VA states, but not as a measure of the amount of
services veterans received.
VA states that in fiscal year 2005 it will begin reporting two other
workload measures in addition to enrolled days, the number of patients
treated and the number of visits veterans receive. We believe that
reporting the number of patients treated will provide useful
information on the number of veterans receiving home-based primary care
but still will not accurately measure the amount of such care veterans
receive. We believe that measuring and reporting the number of visits
veterans receive, as VA said it will do, will be responsive to our
recommendation. This will provide useful information to Congress and
other stakeholders for assessing the amount of home-based primary care
services veterans receive from VA. If VA chooses to also include in its
home-based primary care measure the amount of ancillary work involved
in delivering such care, this could provide a more comprehensive
workload measure. However, based on a discussion with VA officials, VA
cannot currently provide data on the amount of ancillary work involved
with delivering home-based primary care. VA's written comments are in
appendix I.
We are sending copies of this report to the House Committee on
Veterans' Affairs; other interested congressional committees; and other
interested parties. This report is also available at no charge on GAO's
Web site at http://www.gao.gov. If you have questions about this
report, please contact me at (202) 512-7101 or James Musselwhite at
(202) 512-7259. Also contributing to this report were Cheryl A. Brand,
Janet L. Overton, and Thomas A. Walke.
Sincerely yours,
Signed by:
Cynthia A. Bascetta, Director,
Health Care--Veterans' Health and Benefits Issues:
[End of section]
Appendix I: Comments from the Department of Veterans Affairs:
THE SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:
August 11, 2004:
Ms. Cynthia A. Bascetta:
Director:
Health Care Team:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Bascetta:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VA LONG TERM CARE: More
Accurate Measure of Home-Based Primary Care Workload is Needed, (GAO-
04-913). VA acknowledges the need for a more sophisticated and accurate
primary workload measurement methodology for the Veterans Health
Administration's (VHA) Home-Based Primary Care (HBPC) initiative.
However, VA does not concur in your recommendation to measure and
report the amount of home-based primary care services veterans receive
by using visits because the number of visits does not adequately
represent the amount of ancillary work that goes into this type of
care.
VHA has made a deliberate decision to convert from the number of visits
to the number of enrolled days of care as the primary workload
measurement methodology because it promotes more efficient and
comprehensive management of this patient population. Moreover, VHA is
establishing a combination of measures to reduce undesired incentives
from any one workload measure. To assure consistency across all VHA
long-term care programs, VHA will implement this methodology for all
other home and community based care programs beginning in FY 2005.
The enclosure details the Department's reasons for not concurring in
GAO's recommendation. VA appreciates the opportunity to comment on your
draft report and my staff would be happy to discuss this further at
your convenience.
Sincerely yours,
Signed by:
Anthony J. Principi:
Enclosure:
Enclosure:
THE DEPARTMENT OF VETERANS AFFAIRS COMMENTS TO GAO DRAFT REPORT:
VA LONG TERM CARE: More Accurate measure of Home-Based Primary Care
Workload is Needed (GAO-04-913):
Because visits is a more accurate measure of home based primary care
services that veterans receive than enrolled days, GAO recommends that
the Secretary of Veterans Affairs direct the Under Secretary for Health
to measure and report the amount of home based primary care services
veterans receive by using visits.
Do Not Concur - VA does not concur with GAO's recommendation to use the
number of visits received by the veteran in Home-Based Primary Care
(HBPC) because the number of visits does not adequately represent the
amount of ancillary work that goes into this type of care. Home-Based
Primary Care is an alternative to nursing home care. In contrast to
skilled nursing care, which is fee-based per hour of care, HBPC
furnishes continuous coverage. Supporting this distinction, the Joint
Commission on Accreditation of Healthcare Organizations requires that
during orientation to HBPC, patients be given materials that provide
clear instructions on how to reach staff between visits, any time of
the night or day. Accordingly, most of the effort in effective HBPC
patient management involves time that is not captured by the number of
visits. Much of the time used in caring for these patients is in tasks
such as coordinating care with VA and community services, facilitating
medication management, meeting with members of the interdisciplinary
team, reviewing laboratory and other test results, telephone
conversations with the patients, their families and caregivers, and the
travel time to and from home visits.
To the best of VA's knowledge, the Department's HBPC program is not
replicated in the private sector. Services most closely resembling the
HBPC program might be Medicare's Hospice Program, which is paid for on
a per-diem basis and reflects the fact that the interdisciplinary
hospice care team provides continuous oversight and support even if no
patient visit occurred.
VA acknowledges the need for a more sophisticated and accurate primary
workload measurement methodology for the HBPC initiative and across all
VA's long-term care programs. VA believes a combination of measures,
which will be implemented in FY 2005, will better serve veterans than
would any single measure. These measurements are: 1) days of care
(census of enrolled patients); 2) number of patients treated; and 3)
number of visits. Each of these measures serves a different purpose
and allows different aspects of VHA's long-term care programs to be
monitored.
VA focuses on number of enrolled days of care as the key workload
measure for HBPC to encourage comprehensive longitudinal care. This
approach is successful in managing persons with complex, chronic,
progressively disabling conditions. To eliminate the incentive to
enroll and maintain a large patient population that requires little
effort from the home-care team, VA provides oversight by requiring
ongoing review of eligibility criteria, periodic quality management
assessments, and compliance with accreditation standards.
[End of section]
FOOTNOTES
[1] See GAO, VA Long-Term Care: Changes In Service Delivery Raise
Important Questions, GAO-04-425T (Washington, D.C.: Jan. 28, 2004).
[2] Combining workload for each of these services is not a measure of
the number of unique veterans receiving these services because a
patient may receive more than one noninstitutional long-term care
service in the same day.
[3] House Committee on Veterans' Affairs, Statement of the Under
Secretary for Health, Department of Veterans Affairs, VA's Long-Term
Care Programs, 108th Congress, 2nd session, January 28, 2004; House
Subcommittee on Health, Committee on Veterans' Affairs, Statement of
the Under Secretary for Health, Department of Veterans Affairs. VA's
Long-Term Care Programs, 108th Congress, 1st session, May 22, 2003;
Department of Veterans Affairs, Fiscal Year 2004 Budget Submission:
Medical Programs Volume 2 of 5 Final (Washington, D.C.: March 2003), 2-
148; and Department of Veterans Affairs, Fiscal Year 2002 Budget
Submission: Medical Programs, Volume 2 of 6 (Washington, D.C.: April
2001), 2-101.
[4] VA refers to measures of workload for the six services we reviewed
as average daily census.
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