[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
THE STATE OF THE U.S. DEPARTMENT OF
VETERANS AFFAIRS LONG-TERM CARE PROGRAM
PRESENT AND FUTURE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
MAY 9, 2007
__________
Serial No. 110-21
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
Subcommittee on Health
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
May 9, 2007
Page
The State of the U.S. Department of Veterans Affairs (VA) Long-
Term Care Program Present and Future........................... 1
OPENING STATEMENTS
Chairman Michael H. Michaud...................................... 1
Prepared statement of Chairman Michaud....................... 34
Hon. Henry E. Brown.............................................. 2
Prepared statement of Congressman Brown...................... 34
Hon. Timothy J. Walz............................................. 3
WITNESSES
U.S. Department of Veterans Affairs, Patricia Vandenberg, MHA,
BSN, Assistant Deputy Under Secretary for Health for Policy and
Planning, Veterans Health Administration....................... 22
Prepared statement of Ms. Vandenberg......................... 52
______
American Legion, Shannon L. Middleton, Deputy Director,
Healthcare, Veterans Affairs and Rehabilitation Commission..... 14
Prepared statement of Ms. Middleton.......................... 40
Disabled American Veterans, Adrian M. Atizado, Assistant National
Legislative Director........................................... 16
Prepared statement of Mr. Atizado............................ 43
Maine Veterans' Homes, Augusta, ME, Raymond A. Nagel, Chief
Executive Officer.............................................. 4
Prepared statement of Mr. Nagel.............................. 35
National Association of State Veterans Homes, R. Roy Griffith,
Chairman, Liaison Committee, and Administrator, Oklahoma
Veterans Center, Talihina, OK.................................. 6
Prepared statement of Mr. Griffith........................... 38
Paralyzed Veterans of America, Fred Cowell, Senior Associate
Director, Health Analysis...................................... 18
Prepared statement of Mr. Cowell............................. 47
SUBMISSIONS FOR THE RECORD
American Healthcare Association, statement....................... 55
American Occupational Therapy Association, statement............. 56
American Veterans (AMVETS), Kimo S. Hollingsworth, National
Legislative Director, statement................................ 57
Miller, Hon. Jeff, a Representative in Congress from the State of
Florida, statement............................................. 58
MATERIAL SUBMITTED FOR THE RECORD
Priority List of Pending State Home Construction Grant
Applications for FY 2007, supplied by Dr. James F. Burris,
Chief Consultant, Geriatrics and Extended Care, Veterans Health
Administration, U.S. Department of Veterans Affairs, in
response to a request from Chairman Michaud.................... 60
THE STATE OF THE U.S. DEPARTMENT OF
VETERANS AFFAIRS LONG-TERM CARE
PROGRAM PRESENT AND FUTURE
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WEDNESDAY, MAY 9, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:02 a.m., in
Room 334, Cannon House Office Building, Hon. Michael H. Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Hare, Salazar, Brown of
South Carolina.
Also present: Representative Walz.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. The Subcommittee will come to order. I would
like to thank everyone for coming today. Before I begin, I
would ask unanimous consent that Mr. Walz of Minnesota be
invited to sit at the dais of the Subcommittee hearing today.
Hearing no objection, so ordered.
This morning the Subcommittee on Health will examine the
state of VA's long-term care programs and services. In terms of
demographics, the veterans population is aging and will require
a great amount of long-term care services. Out of a veterans
population in this country of 25 million, nearly 45 percent are
over the age of 65 and the number over the age of 80 is
expected to reach 1.3 million by 2010. In addition, the veteran
population is poorer, sicker and older than their non-veteran
counterparts.
The VA will also be facing an entirely new generation of
veterans in need of long-term care services, some of our
wounded returning Operation Enduring Freedom and Operation
Iraqi Freedom (OEF/OIF) veterans who have different needs than
those of our older veterans. Medicaid is a principal financer
of long-term care. In 2004, Medicaid spent $90 billion on long-
term care services, of which $57.6 billion, or 64 percent, was
for institutional care.
The VA has requested $4.6 billion for long-term care
services in fiscal year 2008. Nearly 90 percent is for
institutional care. The VA must, in my view, maintain its
nursing home capacity, while vigorously expanding its non-
institutionalized care capabilities. Contrary to the plain
evidence of an increased long-term care demand, this year the
VA will again ignore its clear legal responsibility to maintain
its nursing home bed capacity.
The VA's fiscal year 2008 budget estimates a further drop
in the average daily census to 11,000, nearly 20 percent below
the required level. I am concerned that VA is not doing enough
to maintain its nursing home capacity, while not moving fast
enough to provide more home and community-based care.
An integral component of the VA's institutional care
service is the State Veterans Home Program. Currently, State
Veterans Homes handle over 50 percent of VA's overall patient
workload in nursing homes. I believe we must maximize this
existing resource, as well as other resources within our
communities, to ensure the best possible care for our veterans.
The VA has a long history of providing long-term care
services and I believe that the VA has many lessons it can
teach other areas of the Federal Government and the private
sector on how best to provide these services. The VA can,
indeed, be a long-term care model for others.
VA continues to have an obligation to meet the long-term
care needs of our veterans and I look forward to hearing from
our witnesses today as to how the VA should meet this
obligation in the future.
It is now my distinct pleasure to recognize the Acting
Ranking Member, a Member who I have served with ever since I
came to the Veterans' Affairs Committee in different
capacities, when I first became Ranking Member of the Benefit
Subcommittee. Then the distinguished Chairman was Chairman
Henry Brown. Following that Congress, I became Ranking Member
of the Healthcare Subcommittee. At that time the distinguished
Chairman was Henry Brown.
And Mr. Brown has actually taken time out to come to the
State of Maine to look at rural healthcare issues and likewise,
I have gone to his State to look at issues in his State. And I
really appreciate his understanding of veterans issues, as well
as his willingness to fight for veterans' healthcare. So I
would yield to the acting Ranking Member, Henry Brown.
[The prepared statement of Chairman Michaud appears on p. 34
.]
OPENING STATEMENT OF HON. HENRY E. BROWN, JR.
Mr. Brown of South Carolina. Well, thank you, Mr. Chairman,
and it has certainly been a pleasure of mine to serve alongside
of you in many different capacities. But in all the capacities
we have served together was to better enhance the quality of
healthcare for our veterans and I commend you for your
continuation along this path.
I am grateful for the Members testifying before the
Committee this morning, and I have met some you earlier and I
look forward to hearing your testimony. I do have some opening
remarks and I will be brief.
Today, one of the biggest challenges in both VA and the
private sector healthcare system is providing long-term care to
a growing aging population. This challenge is amplified for VA
which must facilitate care for the special needs of our
disabled and aging veterans. The Department is also facing an
emerging new need to care for seriously injured younger
veterans returning from the Global War on Terror.
I appreciate at our hearing today we have witnesses
representing the States Veterans Homes. On Veterans Day last
year, I had the privilege of dedicating a new State Veterans
Home in Walterboro, South Carolina. This 220-bed facility, the
Veterans Victory House, is one of the most modern of its kind
in the United States and includes a 52-bed secured dementia
unit.
In partnership with the VA, State Veterans Homes can help
provide a broad range of service to meet the long-term care
needs of our veterans. Last year with the enactment of Public
Law 109-461, the Veterans Benefits, Healthcare and Information
Technology Act of 2006, Congress expanded the authorities for
State Veterans Homes. The law requires VA to reimburse State
Veterans Homes for the full cost of care for a veteran with a
70 percent or greater service-connected disability rating and
in need of care for service-connected conditions. It also
ensures that veterans with a 50 percent or greater service-
connected disability receive, at no cost, medications they need
through VA.
Additionally, Public Law 109-461 requires VA to publish a
strategic plan for long-term care. Hopefully, this plan that
has been a long time in coming will provide a clear map of the
Department's future plans for delivering long-term care for
those veterans who rely on VA to provide these services. I look
forward to the delivery of this plan as required by law. We
have allowed VA to drag its feet on this issue for far too
long.
Mr. Chairman, we need to remember that the quality in which
we provide long-term care is a reflection on how this country
honors the sacrifices of our Nation's veterans.
I look forward to our discussion today and to explore
innovative steps we can take to provide the best patient
centered care to enhance the quality of life of veterans in
need of long-term care services.
Knowing that was a busy day this is, I yield back the
balance of my time and look forward to hearing from the
witnesses. Thank you, Mr. Chairman. It is a pleasure to be here
today.
[The prepared statement of Mr. Brown appears on p. 34.]
Mr. Michaud. Thank you, Mr. Brown. Mr. Walz, any opening
statement?
OPENING STATEMENT OF HON. TIMOTHY J. WALZ
Mr. Walz. Just to keep it short for you, Mr. Chairman.
First of all, I would like to thank you and the acting Ranking
Member Brown for allowing me to be here. But more importantly,
I would like to thank you for your long service to our veterans
and your commitment to them. It is something that is well-known
and I appreciate everything you have done.
I would also like to thank Mr. Nagel and Mr. Griffith for
being here today.
As a 24-year veteran of our armed forces and someone who is
deeply concerned with these issues here, I am here today
because of a re-occurring issue that keeps coming up in
Minneapolis with our Veterans Home there and it has been
ongoing for quite some time. And I know that everyone in this
room is here to be committed to the care of our veterans and to
figure out the best way to do that. So I am here to listen to
your expertise, listen to our Chairman and Ranking Member and
try and figure out what we can do best to help you provide the
care for our veterans and do it in a way that we avoid some of
these problems.
So I thank the Chairman and I yield back.
Mr. Michaud. Thank you very much, Mr. Walz. We really
appreciate your ongoing commitment to our veterans, as well as
your service to this country. I appreciate that.
I will now ask unanimous consent that all written
statements be made part of the record. Without objection, so
ordered.
Mr. Michaud. And I also ask unanimous consent that all
Members be allowed five legislative days to revise and extend
their remarks. Without objection, so ordered.
The first panel, it gives me a pleasure to introduce
Raymond Nagel who is the Chief Executive Office of the Maine
Veterans' Home, as well as Mr. Roy Griffith who is Chairman,
Liaison Committee for the National Association of State
Veterans Homes. I look forward to both of your testimony and we
will start out with Mr. Nagel.
STATEMENTS OF RAYMOND A. NAGEL, CHIEF EXECUTIVE OFFICER, MAINE
VETERANS' HOMES, AUGUSTA, MAINE; R. ROY GRIFFITH, CHAIRMAN,
LIAISON COMMITTEE, NATIONAL ASSOCIATION OF STATE VETERANS
HOMES, AND ADMINISTRATOR, OKLAHOMA VETERANS CENTER, TALIHINA,
OKLAHOMA
STATEMENT OF RAYMOND A. NAGEL
Mr. Nagel. Good morning. Mr. Chairman and Members of the
Subcommittee, thank you for the opportunity to testify today on
behalf of the Maine Veterans' Homes on long-term care. My name
is Ray Nagel. I am the chief executive officer of Maine
Veterans' Homes. I have 23 years of healthcare experience,
including 21 years as a medical service corp. in the United
States Army and the United States Army Reserve. I am a combat
veteran of Operations Desert Shield and Desert Storm.
The Maine Veterans' Homes runs six long-term care
facilities. We operate 640 skilled nursing, long-term nursing
and domiciliary beds and we are very proud of the quality of
the long-term care that we provide.
Our facilities are relatively small in size, 30 to 150 beds
each. They are located throughout the State of Maine allowing
greater access for veterans living in the rural parts of our
State.
We greatly appreciate the Subcommittee's commitment to
long-term care needs of veterans and your understanding of the
indispensable function that State Veterans Homes perform. We
especially appreciate the consistent support of the Veterans
Affairs' Committee and your colleagues on the Appropriations
Committee to ensure that per diem payments by the VA will
continue under current eligibility criteria.
As a Nation, we face the largest aging veterans' population
in our Nation's history. By the end of this decade, the number
of veterans over the age of 85 will have tripled to over 1.3
million. The State Homes now provide about 50 percent of the
VA's total long-term care workload and we should be treated as
a resource that is integrated much more fully with the VA's own
long-term care program.
The State Homes have proposed that our beds be counted
toward the VA's overall long-term care census which will allow
the VA to meet its statutory requirements. Congress' goal
should be to provide long-term care in a manner that expands
the VA's capacity, while paying the lowest available per capita
cost.
The VA reports that the average daily costs of care at a VA
long-term care facility is over $560 a day. The same costs of
care to the VA at a contract nursing home is more than $225 a
day. That same cost to the VA for long-term care at a State
Home is far less, a per diem of under $68 a day. I will repeat,
$68 a day.
This substantially lower daily cost to the VA of the State
Veterans Homes compared to other available long-term care
options led the VA Inspector General to conclude that State
Homes are an economical alternate to contract nursing homes or
VA medical center nursing home care.
The State of Maine, with 640 beds already in operation, has
built all of the long-term care beds for veterans that we
expect to build. Furthermore, we operate our long-term care
beds at 96 percent capacity.
If the State of Maine is to provide greater levels of
service to its veterans, Maine Veterans' Homes must expand the
types of services that we provide. At our 150-bed Bangor
facility, we are proposing to construct an integrated veterans
campus containing a community-based outreach clinic commonly
called a CBOC, a seven-bed hospice facility, and an 18-unit
housing facility.
Attached to my testimony are site plans for this veterans
campus. This campus can be constructed using solely the
financial resources of Maine Veterans Homes, at no cost to
Maine's taxpayers. Later, the services provided could be
expanded to include assisting living in congregate housing,
adult daycare and home healthcare. Our goal is to provide with
an integrated setting comprehensive healthcare services
covering the full continuum of care.
Furthermore, this concept could be replicated at our other
five facilities in order to provide the veterans throughout the
State of Maine with easier access to comprehensive healthcare,
both in rural and urban settings. This concept of veterans
campus could be a model for other States.
Mr. Chairman, we thank you for your support of this concept
and we look forward to welcoming you to the formal announcement
of our plans at our Bangor facility.
In conclusion, we believe that the State Veterans Homes can
play a much more substantial role in meeting the long-term care
needs of veterans. We would be pleased to work with the
Committee and the VA to explore options for developing pilot
programs for innovative, long-term healthcare solutions and for
more closely integrating the State Veterans Homes' programs
into the VA's overall healthcare system.
Mr. Chairman and Members of the Subcommittee, I would be
pleased to answer any questions you may have of me at this
time.
[The prepared statement of Mr. Nagel appears on p. 35.]
Mr. Michaud. Thank you very much, Mr. Nagel.
Mr. Griffith.
STATEMENT OF R. ROY GRIFFITH
Mr. Griffith. Mr. Chairman and Members of the Subcommittee,
I want to thank you for inviting the National Association of
State Veterans Homes (NASVH) to testify on the role that State
Homes do and can play in the VA provision of long-term care.
I especially want to thank you for allowing me to
substitute for our national Legislative Chair, Bob Shaw, who
was unable to make it to today's hearing due to the recent
death of his mother.
This morning I am speaking to you as a member of NASVH's
Executive Committee and Chairman of our VA Liaison Committee
where I am responsible for interfacing with the Department of
Veterans Affairs. In addition, I am here as Administrator of
the Oklahoma Veterans Center, Talihina, Oklahoma, which
provides long-term care to 175 veterans, which includes 48 beds
for dementia patients.
Mr. Chairman, with the aging of our baby boomer generation,
America faces a looming long-term care crisis, one that many of
our Nation's veterans already know too well. VA provides that
today's veteran population of 24.5 million will continue to
fall through 2020, but that the number of veterans over 65
years of age will rise and ultimately peak in the year 2014,
driven by the very large number of Vietnam veterans. Most
alarming, the number of veterans over the age of 85 is
projected to increase by 173 percent by 2020, creating an even
greater number of veterans seeking long-term care.
Mr. Chairman, it is clear that the long-term care needs of
veterans will continue increasing in the coming years and VA
must have a fully developed plan to provide that care. Earlier
this year, in response to a request by VA, NASVH surveyed a
number of State Homes to determine the current unmet demand for
State Home care. We found substantial waiting lists which
indicate as many as 10,000 veterans currently waiting to get
into State Homes, and we believe that there are many more who
don't even bother to put their names on these long waiting
lists.
Mr. Chairman, State Homes today already provide the bulk of
long-term care for our Nation's veterans, with more than 28,000
beds of which 22,000 are skilled beds. Last year the U.S.
government Accountability Office (GAO) reported that State
Homes provide more than 50 percent of VA overall patient
workload in nursing homes, while consuming just 12 percent of
the VA's long-term care budget. And the trend over recent years
shows that State Homes are increasing their share of workload
while their share of VA's budget continues to decline. VA pays
just $67.71 as a per diem payment for each veteran residing in
a State Home, which is less than one-third of the average cost
of that veteran's care.
Compare this to VA's cost when contracting out with
community nursing homes with VA covers a hundred percent of the
cost, often upward of $200 per day, or when VA provides the
care through one of its own nursing homes where the average
cost of care is excess of $500 per day.
Clearly, an investment in State Homes represented an
efficient use of taxpayers' dollars, one that we hope will
continue to receive the strong support it has in the past from
the Committee. The State Homes Program gives you the biggest
bang for your buck.
However, we are deeply troubled by recent cuts in the State
Home Construction Grant Program over the past 2 years, which is
down from $104.3 million to $85 million, which is a total
funding reduction of approximately $40 million in the last 2
years.
As a result of these real dollar reductions, as well as the
effects of inflation and rapidly rising construction costs, the
backlog of State Home construction projects is rapidly rising.
There are currently $242 million in priority one projects,
those that repair life and safety issues in the homes. NASVH
estimates that the total backlog of all potential qualifying
State Home projects could soon surpass $1 billion. Congress
must increase this funding level to at least $160 million in FY
2008 in order to reduce the rising backlog, address the most
serious life and safety issues, and protect the State Homes
system for the future.
Mr. Chairman, since the Civil War, States have assumed the
burden of care for veterans and today spend over $3 billion
annually to provide this care, despite the fact that veterans
of our armed forces are serving the whole Nation, not just
their States. Seen this way, the care rendered to veterans by
the States actually constitutes a subsidy to the Federal
Government.
Finally, Mr. Chairman, I would like to ask you and this
Subcommittee to help ensure that VA moves forward with
regulations necessary to implement legislation that has already
passed Congress. In 2004, Congress approved, and the President
signed Public, Law 107-422 which authorized a scholarship
program to help nurse recruitment and retention in State Homes,
where there is a serious nursing shortage.
This program is modeled on a similar program that the VA
currently operates, yet more than 3 years after the enactment,
we are still waiting for implementing regulations. Last year,
with your strong support, Congress passed legislation that
provided service-connected veterans in State Homes with equity,
both in receiving prescription medications and the 70 percent
service-connected veterans would receive full cost of care. We
are still awaiting these very important regulations. While we
have had hopeful talks with the VA about this progress, we
believe a bit of oversight by Congress can help ensure that all
these regulations come into force this fiscal year.
Mr. Chairman, this concludes my testimony and I would be
pleased to answer any questions you might have.
[The prepared statement of Mr. Griffith appears on p. 38.]
Mr. Michaud. Thank you very much, Mr. Griffith and Mr.
Nagel for your enlightening testimony. I have a couple of
questions.
The first one to Mr. Nagel. You mentioned that you plan on
developing a veterans' campus in Bangor and I think that is a
real innovative approach of what you are looking at, taking
hospice and adult daycare and what have you. And you are
looking at other facilities within Maine. Is Maine unique or do
you think other States can take that approach? Have you talked
to other State Veterans Homes in other areas?
Mr. Nagel. That is a very good question, Congressman. I
believe that the system that we are starting can be replicated
pretty much anywhere across the country. I think it works
extremely well on Maine's behalf because we are by large a
rural State, and by consolidating the veterans' resources at
the Federal, State and local levels, it allows those veterans
in those rural areas to come to one spot instead of driving
many, many miles out of their way to receive the care at the
different levels.
I would be very happy to share this with other States and I
am sure that once our prototype is finished--and it will be
successful--that it will be a pilot project for other States in
the future.
Mr. Michaud. Thank you. I have been to the facilities in my
other capacity when I was in the State Legislature, so I am
very familiar with the facilities and thank you for thinking
outside the box.
My next question is actually for both gentlemen, since you
deal with different States, when you look at the cost
difference for the VA for State Veterans Homes versus what the
VA provides, there is a big difference. However, do you think
that the current capacity--I know for Maine, you said you
pretty much do not intend to build any more right now--do you
think that there is capacity out there throughout the country
to take additional beds?
Mr. Griffith. You can tell by looking at the request for
construction, the States wanting to build, especially in the
areas like California, Texas, Florida, where there is a real
large veteran population and not that many State Homes. There
is definitely an interest for the States to build more beds.
Mr. Michaud. And how long do you think that process will
take if we provided adequate funding?
Mr. Griffith. Not long. The States--to get to priority one,
those numbers I gave you earlier--to be a priority one, the
State already has the matching funds available, which means you
give them the Federal funds and they start to build. They
already have to have their architectural stuff already done and
taken care of, so if Congress funds their side of it, the State
is going to immediately bid it out and start building, because
to get to priority one, you already have to have your State
funds available.
Mr. Michaud. Mr. Nagel, you mentioned you are pretty much
at capacity now. Do you envision that there is going to be a
greater need, particularly with the war in Iraq and Afghanistan
for additional beds in Maine? And are you prepared to expand if
need be?
Mr. Nagel. We are prepared to expand in the future if the
studies indicate that there will be an increased need in the
future. I wouldn't anticipate that the veterans that are
returning right now would be requiring our long-term care
needs, but that is certainly something to be considered for the
future.
And to echo what my association has already said, I also
believe that the other States--there may not be more reason to
build more beds in Maine, but there is great reason to build
State Homes in other States that have the need and the
capacity. And there is a very good system for indicating the
level of need by State.
Mr. Michaud. Okay. My last question--and I see I am running
out of time--do you feel that State Veterans Homes have the
capacity to take care of our newer veterans in terms of
traumatic brain injuries (TBI)?
