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Witness Testimony of Mr. Fred Cowell, Paralyzed Veterans of America, Senior Associate Director, Health Analysis

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 life long 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 caregiver 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 on line 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 poly-trauma 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.

 Veterans 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 on line.  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 two 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 Health Care 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.

Waiting 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 Health Care 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, system-wide 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.