State Veterans’ Nursing Homes Provided Care for over Half of VA’s Total Nursing Home Workload, and Workload in All Three Settings Was Mostly Long Stay

Of the three VA nursing home settings, state veterans’ nursing homes  provided care for just over half of VA’s nursing home workload in fiscal  year 2012. CLCs provided care for 28 percent of the  total workload, and community nursing homes provided care for   19 percent of the workload. Workload in All Three Nursing Home Settings Was Primarily Long Stay

Overall, long-stay care accounted for nearly 90 percent of VA’s total  nursing home workload in fiscal year 2012 (31,750 of the 36,250  residents for whom VA provided or paid for care each day), and long-stay  care accounted for at least three-quarters of all workload in each of VA’s  three nursing home settings. Discretionary Veterans and Veterans Age 65 to 84 Accounted for Most of VA’s Nursing Home Workload

Nearly two-thirds (62 percent) of VA’s nursing home care in fiscal year  2012 was provided to discretionary veterans, while just over one-third   (35 percent) was provided to mandatory veterans. State veterans’ nursing homes provided the highest proportion  of discretionary care compared to the other nursing home settings—  84 percent of workload in state veterans’ nursing homes was for care  provided on a discretionary basis, compared to 48 percent of workload in  CLCs and just 18 percent in community nursing homes. However, VA does not currently publish data on  nursing home workload disaggregated by length of stay and resident  characteristics in its budget justification. Seventy-one percent ($3.5 billion) of VA’s  total expenditures was spent on care provided in CLCs (see fig. Conversely, VA spent 16 percent (about $800 million) for nursing home  care in state veterans’ nursing homes, although state veterans’ nursing  homes accounted for 53 percent of VA’s nursing home workload. However, VA does not  currently include expenditure data disaggregated by length of stay and  resident characteristics in its budget justification, and therefore does not  provide information on unit costs to the maximum extent possible as  encouraged by OMB to justify staffing and other requirements. As a  result, congressional stakeholders have incomplete information on the  budget that is approved for VA nursing home care, including the  proportion of expenditures that is allocated for long-stay and short-stay  care, as well as expenditures by resident characteristics. The lack of such information could hinder congressional decision making  and oversight of budgeting of VA nursing home care staffing and resource  needs for care, which accounts for a significant portion of VA’s health  care budget and serves a vulnerable population. Recommendation for Executive Action

To provide more complete data for Congress, we recommend that the  Secretary of Veterans Affairs supplement nursing home workload and  expenditure data currently included in VA’s budget justification with the  following information:
Average daily census by length of stay and resident characteristics,  including veterans’ eligibility status and age. In its written  comments—reproduced in appendix IX—VA concurred with our  recommendation and stated that it will provide supplemental data on both  nursing home workload and expenditures by length of stay and resident  characteristics upon release of its fiscal year 2015 budget. Appendix I: Percentage of Nursing Home Workload by Network and Setting, Fiscal Year 2012

Appendix II: Percentage of Nursing Home Workload by Network and Length of Stay, Fiscal Year 2012

Appendix III: Percentage of Nursing Home Workload by Network and Eligibility Status, Fiscal Year 2012

Appendix IV: Percentage of Nursing Home Workload by Network and Resident Age, Fiscal Year 2012

Appendix V: Percentage of Nursing Home Expenditures by Network and Setting, Fiscal Year 2012

Appendix VI: Percentage of Nursing Home Expenditures by Network and Length of Stay, Fiscal Year 2012

Appendix VII: Percentage of Nursing Home Expenditures by Network and Eligibility Status, Fiscal Year 2012

Appendix VIII: Percentage of Nursing Home Expenditures by Network and Resident Age, Fiscal Year 2012

Appendix IX: Comments from the Department of Veterans Affairs

Appendix X: GAO Contact and Staff Acknowledgments

	GAO Contact

	Staff Acknowledgments

In addition to the contact named above, James C. Musselwhite, Assistant  Director; Iola D’Souza; Linda Galib; Drew Long; and Hemi Tewarson  made key contributions to this report.
Why GAO Did This Study

In fiscal year 2012, about $4.9 billion of VAs $54 billion health care services budget was spent on nursing home care. To inform Congress of its budgeting priorities, VA prepares a budget justification, which is reviewed by OMB, that includes data on nursing home workload and expenditures in the three settings. VA also collects data on length of stay (long- and short-stay) and resident characteristics, including eligibility status, as VA is required to pay for mandatory veterans nursing home care and may pay for discretionary care as resources permit. These data are important for Congress to understand how funding is allocated for long- and short-stay care and for residents in each setting.
GAO was asked to examine VAs nursing home program. Among other things, GAO examined (1) VAs nursing home workload in each setting, by length of stay and resident characteristics; and (2) VAs expenditures for nursing home care in each setting, by length of stay and resident characteristics. GAO analyzed VA nursing home workload and expenditure data, including fiscal year 2012, by setting, length of stay, and resident characteristics; and interviewed VA officials.

What GAO Found

In fiscal year 2012, the Department of Veterans Affairs' (VA) nursing home workload--the average number of veterans receiving nursing home care per day--was 36,250 across all of the three nursing home settings in which VA provided or paid for veterans' nursing home care. The three settings include Community Living Centers (CLCs), which are VA-owned and operated; community nursing homes with which VA contracts to provide care for veterans; and state veterans' nursing homes, which are owned and operated by states. Over half (53 percent) of this workload was provided in state veterans' nursing homes, 28 percent in CLCs, and 19 percent in community nursing homes. Nearly 90 percent of total workload was long-stay (91 days or more for residents with chronic conditions), and at least 75 percent of care provided in each of VA's three settings was long-stay. In addition, 62 percent of VA's total workload was provided to discretionary veterans (those veterans without certain levels of service-connected disabilities).
In fiscal year 2012, VA spent $3.5 billion (71 percent) of its total nursing home expenditures on care provided in CLCs, 16 percent in state veterans' nursing homes and 13 percent in community nursing homes. Seventy-five percent of total spending was for long-stay care, and at least 70 percent of spending in each setting was for long-stay care. About half of total VA spending was for discretionary veterans.
GAO found that VA does not provide nursing home workload and expenditure data by length of stay and resident characteristics in its budget justification, although the Office of Management and Budget (OMB) encourages agencies to provide such information to the maximum extent possible to justify staffing and other requirements and improve congressional decision making. As a result, VA does not provide complete information, which could hinder Congress' budgeting and oversight of VA's nursing home staffing and resource requirements.

What GAO Recommends

To enhance congressional oversight of VA's nursing home program, GAO recommends that VA supplement data currently included in its budget justification with workload and expenditures by length of stay and resident characteristics. VA concurred with GAO's recommendation and stated it will provide these data upon release of its fiscal year 2015 budget.