Mr. Griffith. That is more of a specialized care. We are
more long-term care. That is kind of what the VA in my
opinion--the specialty care should be done by the VA and we
take care of what we call the primary care. Now, in Oklahoma, I
do IV therapy in-house and we have all--so we are really a step
above a private nursing home, because, you know, if you catch
pneumonia and you are at the veterans center, we are going to
put you on a IV and treat you at the veterans center, where if
you are in a private-sector home, they are going to ship you to
the hospital and collect these big dollars from the hospital
for your care there. So we are kind of a--but the specialty
care, I take--in Oklahoma, we don't do dialysis nor ventilator-
dependent. Those are the only two long-term cares that we can't
manage there.
Mr. Michaud. Okay.
Mr. Griffith. In my opinion, that is what the VA should be
doing is this specialty stuff.
Mr. Michaud. Okay. So for anyone who needs long-term care
that has TBI, you feel that this is best left with the VA
system?
Mr. Griffith. Yes.
Mr. Michaud. Okay. Great. I thank you.
Mr. Brown, do you have any questions?
Mr. Brown of South Carolina. Thank you, Mr. Chairman.
And thank you, gentlemen, for this informative briefing.
Let me see if I can get some clarification on this. You state
that the VA pays only about $68 a day to provide long-term
nursing home care at State Veterans Home. However, Public Law
109-461 requires VA to reimburse State Veterans Homes for the
entire cost of care for service-connected disabled veterans
rated 70 percent or higher for a veteran in need of which such
care for a service-connected disability.
What is your estimate of what VA will be required to pay
for the care of these veterans under Public Law 109-461?
Mr. Griffith. They give us five options. We have met with
the VA, our association has, on this topic. There is five
different options that they can do. It could go anywhere from
the local Medicaid rate, the Medicare rate, their local
contract rate, cost of care of our Homes nationally or
regionally. So there is like several different ways it can go.
Mine is, we need to the VA to hurry up and get us some
regulations.
I have already got families at home that saw this law
passed and are wondering why I am still charging them. They are
having to pay for part of their care. And I said well, until
the VA promulgates these rules, I have no way of, you know--you
are entitled to this.
The law passed December 22nd. It became law March the 22nd.
But the way--it is just like the nurse recruitment thing I was
telling you about. It happened in 2004. We still have no
regulations on it and we are afraid the 70 percenters are going
to go the same route if something doesn't happen. These
veterans are going to be sitting out there which deserve full
cost of care.
They are actually being drove to a private nursing home to
get a lower level of care for free instead coming into the
State Veterans Home and get a higher level of care, but they
have to pay for part of that care. And that is just not right.
Mr. Brown of South Carolina. What percent are they having
to pay now?
Mr. Griffith. Sir?
Mr. Brown of South Carolina. What percent will they have to
pay?
Mr. Griffith. Seventy percent or more.
Mr. Nagel. No. What percentage do they have to pay?
Mr. Brown of South Carolina. Right. I mean what would be
their co-payment?
Mr. Nagel. It depends on what type of funding source that
they have. If it is Medicare, Medicaid, and Medicaid would vary
by State.
Mr. Griffith. Every State is a little bit different. In
Oklahoma, for a married veteran it is 50 percent of total
family income, 85 percent for a single veteran. So they are
having to actually pay for their care by using part of their
pension, and that is not what it is for. And the law
specifically states that they shouldn't pay.
Mr. Brown of South Carolina. Why is it such a differential
between the VA nursing home and the State Veterans Home?
Mr. Nagel. I can answer that, sir. In Maine, we operate
under a competitive model. We take the stipend money that we
receive from the VA and we apply that to our veteran
population. And in addition, as opposed to appropriating money
from the State of Maine for our budget, we act as a competitive
nursing home, just like any other for-profit company, although
we are a public not-for-profit organization.
So under our system, we bill Medicare and Medicaid and as a
result, our veterans receive superb quality of care because we
are competitive. And we are no different than any other nursing
home chain in that aspect. We are held to the same standards,
same quality standards and even more, because we have to be
inspected by both the VA system, as well as our State systems.
And it actually has proven to be a very cost effective as well
as efficient model.
Mr. Griffith. I have got another little approach that--I
have been the Liaison Chairman of the National Association of
State Veterans Homes for the past ten years and I have always
been curious about how the VA actually costs their stuff out.
You know, I don't know where they came up with the dollar
figures so high. In Oklahoma, we provide--we have doctors on
staff or on pharmacy, laboratory, ventilation therapy and our
costs are around $220. So I don't know how they come up--but
the numbers are there and it is their numbers we use. They are
extremely high, but--
Mr. Brown of South Carolina. So the $560 is a pretty
representative number you think?
Mr. Griffith. Those are VA's numbers we are using. I don't
know how they come up with them, but it is their numbers and
they are extremely high.
Mr. Brown of South Carolina. Okay. Thank you, gentlemen,
thank you.
I will yield back the balance of my time.
Mr. Michaud. Mr. Walz?
Mr. Walz. Thank you, Mr. Chairman.
And thank you both for your testimony and the work that you
are doing. The need for our veterans' care, long-term care is
unquestionable and growing and we see that and it is a trend we
have to take into consideration. And I do appreciate what the
State Veterans Homes have done in terms of efficient, effective
care for our veterans.
I am trying to understand the relationship between the VA,
the Veterans Homes, the States and how this works. I am coming
from this from the perspective in Minnesota that our VA
hospital in Minneapolis is a polytrauma center, recognized as
one of the best I would say in the world. The care is
outstanding.
Three blocks away we have our State Veterans Home and it
has had continuous issues that are coming up of care, serious
issues. And my question is on this and on the funding is, the
way that this has been dealt with--and I have watched this
evolve over the past couple years and I am deeply concerned
with it--is that violations result in punitive financial hold-
backs from the institution, from the State Veterans Home.
And I question, I ask both of you, is this the most
efficient way to get and expect change when we are withholding
money that is making it more difficult for them to take
veterans in and to provide the care and it seems that it has
spiraled into a continuous set of violations that has now
rippled out into other things that I think may be attributable
to the lack of resources.
Perhaps the withholding of wages from the people involved
with that might have been more efficient. But please, if you
could help me understand this on this funding issue and why
they are doing it this way. And they are under threat now that
the Federal Government in June is going to cut all funding to
them, which will basically shut them down at a time when we
need them. So if you could help me with this?
Mr. Griffith. It is a VA rule as far as I know. That is the
only leverage they have over a State Home is to pull your per
diem. And that is what--but if they did, if you are having
problems because you are not paying staff enough, you are not
getting good staff, you need some facility changes, whatever,
if they cut your money--well, right now, if the VA would jerk
per diem, the State Home Program would cease to exist because
there is no way they could operate.
So if you are already in a problem because you need more
money to get better staff--well, I don't think pulling your
money would be a very good solution from where I am sitting at.
Mr. Walz. But our only option is the staffs, the VA to
change that--the way they go about it apparently right now. I
am very frustrated by it because it hasn't worked in the past
and they have tried it several times. They are continuing to do
per diem pulls every day on this thing and I am--it just seems
to me we are in a situation we are going to lose that home. It
is spiraling down and I have deep concern over that.
So what would your suggestions be on this? And I ask you
not--I know you don't know the specifics maybe of that
institution. But how would you handle it?
Mr. Nagel. May I----
Mr. Walz. Sure.
Mr. Nagel. That is a really good question. And I am not
exactly sure how the system operates in Minnesota. But I can
tell you that in Maine we look at this from a preventative
standpoint. We have extremely tight, stringent internal
controls. And because we operate as a competitive type of
facility as opposed to a State institution or an appendage of
the State, we have two sets of internal control mechanisms that
we have to respond to at least twice a year. And that is the VA
oversight which is pretty strict----
Mr. Walz. Right.
Mr. Nagel [continuing]. As well as the State and Federal
Medicare or Medicaid guidelines. Now, in States that don't
participate in Medicare or Medicaid, they won't have those
guidelines that they have to follow as well. So in Maine, we
have the guidelines that we have to meet under Medicare/
Medicaid, as well as the VA and we also initiate--because we do
operate as a private type of organization, we have a very, very
strict peer review council where members of different
disciplines go from one home to another and they do pre-
evaluations on those homes and they are pretty scathing and it
keeps us in line.
So in a nutshell, what I will tell you is that we basically
look at it from a preventative standpoint and that by doing
that, it helps to avoid the costly penalties that would happen.
Now, and one more thing is that the VA's penalizing of stipend,
I would not agree with it either. But it is no different,
honestly, than what Medicare does. And Medicare does what is
called a civil monetary penalty, Medicare/Medicaid. So if you
have deficiencies, they fine you. So it is very similar in that
regard.
Mr. Walz. Very good. Thank you.
Thank you, Mr. Chairman.
Mr. Michaud. Thank you.
Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman. My apologies for getting
here a little late. So if the questions that I am asking have
already been covered, I hope you will bear with me. There have
recently been reports that some of the State Veterans Homes
aren't safe or the quality of care isn't what it should be.
How can the VA better ensure that these homes perform to
the national standards that are required of them? What can we
do or what should the VA be able to do to get these homes up to
standard?
Mr. Nagel. Personally?
Mr. Hare. Sure.
Mr. Nagel. Personally I think that the State Homes should
be following both the VA standards as well as the Medicare/
Medicaid guidelines. If they are following Medicare or Medicaid
guidelines, they are going to have two sets of eyes that are
looking at them all the time. And that is a built in internal
control mechanism that ensures quality to the patients.
Mr. Griffith. That is one thing our association has talked
about for years with the VA, is why the VA doesn't use CMS
guidelines. The VA writes their own regulations. CMS has got
theirs. We are being inspected by two different sets of
regulations. With being two Federal agencies--and this is my
personal--I don't know why that we are not inspected by the CMS
regulations. Because if you are Medicare or Medicaid, CMS comes
in with their regulations, VA comes in with their regulations.
And we are like them. We have a peer review of our own internal
agency that does our own peer review which in Oklahoma is
tougher than the other two.
But they are all using different sets of regulations and
mine is, I don't know why that the VA and CMS doesn't get
together, or the VA use their regulations. I mean because they
are tough and they provide--they are geared toward quality of
care. But we in the field have to kind of dance to both tunes
at the same time.
Mr. Hare. Okay. Thank you. Mr. Griffith, you mentioned in
your testimony that the State Homes in Oklahoma are developing
programs or plans for more adult day healthcare programs and
other approaches to developing care in less restricted
settings. I wonder----
Mr. Griffith. Yeah, it is in Maine. We are not doing adult
day healthcare in Oklahoma yet.
Mr. Hare. Okay. Well, I am wondering if you could elaborate
on what other emerging approaches, other things that you are
doing and is this just restricted to the State or are there
other State Homes trying to do the same?
Mr. Nagel. Well, we are trying to bring--there is an idea
in the Army and it is called far forward medicine. And in Maine
they didn't call it that, but they thought of it before the
Army did. And I think they did it out of necessity because the
State is pretty rural.
So rather than--in certain States they have large compounds
where the State Veterans Homes are at. In Maine they decided to
build smaller facilities, but locate them all over the State so
that it would serve that area of the State. So it is much more
patient friendly, if you will.
And taking that one step further and thinking outside of
the box, what we have done is, we have such a good relationship
in Maine between all levels of the veterans service
organizations, whether it is at the Federal level, State,
community, local. We have gotten together with all of them and
we have decided to take that idea one step further and try and
put the Federal, the State and the community veterans services
on one little campus, on those campuses so that they don't have
to travel to numerous places to receive the services that they
are entitled to.
And we are starting with our Bangor campus because it is a
proven facility. We have willing partners there. And the VA
hospice physician approached us asking us to open up a hospice
there. So we have plans to open up a hospice, a seven-bed
hospice there adjacent to our facility, which is something that
I think that the VA should actually start paying a stipend for,
because I think that is a big----
Mr. Hare. I agree.
Mr. Nagel [continuing]. Need. We are also opening up--we
are hoping to link with the VA and open up a community-based
outpatient clinic which right now is located a couple miles
away. And this way they would--our same residents would be able
to access medical care there with the doctors that they already
see. And we are hoping possibly 1 day to build maybe adult
daycare, as well as veteran housing. So those are the programs
that we are looking at currently.
Mr. Hare. That is great. Thank you very much, Mr. Nagel.
I yield back, Mr. Chairman.
Mr. Michaud. Thank you.
Mr. Salazar.
Mr. Salazar. Mr. Chairman, I have no questions at this
time.
Mr. Michaud. Thank you.
Before we release the panel, I just want to ask one
question of Mr. Griffith.
You mentioned the two different regulations between the VA
and the CMS. Which is the tougher of the two?
Mr. Griffith. The CMS.
Mr. Michaud. The CMS, okay.
Mr. Griffith. Seems to be. I am not survey, but a lot of
the States are. Maine is one of them. Colorado is one. Ours is,
we just--and we have asked this--as Liaison Chairman, we meet
with the VA twice a year and we have asked for this one reg for
years and there is one reason or another we haven't done it.
But it really makes a lot of sense that if you are being
inspected, you should be inspected by one regulation.
Mr. Michaud. Great. Well, once again, I would like to thank
both of you gentlemen for your testimony and answering
questions. It has definitely been very helpful. So thank you
both very much.
Mr. Griffith. Thank you, Mr. Chairman.
Mr. Nagel. Thank you, sir.
Mr. Michaud. I would ask the second panel to come forward.
The second panel consists of Shannon Middleton, who is the
Deputy Director of Healthcare, Veterans Affairs and
Rehabilitation Commission for the American Legion, Mr. Adrian
Atizado, who is the Assistant National Legislative Director for
Disabled American Veterans, and Fred Cowell, who is the Senior
Associate Director, Health Analysis for the Paralyzed Veterans
of America. I want to thank all three for coming today. I look
forward to hearing your testimony. And we will start with Ms.
Middleton.
STATEMENTS OF SHANNON L. MIDDLETON, DEPUTY DIRECTOR, HEALTH
CARE, VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN
LEGION; ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS; AND FRED COWELL, SENIOR
ASSOCIATE DIRECTOR, HEALTH ANALYSIS, PARALYZED VETERANS OF
AMERICA
STATEMENT OF SHANNON L. MIDDLETON
Ms. Middleton. Mr. Chairman, Members of the Subcommittee,
thank you for this opportunity to present the American Legion's
views on VA's strategic direction and plans to address the
aging veteran population and the needs of recently separated
veterans.
A July 1984 study, ``Caring for the Older Veteran,''
predicted that a wave of elderly World War II and Korean
Conflict veterans would occur some 20 years ahead of the
elderly in the general U.S. population and had the potential to
overwhelm the VA long-term care system if not properly planned
for.
The study cited an imminent need to provide a coherent and
comprehensive approach to long-term care for veterans. Twenty-3
years later, the comprehensive approach prescribed has yet to
materialize.
The American Legion supports a requirement to mandate that
VA publish a comprehensive long-term strategic plan. In recent
testimony, GAO indicated that veterans' access to
noninstitutional long-term care was still limited by service
gaps and facility restrictions. GAO assessment demonstrated
that for four of the six services, the majority of facilities
did not offer the services or did not provide access to all
veterans living in the geographic area.
On the issue of nursing home care, VA has been equally
resistant in complying with the mandates of the Millennium Act.
The Act required VA to maintain its in-house nursing home care
unit bed capacity at the 1998 level.
The American Legion believes that VA should be required to
restore its nursing home care unit capacity as intended by
Congress to the 1998 level. Additionally, VA should be
prohibited from including any but their own nursing home care
unit beds for the purpose of compliance with the provisions of
the Millennium Act.
VA claims it cannot maintain both the mandated bed capacity
and implement all the requires of the Millennium Act. The
American Legion believes VA should provide the quality of care
mandated by Congress for the long-term care of America's
veterans and Congress should provide adequate funding to VA to
implement its mandates.
Since 1984, nearly all planning for VA inpatient nursing
home care has revolved around State Veterans Homes and
contracts with public and private nursing homes. Currently, VA
is authorized to make payments to State for construction and
maintenance of State Veterans Homes. Recognizing the growing
long-term healthcare needs of older veterans, it is essential
that the State Veterans Home Program be maintained as a viable
and important alternative healthcare provider to the VA system.
In testimony delivered in 2006 addressing VA long-term
care, GAO identified estimating which veterans will seek care
from VA and what their nursing home needs will be as a major
challenge in VA's ability to plan for nursing home care. The
unpredictability of long-term care needs of those suffering
from polytrauma, blast injuries and lasting mental health
conditions as a result of participation in the ongoing Global
War on Terror will no doubt make planning even more
challenging.
The Commission on the Future for America's Veterans was
established to ascertain the needs of veterans 20 years in the
future. The Commission has been conducting townhall meetings
around the country to allow veterans, family members and
caregivers an opportunity to express their views on the future
needs of servicemembers, especially those who have been injured
in the current Global War on Terror.
At the conclusion of this fact finding initiative, the
Commission will create a report that will include
recommendations for addressing the needs identified. The
Commission plans to deliver recommendations to the President,
Congress and the American public by Memorial Day 2008 and the
American Legion supports this timely and proactive endeavor in
the hopes that VA and Congress will utilize the findings to
prepare for long-term care needs of the newest era of war
veterans.
A new generation of young Americans is once again deployed
around the world answering the Nation's call to arms.
Unfortunately, without urgent changes in healthcare funding,
new veterans will soon discover that their battles are not
over. They will be forced to fight for the life of a healthcare
system that was designed specifically for their unique needs.
The American Legion believes that the solution to the
Veterans Health Administration's recurring financial
difficulties will only be achieved when VA funding becomes
mandatory. Under a mandatory funding, VA healthcare would be
funded by law for all enrollees who meet the eligibility
requirements, guaranteeing yearly appropriations for the earned
healthcare benefits of enrolled veterans.
The Veterans Health Administration is now struggling to
meet its requirement to provide timely access to care and the
American Legion believes that healthcare rationing for veterans
must end. It is time to guarantee healthcare funding for all
veterans.
Mr. Chairman, this concludes my testimony. Again, thank you
for giving the American Legion an opportunity to present its
views on this important issue.
[The prepared statement of Ms. Middleton appears on p. 40.]
Mr. Michaud. Thank you very much.
Mr. Atizado.
STATEMENT OF ADRIAN M. ATIZADO
Mr. Atizado. Mr. Chairman, Members of the Subcommittee, I
want to thank you for this opportunity to present the views of
the Disabled American Veterans on the present and future state
of VA's long-term care programs.
I will try to cover as many items that DAV believes to be
with regards to overarching issues that exist today that hold
tremendous sway over the future of VA long-term care programs.
As with this Committee, the DAV is greatly concerned about
the last published strategic plan for VA's long-term care which
was prepared over 7 years ago. Whatever strategic planning VA
has for the program, the DAV is also concerned that VA has not
sought involvement, input or advice from veteran service
organizations, unlike the 1999 strategic plan in which this
community was directly involved.
The 1998 report of the Advisory Committee on the Future of
VA Long-Term Care compelled this 1999 VA strategic plan.
Sustaining this momentum, passage of Public Law 106-117,
Veterans' Millennium Healthcare and Benefits Improvement Act,
brought about some degree parity between long-term care and
acute care. However, some bias remains within VA's medical
benefits package that has translated down and between
institutional and noninstitutional extended care.
By policy, noninstitutional services must be made available
to all enrolled veterans in need of such care. But VA is
required to provide institutional services only to a subset of
these enrolled veterans.
Mr. Chairman, coupling this protocol with a tremendous
pressure of limited resources requires VA to drive down the
costs of care while increasing the number of veterans served.
This produces a synergistic effect that puts long-term care at
a disadvantage against other services in VA's medical benefits
package, and all the more so for the resource intensive
institutional extended care service line.
It is without doubt that our concern remains about VA's
obvious shift away from meeting its statutory mandate of
maintaining nursing home capacity. This practice must be
addressed considering VA's own projection of the growing gap
between capacity and demand. As VA shifts more of its
institutional care workload to State Veterans Homes, we applaud
Congress for taking what we hope is a first step to provide
equitable relief to State Veterans Homes.
What seems to be lost is what DAV believes, that long-term
care is a fundamental part of the continuum of medical care.
Further, while institutional care has been painted with a broad
brush, it is most certainly still needed. As our colleagues
from the State Veterans Homes have testified, particularly for
veterans that VA has termed hard to place patients.
While VA has become highly efficient at converting its non-
service-connected community nursing home placements to Medicaid
status, it has established no formal tie to centers of Medicaid
and Medicare services, or with the States to oversee that
unwritten policy.
Also, with regards to institutional and home hospice,
despite offering to purchase hospice, VA refers thousands of
veterans from its own program to those of Medicare without
acknowledging it is doing so.
Mr. Chairman, VA is the only public healthcare system that
charges co-payments to hospice patients. The DAV recommends the
fulfillment of Congress' original intent in Public Law 108-422
in exempting veterans from having to pay co-payments when they
receive VA hospice care in any setting.
As a number of dying veterans have increased to a current
average of 1,800 a day, it is unconscionable to use co-payments
as a healthcare utilization tool on dying veterans. With regard
to noninstitutional care, the DAV believes growing its capacity
is important to meet the swelling long-term care needs of aging
veterans.
We applaud VA leadership in eliminating local restrictions
that depress capacity and limit access to noninstitutional
care. However, the reports we continue to receive about
veterans not receiving the care they need for their service-
connected conditions tells us more needs to be done,
particularly in the funding level that VA requests or that
which Congress provides.
In closing, Mr. Chairman, the DAV urges this Subcommittee
to consider holding additional hearings in order for Congress
and the public to gain fuller understanding of what needs to be
done for our Nation's aging, sick and disabled veterans.
This concludes my statement and I would be happy to answer
any questions you may have.
[The prepared statement of Mr. Atizado appears on p. 43.]
Mr. Michaud. Thank you very much, Mr. Atizado.
Mr. Cowell.
