1.) In  recognition of this change in approach to how long-term care is provided,  the Federal Advisory Committee on the Future of VA Long-Term Care  recommended, in 1998, that VA update its long-term care policy by  meeting the growing demand for long-term care through significant  expansion of its capacity to provide home and community-based  services—also known as noninstitutional long-term care services—while  maintaining its nursing home capacity at the 1998 level. Medicare also pays for home  health care. Nursing Home Workload Declined Slightly And Use Of Nursing Home Care By Setting Changed

VA’s overall nursing home workload—-average daily census—-was 33,214  in fiscal year 2003, slightly below its fiscal year 1998 workload. Nursing home workload  varied over this period but was consistently below the fiscal year 1998  level, decreasing by as much as 8 percent in fiscal year 2000 from its fiscal  year 1998 level. In addition, workload in community nursing homes declined by  1,434. 2.) This  increase is attributable in large part to 18 more state veterans’ nursing  homes receiving payment from VA to provide such care. VA is authorized to pay for about two-thirds of the costs of  construction of state veterans’ nursing homes and pays about a third of the  costs per day to provide care to veterans in these homes. In Network  21 (San Francisco), the percentage of care in VA-operated nursing homes  increased by 7 percent and in the remaining 6 networks the percentage of  care in VA-operated nursing homes increased 3 percent or less. Among VA’s networks, 16 had declines in the number of long-stay patients  in VA-operated homes during this period. The percentage of workload in community nursing homes declined from  17 to 13 percent from fiscal year 1998 through fiscal year 2003. This  decline occurred because VA reduced the number of patients served and  the number of days paid for under contract in this setting. VA officials told us that now shorter-term contracts are often  used to transition veterans to nursing home care, which is paid by other  payers such as Medicaid. VA Noninstitutional Long-Term Care Workload Increased

VA’s noninstitutional long-term care workload—-average daily census—- for the six services in our review increased by approximately 75 percent  from fiscal years 1998 through 2003. Workload increased by 4,655 during  this period to 10,892. Much of this growth came from  increases in skilled home health and homemaker/home health aide care— services that are most likely to help veterans prevent or delay the need for  nursing home care. Concluding Observations

Over the last 6 years, the veteran population most in need of long-term  care has grown dramatically. During this period, VA’s use of nursing home  care by setting has changed so that state veterans’ nursing homes now  provide one-half of all nursing home workload provided or paid for by VA.  At the same time, VA decreased the workload it serves in its own nursing  homes consistent with VA’s policy to emphasize short-stay, post-acute care  in its own nursing homes. These trends over the last 6 years raise important questions for how VA is  meeting current long-term care need and what it may need to do to meet  future long-term care need. To what extent does total VA long-term care workload—-composed of a  fairly constant nursing home workload and a rapidly expanding but  smaller noninstitutional workload—-meet the needs of a rapidly growing  elderly veteran population?
Why GAO Did This Study

The Department of Veterans Affairs (VA) is likely to see a significant increase in long-term care need over the next decade. The number of veterans most in need of longterm care services--those 85 years old and older--is expected to increase from about 870,000 to 1.3 million over this period. Many of these veterans will rely on VA to provide or pay for nursing home care or noninstitutional services that may help them remain at home and, for some, delay or prevent the need for nursing home care. VA operates its own nursing home care units in 132 locations. VA also pays for nursing home care under contract in non-VA nursing homes--referred to as community nursing homes. In addition, VA pays part of the cost of care for veterans at state veterans' nursing homes and also pays a portion of the construction costs for some state veterans' nursing homes. Congress has expressed concerns about recent trends in VA long-term care service delivery and how VA plans to meet the nursing home care needs and related longterm care needs of veterans as the elderly population most in need of long-term care increases. GAO was asked to determine for fiscal years 1998 through 2003 (1) how VA nursing home workload has changed and (2) how VA noninstitutional long-term care workload has changed.

What GAO Found

Recent trends in VA nursing home care and noninstitutional service delivery raise important questions, particularly whether access to services is sufficient to meet the needs of a rapidly growing elderly veteran population. VA's overall nursing home workload--average daily census--was 33,214 in fiscal year 2003, 1 percent below its fiscal year 1998 workload. The workload was below the fiscal year 1998 level each year, decreasing by as much as 8 percent below the fiscal year 1998 level in fiscal year 2000. VA's use of nursing home care by setting also changed over the 6-year period. First, the percentage of workload in state veterans' nursing homes increased as the number of state veterans' nursing homes receiving VA payments increased. Second, the percentage of workload in VA's own nursing homes declined, in part, because VA decreased the number of long-stay patients and increased the number of short-stay patients it treats in the nursing homes it operates. This is consistent with VA's increased emphasis on post-acute care. Third, the percentage of workload in community nursing homes declined from 17 to 13 percent. VA officials told us that now shorter-term contracts are often used to transition veterans to nursing home care, which is paid for by other payers such as Medicaid. VA's noninstitutional long-term care workload--average daily census--increased by approximately 75 percent from fiscal years 1998 through 2003. Workload increased by 4,655 during this period to 10,892, reflecting a change in VA's approach to care which includes meeting more long-term care need through noninstitutional services. Most of the growth in noninstitutional workload came from VA's greater use of contract skilled home health care, which includes medical services provided to veterans at home, and homemaker/home health aide such as grooming and meal preparation.