VA Long-Term Care
By: the U.S. Department of Veterans Affairs
The Department of Veterans Affairs (VA) offers a spectrum of geriatric and extended care services to veterans enrolled in its health care 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 veterans homes.
Veterans can receive home-based primary care, contract home health care, adult day health care, homemaker and home health aide services, home respite care, home hospice care and community residential care. In fiscal year 2003, 50 percent of VA’s total extended care patient population received care in non-institutional settings, including:
Home-Based Primary Care
This program (formerly Hospital Based Home Care) began in 1970 and provides long-term primary medical care to chronically ill veterans in their own homes under the coordinated care of an interdisciplinary treatment team. This program has led to guidelines for medical education in home care, use of emerging technology in home care and improved care for veterans with dementia and their families who support them. In 2003, home-based primary care programs were located in 76 VA medical centers.
Contract Home Health Care
Professional home care services, mostly nursing services, are purchased from private-sector providers at every VA medical center. The program is commonly called "fee basis" home care.
Adult Day Health Care (ADHC)
Adult Day Health Care programs provide health maintenance and rehabilitative services to veterans in a group setting during daytime hours. VA introduced this program in 1985. In 2004, VA operated 21 programs directly and provided contract ADHC services at 112 VA medical centers. Two state homes have received recognition from VA to provide ADHC, which has recently been authorized under the State Home Per Diem Program.
Homemaker and Home Health Aide (H/HHA)
VA began a program in 1993 of health-related services for service-connected veterans needing nursing home care. These services are provided in the community by public and private agencies under a system of case management provided directly by VA staff. VA purchased H/HHA services at 122 medical centers in 2004.
Community Residential Care
The community residential care program provides room, board, limited personal care and supervision to veterans who do not require hospital or nursing home care but are not able to live independently because of medical or psychiatric conditions, and who have no family to provide care. The veteran pays for the cost of this living arrangement. VA's contribution is limited to the cost of administration and clinical services, which include inspection of the home and periodic visits to the veteran by VA health care professionals. Medical care is provided to the veteran primarily on an outpatient basis at VA facilities. Primarily focused on psychiatric patients in the past, this program will be increasingly focused on older veterans with multiple chronic illnesses that can be managed in the home under proper care and supervision.
Respite care temporarily relieves the spouse or other caregiver from the burden of caring for a chronically ill or disabled veteran at home. In the past, respite care admission was limited to an institutional setting, typically a VA nursing home. The Veterans Millennium Health Care and Benefits Act expanded respite care to home and other community settings, and home respite care was provided at 15 VA medical centers in fiscal year 2003. Currently, respite care programs are operating in 136 VA medical centers, with each program typically providing care to approximately five veterans on any given day. Respite care is usually limited to 30 days per year.
Home Hospice Care
Home hospice care provides comfort-oriented and supportive services in the home for persons in the advanced stages of incurable disease. The goal is to achieve the best possible quality of life through relief of suffering, control of symptoms, and restoration or maintenance of functional capacity. Services are provided by an interdisciplinary team of health care providers and volunteers. Bereavement care is available to the family following the death of the patient. Hospice services are available 24 hours a day, seven days a week. VA provided home hospice care at 73 medical centers in fiscal year 2003, the first year the service was offered.
Domiciliary care is a residential rehabilitation program that provides short-term rehabilitation and long-term health maintenance to veterans who require minimal medical care as they recover from medical, psychiatric or psychosocial problems. Most domiciliary patients return to the community after a period of rehabilitation.
Domiciliary care is provided by VA and state homes. VA currently operates 43 facilities. State homes operate 49 domiciliaries in 33 states. VA also provides a number of psychiatric residential rehabilitation programs, including ones for veterans coping with post-traumatic stress disorder and substance abuse, and compensated work therapy or transitional residences for homeless chronically mentally ill veterans and veterans recovering from substance abuse.
For most of VA's non-institutional care, telehealth communication technology can play a major role in coordinating veterans’ total care with the goal of maintaining independence. Telehealth offers the possibility of treating chronic illnesses cost-effectively while contributing to the patient satisfaction generally found with care available at home.
Geriatric Evaluation and Management (GEM)
Older veterans with multiple medical, functional or psychosocial problems and those with particular geriatric problems receive assessment and treatment from an interdisciplinary team of VA health professionals. GEM services can be found on inpatient units, in outpatient clinics and in geriatric primary care clinics. In 2004, there were 57 inpatient GEM programs and more than 195,000 visits to GEM and geriatric primary care clinics.
Geriatric Research, Education and Clinical Centers (GRECC)
These centers increase the basic knowledge of aging for health care providers and improve the quality of care through the development of improved models of clinical services. Each GRECC has an identified focus of research in the basic biomedical, clinical and health services areas, such as the geriatric evaluation and management program. Medical and associated health students and staff in geriatrics and gerontology are trained at these centers. Begun in 1975, there are now 21 GRECCs in all but two of VA’s health care networks.
Nursing Home Care
VA's nursing home programs include VA-operated nursing home care units, contract community nursing homes and state homes. VA contracts with approximately 2,500 community nursing homes. The state home program is growing and currently encompasses 114 nursing homes in 47 states and Puerto Rico. In fiscal year 2003, approximately 70 percent of VA’s institutional nursing home care occurred in contract community and state home nursing homes.
Nursing home care units are located at VA hospitals where they are supported by an array of clinical specialties. The community nursing home program has the advantage of being offered in many local communities where veterans can receive care near their homes and families. VA contracts for the care of veterans in community nursing homes approved by VA. The state home program is based on a joint cost-sharing agreement between VA, the veteran and the state.
Who is Eligible for Nursing Home Care
• Any veteran who has a service-connected disability rating of 70 percent or more;
• A veteran who is rated 60 percent service-connected and is unemployable or has an official rating of "permanent and total disabled;"
• A veteran with combined disability ratings of 70 percent or more;
• A veteran whose service-connected disability is clinically determined to require nursing home care;
• Nonservice-connected veterans and those officially referred to as "zero percent, noncompensable, service-connected" veterans who require nursing home care for any nonservice-connected disability and who meet income and asset criteria; or
• If space and resources are available, other veterans on a case-by-case basis with priority given to service-connected veterans and those who need care for post-acute rehabilitation, respite, hospice, geriatric evaluation and management, or spinal cord injury.
Millennium Act and VA’s Efforts to Increase Long-Term Care Capacity
Public Law 106-117, the Veterans Millennium Health Care and Benefits Act, enacted in November 1999, requires VA to provide extended care services in its facilities, including nursing home care, domiciliary, home-based primary care and adult day health care, with the goal of providing as much care as in 1998.
The budget for VA long-term care grew by more then $850 million between fiscal year 1998 and fiscal year 2003, and the number of full-time employees increased in nursing home care units and outpatient programs.