STATEMENT OF FRED COWELL
Mr. Cowell. Mr. Chairman and Members of the Subcommittee,
the Paralyzed Veterans of American (PVA) is pleased to present
its views concerning access to and the availability of quality
long-term care service for our Nation's veterans.
In the interest of time, PVA's oral testimony is focused in
two primary areas with brief mention of other important issues.
The long-term care needs of younger OIF/OEF Veterans. Mr.
Chairman, PVA believes that age-appropriate VA noninstitutional
and institutional long-term programming for younger OIF/OEF
veterans must be a priority for VA and your Subcommittee. New
VA noninstitutional and institutional long-term programs must
come online and existing programs must be reengineered to meet
the various needs of a younger veteran population.
VA's noninstitutional long-term care programs will be
required to assist younger veterans with catastrophic
disabilities who need a wide range of support services, such as
personal attendant services, programs to train attendants, peer
support programs, assistive technology, hospital-based home
care teams that are trained to treat and monitor specific
disabilities, and transportation services.
These younger veterans need expedited access to VA benefits
such as VA's Home Improvement/Structural Alteration grant and
VA's adaptive housing and auto programs, so that they can leave
institutional settings and go home as soon as possible.
VA's institutional nursing home care programs must change
direction as well. Nursing home services created to meet the
needs of aging veterans will not serve young veterans well. As
pointed out in the Independent Budget, VA must make every
effort to create an environment for younger veterans that
recognizes they have different needs.
Younger, catastrophically injured veterans must be
surrounded by forward-thinking administrators and staff that
can adapt programs to youthful needs and interests. The entire
nursing home culture must be changed for these individuals, not
just modified.
For example, therapy programs, living units, meals,
recreational programs and policy must be changed to accommodate
younger veterans entering the VA long-term care system.
Veterans with spinal cord injury and disease. PVA is
concerned that many veterans with spinal cord injury and
disease are not receiving the specialized long-term care
services they require. Today's VA Spinal Cord Injury and
Disease (SCI/D) long-term care capacity cannot meet current or
future demand for these specialized services. Waiting lists
exist at the four designated SCI/D long-term care facilities.
Geographic accessibility is a major problem because none of
these facilities are located west of the Mississippi River.
VA's own Capital Asset Realignment for Enhanced Services
(CARES) data for SCI/D long-term care reveals a looming gap in
long-term care beds to meet future demand. VA data projects an
SCI/D long-term care bed gap of 705 beds in 2012 and a larger
bed gap of 1,358 beds for the year 2022.
Methods for closing the VA SCI/D long-term care bed gap and
resolving the geographic service issue are part of the same
problem for PVA.
VA's construction budget for 2008 includes plans for new
120-bed VA nursing homes to be located in Las Vegas, Nevada,
and at the new medical center campus in Denver, Colorado. Also,
VA has announced construction planning of a new 140-bed nursing
home care unit in Des Moines, Iowa.
Mr. Chairman, PVA needs your support to ensure VA nursing
home construction planning includes the percentage of beds at
each new VA nursing home facility for veterans with SCI and D.
PVA requests that Congress mandate that VA provide for a 15
percent bed set aside in each new VA nursing home construction
project to serve veterans with SCI/D and other catastrophic
disabilities.
A 15 percent bed allocation in new VA nursing home
construction projects would be a good first step toward
resolving and improving the VA SCI/D long-term care bed
capacity problem.
Mr. Chairman, PVA's written statement includes important
detailed information on other VA long-term care issues that we
feel deserve your consideration, such as the nursing home
capacity mandate, the State Veterans Home life safety issues,
and waiting lists for noninstitutional long-term care services.
PVA supports the Congressional decision to require VA to
develop a strategic plan for long-term care. However, for this
new plan to become a success, it must be a living document that
contains positive and achievable recommendations and provisions
for accountability. PVA supports a strategic long-term care
plan that monitors the quality, availability and the
appropriate balance between noninstitutional and institutional
long-term care programs.
VA's strategic plan will also enable Congress to make
better informed decisions regarding the provision of adequate
financial resources to support VA care. If done correctly, VA's
strategic long-term care plan will assist VA's planning and
monitoring efforts to ensure appropriate programming,
systemwide availability and quality of services.
Mr. Chairman, that concludes my remarks. I would be happy
to answer any questions you may have.
[The prepared statement of Mr. Cowell appears on p. 47.]
Mr. Michaud. Thank you very much.
I really enjoyed the testimony of this panel as well. My
first question for each of you is have your organizations heard
of any problems with veterans not getting access to a bed
because of a shortage of beds?
Mr. Cowell. Well, our members have problems. There are
waiting lists for the four designated SCI/D long-term care
facilities, Mr. Chairman. Those facilities are located in
Brockton, Massachusetts, Castle Point, New York, Hampton,
Virginia, and the residential care facility at Hines, Illinois.
It is our understanding that all four of those facilities have
waiting lists for our members.
Also, because of the high acute needs of paralyzed veterans
they are often shunned and denied access to both community
nursing home facilities, VA nursing homes and in some cases
State Veterans Homes. So we have an access problem.
Mr. Michaud. And do you know how long that waiting list is
at each of the facilities?
Mr. Cowell. Well, I can't speak for each facility, but the
most recent information we have at the Hampton facility, that
could be up to a year and it is kind of an attrition issue.
They need a veteran either to leave the facility, or in some
cases to die before a new bed becomes available.
Mr. Michaud. Okay. And the DAV, have you heard problems
from your members?
Mr. Atizado. Yes, Mr. Chairman, sparingly. But our greater
concern is from here on, what is happening with the capacity to
provide institutional long-term care paid for or provided by VA
at the current level. And recent trends really lead us to be
greatly concerned about how this is going to fit into the
demographic imperative of the aging population. That is really
what we are concerned about.
Mr. Michaud. Okay. And the American Legion, have you heard
of problems with your members accessing beds for long-term
care?
Ms. Middleton. Mr. Chairman, I haven't--I am not aware of
any so far. However, I do know that I haven't had a chance to
speak with the different departments to see whether or not they
have had any situations. And I am sure that there have been
instances that I am just not aware of at this point. But I can
find out for you.
Mr. Michaud. Great. The next question is for all three of
you. As we heard from the State Veterans Homes, when you look
at the regulations, the VA has certain regulations and the CMS
has certain regulations. From what we are told, the CMS has
stronger regulations. How would the American Legion feel about
adopting the CMS regulations if they are stronger?
Or while you are thinking about that, how about DAV?
Mr. Atizado. Mr. Chairman, I can't speak intelligently
about CMS' standards with regards to the quality of care
provided in institutional settings. But if the State Veterans
Homes believes this to be true, then obviously if it fosters
higher quality of care, then I believe DAV would support that.
Mr. Michaud. Okay. PVA.
Mr. Cowell. I am sure we echo his remarks, Mr. Chairman.
Also, I am not just sure who accredits the States Veterans
Homes. But accreditation of a long-term care facility is an
important step. And if you are just talking about the
operational guidelines that CMS would require, I think that is
a positive step. But also accreditation is something that
should be looked at if it doesn't currently happen.
Mr. Michaud. Okay. American Legion, have you--are you still
thinking? Okay.
Ms. Middleton. I would agree to agree with what they said,
echo what they said also.
Mr. Michaud. Okay. Thank you.
My next question, Mr. Atizado, is in your statement you had
mentioned about the co-payments for hospice care. And if you
don't know, hopefully the VA will be able to give me the
number, what is the total amount of money those co-payments
bring in? Do you have any idea?
Mr. Atizado. I have a rough idea, Mr. Chairman. But it is
rather dated, not more than a couple years. I think it is
around $5,000 in collections.
Mr. Michaud. Five thousand?
Mr. Atizado. In collections.
Mr. Michaud. Five thousand dollars in collections?
Mr. Atizado. Yes, sir.
Mr. Michaud. Total? Okay. Also relating to that same issue,
you had mentioned that some VA facilities have been aggressive
in establishing end of life programs while others have lagged
behind. Do you have a list of those who are lagging? Or could
you provide the Committee----
Mr. Atizado. We are talking about hospice?
Mr. Michaud. Yes, hospice.
Mr. Atizado. I apologize. I don't have that off the top of
my head. I can get that information for you though, sir. So if
I could submit that for the record to you, I would greatly
appreciate it.
[The information was subsequently provided by the U.S.
Department of Veterans Affairs in materials requested during
the hearing, which appear here.]
Mr. Michaud. Okay. Great. No problem. Thank you very much.
Mr. Brown.
Mr. Brown of South Carolina. Thank you, Mr. Chairman. I
just would like to thank the witnesses for their informative
testimony and I don't have any questions. But thank you all for
coming.
Mr. Michaud. Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman.
I have a question for all three of you folks. You know, we
have a lot of OEF and OIF veterans returning with catastrophic
injuries that are going to require them to get care for the
rest of their lives. And this generation is generally younger.
They are computer literate. They have children and high
standards for the type of care that they need, obviously.
At the same time, you have an aging population with very
different needs. So from your perspectives, what goals do you
think the VA should be working toward to provide extended care
to this diverse group of vets?
Mr. Cowell. Well, sir, in our opinion at PVA--and we have
done considerable thinking about this. As you know, many
veterans that are returning from OEF and OIF that have been
paralyzed, some are able to transition to noninstitutional home
and community-based programs fairly well. And I think VA will
obviously be doing a good job in trying to make sure that those
programs fit the needs of a younger population.
It seems to me the greater challenge is how to carve out a
niche in VA institutional programming, nursing home type care
that is going to meet the needs of these individuals. I mean,
as you stated and our testimony talks about institutional care
is basically built around an aging veteran population and how
to try to meet the needs of a younger veteran population and
co-mix those two age groups is going to be a difficult
challenge. And I am glad to hear that the Committee is thinking
about that problem and I am sure VA as well.
We just think that they really need to enlighten their
staff. I know VA has been doing a lot of work for culture
change in the nursing home care program and I think they need
to give added emphasis on the needs of younger veterans.
Mr. Hare. Thank you.
Mr. Atizado.
Mr. Atizado. Yes, sir. I want to echo my colleague's
statement with regards to finding age appropriate settings for
our younger, more severely injured soldiers. There is one thing
that I think we can be thankful about with this new population,
is that they are most likely going to have a support network,
whereas aging or older, elder veterans have a higher rate of
dependency and nobody there to assist them with that.
I would like to speak very briefly about--at least mention
all inclusive and/or assisted living, which is probably a
program--in fact, it was a pilot program in the Mill Bill and
it had glowing remarks both for care and patient satisfaction.
But for whatever reason, VA has decided to decline using those
services. That might be also an avenue that we could look into
as far as treating our newer veterans.
Mr. Hare. Ms. Middleton.
Ms. Middleton. In addition to what they have said, I would
think that it also would be important to--as the patients, the
newer, the younger veterans are at the long-term care
facilities, to see, ask them what they feel should be changed.
Because their impression, their perception of their place in
the facility is also important. So to ask them what kind of
things they feel should be changed and how they can be more
integrated with the things that are going on, what kind of
needs they feel should be addressed would be important also.
Mr. Hare. Okay. Thank you very much.
I yield back.
Mr. Michaud. Thank you very much. Once again, I would like
to thank the three panelists for your enlightening testimony
today. I look forward to our continuing to work together as we
look at what we can do to help our veterans as they access
long-term care needs. So once again, I thank all three of you
very much.
And while the third and final panel is coming forward, we
have Patricia Vandenberg who is the Assistant Deputy Under
Secretary for Policy and Planning from the Veterans Health
Administration. And she is accompanied by Dr. James Burris who
is the Chief Consultant for Geriatric and Extended Care for the
VHA. So I want to welcome you hear today and look forward to
hearing your testimony.
STATEMENT OF PATRICIA VANDENBERG, MHA, BSN, ASSISTANT DEPUTY
UNDER SECRETARY FOR HEALTH POLICY AND PLANNING, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND JAMES
F. BURRIS, M.D., CHIEF CONSULTANT, GERIATRICS AND EXTENDED
CARE, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS
Ms. Vandenberg. Thank you, Mr. Chairman and Members of the
Subcommittee. I am very pleased to be here today accompanied by
Dr. Jim Burris, our Chief Consultant in Geriatrics and Extended
Care.
Mr. Chairman, I want to begin by thanking you for your
recognition in your opening comments regarding the role that VA
plays in being a model in long-term care. My 40 years of
experience in healthcare, the majority of it in the private
sector, have given me broad exposure to what is happening in
the field of long-term care and I am very pleased with what we
will talking about today in terms of VA's approach to long-term
care.
Our philosophy is to provide patient-centered long-term
care services in the least restrictive setting that is suitable
for a veteran's medical condition and personal circumstances,
and wherever possible in a home and community-based setting.
Nursing home care should be reserved for situations in which
the veteran can no longer be safely maintained in the home or
community.
VA expects to meet the growing need for long-term care
through such innovative services as Care Coordination and Home
Telehealth. VA's Care Coordination involves the use of health
informatics, telehealth and disease management technologies to
enhance and extend existing care. Care Coordination enables
appropriate veteran patients with chronic conditions such as
diabetes and congestive heart failure to remain in their own
homes and defers the need for institutional care for as long as
possible. This technology enables us to deliver care to
veterans living remotely from VA facilities, including those in
rural communities.
Inevitably, veterans will require nursing home care and VA
will continue to provide nursing home care for all veterans for
whom such care is mandated by statute and who seek that care
from us. VA will also continue to provide nursing home care for
veterans with special needs, including those with spinal cord
injury, ventilator dependence, or serious chronic mental
illness.
Transforming the culture of care in nursing homes from the
traditional medical model to a more home-like patient-centered
model is an imperative and we are pursuing this very actively.
Recently, VA has also begun to care for younger veterans who
have sustained polytraumatic injuries during their service in
Enduring Freedom and Iraqi Freedom. But I have to note that
this is not the first time that we have cared for young
veterans. We have a history of caring for them for a number of
years.
While the number of these seriously disabled OIF/OEF
veterans is relatively small, the complexity of care they
require is higher and their personal and social needs do differ
from those of older veterans. VA is moving to adapt its long-
term care services to meet the needs of these veterans.
VA is taking steps, first, to recognize the generational
differences of this population and to incorporate appropriate
changes into our care routines. For example, in VA nursing
homes, transforming the culture of care to make the living
space more home-like and friendly is an imperative, as is
having resources such as an Internet cafe computer games or
age-appropriate music and food. Allowing for family, and
especially children to visit or perhaps stay overnight is
another example of the accommodation that we are already making
to generational differences.
In addition to VA nursing homes, VA supports the State
Veteran Home Program with the provision of grants for
construction and renovation and through per diem payments.
Moreover, VA provides oversight to these homes. VA has
developed a system of on-site inspections to assure quality of
care in State Veteran Homes, including the identification of
life safety issues.
In compliance with Public Law 109-461, VA is currently in
the process of developing regulations to implement the
provisions of this law. VA takes great pride in our
accomplishments thus far and looks forward to working with the
members of this Subcommittee to continue the Department's
tradition of providing high quality care to those who have
helped defend our Nation around the world.
This completes my oral statement and I look forward to your
questions.
[The prepared statement of Ms. Vandenberg appears on p.
52.]
Mr. Michaud. Thank you very much, Ms. Vandenberg. I really
appreciate your coming here today. Actually, I have several
questions that relate to a lot of the comments that were made
from our previous two panels.
The first one is the co-payment for hospice. What is the
total amount of revenue that the VA brings in for that co-
payment?
Ms. Vandenberg. I will have to defer to Dr. Burris on that
topic.
Dr. Burris. Actually, I don't have a number. We will have
to get back to you, sir, for the record.
[The following was subsequently received:]
Deliverable 1: What is the amount of revenue VA received from
hospice co payment?
Response: VA tracks co-payment amounts for inpatient services
and outpatient services collectively rather than by individual
services, so it is difficult to determine the exact amount of
revenue VA received from hospice co-payments. However, VA
estimated a total of $343,542 in annual revenue ($183,180 for
home hospice and $160,362 for inpatient hospice, calculated at
FY2006 rates).
Mr. Michaud. Okay. The DAV commented about the end-of-life
program at many VA facilities, and that some have been
aggressively established. But there are some that have been
lagging behind. Do you have any idea who is lagging behind?
Ms. Vandenberg. I can't tell you that. We can certainly
provide that information for the record. I think I can say with
personal conviction that this is a facet of our care continuum
that I have been very actively promoting with my colleagues and
I think it is one that we believe deeply and philosophically.
And so, what creates inertia in some environments to move in
that direction is something that we continue to look at. But we
will supply that information for the record.
[The following was subsequently received:]
Deliverable 2: Which VA facilities offer Hospice and End of
Life Care? Which do not--why are they lagging?
Response: In FY2006, every VA facility offered some form of
hospice and end of life care service, while a recent survey
found that only one-fourth of other US hospitals had a
palliative care program. The VA's Hospice and Palliative Care
program has transformed much of the end of life care provided
or purchased by VA which has resulted in the following:
a. In FY2006, of all veterans who died in a VA facility, 42
percent received prior consultation from a palliative care team
(up from 30 percent in FY2003).
b. The number of palliative care consults in our VA
hospitals more than doubled between FY2003 and FY2006 and
surpassed 20,000 this past year.
c. The number of veterans receiving VA-paid home hospice
care tripled between FY2003 and FY2005, and has increased
another 30 percent in the past fiscal year (to an average daily
census of 427 veterans for FY2006).
While this growth provides evidence of VA's leadership as a
healthcare system in the provision of end of life care, we
recognize there are some areas in which utilization of hospice
and end of life services is absent or low. Often the low
utilization appears to be related to regional and cultural
variations in the desire for hospice services. Overall,
Veterans Integrated Service Networks (VISNs) 1,2,3,12, and 19
report lower levels of VA-paid home hospice care than other
VISNs. While a number of individual facilities report little or
no VA-paid home hospice census such as the VA Medical Centers
in Albany and Northport, New York; Chicago; Dallas; Nashville;
Providence, RI; Salt Lake City; San Diego; and Shreveport, LA
these facilities have active palliative care programs within
their medical centers and make numerous referrals for hospice
care in the community, though not at VA expense.
To promote and honor veterans' preferences for remaining in
their homes at the end of life, VA has established minimum
levels of VA-paid home hospice as a VISN Directors Performance
Measure. Additionally, VA tracks both home hospice and
inpatient palliative care activity and is working with VISNs
and facilities to assure reliable access to quality end of life
care in all settings at every VA facility. To promote reliable
access the following national conferences are planned for this
year:
a. A senior leadership conference of Network Directors on
July 17th to develop action plans to disseminate ``best
practices'' in end of life care
b. A national conference of acute care, home care and
hospice/palliative care staff on integrating palliative care
across VA will be held July 24th to 26th
Mr. Michaud. Since you feel so deeply about this and we
heard a number earlier about the co-payments. You know, it is
end of life and why would we be charging any veteran co-
payments?
Ms. Vandenberg. Sir, I think that is a very relevant
question and one that I can take back and take under
advisement.
[The following was subsequently received:]
Deliverable 3: Why does VA charge veterans a hospice co-
payment?
Response: Public Law 106-117, the Veterans Millennium
Healthcare and Benefits Act 1999, requires that non-service-
connected veterans receiving extended care services from VA pay
a co-payment to the United States. Inpatient and home hospice
services are among the services subject to a mandatory co-
payment, with the exception of hospice services provided in a
nursing home.
Mr. Michaud. Okay. Thank you. We heard from the State Homes
about VA regulations versus the CMS and that CMS is more
stringent. Have you looked at this issue? And if CMS is more
stringent, would you consider adopting the CMS regulations if
appropriate?
Ms. Vandenberg. Sir, I think our regulations are fairly
consistent. Perhaps one difference in the application of the
regulations is the way the survey process is conducted. And we
will certainly take the comments that were made by our
colleagues today under advisement in terms of the rigor of the
survey process.
Mr. Michaud. And if you could provide the Committee with
what the differences between the two, I would be really
interested.
Ms. Vandenberg. I would be happy to do a side by side
comparison.
[The following was subsequently received:]
Deliverable 4: Side by Side comparison of Center Medicare
Services (CMS) and VA regulations for State Homes--Which is
more stringent--Why not adopt one?
Response: The CMS standards are a generic set of national
standards that are required to be met for all nursing homes in
the United States that are certified under Medicare and
Medicaid. They are used to determine continued eligibility for
reimbursement and to assure the public that a nursing home
meets at least the minimum standards for quality of care.
Each State is required to apply these standards but may in
fact add requirements that are more stringent. The standard
that applies is whichever--State or national--is the most
stringent. For example, CMS standards do not address a specific
nurse staffing requirement. The CMS standard states that
staffing must be adequate. On the other hand States specify
nursing hours per patient day that range in some states from
2.0 hours per patient day to 3.35 hours per patient day.
VA standards are based on the CMS standards but because the
reimbursement framework and some other requirements are VA
specific, the VA standards also address VA specific
requirements.
The following are similarities and significant areas of
difference between the VA and CMS national standards:
Similarities: In general, the basic clinical standards are
similar for both organizations. There are nuances regarding in
how they are written. Both sets of standards, because they are
essentially the same in regard to resident care, are equally
stringent. Both organizations are currently updating their
requirements for Life Safety and intend to deploy the 2006
standards.
Differences: Areas of clear differences are primarily in the
responsibilities of the homes in regard to payment oversight
and processes and other system related requirements that
differentiate the payment sources and mechanisms. These are VA
Per Diem requirements versus Medicare/Medicaid requirements;
oversight responsibilities as they relate to the payers; and an
occasional technical difference. These differences will be
pointed out more specifically below where a standard is present
in one system but not the other.
Standards Unique to VA
Notification of the Office of Geriatrics and Extended
Care regarding changes in SVH administration is required.
Specification of the percentage of veterans that must
occupy the SVH
Requirements for management of a SVH by a contractor
Credentialing and privileging of the Medical Director
Monthly required submission to VA of a request for per
diem payment
Requirements for nursing home with 100 or more beds to
have a qualified social worker
Requirement for RN staffing 24 hours per day 7 days per
week
Nurse staffing requirement of 2.5 hours per patient day
for all State homes
Specific requirements for reporting and following up on
sentinel events including conducting a root cause analysis
Specific bed hold and transfer policy
A set of comprehensive standards around the SVH
recognition process for new construction and/or renovation
Standards for withholding per diem
Standards Unique to CMS
Definition of skilled nursing
Requirement to inform residents about Medicare and
Medicaid eligibility and responsibility for certain charges
Instructions regarding public display of information
about how to apply for Medicare or Medicaid benefits
Notification of the amount of money in a resident's
account for SSI limits
Limitations on charges to personal funds for Medicare and
Medicaid covered services
Admission requirements and Medicare and Medicaid
eligibility
Prescriptive detail about requirements for activities
programming
Automated data processing and transmission requirements
for the Minimum Data Set (MDS)
Penalties for falsification of data
Preadmission Screening for Mentally III and Individuals
with Mental Retardation
Requirements for influenza and pneumococcal vaccine
Disclosure of ownership requirements
Summary and Conclusions:
Although the clinical standards are essentially the same, the
standards regarding admission, payment, transmission of data,
ownership, and Medicaid and Medicare requirements differ
because of the significantly different payment mechanisms,
requirements for recognition, and accountability.
Another important distinction between the two sets of
standards is that the CMS standards are overarching but defer
to individual States for definition in a number of areas
including but not limited to nurse staffing, bed hold days, and
follow up on sentinel events so that the most stringent
standard would prevail.
Finally, an important variation in the CMS approach is the
nature of the interpretive guidelines and the survey process
itself. CMS' interpretive guidelines are more prescriptive and
provide more specific guidance than VA's. The CMS survey
process is very clearly defined including the application of
survey findings to a grid that distinguishes serious findings
and proposes a solution ranging from a mere recommendation to
serious monetary penalties and sanctions until findings are
improved. VA intends to rewrite its own interpretive guidelines
to provide clearer and more precise guidance for application of
the VA standards.
VA will continue to utilize the current VA standards for
survey of SVH. The current approach allows for application of
the VA standards from the VA perspective as a payer for
services and allows for one standard approach for all State
Veterans Homes. Adoption of the CMS standards would introduce
State-to-State variation in standards that is undesirable for
the VA's integrated healthcare system approach to care. Some
State requirements could be less than what VA would consider
acceptable. In addition, since only approximately 40 percent of
State Veterans Homes are CMS certified, VA would still be
required to maintain its own national standards for the
remaining 60 percent.
Mr. Michaud. Yes. The other issue, and if you could provide
for the Committee--I know there is a priority list when you
look at the State Homes. I believe it is $250 million, I think,
is the backlog for priority ones. Could you provide the
Committee with the priority one projects out there and the
cost, as well as how many priorities you have?
Ms. Vandenberg. Dr. Burris, could you please respond to
that?
Dr. Burris. Yes. There are seven priorities and the
priority group one projects are those for which, as you have
already heard, the States have committed their share of the
funding, so that when VA is able to offer a grant, the State is
able to proceed.
Mr. Michaud. Okay. Could you provide the Committee with the
different priority lists that you have available?
Ms. Vandenberg. Yes, sir. We will provide that for the
record.
[The following was subsequently received:]
Deliverable 5: List of different priorities for SVS Program.
Response: Priority Group Definitions for the Priority List
Priority Group 1. An application from a State that has
certified Sate matching funds for the project.
Priority Group 1--Subpriority 1. A project to remedy
conditions at an existing facility that have been cited as
threatening to the lives or safety of the residents.
Priority Group 1--Subpriority 2. An application from a State
that has not previously applied for a grant under 38 U.S.C.
8131-8137. Great Need: If State has no State homes beds.
Priority Group 1--Subpriority 3. An application from a State
that has a great need for the beds. Great Need: If State has an
unmet need of 2,000 or more beds.
Priority Group 1--Subpriority 4. An application from a State
for renovations not included in Subpriority 1 of Priority Group
1.
Priority Group 1--Subpriority 5. An application from a State
that has a significant need for the beds.
Significant Need: If State has an unmet need of 1,000 to
1,999 beds.
Priority Group 1--Subpriority 6. An application for
construction or acquisition of a nursing home or domiciliary
from a State that has a limited need for the beds that the
State, in that application, proposes to establish. Limited
Need: If State has an unmet need of 999 or fewer beds.
Priority Groups 2 through 7. Applications from a State that
does not have certified State matching funds for the project.
Ranked same as Priority Group 1
Priority Group 2--Subpriority 1. A project to remedy
conditions at an existing facility that have been cited as
threatening to the lives or safety of the residents.
Priority Group 3--Subpriority 2. An application from a State
that has not previously applied for a grant under 38 U.S.C.
8131-8137. Great Need: If State has no State homes beds.
Priority Group 4--Subpriority 3. An application from a State
that has a great need for the beds. Great Need: If State has an
unmet need of 2,000 or more beds.
Priority Group 5--Subpriority 4. An application from a State
for renovations not included in Subpriority 1 of Priority Group
1.
Priority Group 6--Subpriority 5. An application for
construction or acquisition of a nursing home or domiciliary
from a State that has a significant need for the beds that the
State, in that application, proposes to establish. Significant
need if State has an unmet need of 1,000 to 1,999 beds.
Priority Group 7--Subpriority 6. An application for
construction or acquisition of a nursing home or domiciliary
from a State that has a limited need for the beds that the
State, in that application, proposes to establish. Limited
Need: If State has an unmet need of 999 or fewer beds.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Mr. Michaud. Okay. You have heard from the State Homes in
Maine and I don't know if you had a chance to look at the
testimony of Mr. Nagel, but in the back it showed a veterans
complex that they are looking at doing in the State of Maine
that has hospice and the State Home, and is a nice complex.
Have you any initial thoughts on that concept, whether it is a
good idea?
Ms. Vandenberg. Well, I think when you look at the vision
that we have in the VHA of providing patient-centered,
integrated care, on the face of it, that concept makes a great
deal of sense, that we would aggregate resources and have them
be as patient-centered and as integrated as we possibly could.
I didn't have a chance to look at it from a policy
standpoint prior to the hearing, but we will certainly review
that.
Mr. Michaud. Okay. Great. We also heard from the previous
panels concerning waiting lists, whether it is trying to get
into the VA system or a State veterans nursing home. How big of
a waiting list is there for veterans who are trying to get into
a home?
Ms. Vandenberg. I would like to have Dr. Burris respond to
that question.
Dr. Burris. As far as we are aware, there is no waiting
list in the VA system for the category P-1-A veterans for whom
nursing home care is mandatory. We don't maintain information
about waiting lists in the State Homes. They really are owned,
operated and managed by the States. But the State Veterans Home
organization has surveyed their members and I believe the
figure that was cited earlier in testimony was about 10,000.
Mr. Michaud. Okay. I don't know if you have microphones on
or if you can pull it a little bit closer. If there is no
waiting list, is there a surplus of beds? And if so, how many?
Dr. Burris. No, we don't feel there is a surplus. The
average daily census of a little over 11,000 that we have
currently represents the demand for both long-term residential
care and for short-term care for post-acute care for patients
who had had a stroke or an operation, a broken hip, a serious
infection and need a period of restorative care or
rehabilitation before they can be discharged back into the
community.
Mr. Michaud. You heard from PVA earlier that there is a
waiting list, in some cases a year, to try to get into--was it
the four facilities?
Dr. Burris. Yes. That is something that VA has recognized
and there are four new centers that are under development. But
that is something that VA works very closely with PVA to
monitor the demand for care.
Mr. Michaud. And when will the VA be able to eliminate that
waiting list? Particularly when you look at what is happening
with the war in Iraq and Afghanistan, I think we are going to
see a higher need, unfortunately, in that particular area. So
when is that waiting list going to be gone?
Dr. Burris. It is a little bit hard to predict. It is a
moving target because there are new patients coming into the
system all the time. I actually would have to defer to Dr.
Margaret Hammond who directs that program for a definitive
response.
Mr. Michaud. And could you provide us with what the waiting
list is at each of those four facilities?
Dr. Burris. Yes, sir.
[The following was subsequently received:]
Deliverable 6:
a. What are the waiting times at the 4 SCI centers (PVA
asserted it was up to a year)?
Response:
Boston: 10 patients with waiting range from July 2005
to April 2007.
Hampton: 12 patients with waiting range from
September 2005 to March 2007.
Castle Point: No wait list. Hines: 6 patients with
waiting range from January 2007 to April 2007.
b. What is VA's timeline to eliminate the waiting list for
the 4 SCI Centers?
Response: Implementation of the CARES Planning Initiatives will
be used to increase geographic access to SCI LTC services. The
timeline is dependent upon completion of the Tampa beds for
which construction has begun, and the implementation of LTC
beds at Cleveland, Long Beach and Memphis which are in planning
or design phases.
Access to non-institutionalized extended care services is being
encouraged under the Uniform Benefits Package.
c. What is VA's estimate of the future need for inpatient beds
for SCI patients (PVA cited CARES data projecting an SCI/D long-term
care bed gap of 705 beds in 2021 and 1,358 beds in 2022)?
Response: The CARES spinal cord injury planning model for
institutional care projected a demand for 1,388 available beds
in FY2012 and for 1,575 beds in FY2022. Using existing workload
data, the demand was met, in part, by SCI long term care center
beds, by the average daily census of veterans with SCI in VA
nursing home care units, in contract nursing homes, and other
VA LTC settings. The model provided the basis for
recommendations approved by the Secretary for 30 SCI LTC beds
at Tampa, 20 at Memphis, 20 at Cleveland, and 30 at Long Beach.
Subsequently in 2004, VA was requested to revalidate the
original 2001 SCI LTC planning model using a revised approach.
This tentative model supported the original CARES
recommendations to enhance access. This model projected a
demand for 1,969 available beds in FY2012 and 2,622 beds in
FY2022 for a 100 percent market share of veterans with SCI in
priority group 1 a. Utilization data and inclusion of the CARES
recommendations resulted in a projected gap of 705 as recently
reported by PV A. Incorporating 2006 workload data of 154 SCI
long term care beds, an average daily census of 905 in VA
Nursing Home Care Unit, 293 in contract care, 42 in other VA
LTC settings, and with full implementation of the CARES
recommendations, there is a projected gap of 475 in FY 2012.
Internal discussion and planning are needed to address this
projected gap.
Mr. Michaud. And what would the VA estimate the future need
will be, particularly when you look at what is happening with
the war in Iraq and Afghanistan?
[The Priority List of Pending State Home Construction Grant
Applications for FY 2007 appears on p. 60.]
My last question--I know I have run over time. But in the
closing remarks of the DAV, they talked about the lack of a
strategic plan that involves stakeholders input. It is
discouraging to DAV and others in this community. I have always
been one who will try to bring in--if you are trying to solve a
problem, you bring in those who are really affected by it.
Whether you agree or disagree, at least it gives you a broad
perspective of what is going on.
What is VA doing to--when you look at these strategic
plans, to bring in those who are going to be using the
facilities?
Ms. Vandenberg. I will refer to Dr. Burris who has had the
lead in the formulation of the strategic plan.
Dr. Burris. Well, first of all, I would say that the long-
term care strategic planning is part, really an integral part
of the broader VA and VHA strategic planning. It is not a free-
standing event. And so what we have done is to pull together
the elements of those larger strategic plans, VA and VHA, that
reflect long-term care needs and are developing a report for
Congress as required by the law.
Public Law 109-461 provided really a very short turnaround
time for this so that we haven't had a very extensive planning
process as we did in the report that followed the Millennium
Act. But we do consult with the stakeholders. The veterans
service organizations, for example, are represented on our
Geriatrics and Gerontology Advisory Committee, which is a
Federal advisory Committee of folks external to VA. It meets
twice a year. It just met last month here in Washington and we
really had very extensive discussion with the Advisory
Committee about where our long-term care programs are going.
We also consult regularly with the State Veterans Homes
organizations, both the National Association of State Directors
of Veterans Affairs and the National Association of State
Veterans Homes. There is a liaison Committee that meets
formally twice a year and we have informal communications
throughout the year.
So we do make an effort to get input from stakeholders and
those we collaborate with in providing care to veterans.
Mr. Michaud. Well, I would strongly encourage you to make
sure that that input is taken in and taken seriously, because I
feel--even though it might add a little extra time or energy, I
feel very strongly that the more people you get involved in the
process hearing their input, the better product that you will
have in the end. And hopefully, it will definitely bring a lot
more support for whatever programs that the VA brings forward
to dealing with our veterans.
Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman. I had a whole list of
questions and you asked them all but one.
And again, I appreciate your taking the time to come this
morning. Real time health information is critical to providing
high quality healthcare. And the VA currently has the best
electronic medical records available. Has there been any
consideration given to sharing those electronic medical records
with the State Veterans Homes? If not, could you tell me if
that something that you might consider doing?
Ms. Vandenberg. We have had extensive internal
conversations regarding the parameters that we have to operate
within in order to maintain patient privacy. And so the actual
electronic medical record software is available in the public
domain and we have talked to the State Veteran Home
representatives about how we could collaborate with them using
that tool. Direct interoperability does not seem to be legally
feasible at this time given the parameters of the privacy laws
that we operate under.
Mr. Hare. Okay. Thank you very much.
I yield back, Mr. Chairman. Thank you for this important
hearing this morning.
Mr. Michaud. Thank you very much, Mr. Hare. And thank you
for your advocacy for our veterans.
For those of you who don't know, Congressman Hare is a
former staffer of the Ranking Member of this Committee for a
number of years, Lane Evans. And he definitely has taken on
where Mr. Evans has left off in dealing with veterans' issues.
Mr. Brown, unfortunately, had another commitment so he was
unable to stay, but I would ask counsel if he has any
questions.
Mr. Tucker. Yes. I actually have a couple of questions. And
it is always good to see a staffer do well there, Mr. Hare.
A question for Dr. Burris and a question for Ms.
Vandenberg.
Dr. Burris, you state that the 11,000 average daily census
which you are currently estimating for FY 2008 does not provide
any surplus and it does not give you any problems with a
waiting list. If 2,391 nursing home beds suddenly appeared
across the country, would you be able to find veterans to fill
those beds?
Dr. Burris. We might be able to find people to put in the
beds, yes. One of the problems we were having, though, with the
13,391 requirement was that our medical centers were having
trouble finding appropriate patients to admit to the nursing
home, who met the eligibility requirements for that level of
care. So I think we would have difficulty filling those beds,
frankly.
Mr. Tucker. And Ms. Vandenberg, VA spends approximately 90
percent of its long-term care budget on institutional care. For
Medicaid, it is nearly 60 percent. Do you believe this
differential is due to the unique qualities of the veterans'
population, that you are going to always have to have more
institutional care than noninstitutional care?
Ms. Vandenberg. Well, I think that as was evidenced in some
of the prior comments, what contributes to the cost in our
facilities is a function of the complexity of the care that we
are providing. And so when we look at the funds that are
allocated for institutional care, that complexity is reflected
in that. If the question underlying your question is are we
devoting sufficient funds to promote the noninstitutional care,
at this point in time we believe we are making steady progress
in reaching our targets for noninstitutional care and we are
constantly monitoring that. Does that respond to the question?
Mr. Tucker. Yes. I think we are getting to a point where
the VA needs to provide more home and community-based care and
I think our concern up here is that those funds should not just
be shifted from institutional care to noninstitutional
programs, that we actually grow the home and community-based
funding streams and programs, as well as maintain a capacity
and a capability of providing nursing home care.
Ms. Vandenberg. Thank you.
Mr. Tucker. Okay. Thank you.
Mr. Michaud. Once again, I would like to thank this panel
and the previous two panels for your coming here this morning.
I enjoyed the testimony and look forward to working with all of
you as we move forward dealing with this very important issue
of long-term care for our veterans. So once again, thank you
very much.
Ms. Vandenberg. Thank you, sir.
Mr. Michaud. The hearing is adjourned.
[Whereupon, at 11:30 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud
Chairman, Subcommittee on Health
I would like to thank everyone for coming today.
This morning, the Subcommittee on Health will examine the state of
VA's long-term care programs and services.
In terms of demographics, the veteran population is aging and will
require a greater amount of long-term care services. Out of a veteran
population in this country of 25 million, nearly 45 percent are over
the age of 65, and the number over the age of 85 is expected to reach
1.3 million by 2010.
In addition, the veteran population is poorer, sicker and older
than their non-veteran counterparts.
The VA will also be facing an entirely new generation of veterans
in need of long-term care services--some of our wounded returning OEF/
OIF veterans, who have different needs than those of our older
veterans.
Medicaid is the principal financer of long-term care. In 2004,
Medicaid spent $90 billion on long-term care services, of which $57.6
billion, or 64 percent, was for institutional care.
The VA has requested $4.6 billion for long-term care services in FY
2008. Nearly 90 percent is for institutional care.
The VA must, in my view, maintain its nursing home capacity while
vigorously expanding its non-institutional care capabilities.
Contrary to the plain evidence of an increasing long-term care
demand, this year the VA will again ignore its clear legal
responsibility to maintain its nursing home bed capacity. The VA's FY
2008 budget estimates a further drop in the average daily census to
11,000, nearly 20 percent below the required level.
I am concerned that VA is not doing enough to maintain its nursing
home capacity, while not moving fast enough to provide more home and
community-based care.
An integral component to VA's institutional care services is The
State Veterans Home Program. Currently, State Veterans Homes handle
over 50 percent of the VA's overall patient work load in nursing homes.
I believe we must maximize this existing resource as well as other
resources within our communities to ensure the best possible care for
our veterans.
The VA has a long history of providing long-term care services, and
I believe that the VA has many lessons it can teach other areas of the
Federal Government, and the private sector, on how best to provide
these services. The VA can indeed be a long-term care model for others.
VA continues to have an obligation to meet the long-term care needs
of our veterans. I look forward to hearing from our witnesses as to how
VA should meet this obligation in the future.
Prepared Statement of Hon. Henry E. Brown, Jr.
Thank you Mr. Chairman for holding this hearing to examine how the
Department of Veterans of Affairs is providing a mix of extended care
services and how VA intends to address the provision of long term care
in the future.
Today, one of the biggest challenges in both VA and the private
sector healthcare systems is providing long-term care to a growing
aging population. This challenge is amplified for VA, which must
facilitate care for the special needs of our disabled and aging
veterans. The Department is also facing an emerging new need to care
for seriously injured younger veterans returning from the Global War on
Terror.
I appreciate that at our hearing today we have witnesses
representing the State Veterans Homes. On Veterans Day last year, I had
the privilege of dedicating a new State Veterans Home in Walterboro,
South Carolina. This 220 bed facility, the Veterans' Victory House, is
one of the most modern of its kind in the United States, and includes a
52 bed secured dementia unit.
In partnership with the VA, State veterans' homes can help provide
a broad range of services to meet the long-term care needs of our
veterans. Last year, with the enactment of Public Law 109-461, the
Veterans Benefits, Healthcare, and Information Technology Act of 2006,
Congress expanded the authorities for State veterans' homes. The law
requires VA to reimburse State veterans' homes for the full cost of
care for a veteran with a 70 percent or greater service-connected
disability rating and in need of care for service-connected conditions.
It also ensures that veterans with a 50 percent or greater service-
connected disability receive, at no cost, medications they need through
VA.
Additionally, Public Law 109-461, requires VA to publish a
strategic plan for long-term care. Hopefully, this plan that has been a
long time in coming will provide a clear map of the Department's future
plans for delivering long term care for those veterans who rely on VA
to provide these services. I look forward to the delivery of this plan
as required by law. We have allowed VA to drag its feet on this issue
for far too long.
Mr. Chairman, we need to remember that the quality in which we
provide long-term care is a reflection on how this country honors the
sacrifices of our Nation's veterans.
I look forward to our discussion today and to explore innovative
steps we can take to provide the best patient-centered care to enhance
the quality of life of veterans in need of long-term care services.
Knowing what a busy day today is, I yield back
Prepared Statement of Raymond A. Nagel, Chief Executive Officer
Main Veterans' Homes, Augusta, ME
Mr. Chairman and Members of the Committee, thank you for the
opportunity to testify today on behalf of the Maine Veterans' Homes
(``MVH'') on the topic of ``The State of VA's Long-Term Care Program:
Present and Future,'' including the important issue of access by rural
veterans to quality long-term nursing care.
I am the Chief Executive Officer of MVH. I have 23 years of
healthcare management experience including 19 years of experience as a
Medical Services Officer within the United States Army and the United
States Army Reserves. I am a combat veteran of Operations Desert Shield
and Desert Storm. I recently retired from the U.S. Army Reserves as a
Lieutenant Colonel and commander of a 296-bed Combat Support Hospital.
I have been the chief executive officer of the Maine Veterans' Homes
for nearly 1 year.
MVH is a public body corporate created by the State of Maine to
provide long-term nursing care to Maine veterans. MVH operates six
long-term nursing care facilities for veterans at Augusta, Bangor,
Caribou, Machias, Scarborough, and South Paris. In the aggregate, MVH
currently operates 640 skilled nursing, long-term nursing, and
domiciliary beds for Maine veterans. This makes MVH one of the largest
systems of long-term nursing facilities in the State of Maine, and we
are very proud of the quality long-term care nursing services that we
provide to Maine veterans.
Also, as one of the largest and most successful State Veterans
Homes systems in the nation, MVH provides a crucial portion of the
healthcare continuum for Maine veterans. Our facilities are each
relatively small in size, 30 to 150 beds each, and this allows them to
be located not only at one or two locations, but throughout the State
of Maine, allowing greater ease of access to our facilities by veterans
living in the most rural parts of Maine. In the future, we hope to
develop additional in-patient and out-patient services at all of our
six locations in order to offer rural Maine veterans greater access to
all of the services that the Maine Veterans' Homes, the Maine Bureau of
Veterans Services, and the United States Department of Veterans Affairs
(``VA'') provide.
MVH is part of a national system of State Veterans Homes. The State
Veterans Homes system is the largest provider of long-term care to our
Nation's veterans. There are 126 veterans homes in all 50 States and
the Commonwealth of Puerto Rico. Nursing home care is provided in 121
homes, domiciliary care in 53 homes, and hospital care in 5 homes.
These homes presently provide over28,000 resident beds for veterans of
which almost 22,000 are nursing home beds. These beds represent about
50 percent of the long-term care workload for the VA.
The State Veterans Homes play an irreplaceable role in assuring
that eligible veterans receive the benefits, services, and quality
long-term healthcare that they have rightfully earned by their service
and sacrifice to our country. We greatly appreciate the Veterans'
Affairs Committee's commitment to the long-term care needs of veterans,
your understanding of the indispensable function that State Veterans
Homes perform, and your strong support for our programs. We especially
appreciate the consistent support of the Veterans' Affairs Committee,
working with the Appropriations Committee, to ensure that per diem
payments by the VA will continue under current eligibility criteria.
The Maine Veterans' Homes is a leader in the national system of
State Veterans Homes and a leader in the National Association of State
Veterans Homes (``NASVH''). The membership of NASVH consists of the
administrators and staff of State-operated veterans homes throughout
the United States. We work closely with the VA, State governments, the
National Association of State Directors of Veterans Affairs, veterans
service organizations, and other entities dedicated to the long-term
healthcare of our veterans. Our goal is to ensure that the level of
care and services provided by State Veterans Homes meet orexceed the
highest standards available.
Role of the State Veterans Homes
State Veterans Homes first began serving veterans after the Civil
War. Faced with a large number of soldiers and sailors needing long-
term care, several States established veterans homes to care for those
who had served in the military.
In 1888, Congress first authorized Federal grants-in-aid to states
that operated homes in which American soldiers and sailors received
long-term care. At the time, such payments amounted to about 30 cents
per resident per day. In the years since, Congress has made several
revisions to the State Veterans Homes program to expand the base of
payments to include nursing home, domiciliary, and adult day
healthcare.
For nearly half a century, State Veterans Homes have operated under
a program administered by the VA which supports the Homes through
construction grants and per diem payments. Both the VA construction
grants and the VA per diem payments are essential components of this
support. Each State Veterans Home must meet stringent VA-prescribed
standards of care, which exceed standards mandated by Federal and State
governments for other long-term care facilities. The VA conducts annual
inspections to assure that these standards are met and to assure the
proper disbursement of funds. Together, the VA and the State Veterans
Homes represent a very effective and financially efficient Federal-
State partnership in the service of our Nations veterans.
VA per diem payments to State Homes are authorized by 38 U.S.C.
Sec. 1741-1743. The per diem payments are intended by Congress to
assist the States in providing for the level of care and treatment
required for eligible veterans residing in State Veterans Homes. As you
know, the per diem rates are established by the VA annually and may not
exceed 50 percent of the cost of care. They are currently $67.71 per
day for nursing home care, $40.48 per day for adult day healthcare, and
$30.31 per day for domiciliary care. Our State Veterans Homes cannot
operate without receipt of per diem payments from the VA under current
eligibility criteria.
Construction grants are authorized by 38 U.S.C. Sec. Sec. 8131-
8137. The objective of such grants is to assist the States in
constructing or acquiring State Veterans Home facilities. Construction
grants are also utilized to renovate existing facilities and to assure
continuing compliance with life safety and building codes. Construction
grants made by the VA may not exceed 65 percent of the estimated cost
of construction or renovation of facilities, including the provision of
initial equipment for any project. State funding covers at least 35
percent of the cost. Our program cannot meet our veterans' needs
without an adequate level of construction grant funding.
In recent years, State Veterans Homes have experienced a period of
controlled growth in response to the increasing number of elderly
veterans who require long-term healthcare. In fact, as a nation we face
the largest aging veterans population in our history. By the end of
this decade, the number of veterans aged 85 and older will have tripled
from 422,000 to 1.3 million. If the State Veterans Homes program is to
fill the need for additional long-term care beds required in certain
States and to respond to the increase in the number of veterans
eligible for long-term care nationally, it is critical that the State
Veterans Home construction grant program be sustained at adequate
levels.
The State Veterans Home program now provides about 50 percent of
the VA's total long-term care workload. The VA has estimated that
nursing care beds in the State Veterans Homes nationwide are 87 percent
occupied. The beds at our homes in Maine are approximately 96 percent
occupied. Many of the State Veterans Homes nationally have occupancy
rates near 100 percent, and some have long waiting lists. The State
Veterans Homes provide long-term medical services to frail, elderly
veterans at a cost to the VA of less than $68 per day, well below the
cost of care in a VA nursing home, which is over $560 per day.
Although there are no national admission requirements for the State
Veterans Homes, there are State-by-State medical requirements for
admission to such homes. Generally, a State will require a medical
certification confirming several significant deficits in activities of
daily living (an assessment of basic living functions) that together
require 24-hour nursing care. Moreover, no per diem is paid by the VA
unless and until a VA official certifies that nursing home care is
required. Veterans qualifying for long-term nursing care at a State
Veterans Home are almost always very ill and elderly, and many are
afflicted with mental health conditions.
State Veterans Homes as a VA Resource
The Veterans' Millennium Healthcare Act (``Mill Bill''), Pub. L.
No. 106-117, enacted significant changes to veterans' long-term
healthcare. Significantly, the VA is directed to provide long-term care
for all veterans who have a 70 percent or greater service-connected
disability or who need nursing care for a service-connected disability.
The State Veterans Homes should play a major role in meeting these
requirements and be treated as a resource that is integrated much more
fully with the VA's own long-term care program.
The State Veterans Homes have proposed that our beds be counted
toward the VA's overall long-term care census. Doing so would allow the
VA to meet the Mill Bill's long-term care bed requirements. A nursing
home bed in a State Veterans Home is a very cost-effective alternative
to a nursing home bed in a VA-operated facility. Congress's goal should
be to provide long-term care to veterans in a manner that expands the
VA's capacity to provide services, while paying the lowest available
per capita cost for each eligible veteran. Including State Veterans
Homes nursing beds in the mandated VA long-term care totals would allow
the VA to meet its legislative mandate, shift some of its long-term
care services to the State Veterans Homes, and ultimately increase the
capacity of the VA to provide greater short-stay, highly specialized,
post-acute rehabilitative care.
This goal can be accomplished by the State Veterans Homes at
substantially less cost to taxpayers than other alternatives. The
average daily cost of care for a veteran at a long-term care facility
run directly by the VA has been calculated nationally to be $563.45 per
day. The cost of care to the VA for the placement of a veteran at a
contract nursing home, which is not required to meet more stringent
State Veterans Home standards, is approximately $225.30 per day. The
same daily cost to the VA to provide quality long-term nursing care at
a State Veterans Home is far less--only $67.71 per day.
This substantially lower daily cost to the VA of the State Veterans
Homes compared to other available long-term care alternatives led the
VA Office of Inspector General to conclude in a 1999 report: ``the SVH
[State Veterans Home] program provides an economical alternative to
Contract Nursing Home (CNH) placements, and VAMC [VA Medical Center]
Nursing Home Care Unit (NHCU) care'' (emphasis added). In this same
report, the VA Office of Inspector General went on to say:
A growing portion of the aging and infirm veteran population
requires domiciliary and nursing home care. The SVH [State Veterans
Home] option has become increasingly necessary in the era of VAMC [VA
Medical Center] downsizing and the increasing need to discharge long-
term care patients to community based facilities. VA's contribution to
SVH per diem rates, which does not exceed 50 percent of the cost to
treat patients, is significantly less than the cost of care in VA and
community facilities.
Innovative Programs at the State Veterans Homes
Although several states have either a ``great'' or ``significant''
need, as defined by Federal law, to build new State Veterans Homes
immediately, the State of Maine, with 640 beds already in successful
operation, has built all of the long-term care beds for veterans that
we expect to build. We are limited by Federal law to the 640 long-term
care beds for veterans that we currently operate. Furthermore, the
State of Maine operates our long-term care beds for veterans at over 96
percent of capacity, and this is virtually full occupancy, since
veterans continually are admitted to or discharged from the homes.
If the State of Maine is to provide greater levels of services to
its veterans, MVH must expand the types of services we offer to Maine
veterans. Therefore, MVH has initiated an ambitious new program to
expand the delivery of additional health-care related services at
locations clustered around its existing State Veterans Homes.
For example, at the 150-bed MVH nursing and domiciliary facility
located at Bangor, Maine, MVH is proposing to construct an integrated
``veterans campus'' containing an 18,500 square foot Community Based
Outreach Clinic (``CBOC''), a seven-bed hospice facility, and an 18-
unit elderly veterans housing facility. Attached to my testimony are
proposed site plans for this veterans' campus. The CBOC (to be operated
by the VA) will provide primary healthcare to Maine veterans and house
State offices providing veterans services. The hospice (to be operated
by MVH) will provide critically needed end-of-life and palliative care
services to Maine veterans. Finally, the elderly housing facility will
provide short and long-term housing to Maine veterans who may be using
the other health-related services provided at the veterans' campus.
This veterans' campus can be constructed using solely the financial
resources of MVH, and at no cost to Maine taxpayers. Later, if
appropriate, the services provided at such a veterans campus could be
expanded to include assisted living and congregate housing, adult
daycare services, and home healthcare services for veterans. In this
manner, MVH will provide, within an integrated setting, comprehensive
healthcare services to Maine veterans covering the full continuum of
care. Furthermore, this concept could be replicated at the sites of
each of the other five existing MVH facilities, in order to provide
veterans throughout the State of Maine with easy access to
comprehensive healthcare in both urban and rural settings. Attached to
my testimony is a map of the State of Maine showing the locations of
all six existing MVH facilities. This concept, if successful in Maine,
can be replicated elsewhere in the country.
Conclusion
Mr. Chairman and Members of the Subcommittee, thank you for your
commitment to quality long-term care for veterans and for your support
of the State Veterans Home system as a central component of that care.
We believe that the State Veterans Homes can play a much more
substantial role in meeting the long-term care needs of veterans. MVH
recognizes and supports the national trend toward
deinstitutionalization of healthcare and the provision of long-term
healthcare in the most independent and cost-effective setting. We have
previously proposed to the VA that we explore together creative ways to
provide a complete and conveniently located continuum of healthcare to
our veterans, both rural and urban, at State Veterans Home-sponsored
facilities and in the community. We would be pleased to work with the
Committee and the VA to explore options for developing pilot programs
for innovative long-term healthcare solutions and for more closely
integrating the State Veterans Home program into the VA's overall
healthcare system for veterans.
Prepared Statement of R. Roy Griffith, Chairman, Liaison Committee
National Association of State Veterans Homes, and
Administrator, Oklahoma Veterans Center, Talihina, OK
Chairman Michaud, Ranking Member Miller, Members of the
Subcommittee:
I want to commend you for holding today's hearing and thank you
very much for inviting the National Association of State Veterans Homes
(NASVH) to testify on the role of State Homes in the provision of long
term care to our Nation's veterans. I especially want to thank you for
allowing me to substitute for our national Legislative Chair, Bob Shaw,
who was unable to make it to today's hearing due to the recent death of
his mother.
This morning I am speaking as a member of NASVH's Executive
Committee and Chairman of our VA Liaison Committee, where I am
responsible for interfacing with the Department of Veterans Affairs. In
addition, I am here as the Administrator of the Oklahoma Veterans
Center in Talihina, Oklahoma, which provides long term care for 175
veterans, including a 48 bed wing for ambulatory Alzheimer's patients.
Mr. Chairman, the State Home program dates back to the post-Civil
War era when several States established homes in which to provide
shelter and care to otherwise homeless, sick and maimed Union soldiers
and sailors. In 1888 Congress first authorized Federal grants-in-aid to
the States that maintained these homes, including a per diem allowance
for each veteran of twenty-seven cents ($100 per year per veteran).
Over the years since that time, the State Home program has been
expanded and refined to reflect the improvements in standards of
medical practice, including the advent of nursing home, domiciliary,
adult day health, and other specialized geriatric care for veterans.
For example, as I mentioned, the facility that I manage in Talihina
has a 30-bed secure unit for Alzheimer's patients, a growing need in
this veterans' population. At least two State Homes are providing adult
day healthcare, and a number of others are developing programs or plans
for this discipline and other emerging approaches to delivering care in
less restrictive settings. In fact we are presently working with VA and
State officials in a task force established by Deputy VA Secretary
Gordon Mansfield to examine ways to establish more veterans adult day
healthcare programs through auspices of the States and their State
Veterans Homes.
Mr. Chairman, with the aging of our ``baby boomer'' generation,
America faces a looming long term care crisis, one that many of our
Nation's veterans are already facing. Although the veteran population
is declining, their needs are still rising. VA projects that today's
veteran population of 24.5 million will continue to decline through
2020, but that the number of veterans over 65 years of age will rise
and ultimately peak in the year 2014, driven by the very large number
of Vietnam veterans. Most alarming, the number of veterans over the age
of 85 is projected to increase by 173 percent by 2020, creating an ever
greater number of veterans seeking long term care services.
Another important factor to consider is that we are seeing
extraordinarily disabled veterans coming home from Iraq and Afghanistan
with levels of injury and disability unheard of in past wars. Our
incredible military medical triage and its applied technology has saved
them, and many of them are now in VA polytrauma centers, but they
present a medical and social challenge the likes of which we have never
seen before. We are grateful that the numbers of these polytraumatic''
injured are relatively small, but we must be cognizant that they will
need extraordinary care and shelter for the remainder of their lives.
While VA is doing an excellent job to address their immediate needs,
neither VA nor these veterans' families are fully prepared today to
deal with their longer term needs. I am hopeful that our partnership
with VA might be a basis for the State Veterans Homes to play a small
but vital role in aiding these catastrophically injured veterans by
providing them a home-like atmosphere, a caring environment and the
level of clinical services they are going to need for the remainder of
their lives.
Finally, the newest generation of veterans, from the Persian gulf
war until today, exhibits different expectations than their
counterparts of the past. In general they are computer literate, well
educated, want more involvement in their own care and want to control
their own destinies. As these veterans age into later life and begin to
need long-term care services, this will make VA's and our jobs much
more challenging.
Mr. Chairman, today State Homes provide the bulk of long term care
for our Nation's veterans. Last year GAO reported that State Homes
provide more than 50 percent of VA's overall patient workload in
nursing homes, while consuming just 12 percent of VA's long term care
budget. And the trend over recent years shows that State Homes are
increasing their share of workload while their share of VA's budget
continues to decline. VA pays just $67.71 as a per diem payment for
each veteran residing in a State Home, which is less than one-third of
the average cost of that veteran's care. The remaining two-thirds is
made up from a mix of funding, including State support, Medicaid, and
other public and private sources.
Compare this to VA's cost when contracting out with community
nursing homes where VA covers 100 percent of the cost of care, often
upward of $200 per day, or when VA provides the care through one of its
own nursing homes, where the average cost of care is in excess of $400
per day.
In addition to this per diem support, VA also helps cover the cost
of construction, rehabilitation, and repair of State Veterans Homes on
a matching basis with States. VA will provide up to 65 percent of the
cost with the State providing at least 35 percent of the project's
costs. The program was refined in 1999 under the Veterans Millennium
Healthcare and Benefits Act, which created a series of priority
categories for pending construction projects. At the top of the
priority list are life and safety projects, and new home construction
in States without any State Home beds.
Unfortunately, in FY 2006, the construction grant program was cut
from $104.3 million down to $85 million after a decade of stable
funding marked by modest Consumer Price Index-type increases. In FY
2007 the administration proposed and succeeded in holding down this
funding at the reduced level of $85 million, continuing the $20 million
reduction below the established 2005 baseline. The total funding
reduction over 2 years is approximately $40 million.
As a result of these real-dollar reductions, as well as the effects
of inflation and rapidly rising construction costs, the backlog of
State Home construction projects is rapidly rising. There are currently
$242 million in pending ``priority 1'' State Home projects, and NASVH
estimates that the total backlog of all potential qualifying State Home
projects, including new and replacement bed and new home proposals in
Texas, North Carolina, North Dakota, California, Florida and other
States, could soon surpass $1 billion.
Last month, NASVH testified before the Appropriations Subcommittee
and requested that funding for the State Home construction grant
program be increased to at least $160 million in FY 2008 in order to
reduce the rising backlog, address the most serious life and safety
issues, and protect the State Home system for the future. We would be
grateful for any support you and this Committee can offer in that
regard.
I believe it is important to note for the Subcommittee that, since
the Civil War, States have assumed the burden of care for veterans and
today spend over $3 billion annually to provide this care, despite the
fact that veterans of our armed forces are serving the whole nation,
not just their States. Seen this way, the care rendered to veterans by
the States actually constitutes a subsidy to the Federal Government,
even though the rhetoric you may hear makes the opposite argument--that
VA subsidizes the States. In fact, if the States were to choose to
abandon the State Home program, the burden of care for these veterans
would revert to the Federal Government, either through the VA directly,
or to Medicare and Medicaid.
Finally, Mr. Chairman, like all healthcare facilities, State Homes
are not immune from human errors and operational problems, such those
recently reported in Arizona and Minnesota When such problems are
discovered, they must not only be aggressively investigated and
corrected, but the State Home has an obligation to take additional
measures to ensure that such problems do not recur. As a system,
however, NASVH is quite proud of the record of State Homes in providing
quality care. One reason for this record is the extremely tough
regulatory and oversight controls placed on State Homes--by both
Federal and State agencies.
Most State Veterans Homes are part of a State's departments of
veterans' affairs, public health, or other State agency. Some Homes
operate under the governance of a Board of trustees, a Board of
Visitors, or other body made up of prominent citizens, retired senior
military personnel, former state and Federal public officials and
veterans. In addition, State financial and management agencies and
offices will often perform extensive audits of State Homes every two to
3 years.
Each State is responsible for ensuring veterans receive quality
long term and healthcare services and achieve high patient
satisfaction, safe environmental conditions, and sound financial
management. The primary responsibility resides in the State agency or
office that manages State Homes, although other State agencies may
share some oversight responsibilities, such as for finances. State
Homes that are overseen by Boards also face direct scrutiny from their
appointed Board Members. As State-owned public buildings, State Homes
are subject to State and local fire marshal and life-safety inspections
on a routine basis to examine for fire hazards and life-safety issues.
In addition, the Department of Veterans Affairs holds State Homes
to the same high standards as are applied to nursing homes that VA owns
and operates. State Homes are inspected annually by teams of VA
examiners, including physicians, nurses, social workers, dieticians,
activity specialists and mechanical and structural engineers. These
visits typically consume a week, with more time involved for resolving
any issues VA's examiners identify. VA's Inspector General also audits
and inspects State Homes whenever and wherever it is determined
necessary.
In addition, States Homes authorized to receive Medicaid and
Medicare reimbursement are subject to unannounced inspections by the
Centers for Medicare and Medicaid Services (CMS), usually consuming
three or more workdays, and staffed by a variety of long term care
experts. State Homes are also subject to announced and unannounced
inspections by HHS's Inspector General. Furthermore, the Department of
Justice's Civil Rights Division is fully authorized to conduct
investigations and takes necessary legal action to correct any
complaints of neglect or abuse found to exist at State-run nursing
homes. Finally, in some State Homes national veterans service
organizations (VSOs), such as The American Legion, will regularly
inspect State Homes, looking at both operational and management issues.
Mr. Chairman, State Veterans Home provide safe, high-quality and
affordable care to our Nation's veterans. This successful Federal-State
partnership is an indispensable component of our nation's long term
care resources, and we are grateful for your continued support.
Millions of American veterans are going to need long-term care in the
years ahead and the State Veterans Home system must continue to be an
important component of the solution.
Mr. Chairman, this concludes my testimony. I would be pleased to
answer any questions you may have.
Prepared Statement of Shannon L. Middleton, Deputy Director, Veterans
Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to submit The American Legion's
views on VA's strategic direction and plans to address the aging
veteran population and the needs of the recently separated veterans.
AGING VETERAN POPULATION
A July 1984 study, Caring for the Older Veteran, predicted that a
``wave'' of elderly World War II and Korean Conflict veterans would
occur some 20 years ahead of the elderly in the general U.S. population
and had the potential to overwhelm the VA Long Term Care (LTC) system
if not properly planned for. The most recent available data from VA,
2000 Census-based VETPOP 2001 Adjusted, show there were 25.6 million
veterans in 2002 and 9.76 million, or 37 percent, are aged 65 or older.
According to the 2003 National Survey of Veteran Enrollees' Health and
Reliance on VA, 14 percent of the veteran population was under the age
of 45, 39 percent were between the ages of 45 and 64, and 47 percent of
veterans were 65 years or older. Compared to the 2001 Survey, in which
age distribution was 21, 41 and 39 percent respectively, it is clear
that the ``demographic imperative'' predicted in 1984 is now upon us.
The study cited an ``imminent need to provide a coherent and
comprehensive approach to long-term care for veterans.'' Twenty-three
years hence, the coherent and comprehensive approach called for has yet
to materialize. The American Legion supports a requirement to mandate
that VA publish a comprehensive Long Term Care Strategic Plan.
The Veterans Millennium Healthcare and Benefits Act 1999 provided
VA the authority to act on these projections. Based on an ``aging in
place'' continuum of care model, VA was mandated to begin providing a
variety of non-institutional services to aging veterans, including;
home-based primary care, contract home healthcare, adult day
healthcare, homemaker and home health aides, respite care, telehealth
and geriatric evaluation and management.
On March 29, 2002, the government Accountability Office issued a
report that stated that nearly 2 years after the Millennium Acts
passage, VA had not implemented its response to the requirements that
all eligible veterans be offered adult day healthcare, respite care and
geriatric evaluation. At the time of GAO's inquiry, access to these
services was ``far from universal.'' While VA served about one-third of
its 3rd Quarter 2001 LTC workload (23,205 out of an Average Daily
Census of 68,238) in non-institutional settings, VA only spent 8
percent of its LTC budget on these services. Additionally, VA had not
even issued final regulations for non-institutional care, but was
implementing the services by issuing internal policy directives,
according to GAO. Of 140 VAMCs, only 100 or 71 percent were offering
adult day healthcare in non-institutional settings.
By May 22, 2003, over 1 year later, GAO testified before this
Subcommittee that things had not improved and that veterans' access to
non-institutional LTC was still limited by service gaps and facility
restrictions. GAO's assessment showed that for four of the six
services, the majority of facilities either did not offer the service
or did not provide access to all veterans living in the geographic
service area. GAO summarized the problem nicely when it testified that
``[f]aced with competing priorities and little guidance from
headquarters, field officials have chosen to use available resources to
address other priorities.''
In the area of nursing home care, VA is equally recalcitrant in
implementing the mandates of the Millennium Act. The Act required VA to
maintain its in-house Nursing Home Care Unit (NHCU) bed capacity at the
1998 level of 13,391. In 1999 there were 12,653 VA NHCU beds, 11,812 in
2000, 11,672 in 2001, 11,969 in 2002 and 12,339 beds in 2003. VHA
estimates it had 11,000 beds in 2004 and projected only 8,500 beds for
fiscal year 2005. The American Legion believes that VA should be
required to restore its nursing home care unit capacity as intended by
Congress to the 1998 level. Additionally, VA should be prohibited from
counting any but their own nursing home care unit beds for the purpose
of compliance with the provisions of the Millennium Act.
VA claims that it cannot maintain both the mandated bed capacity
and implement all the requirements of the Millennium Act. Providing
adequate inpatient LTC capacity is good policy and good medicine. The
American Legion opposes attempts to repeal 38 U.S.C.
1710B(b).The American Legion believes VA should provide the quality of
care mandated by Congress for the long term care of America's veterans.
Congress should provide adequate funding to VA to implement its
mandates.
State Extended Care Facility Construction Grants Program
Since 1984, nearly all planning for VA inpatient nursing home care
has revolved around State Veterans' Homes (SVHs) and contracts with
public and private nursing homes. The reason for this is obvious; for
fiscal year 2004 VA paid a per diem of $59.48 for each veteran it
places in SVHs, compared to the $354.00 VA said it cost in FY 2002 to
maintain a veteran for 1 day in its own NHCUs.
Currently, VA is authorized to make payments to states for
construction and maintenance of SVHs. Today, there are 109 SVHs in 47
states with over 23,000 beds providing nursing home, hospital, and
domiciliary care. Grants for construction of state extended care
facilities provide funding for 65 percent of the total cost of building
new veterans' homes. Recognizing the growing long-term healthcare needs
of older veterans, it is essential that the State Veterans' Home
Program be maintained as a viable and important alternative healthcare
provider to the VA system. State authorizing legislation has been
enacted and state funds have been committed. The West Los Angeles State
Veterans' Home, alone, is a $125 million project. Delaying this and
other projects will result in cost overruns from increasing building
materials costs and may lead states to cancel these much-needed
facilities.
The American Legion supports increasing the amount of authorized
per diem payments to 50 percent for nursing home and domiciliary care
provided to veterans in State Veterans' Homes. The American Legion also
supports providing prescription drugs and over-the-counter medications
to State Homes Aid and Attendance patients, along with the payment of
authorized per diem to State Veterans' Homes. Additionally, VA should
allow for full reimbursement of nursing home care to 70 percent
service-connected veterans or higher, if the veteran resides in a State
Veterans' Home.
COMMISSION ON THE FUTURE FOR AMERICAN'S VETERANS
In testimony delivered in 2006 addressing VA Long Term Care, GAO
identified a major challenge in VA's ability to plan for nursing home
care as estimating which veterans will seek care from VA and what their
nursing home needs will be. The unpredictability of the long term care
needs of those suffering from polytrauma, blast injuries and lasting
mental health conditions as a result of participation in the ongoing
Global War on Terror will no doubt make planning even more challenging.
The Commission on the Future for America's Veterans was established
in September 2006. The Commission's purpose is to ascertain the needs
of veterans 20 years in the future. The Commissioners are experts on
veterans' issues and include Past National Commanders of the largest
veterans service organizations, those who have treated combat veterans,
as well as a former VA administrator and a former Congressman. The
Commission was created by the Veterans Coalition, which includes The
American Legion, Veterans of Foreign Wars (VFW), Disabled American
Veterans (DAV), Paralyzed Veterans of America (PVA), AMVETS, Vietnam
Veterans of America, Blinded American Veterans, Jewish War Veterans,
and Military Order of the Purple Heart
The Commission has been conducting townhall meetings around the
country to allow veterans, family members and caregivers an opportunity
to express their views on the future needs of servicemembers,
especially those who have been injured in the current Global War on
Terror. At the conclusion of this fact finding initiative, the
Commission will create a report that will include recommendations for
addressing the needs identified. The Commission plans to deliver
recommendations to the President, Congress, and the American public by
Memorial Day 2008.
The American Legion supports this timely and proactive endeavor and
hopes VA and Congress utilize the findings to prepare for the long-term
needs of the newest era of war veterans.
MANDATORY FUNDING FOR VETERANS HEALTH CARE
A new generation of young Americans is once again deployed around
the world, answering the nation's call to arms. Like so many brave men
and women who honorably served before them, these new veterans are
fighting for the freedom, liberty and security of us all. Also, like
those who fought before them, today's veterans deserve the due respect
of a grateful nation when they return home.
Unfortunately, without urgent changes in healthcare funding, new
veterans will soon discover their battles are not over. They will be
forced to fight for the life of a healthcare system that was designed
specifically for their unique needs. The American Legion believes that
the solution to the Veterans Health Administration (VHA) recurring
fiscal difficulties will only be achieved when VA funding becomes
mandatory. Funding for VA healthcare currently falls under
discretionary spending within the Federal budget. VA's healthcare
budget competes with other agencies and programs for Federal dollars
each year. VA's ability to treat veterans with service-connected
injuries is dependent upon discretionary funding approval from Congress
each year.
Under mandatory funding, VA healthcare would be funded by law for
all enrollees who meet the eligibility requirements, guaranteeing
yearly appropriations for the earned healthcare benefits of enrolled
veterans.
The Veterans Health Administration is now struggling to meet its
requirement to provide timely access to healthcare with funding methods
that were developed in the 19th century. The American Legion believes
that healthcare rationing for veterans must end. It is time to
guarantee healthcare funding for all veterans.
Mr. Chairman, that concludes my testimony.
Prepared Statement of Adrian M. Atizado, Assistant National Legislative
Director, Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
On behalf of the more than 1.3 million members of the Disabled
American Veterans (DAV) and its Auxiliary, I wish to express my
appreciation for this opportunity to present the Subcommittee our views
on the present and future state of long-term care programs in the
Department of Veterans Affairs (VA). Mr. Chairman, as you know, DAV is
an organization devoted to advancing the interests of service-connected
disabled veterans, their dependents, and survivors. For the past eight
decades, the DAV has devoted itself to a single purpose: building
better lives for our Nation's disabled veterans and their families.
The DAV is cognizant of VA's need to plan strategically how best to
use its resources to provide equitable access for veterans needing
acute care services, while also providing a growing elderly veteran
population with institutional and non-institutional long-term care
services. However, the present state of VA's long-term care program is
now lagging behind its rich history as an early leader in caring for
aging veterans, and is in danger of falling behind non-VA healthcare
systems. We are concerned that the last published strategic plan for
long-term care was prepared over 7 years ago. That strategic plan was
intended to implement a number of recommendations from a 1998 report of
VA's Federal Advisory Committee On the Future of VA Long-Term Care,
entitled VA Long-Term Care At the Crossroads. This Crossroads report
took a critical look at VA's long-term care program and highlighted the
growing gulf between VA and non-VA long-term care systems. To address
this disparity the report recommended swift and definitive action for
VA to ``. . . retain its core of VA-operated long-term care services
while improving access and efficiency of operations. Most new demand
for care should be met through non-institutional services, contracting,
and where available, State Veterans Homes.'' In 1999 a number of the
Crossroads recommendations to expand and enhance VA's long-term care
programs were incorporated in Public Law 106-117, the Veterans
Millennium Healthcare and Benefits Act, but much of the promise of the
Millennium Act remains unfulfilled.
The number of service-connected disabled veterans rated 70 percent
or higher for whom VA is required to provide extended care services has
been increasing every year and experienced the highest growth from
fiscal year 1999 through 2005. Accordingly, the delegates to the 2006
DAV National Convention, held in Chicago, Illinois, once again approved
a resolution calling for the expansion of a comprehensive program of
long-term care services for service-connected disabled veterans,
regardless of their percentages of disability ratings.
Many elderly and infirm veterans, particularly those with service-
connected disabilities, use the VA for their healthcare needs in post-
acute and long-term care settings. Today, nearly 45 percent of the over
24 million veterans and nearly 50 percent of the almost 8 million
veterans enrolled in VA healthcare are over the age of 65. The number
of veterans over age 85 is expected to reach 1.3 million by 2011. In
addition, the majority of VA enrollees plan to use VA as their primary
source of healthcare. Given these projections, the wave of aging
veterans will become a geriatric imperative with which VA will likely
see a steadily rising and significant demand for long-term care
services in the near future.
We are appreciative that in section 206 of P.L. 109-461 Congress
required VA to develop a new strategic long-term care plan; however, we
are concerned about the limited time the Act afforded VA in preparing
such a critical plan. Furthermore, a March 20, 2006, report by the VA
Office of Inspector General indicated VA is developing a Capital Asset
Realignment for Enhanced Services (CARES) based strategic plan to
address nursing home infrastructure inequities and realignments;
however, the DAV is concerned that VA has not sought involvement, input
or advice from veterans service organizations with any of these
initiatives, unlike the 1999 VA strategic plan for long-term care in
which this community was directly involved.
VA's long-term care program received significant modification with
the passage of Public Law 106-117, which brought some degree of parity
between long-term care, which was considered discretionary care, and
acute care, which was considered ``mandatory;'' however, some tension
remains. Furthermore, this tension has translated down and between
institutional and non-institutional extended care, where VA is required
to provide non-institutional services to all enrolled veterans in need
of such care but only requires VA to provide institutional services to
a subset of enrolled veterans. Coupling this with the push for VA to
drive down the cost of care while increasing the number of veterans
served puts long-term care at a disadvantage, and all the more for
institutional extended care. The DAV believes that long-term care is a
fundamental part of the continuum of VA medical care. We therefore urge
Congress and VA to address this aspect of the current state of VA long-
term care as you consider the future of this essential program.
Non-Institutional Long-Term Care
As referenced above, VA's enhanced authority to use and make
available non-institutional services, including respite care, assisted
living and residential care such as adult day healthcare, skilled home
nursing, home-based care models, homemaker/home health aide services,
was added to VA's medical benefits package by the Millennium Act.
However, nearly four years post-enactment, the government
Accountability Office (GAO) testified and reported these enhanced VA
services remained highly variable from facility to facility, and from
Veterans Integrated Services Network (VISN) to VISN. The information
noted existing variations in availability of non-institutional services
across VA due to, among other reasons, the lack of existence of
particular programs at a given VA facility and whether the veteran
resides within a facility's geographic service area.
More recently VA has reported large year-to-year increases in non-
institutional long-term care activity, but VA's data conventions for
reporting this workload, which assists VA's ability to manage this
program's patient population, are problematic for the purposes of
oversight and may misstate that activity.
While we applaud VA leadership in reinforcing the elimination of
local restrictions limiting eligible veterans' access to non-
institutional care, we continue to receive reports that service-
connected disabled veterans are not receiving the care they need for
their service-connected conditions because they do not reside in a VA
facility's geographic service area. Moreover, we are concerned by the
lack of systematic oversight to capitalize and advance the progress
made in addressing this issue.
Hospice and Palliative Care
To address the number of veteran deaths that has been increasing by
about 8 percent annually to a current average of 1,800 per day, VA has
emphasized providing hospice and palliative care to honor personal
preferences for care at the end of life. While hospice and palliative
care are covered benefits available to all enrolled veterans in all
settings, VA must offer to provide or purchase hospice and palliative
care that VA determines an enrolled veteran needs.
Unfortunately, VA is the only public healthcare system that charges
co-payments to hospice patients. Veterans who utilize this benefit may
be subject to inpatient and outpatient co-payments if hospice is not
provided in a VA nursing home bed.
The DAV recommends the fulfillment of Congress's original intent in
Public Law 108-422 that VA provide equitable and compassionate end of
life services to veterans by exempting them from the requirement to pay
co-payments when they receive VA hospice care in any setting. We also
urge greater Subcommittee oversight on VA's end of life programs as
many VA facilities have been aggressive in establishing end of life
programs while others have lagged behind.
Institutional Long-Term Care
VA Nursing Home Care Units
A common description of nursing home care is that it is the most
restrictive and the least flexible mode of providing extended care
services. Further, much like hospice care in its infancy, nursing home
care is seen as an antithesis to medical care--a form of care in which
patients will never recover or stabilize to the point where they can
take care of themselves, or with a support system would be able go
return home. While seemingly accurate, these observations do not fairly
or entirely represent the value of institutional care, particularly for
the veteran patient that suffers from serious chronic mental illness,
spinal cord injury, behavioral problems, or is ventilator dependent and
thus poses a significant problem for community placement.
On average, elderly enrolled veterans have a higher divorce rate, a
higher rate of marital separation, lower incomes, savings and other
personal assets than age-matched non-veteran populations. They are more
likely to live alone, be estranged from families, less likely to engage
in social and community activities, more likely to exhibit unhealthy
lifestyles with respect to exercise, alcohol, tobacco, and nutrition,
and exhibit more tendencies to chronic mental illnesses. Caring for an
aging veteran population with some of these characteristics in the
least restrictive setting may well be in VA nursing home care units,
rather than in community settings.
Furthermore, the DAV believes that in addition to serving a
specific patient population providing invaluable service such as
indefinite self-care support, rehabilitative, and recuperative care,
nursing home care is an integral component to VA's extended care
benefits package as a part of that continuum. Moreover, VA's ``Culture
Transformation'' initiative for nursing home care is centered on such
core concepts as personal autonomy, privacy, dignity, flexibility, and
individualized services. The culture change movement, which is well
underway, is changing the old philosophy of patient centered care,
which operates in a medical model of technical service delivery and
intervention, and toward the new thinking of patient centered living in
old age.
State Veterans Homes
The DAV is concerned about the obvious shift in VA's long-term care
workload away from meeting its statutory mandate to maintain VA nursing
home capacity. This policy is unconscionable considering VA's own
projected demand that the anticipated capacity in all three
institutional settings (VA nursing home care units, community nursing
homes, and State Veterans Homes) will not be sufficient to meet the
total demand of enrolled veterans for institutional nursing services.
While it is laudable that VA seeks to provide care to veterans who
need VA the most by shifting more of its institutional care workload
into State Veterans Homes, we applaud Congress for taking the first
step to provide equitable relief for service-connected disabled
veterans in State Veterans Homes through passage of section 211 of P.L.
109-461. This provision authorizes direct VA placement of service-
connected veterans in State Veterans Homes, with VA reimbursement to
the homes for the full cost of that care. We understand VA is moving
forward rapidly to implement that provision with statutory regulations,
and we commend VA for that action.
The Crossroads report included important recommendations dealing
with State Veterans Homes, but one that VA has not implemented nor
recommended that Congress authorize. The Crossroads report
enthusiastically endorsed VA facilities' making significantly greater
use of State veterans facilities to meet enrolled veterans'
institutional care needs, rather than building additional VA in-house
capacity for that purpose. Unfortunately, VA has done neither. It is
true that State capacity has increased to about 21,000 average daily
census (ADC) compared to the 1997 level of 14,039 ADC, but
proportionately the workload remains at about 52 percent of VA's total
nursing home capability. There are ample reasons for this stagnation,
related to individual State financial conditions; lack of a formal
relationship providing incentives for VA facilities to refer veterans
directly to State care; lack of resources to address the growing State
home construction backlog (now nearing $500 million); and, VA legal
interpretations that block better relations between State and VA
facilities. VA has long articulated a ``partnership'' with the States
in long-term care, but DAV recommends some of these obstacles be
surmounted or legislatively removed in order for a true long-term care
partnership to be established between VA and the States.
Community Nursing Home Care
Mr. Chairman, in July 2001, GAO reported to Congress the results of
its review of VA inspections of community nursing homes caring for VA-
referred patients. As a general rule, VA requires its facilities to
inspect State Veterans Homes and contract community nursing homes on an
annual basis, and to make staff visits to community nursing homes on a
monthly basis. While GAO was satisfied that State home oversight was
sufficient at that time, GAO recommended additional oversight by VA
Central Office over inspection activities of community nursing homes.
DAV recommends the Committee ask GAO to repeat its review of the
inspection and monitoring of State Veterans Homes and community nursing
homes caring for veterans under VA auspices.
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
Veterans
Mr. Chairman, when we think of long-term care, we assume that these
programs are reserved for the oldest veterans, near the end of life.
Today, however, we confront a new population of veterans in need of
specialized forms of long-term care--a population that will need
comfort and care for decades. These are the veterans suffering from
polytraumatic injuries and traumatic brain injuries as a consequence of
combat in Iraq and Afghanistan. In discussion with VA officials,
including facility executives and clinicians now caring for some of
these injured veterans, it has become apparent to DAV and others in our
community that VA still needs to adapt its existing long-term care
programs to better meet the individualized needs of a truly special and
unique population, VA's existing programs will not be satisfactory or
sufficient in the long run. In that regard, VA needs to plan to
establish age-appropriate residential facilities, and additional
programs to support these facilities, to meet the needs of this new
population. While the numbers of veterans sustaining these catastrophic
injuries are small, their needs are extraordinary. While today they are
under the close supervision of the Department of Defense and its health
agencies, their family members, and VA, as years go by, VA will become
a more crucial part of their care and social support system, and in
many cases may need to provide for their permanent living arrangements
in an age-appropriate therapeutic environment.
Unresolved Policy Issues
Nearly a decade after issuance of the Crossroads report and
enactment of the Millennium Act, and despite encouragement from this
Subcommittee and others, VA remains without a clearly articulated
policy on long-term care. We commend VA for adding new long-term care
programs over those years, especially those dealing with home--and
community-based approaches, but we were concerned in 2005 when the VA
proposed that Congress further restrict long-term care eligibility and
to probably deny access to VA long-term care to major segments of the
veteran population, at a moment when the elderly veteran population was
peaking. We thank this Subcommittee for its support of a continuation
of current eligibility for these services.
As VA has ramped up community-based, non-bed programs such as home-
based primary care, it has not changed its reporting conventions such
that it still equates a day of care in a community-based or home-based
program to that of a day of care in a nursing home or other
institutional setting. This type of data collection and reporting may
produce a distortion of activity or workload when in fact none may be
present.
While VA has become highly efficient at converting its nonservice-
connected community nursing home placements to Medicaid status, it has
established no formal tie to the Centers for Medicare and Medicaid
Services (CMS) or with the States to oversee that unwritten policy.
Also with regard to institutional and home hospice, despite offering to
purchase hospice VA refers thousands of veterans from its own program
to those of Medicare without acknowledging it is doing so, while
charging co-payments to dying veterans in its own hospice programs.
In the State Veterans Home program, VA claims to be participating
in a ``partnership'' but only provides a per diem payment to the States
as they deal with their veterans' long-term care burdens. Some VA
facilities even deny access to enrollment and to specialized VA care
for residents of State Veterans Homes on the basis that the homes are
responsible for comprehensive care, not VA.
All these informal policies are working their will, but we question
whether they are working to the betterment of the care of elderly
veterans or simply are manifestations of ways to shift VA costs for
long-term care to other willing payers. DAV does not expect VA to
provide long-term care to every American veteran, but to the degree VA
holds itself out as a provider of these services, DAV believes the
policies under which it operates ought to be transparent and well
understood. Neither case is true today.
Closing
Mr. Chairman, the future of VA long-term care planning remains
uncertain. The lack of a strategic plan that involves stakeholder input
is discouraging to DAV and others in this community. Also, as this
Subcommittee conducts needed hearings on VA long-term care services, we
urge the Subcommittee to provide stronger oversight of VA's unwritten
long-term care policies to be sure they are equitable for veterans who
need such care.
Although DAV advocates for a more comprehensive geriatric and
extended care benefits package for service-connected disabled veterans
regardless of their percentages of disability ratings, it is clear that
VA's current policy reflects a struggle between what is expected and
what it can deliver based on available resources. As the late Dr. Paul
Haber said of VA in 1975 on the occasion of the establishment of the VA
Office of Extended Care, ``As the number of aging veterans increases
over the next decades, the Department will need to expend more
resources for their care. Expanding services for old, chronically ill
patients will cause disquietude among some in the Department.''
Although he was referring to the ``Department of Medicine and
Surgery,'' now known as the Veterans Health Administration (VHA), Dr.
Haber's words still ring true today. The VHA is forced to choose
between emphasizing institutional or non-institutional modes of long-
term care, both of which are not available to the same population of
enrolled veterans. These needs must compete internally with the funding
of VA acute care and primary care services. Moreover, VA is operating
with limited overall healthcare resources, making allocation decisions
ever more difficult, and further hampered by the absence of clear
direction due to inequities in existing authority in the eligibility
criteria for institutional and non-institutional VA long-term care.
A continuum of care is essential to effectively meet the healthcare
needs of our aging veteran population who live with complex medical,
social, behavioral, and functional impairments, as well as to fully
meet the needs of the newest generation of veterans injured by war. To
ensure that veterans receive the benefits of these programs in a
coordinated, integrated manner, a full array of non-institutional
extended care services complemented with institutional geriatric care
services must be available throughout each VISN, and accessible to all
enrolled veterans.
Mr. Chairman, 25 years ago VA published a report entitled Care for
the Aging Veteran. This was a landmark study and set the stage for many
of the programs VA uses today to care for elderly veterans. One of the
premises of that era was that VA would take the lead in the ``graying
of America,'' by establishing models of care in geriatrics and
gerontology that would be emulated and replicated in other public and
private systems of care. While we applaud the obvious progress VA has
made, we observe most of the promise that was in the ``Aging Report''
has not materialized in long-term care policy in the United States.
While we hope other Congressional Committees will eventually address
the larger picture of an aging America and how to meet those needs, we
urge this Subcommittee to establish clear guidelines for prioritizing
among VA's existing and emerging programs and the eligibility of
veterans to receive care in such programs. We hope the Subcommittee and
your colleagues on the Appropriations Committees of both Chambers will
ensure VA has the resources to meet the expectation to provide sick and
disabled veterans the levels of care they need, including the needs of
the programs we have addressed today in this testimony. Equally
important, we urge Congress to continue to hold VA accountable in
providing a full complement of high quality, cost effective geriatric
and extended care services to aging veterans.
Mr. Chairman, we thank you for holding this important hearing to
discuss the state of the VA's long-term care programs. While I have
tried to bring forward relevant issues in long-term care that are
important to DAV, the complexity, magnitude and impact of this program
compel additional hearings. We urge the Subcommittee to consider
holding those hearings in order for Congress to gain a fuller
understanding on what needs to be done, for veterans and for all of our
citizens as we age. As of today, much still remains despite the obvious
progress we have observed.
This concludes my statement, and I will be happy to address any
questions the Subcommittee may have.
Prepared Statement of Fred Cowell, Senior Associate Director, Health
Analysis, Paralyzed Veterans of America
Mr. Chairman and Members of the Committee, the Paralyzed Veterans
of America (PVA) is pleased to present its views concerning access to,
and the availability of, quality long-term care services for our
Nation's veterans. PVA's testimony is focused in three areas. First, we
would like to draw your attention to the long-term care needs of
America's returning heroes from Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF). Thousands of these brave young men
and women are facing lifelong challenges because of the severity of
their wounds and will depend on VA non-institutional and VA
institutional long-term care programs for much, if not all, of their
lives. Second, our testimony will address the unique long-term care
needs of veterans with spinal cord injury or disease (SCI/D) and the
looming gap in providing specialized care for these men and women.
Finally, we will address broad long-term care issues affecting all
aging veterans and how a VA long-term care strategic plan can make a
difference in their care.
Currently, VA provides an array of non-institutional (home and
community-based) long-term care programs designed to support veterans
in their own communities while living in their own homes. Additionally,
VA provides institutional (nursing home) care in three venues to
eligible veterans and others as resources permit. VA provides nursing
home care in VA operated nursing homes, under contract with private
community providers, and in State Veterans Homes.
Mr. Chairman, PVA is a long time supporter of non-institutional
long-term care programs because they have, in many cases, enabled aging
veterans, our members, and other veterans with catastrophic
disabilities to live independent and productive lives in the least
restrictive setting. PVA has always believed that nursing home care
must always be a choice of last resort and that no veteran should be
forced into a nursing home just because of his/her spinal cord injury,
spinal cord disease or other catastrophic disability.
However, many aging veterans and veterans with catastrophic
disabilities live on a slippery slope even with the support of non-
institutional long-term care. Slight changes in function associated
with aging, a serious episode related to a secondary condition, or the
loss of a care giver can plunge even a young veteran with a
catastrophic disability down that slippery slope from independent
living at home into institutional nursing home care. Therefore, it is
imperative that VA continue to provide quality nursing home care not
only for aging veterans but for those younger catastrophically injured
veterans who cannot benefit from non-institutional long-term care
services.
Young OIF/OEF Veterans
Mr. Chairman, PVA believes that age-appropriate VA non-
institutional and institutional long-term care programming for young
OIF/OEF veterans must be a priority for VA and your Subcommittee. New
VA non-institutional and institutional long-term care programs must
come online and existing programs must be re-engineered to meet the
various needs of a younger veteran population.
VA's non-institutional long-term care programs will be required to
assist younger injured veterans with catastrophic disabilities who need
a wide range of support services such as: personal attendant services,
programs to train attendants, peer support programs, assistive
technology, hospital-based home care teams that are trained to treat
and monitor specific disabilities, and transportation services. These
younger veterans need expedited access to VA benefits such as VA's Home
Improvement/Structural Alteration (HISA) grant, and VA's adaptive
housing and auto programs so they can leave institutional settings and
go home as soon as possible. PVA also believes that VA's long-term care
programs must be linked to VA's new polytrauma centers so that younger
veterans can receive injury specific annual medical evaluations and
continued access to specialized rehabilitation, if required, following
initial discharge.
VA's institutional nursing home care programs must change direction
as well. Nursing home services created to meet the needs of aging
veterans will not serve young veterans well. As pointed out in The
Independent Budget, VA's Geriatric and Extended Care staff must make
every effort to create an environment for young veterans that
recognizes they have different needs. Younger catastrophically injured
veterans must be surrounded by forward-thinking administrators and
staff that can adapt to youthful needs and interests. The entire
nursing home culture must be changed for these individuals, not just
modified. For example, therapy programs, living units, meals,
recreation programs, and policy must be changed to accommodate young
veterans entering the VA long-term care system.
Veteran with Spinal Cord Injury or Disease (SCI/D)
PVA is concerned that many veterans with spinal cord injury and
disease are not receiving the specialized long-term care they require.
VA has reported that over 900 veterans with SCI/D are receiving long-
term care outside of VA's four SCI/D designated long-term care
facilities. However, VA cannot report where these veterans are located
or if their need for specialized medical care is being coordinated with
area VA SCI/D centers.
Today's VA SCI/D long-term care capacity cannot meet current or
future demand for these specialized services. Waiting lists exist at
the four designated SCI/D facilities. Currently, VA only operates 125
staffed long-term care (nursing home) beds for veterans with SCI/D.
These facilities are located at: Brockton, Massachusetts (30 beds);
Castle Point, New York (15 beds); Hampton, Virginia (50 beds); and 30
beds at the Hines Residential Care Facility in Chicago, Illinois.
Geographic accessibility is a major problem because none of these
facilities are located west of the Mississippi River. New designated VA
SCI/D long-term care facilities must be strategically located to
achieve a national geographic balance to long-term care to meet the
needs of veterans with SCI/D that do not live on the East coast of the
United States.
VA's own Capital Asset Realignment for Enhanced Services (CARES)
data for SCI/D long-term care reveals a looming gap in long-term care
beds to meet future demand. VA data projects an SCI/D long-term care
bed gap of 705 beds in 2012 and a larger bed gap of 1,358 for the year
2022. VA's proposed CARES SCI/D long-term care projects would add
needed capacity (100 beds) but are very slow to come online. CARES
proposes adding 30 SCI/D LTC beds at Tampa, Florida; 20 beds at
Cleveland, Ohio; 20 beds at Memphis, Tennessee; and 30 beds at Long
Beach, California. The CARES Tampa project is currently under
construction but is not scheduled to open for another 2 years and the
Cleveland project is currently in the design phase but remains years
from completion. The Memphis and Long Beach projects have not even
entered the planning stage at this time.
Methods for closing the VA SCI/D long-term care bed gap and
resolving the geographic access service issue are part of the same
problem for PVA. VA's Construction Budget for 2008 includes plans for
new 120 bed VA nursing homes to be located in Las Vegas, Nevada and at
the new medical center campus in Denver, Colorado. Also, VA has
announced construction planning of a new 140 bed nursing home care unit
in Des Moines, Iowa.
Mr. Chairman, PVA needs your support to ensure VA construction
planning dedicates a percentage of beds at each new VA nursing home
facility for veterans with SCI/D. PVA requests that Congress mandate
that VA provide for a 15 percent bed set-aside in each new VA nursing
home construction project to serve veterans with SCI/D and other
catastrophic disabilities. These facilities will require some special
architectural design improvements and trained staff to meet veteran
need. However, much of the design work has already been accomplished by
PVA and VA's Facility Management team. This Congressional action will
help reduce the SCI/D bed-gap and help meet the current and future
demand for long-term care. While a 15 percent bed allocation in new VA
nursing home construction plus the proposed CARES LTC projects do not
solve the looming bed gap problem in the short run it is a good first
step and these additions will improve VA's SCI/D long-term care
capacity in the western portion of the country.
Public Law 109-461 required VA to develop and publish a strategic
plan for long-term care. PVA congratulates Congress on understanding
the importance of this issue to ensure that America's catastrophically
disabled and aging veteran population is well cared for. During the
organization of VA's strategic long-term care plan PVA, calls on VA and
Congress to pay careful attention to the institutional and non-
institutional long-term care needs of veterans with SCI/D and other
catastrophic disabilities. We request that PVA and other veteran
service organizations have an opportunity to provide input and assist
VA as it moves forward in the development of this important document.
Mr. Chairman, in the past and even today many veterans with spinal
cord injury or disease and other catastrophic disabilities have been
shunned from admittance to both VA and community nursing homes because
of their high acuity needs. PVA believes that catastrophic disability
must never be grounds to refuse admittance to VA or contract VA long-
term care services. PL 109-461 requires VA to include data on, ``the
provision of care for catastrophically disabled veterans; and the
geographic distribution of catastrophically disabled veterans.'' This
information is critical if VA's strategic plan is to adequately address
the needs of this population.
VA's Nursing Home Capacity Mandate
Congress has mandated that VA maintain its nursing home average
daily census (ADC) at the 1998 level of 13,391 but VA has not done so
(Chart 1.). Instead, VA has been steadily shifting its institutional
long-term care workload to State Veterans Homes and to contract
community (private sector) providers (Chart 2.). According to the
government Accountability Office (GAO) (GAO Report # 06-333T), VA's
overall nursing home workload for 2005 is split as follows: 52 percent
State Veterans' Homes, 35 percent VA nursing homes, and 13 percent
Contract Community nursing homes.
Chart 1. ADC for VA's Nursing Home Care Program
------------------------------------------------------------------------
Year Average Daily Census
-----------------------------------------------------------------------
1998 13,391
------------------------------------------------------------------------
2004 12,354
------------------------------------------------------------------------
2005 11,548
------------------------------------------------------------------------
2006 11,434
------------------------------------------------------------------------
Decrease 1998-2006 1,957
------------------------------------------------------------------------
Chart 2. ADC Increases in VA's Contract Community Nursing Home Program and in the State Veterans Homes Program
----------------------------------------------------------------------------------------------------------------
Contract Community Providers
-----------------------------------------------------------------------------------------------------------------
Year ADC Year ADC
----------------------------------------------------------------------------------------------------------------
2004 4,302 2004 17,328
----------------------------------------------------------------------------------------------------------------
2005 4,254 2005 17,794
----------------------------------------------------------------------------------------------------------------
2006 4,395 2006 17,747
----------------------------------------------------------------------------------------------------------------
Increase 2004-2006 93 Increase 2004-2006 419
----------------------------------------------------------------------------------------------------------------
Despite clear VA data that highlights the aging of the veteran
population and an associated increasing demand for services, the ADC
for VA nursing home care continues to trend downward. This is
especially concerning because of the nation's large elderly population.
According to VA data, (VA Strategic Plan FY 2006-2011) veterans 85 and
older represent 4.5 percent of the total veteran population and VA
projects that by 2011, the number of veterans age 85 and older will
grow to more than 1.3 million. Veterans 65 to 84 years old represent
33.9 of the total veteran population; and veterans 45 to 64 years old
represent 41.4 percent of the total veteran population. VA goes on to
say that the median age of all living veterans today is 60 years old.
Mr. Chairman, PVA calls upon Congress to enforce and maintain the
nursing home capacity mandate as outlined in the Millennium Benefits
and Healthcare Act. This capacity mandate sets a minimum floor of VA
nursing home care at a critical time in our Nation's history. This is a
critical point in time because members of America's ``greatest
generation'' our World War II veterans, desperately require quality
nursing home care and because of the demand being created today as
America's newest and most severely wounded heroes are returning from
Iraq and Afghanistan.
State Veterans Home's Life-Safety Issues
PVA's testimony has pointed out that State Veterans' Homes have
been shouldering an increasing share of VA's nursing home care workload
over the last few years. VA has found it cost-effective to utilize
State Veterans' Homes because the expense of this care is shared by
both VA and the States. However, as increased numbers of veterans
utilize the State Veterans' Homes program VA must accept increased
responsibility for the up-keep of these facilities. Congress and VA
must move quickly to provide needed funding to address life-safety
construction issues that exist in these State Veterans' Homes. The
Independent Budgetet supports an appropriation that provides $150
million to correct these
facility deficiencies. While $150 million does not meet the $250
million overall cost needed to correct the entire priority-1 life-
safety problem list, it is a good first step toward bringing these
facilities into a safer condition.
Wiating Lists for VA Non-Institutional Long-Term Care
PVA is concerned about reports from our members and from VA
officials that long waiting lists exist for aging veterans who need
access to VA's non-institutional long-term care programs. Many of VA's
Home-Based Primary Care programs have extended waiting lists for
veterans who need the range of services associated with that program.
Some waiting times are approaching almost a year before a veteran can
enter the program and receive nursing visits at home. PVA also
understands that VA's Adult Day Care Program, its Contract Adult Day
Care Program, and it Homemaker/Home Health Aide Services programs also
have extended waiting periods for admission.
These are the types of VA non-institutional long-term care programs
that can prevent, in many cases, or delay more expensive and more
restrictive nursing home care. Mr. Chairman, in plain economical terms
the return on investment related to VA's non-institutional long-term
care programs is overwhelmingly positive. Additionally, these programs
are exactly what veterans want. America's aging veterans want to remain
in their own homes and communities as long as possible. We call on your
Subcommittee to review the demand, availability and associated waiting
lists for VA non-institutional long-term care programs and to provide
the resources necessary to enable VA to expand these valuable programs
that are favored by veterans.
VA's Care Coordination Program
VA's Care Coordination/Home Telehealth (CCHT) Program provides a
range of services designed to help older veterans with chronic
conditions such as diabetes, heart failure, and Post Traumatic Stress
Disorder to remain in their own homes and receive non-institutional VA
care services.
CCHT is a relatively new VA program that resulted from a VA pilot
program in VISN 8 between 2000 and 2003. VA implemented its national
care coordination program in July of 2003. Each veteran patient being
supported by CCHT has a care coordinator who is usually a nurse
practitioner, a registered nurse or a social worker. In some complex
cases physicians coordinate the patients care.
PVA believes that care coordination is an important element in VA's
medical service toolkit that can help reduce expensive episodes of
inpatient hospital care and enable aging veterans with chronic
conditions to remain in their homes longer than ever before. This
valuable VA program's reach should be extended and closely linked to
VA's Geriatric and Extended Care Program to reach additional chronic
care patients and bring the advantages of modern medical technology to
their doorstep. VA's strategic plan for long-term care should find ways
to integrate its CCHT program into a comprehensive mix of services for
older veterans and veterans with catastrophic disabilities.
Assisted Living
Assisted Living has proven itself to be a desired alternative to
nursing home care for many Americans. Consequently, Congress mandated
that VA, via the Millennium Benefits and Healthcare Act, conduct a
pilot project to provide assisted living services for veterans. VA did
so between January of 2003 and June of 2004. The pilot project was
conducted in VISN-20 and included seven medical centers in four states.
VA's subsequent report on the project was forwarded to Congress by
Secretary Principi in November of 2004. The report revealed a number of
positive findings including information on cost, quality of care and
veteran satisfaction.
The Independent Budget has called for the Assisted Living Pilot
Project to be replicated in at least three VISN's with high
concentrations of elderly veterans. VA's strategic long-term care plan
must explore all available programs and services that provide quality
community-based long-term care. An extension of VA's original assisted
living project is one of those opportunities.
Conclusion
Mr. Chairman, PVA believes that one of the most positive moves by
Congress in recent years has been to require VA to develop a strategic
long-term care plan. However, for this new VA plan to be a success it
must have positive and achievable recommendations and provisions for
accountability. Performance measures, program evaluation, wait times,
patient satisfaction surveys, and outcome measures are all elements
that must be used in the development, monitoring and periodic revision
of a strategic plan for long-term care. PVA believes that VA' strategic
plan for long-term care must not just be a static, one time, report but
one that is a living document that receives constant review and up/
dates to be capable of responding to changing veteran needs and
innovations in long-term care services.
PVA supports a VA strategic long-term care plan that monitors the
appropriate balance between non-institutional and institutional long
term care programs. When periods of projected peak program demand
exist, VA and Congress must be flexible enough to concentrate resources
to meet that demand. For example, the growing number of veterans 85 and
older is well documented and their increased need for nursing home care
must force VA to maintain adequate levels of nursing home bed space to
accommodate that need. Correspondingly, when veteran demographics and
demand shift, resources should follow demand and flow to alternative
services.
PVA believes that VA's strategic plan will enable Congress to
make better informed decisions regarding the provision of
adequate financial resources to support VA care. Additionally,
the strategic plan will assist VA's planning and monitoring
efforts to ensure appropriate programming, systemwide
availability and quality of services. We hope that both your
Subcommittee and VA utilize the knowledge and experience of
America's Veterans Service Organizations in the development of
a strategic plan for VA long-term care.
Prepared Statement of Patricia Vandenberg, MHA, BSN
Assistant Deputy Under Secretary for Health for Policy and Planning
Veterans Health Administration, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Subcommittee, I am pleased to be
here today, accompanied by James F. Burris, MD, Chief Consultant
Geriatrics and Extended Care to discuss the strategic direction and
plan for the future of long term care in the Department of Veterans
Affairs (VA). I would like to take this opportunity to give an overview
of VA's long-term care services and programs.
Growing Need For Long-Term Care
VA has testified previously that there is a great and growing need
for long-term care services for elderly and disabled veterans. Between
2005 and 2012, the number of enrolled veterans aged 65 and older is
projected to increase from 3.45 million to 3.92 million. The number of
enrolled veterans aged 85 and older will increase from 337,000 to
741,000 during the same period. This latter group, those aged 85 and
older, are the most vulnerable of the older veteran population and are
especially likely to require not only long-term care services, but also
other healthcare services along the continuum of care such as acute
care and preventive care.
VA is addressing the mandates for nursing home care for service-
connected veterans with a disability rated at seventy percent or
greater and veterans who need nursing home care for their service-
connected disability and for selected home and community based care
services for all enrolled veterans, as set by Congress in the Veterans
Millennium Healthcare and Benefits Act, Public Law 106-117, and
prioritizing care for those veterans most in need of our services
including:
veterans returning from Operation Enduring Freedom and
Operation Iraqi Freedom (OEF/OIF) service,
veterans with service-connected disabilities,
veterans with lower incomes, and
veterans with special healthcare needs such as serious
chronic mental illness and spinal cord injury and disease
Since many enrolled veterans are also eligible for long-term care
through other public and private programs, including Medicare,
Medicaid, State Veterans Homes, and private insurance, it is in the
interest of both the government and veterans to coordinate the benefits
of their various programs and work together toward the goal of
providing compassionate, and high-quality care. VA staff have extensive
experience in coordinating services among agencies for the benefit of
veterans, within statutory limitations and in accordance with desires
of patients and their families. I want to emphasize that our efforts in
long-term care case management are driven by the clinical needs of each
patient, the patient's preferences, and the benefit options available
to that patient. VA healthcare providers work closely with patients and
family, on a case-by-case basis, to coordinate the veteran's various
Federal and State benefits, and to maximize options for that veteran.
Among those programs within VA that address coordinating veteran care
needs are Social Work Service, Home Based Primary Care Program,
community health nurse coordinators, and Care Coordination/Telehealth.
SPECTRUM OF VA LONG-TERM CARE SERVICES
VA's philosophy of care, in keeping with practice patterns
throughout the public and private sectors, is to provide patient-
centered long-term care services in the least restrictive setting that
is suitable for a veteran's medical condition and personal
circumstances, and whenever possible, in home and community-based
settings. This approach honors veterans' preferences at the end of life
and helps to maintain relationships with the veteran's spouse, family,
friends, faith and community. Nursing home care should be reserved for
situations in which the veteran can no longer be safely maintained in
the home and community. VA long-term care is composed of a dynamic
array of services provided in residential, outpatient, and inpatient
settings that can be deployed as needed to meet a veteran's changing
healthcare needs over time. In addition to direct patient care
services, VA supports important research and education related to the
healthcare needs of elderly and disabled veterans through the work of
its 21 Geriatric Research, Education, and Clinical Centers, or GRECCs.
Non-institutional Care Programs
VA's strategic goal is to make non-institutional long-term care
services available to every enrolled veteran who needs them and seeks
them from VA. The spectrum of non-institutional home and community-
based long-term care services supported by VA includes:
Home Based Primary Care,
Contract Skilled Home Care,
Homemaker/Home Health Aide,
Adult Day Healthcare,
Home Respite,
Home Hospice, Spinal Cord Injury Home Care, and
Care Coordination/Home Telehealth.
VA also provides quality oversight of care purchased by veterans in
Community Residential Care and Medical Foster Home facilities through
an annual review process and monthly or more frequent monitoring by VA
staff.
The workload in the non-institutional care programs included in
Long-Term Care has grown from an average daily census 19,810 in 1998 to
29,489 through the end of FY 2006. More than 9 out of 10 VA Medical
Centers now offer some or all of these services, substantially
enhancing veterans' access to non-institutional long-term care
services. VA continues to have a VISN performance measure to increase
the average daily census of veterans receiving home and community-based
care. Each VISN has been assigned targets for increase in their non-
institutional long-term care workload. VA is expanding both the
services it provides directly and those it purchases from providers in
the community.
Care Coordination Initiative/Home Telehealth
VA expects to meet a substantial part of the growing need for long-
term care through such innovative services as Care Coordination/Home
Telehealth. Care Coordination in VA involves the use of health
informatics; telehealth and disease management technologies to enhance
and extend existing care; and case management activities. VA's national
Care Coordination initiative commenced in 2003 and is supported by a
national program office. Care Coordination enables appropriately
selected veteran patients with chronic conditions such as diabetes and
congestive heart failure to remain in their own homes, and it defers or
obviates the need for long-term institutional care. Care Coordination
services are linked not only with services for the elderly such as Home
Based Primary Care, but also with other services including Mental
Health Intensive Case Management and General Primary and Ambulatory
Care. Care Coordination/Home Telehealth enables delivery of VA
healthcare to veterans living remotely from VA medical facilities,
including those in rural areas.
Nursing Home Care
Inevitably, some veterans will be unable to continue to live safely
in the community and will require nursing home care. VA will continue
to provide nursing home care for all veterans for whom such care is
mandated by statute, who need such care and seek it from VA. In
addition, VA will continue to provide post-acute care for veterans who
have suffered an accident or illness such as a broken hip or stroke,
who require a period of recovery and rehabilitation before returning to
the community. VA will also continue to provide nursing home care for
veterans with special needs, including those with spinal cord injury or
disease, ventilator dependence, and serious chronic mental illness. VA
expects to sustain existing capacity in its own Nursing Home Care Units
and in the Community Nursing Home Program and to support continued
expansion of capacity in the State Veterans Home Program. Transforming
the culture of care in nursing homes from the traditional medical model
to a more home-like, patient-centered model is an important initiative
in all of our nursing home programs.
State Veterans Homes
VA's State Veterans Home Program assists states in providing care
to veterans in State Veterans Homes. Veterans' eligibility for each
state's program is determined by the individual state using the state's
own criteria. There are State Veterans Homes in operation or under
construction in all 50 states and Puerto Rico. VA supports construction
and renovation of State Veterans Homes through the State Home
Construction Grant Program, which provides matching funds to assist
states in purchasing, constructing, and renovating properties to serve
as nursing homes, domiciliaries, and adult day healthcare centers.
Projects are funded in priority order until available funds for each
fiscal year are exhausted, with highest priority given to renovation
projects needed to correct life safety deficiencies and for
construction of new capacity in geographic areas of need.
The second component of the State Veterans Home is the Per Diem
Program. VA pays a per diem to assist the states in providing care for
eligible veteran residents. Recently, Public Law 109-461, section 211
provided VA authority to pay State Veterans Homes the prevailing rate
or the home's daily cost of care, whichever is less, for veterans in
need of such care for a service-connected disability and for veterans
who have a service-connected disability rated at 70 percent or more. VA
is currently in the process of developing regulations to implement the
provisions of this authority.
Thirdly, we provide medication at VA expense to eligible veterans
residing in State Veterans Homes.
The fourth component of the State Veterans Home program is VA's
oversight function. VA has developed a system of on-site inspections to
assure quality of care in State Veterans Homes, including the
identification of life safety issues.
The VA Deputy Secretary charged a VA Task Force earlier this year
to explore opportunities for State Veterans Homes to provide non-
institutional care for veterans. The Task Force solicited the views of
representatives of the State Veterans Homes and State Departments of
Veterans Affairs, who indicated that the most important need is to
lower barriers to their participation in the Adult Day Healthcare
program. VA will revise the regulations for the State Home Adult Day
Healthcare program accordingly. Also, VA increases the per diem payment
for this program annually, which should encourage greater participation
by the states. VA staff responsible for the State Home Program
communicate frequently with State Veterans Home and State Department of
Veterans Affairs personnel to answer questions, share information, and
solicit stakeholder input on VA policies and programs.
FUTURE NEEDS
The total FY 2008 budget request for long-term care is $4.6
billion, of which 90 percent will support institutional services and 10
percent non-institutional home and community-based care. This request
will provide the resources necessary for VA to strengthen our position
as a leader in providing high-quality services for a growing population
of elderly and disabled veterans, as well as those veterans returning
from service in OEF/OIF, veterans with service-connected disabilities,
veterans with lower incomes, and veterans with special healthcare
needs.
As you know, the population of veterans who are enrolled for
healthcare in the VA are, on average, older, poorer, and sicker than
the general population. VA is already seeing the kinds of demographic
changes that are projected for the nation as a whole in coming decades.
Recently, VA has also begun to care for younger veterans who have
sustained polytraumatic injuries during their service in Operation
Enduring Freedom and Operation Iraqi Freedom. While the number of
seriously disabled OEF/OIF veterans is relatively small, compared to
the total number of veterans requiring extended care services, the
complexity of care they require is high and their personal and social
needs differ from those of older veterans. VA is moving to adapt its
long-term care services to meet the needs of all veterans.
Many returning veterans are presenting with multiple and severe
disabilities including speech, hearing and visual impairment as well as
loss of limbs and brain injuries, and behavioral issues due to the
stress of combat. In addition, they have families, including children,
who want to be actively involved in their care. Unlike other cohorts of
veterans in long-term care, this cohort thrives on independence, is
physically strong, and is part of a generation socialized differently
than their older counterparts. These generational differences pose
unique challenges in the institutional and long-term care environment.
VA is taking measures to first recognize the generational
differences of this population and incorporate them into the care
routines. For example, in VA nursing homes, transforming the culture of
care to make the living space more home friendly is important, as is
having an ``Internet cafe'', computer games, or age appropriate music
and videos available for nursing home residents. Allowing for family,
especially children, to visit and perhaps even stay over when needed is
another example of accommodating generational differences.
Personalizing care routines such as bathing and dining times and
offering food items that are palatable to younger persons are examples
of the changes that are occurring in long-term care.
Conclusion
VA takes great pride in our accomplishments, and looks forward to
working with the members of this Subcommittee to continue the
Department's tradition of providing timely, high-quality healthcare to
those who have helped defend and preserve freedom around the world.
Mr. Chairman, this completes my statement. I will be happy to
address any questions that you and other Members of the Subcommittee
may have.
Statement of American Healthcare Association
On behalf of the nearly 11,000 long term care facilities
represented by the American Healthcare Association (AHCA), we salute
the Veterans' Affairs Committee for not only recognizing the needs of
America's frail, elderly, and disabled veterans, but also for
continually seeking to optimize the quality of their care in the face
of substantial budgetary and demographic challenges.
In light of the increasing number of aging baby boomer veterans now
seeking to access VA healthcare services, the increased care needs for
older veterans already enrolled, and younger wounded veterans now in
need of care, we recognize and are extremely sympathetic to the fact
the VA's resource base and capacity are stretched to the maximum limit,
and then some.
Consequently, it may not have the resources to address the existing
and projected needs for skilled nursing and rehabilitative care--
especially in light of the type and nature of injuries being sustained
in Iraq and Afghanistan. From this important standpoint, Mr. Chairman,
we want to support the VA's essential mission one hundred percent--not
somehow impede or supplant it in a manner that prevents our returning
heroes from receiving the best care our grateful nation has to offer.
Our nation's community nursing homes (CNHs) stand ready to help
veterans and the VA through this crisis.
CNHs are a vital component of the VA long term care system. Whereas
VA medical facilities tend to provide care to residents with high
acuity levels, CNHs are an excellent choice for veterans who either
have acuity levels that do not warrant placement in a VA facility, but
are too high for home healthcare--or for veterans who would be too far
from their families if placed in one of their state's VA Medical
Facilities or State Veterans Nursing Homes. In 2006, over 13 percent of
all veterans receiving nursing home care were in CNHs. That percentage
should increase, given the VA's stated plan in the FY 2008 Budget
Submission to focus its long term care efforts on the ``best setting
for the [veteran] . . . and providing that care closer to where the
veteran lives.'' Given that there is a skilled nursing facility in
almost every county in the nation, AHCA remains ready to help the VA
continue providing high quality, clinically appropriate long term care
to our Nation's veterans through CNH placements.
By 2012, there are expected to be approximately 1.3 million
veterans over 85 years of age, and it is imperative that we work
together to insure that both the veteran and civilian populations
receive the best possible care, and that one population should not
receive care at the expense of another.
One key issue negatively impacting our ability to serve veterans
and others in need of long term care is the ongoing staffing crisis,
and we need to ensure that we do not compete against one another for
the shrinking pool of qualified workers who serve as the backbone of
our Nation's long term care system. In that context, we should
fundamentally reevaluate elements of the Veteran's Millennium
Healthcare and Benefits Act 1999--which established new standards for
evaluating a state's need for constructing new facilities for veterans.
Specifically, the methodology for establishing the need for new
veterans' beds does not take into account the number of available
community nursing home (CNH) beds in each state--beds immediately
available, and which may be far closer to home. CNHs provide the option
of living closer to one's family while receiving health benefits from
the VA. As we all know, proximity to loved ones is critical in
maintaining quality of life for any nursing home resident.
For the record, Mr. Chairman, AHCA does not discourage in any way
funding necessary improvements to veteran's homes. But we ask that
prior to appropriating millions in construction costs for additional
facilities, the VA should work to determine whether there are existing
quality facilities in proximity to the proposed new homes that could
otherwise provide high quality care.
In an era of limited resources, especially at the VA, we should as
a matter of intelligent public policy work to provide care in homes
that currently exist, rather than constructing new facilities that,
again, compete for staff and weaken our Nation's entire long term care
infrastructure.
AHCA looks forward to working with you, Mr. Chairman, and the rest
of the Committee, in examining this issue in greater detail going
forward. Our members are proud to serve America's veterans in their
time of need and we look forward to working with the Committee and the
Department to continue doing so in the future.
Thank you again Mr. Chairman, and Members of this Committee, for
holding this important hearing. With our Nation's soldiers and veterans
in both the national and international spotlight, our concern for their
care and safety today as well as tomorrow has never been more important
to the soul and conscience of the American people. They deserve the
best we have to offer.
Statement of American Occupational Therapy Association
The American Occupational Therapy Association (AOTA) submits this
statement for the record of the May 9, 2007 hearing. We appreciate the
opportunity to provide this information regarding the use of
occupational therapy in long-term care in the Department of Veteran
Affair's long-term care programs. With the aging of our Nation's
veterans, quality long-term care programs to assist those who are in
need should be a priority for our country. Occupational therapists and
occupational therapy assistants work in long-term care settings,
including home and community based settings, to increase the
independence and quality of life of their patients.
AOTA is the nationally recognized professional association of
35,000 occupational therapists, occupational therapy assistants, and
students of occupational therapy. Occupational therapy is a health,
wellness, and rehabilitation profession working with people
experiencing stroke, spinal cord injuries, cancer, congenital
conditions, developmental delay, mental illness, and other conditions.
It helps people regain, develop, and build skills that are essential
for independent functioning, health, and well-being. Occupational
therapy is provided in a wide range of settings including daycare,
schools, hospitals, skilled nursing facilities, home health, outpatient
rehabilitation clinics, psychiatric facilities, and community programs.
Occupational therapy professionals assist those with traumatic
injuries--young and old alike--to return to active, satisfying lives by
showing survivors new ways to perform activities of daily living,
including how to dress, eat, bathe, cook, do laundry, drive, and work.
It helps older people with common problems like stroke, arthritis, hip
fractures and replacements, and cognitive problems like dementia. In
addition, occupational therapists work with individuals with chronic
disabilities including mental retardation, cerebral palsy, and mental
illness to assist them to live productive lives. Occupational therapy
practitioners also provide care to veterans who suffer from traumatic
brain injuries, post-traumatic stress disorder, spinal cord injuries,
and other conditions. By providing strategies for doing work and home
tasks, maintaining mobility, and continuing self-care, occupational
therapy professionals can improve quality of life, speed healing,
reduce the chance of further injury, and promote productivity and
community participation for veterans.
The Department of Veterans Affairs (VA) offers a spectrum of
geriatric and extended care services to veterans enrolled in its
healthcare system. More than 90 percent of VA's medical centers provide
home- and community-based outpatient long-term care programs. This
patient-focused approach supports the wishes of most patients to live
at home in their own communities for as long as possible. In addition,
nearly 65,000 veterans will receive inpatient long-term care this year
through programs of VA or state veteran's homes.
Occupational Therapy's Role for veterans in Long-term Care Programs
Occupational therapy practitioners provide care in a number of
settings and programs, including both institutional and non-
institutional programs. Veterans long-term care programs include
options to receive care in the home and community as well as in nursing
homes. Regardless of setting or program, it is proven that elderly
individuals benefit from occupational therapy services [Journal of the
American Medical Association (JAMA) ``Occupational therapy for
independent-living older adults: A randomized controlled trail.'' JAMA,
Vol. 278, No. 16, p. 1321-1326. 1997]. Occupational therapy
practitioners can provide a unique and valuable service in supporting
veterans in long-term care programs, in their occupations and
activities of daily living, and in their efforts to remain independent
and to successfully age in place.
Activities of Daily Living (ADLs) are basic self-care activities
that need to be completed on a daily basis (for example self-feeding,
grooming, bathing, dressing, and toileting). Instrumental activities of
daily living (IADLs) such as reading and managing money are also
critical. Occupational therapy practitioners work with veterans to gain
the skills that are needed to accomplish their ADLs and pursue IADLs as
appropriate. Occupational therapists and occupational therapy
assistants are experts at identifying the causes of difficulties
limiting participation. Their expertise enables them to consider client
needs and environmental factors to develop effective strategies that
will maximize quality of life as well as independence in those daily
activities that are important to each Veteran.
Veterans who wish to age in place in their home or community look
toward occupational therapy as a means to achieve their goals.
Occupational therapy plays a key role in identifying strategies that
enable individuals to modify their homes and environment to meet their
goal of aging in place at home and in the community. Aging in place
refers to the ability to remain in the home even if the client's
abilities have declined.
Home modifications are adaptations to living environments intended
to increase usage, safety, security, and independence for the user. As
part of the home modification process, occupational therapy services
include assessing needs, identifying solutions, implanting solutions,
training in the use of solutions, and evaluating outcomes that
contribute to the home modification product. Occupational therapy
practitioners may recommend the installation of chair lifts for stairs
or adding railings or grab bars to bathrooms or other walls to provide
support. Occupational therapy practitioners can enhance Veteran's well-
being and participation by serving as a resource in home modification.
Occupational therapy is also recommended to help keep individuals
mobile and independent, helping to ensure meaningful participation in
the community. For some people, some forms of transportation, such as
driving, become less safe, and many veterans will need to address
alternatives to driving at some point in their lives. Occupational
therapy can optimize and prolong an older driver's ability to drive
safely, and ease the transition to other forms of transportation if
driving cessation becomes necessary. By identifying strengths as well
as physical and cognitive challenges, occupational therapists can
evaluate an individual's overall ability to operate a vehicle safely
and recommend assistive devices or behavioral changes to limit risks.
The goal of assessing individuals for driving is to enable them to stay
in the community and reduce the need for nursing home care.
Veterans who receive care in nursing homes also benefit from
occupational therapy services. Occupational therapy starts where the
person is, looks at their desires and potential, and facilitates
diminishment of frailties and support of abilities. As veterans are
treated in nursing homes, their needs range widely. Occupational
therapy is there to assist and enable them to overcome or heal from
disability and illness. It is a critical component to achieving quality
of life which is the goal of the Veteran Affair's long-term care
programs. The veteran population will continue to grow and nursing
homes will remain an important site of care for veteran's who require
constant nursing care and have significant deficiencies with activities
of daily living.
People in the United States are living longer, and that includes
our Nation's veterans. For some, a consequence of increased longevity
is increased frailty and dependency. Many veterans live alone, have
limited resources, and require special services for meeting everyday
needs. Helping elderly persons to maximize their independence and
enabling them to continue to perform activities of daily living is
crucial. The Department of Veterans Affairs long-term care programs are
structured to provide care to our country's veterans as they age and
need help with various areas of their lives. Occupational therapy is a
unique and valuable service that can help veterans achieve their goals
of living a healthy and independent life.
AOTA hopes that Congress will continue to look at occupational
therapy as a service that benefits all Americans. We look forward to
discussing how we can better serve our Nation's veterans and all aging
Americans.
Contact: Daniel R. Jones
Statement of Kimo S. Hollingsworth, National Legislative Director
American Veterans (AMVETS)
Mr. Chairman and Members of the Subcommittee:
I am pleased to offer testimony on behalf of American veterans
(AMVETS) regarding the Department of Veterans Affairs long-term care
program.
The Department of Veterans Affairs (VA) offers a fairly robust
variety of inpatient long-term care services for veterans enrolled in
the VA healthcare system. VA services are generally divided into non-
institutional care and institutional care. More than 90 percent of VA
medical centers provide home and community-based outpatient long-term
care programs. Overall, eligible veterans can receive home-based
primary care, contract home healthcare, adult day healthcare, homemaker
and home health aide services, home respite care, home hospice care and
community residential care. In addition, VA nursing home programs
include VA-operated nursing home care units, contract community nursing
homes and state homes.
As this Committee is aware, AMVETS hosted the ``National Symposium
for the Needs of Young Veterans'' in Chicago, Illinois last year. More
than 500 veterans, active duty and National Guard and reserve
personnel, family members, and others who care for veterans examined
the growing needs of our returning veterans. One of they Symposium
findings revealed a general lack of knowledge about VA long-term care
programs among veterans and their family members.
Mr. Chairman, the changing dynamics within the enrollee population,
such as aging, changes in morbidity, and VA enrollees shifting to a
higher cost priority level will continue to impact medical care
expenditures. In testimony before the House Committee on
Appropriations, VA recently reported, ``that there is a great and
growing need for long-term care services for elderly and disabled
veterans.'' VA projects that between 2005 and 2012, the number of
enrolled veterans aged 65 and will increase from 3.45 million to 3.92
million, and the number of enrolled veterans aged 85 and older will
increase from 337,000 to 741,000 during the same period. The latter
group will most likely require long-term care services and other
healthcare services along the continuum of care such as acute care and
preventive care.
Public Law 106-117 mandated that VA prioritize care for those
veterans most in need of VA services, to include veterans returning
from OEF/OIF service, veterans with service-connected disabilities,
those with lower incomes, and veterans with special healthcare needs
such as serious chronic mental illness and spinal cord injury and
disease. It is within the guidelines of this mandate that VA is
currently focused. AMVETS reaffirms its commitment that service-
disabled veterans should have the highest priority access to VA
healthcare services and these services should be of the highest
quality. AMVETS believes that service-connected veterans currently have
that level of access and quality in VA today.
In 2004, VA commissioned a study on VA Long-Term Care Patients'
Medicare and Medicaid Expenditures. The study concluded that three
quarters of VA long-term care patients rely to some extent on the
national Medicare and Medicaid programs. The study also found that VA
funds approximately 90 percent of the care provided for these veterans.
Given these dynamics of cross enrollment, AMVETS believes that it is in
the interest of both the government and veterans to coordinate the
benefits of their various programs and work together toward the goal of
providing compassionate, and high-quality care.
Overall, the Veterans Health Administration's efforts in long-term
care case management are driven by the clinical needs of each patient,
the patient's preferences, and the benefit options available to that
patient. As part of this process, VA healthcare providers work closely
with patients and family to ensure veterans receive appropriate care.
Despite VA's best efforts to coordinate care through its many programs
and with other federal, state and private organizations, the cost of
long-term care is expensive and continues to rapidly increase.
To VA's credit, the department has effectively managed its
healthcare expenditures and it provides a significant dollar cost value
compared to other Federal and private programs. From 1996 through 2004,
the Medical Consumer price index increased by approximately 40 percent.
During this same period, the average Medicare cost per payment per
enrollee increased by almost 45 percent. The VA cost per patient during
this same time period increased less than 1 percent, yet VA customer
service and satisfaction ratings have increased. Ultimately, good
business practices make sense, but VA is in the people business and
taking care of veterans remains paramount. VA has done both!
AMVETS will continue to support VA long-term care programs and
believes that the department continues to set the standard for
excellence in care and dollar cost value per patient. AMVETS would
continue to urge Congress to support VA long-term care programs and
seriously consider allowing VA to recoup Medicare and Medicaid
reimbursements as a way to save money for the Federal Government.
Mr. Chairman, this concludes my testimony.
Statement of Hon. Jeff Miller
Ranking Republican Member, Subcommittee on Health
Thank you, Mr. Chairman. I appreciate having this important hearing
to look at the performance of the Department of Veterans Affairs (VA)
in meeting the existing long-term care needs of our disabled and aging
veterans and assess the Department's strategy for addressing long-term
care challenges in the future.
The number of enrolled veterans most in need of long-term care
services, those 85 years and older, will dramatically increase by the
year 2012, growing from 337,000 to 741,000 veterans, a 120 percent
increase. In addition to a large elderly veteran population, VA is
facing a new demographic of veterans who are limited in their capacity
to care for themselves due to multi-trauma injuries incurred during the
Global War on Terror. It is vital that the generational differences of
these young veterans be taken into consideration and that VA provides
age-appropriate services in the right setting.
In 2003, 2004, 2005 and 2006 the government Accountability Office
analyzed various aspects of VA's long-term care programs at both the
House and Senate Committees' direction. It is of great concern that in
these GAO reviews, we continue to find that access to a complete
continuum of VA long-term care services remains markedly variable from
network to network.
VA's lack of a reliable long-term care planning model not only led
to a glaring gap in the Capital Asset Realignment for Enhanced Services
(CARES) plan, but was also a major factor in the budget formulation
problems this Committee uncovered in 2005. For more than five years, VA
has been promising to adopt a strategic plan for long-term care, but
has failed to establish one. Last year, in Public Law 109-461, Congress
showed its resolve by requiring VA to publish a strategic plan for the
provision of long-term care not later than 180 days after enactment of
the law. Let me put VA on notice that the date is near and we expect VA
to submit that plan in mid-June, on time, with no excuses.
I want to also remind all of us that the way VA delivers long-term
care very deeply affects each individual veteran patient and their
families. Important to enhancing a veteran patient's quality of life is
ensuring that care is provided in the least restrictive setting and
that the personal dignity and emotional well-being of the patient is
the top priority. In this regard, I am a strong advocate for supporting
new and innovative programs to meet these needs.
I look forward to the testimony our witnesses will provide today to
assist us in confronting the unresolved issues related to meeting the
long-term care needs of all our veterans and improving the management
and direction of VA's long-term care mission.
Thank you Mr. Chairman, I yield back.
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