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Four decades ago, VA recognized that aging
of World War II and Korean War veterans
would one day challenge its delivery system.
At the time, VA had been focused primarily
on inpatient and acute care, and was not
prepared to address the long-term care
needs of an aging veteran population. In response,
VA developed capabilities to meet
these needs by building long-term care facilities
and by developing cooperative agreements
with state veterans' homes.
In the 1980s, VA established the Geriatric
Research Education and Clinical Centers
(GRECCs) with the specific mission to
study those medical conditions associated
with aging, train health care providers in the
care of the elderly, and to improve the care
provided to older veterans. Now situated in
20 VA medical centers across the country,
these centers serve a critical role in advancing
geriatric expertise across the system.
In the 1990s, VA began reassessing the care
it provided to the elderly and recognized the
need to provide a continuum of care rather
than providing care in discrete settings (e.g.,
inpatient acute, long term, etc.). This shift
became more urgent with the rapid aging of
the enrolled veteran population as well as
growing enrollment by aging veterans.
These trends resulted in the landmark 1998
report, VA Long Term Care at the Crossroads,
which urged a shift in long-term care from
inpatient facilities to home- and communitybased
settings. This shift was further supported
by the Veterans Millenium Healthcare
and Benefits Act of 1999, which set
forth basic benefits of home- and community-
based long-term care along with Congressionally-
mandated nursing home
benefits for select veterans. 1
Over the last decade, VA has focused on
implementing the recommendations of the
Crossroads report and the requirements of the
Millenium Act. As a result, VA anticipates a
continued expansion of community-based
programs over the next five years. Today,
VA is focused on implementing a spectrum
of services, which includes relatively minor
assistance that enables veterans to stay in
their homes, skilled nursing care and primary
care in the home, and institutional
care in VA, state, and community facilities.
Today, every medical center in the VA system
must implement a range of non-institutional
services. Specifically, medical centers must
implement a care coordination program,
plus at least six of the following services:
Homemaker/home health aides
Skilled home care
Home-based primary care
Home respite care
Home hospice and palliative care
Community and VA operated adult
day care
Spinal cord home care
VA recently launched a medical foster home
program that enables veterans to live in
small facilities with a home-like environment.
These community residential sites
must be approved by VA, and are especially
well suited to veterans of Operation Iraqi
Freedom (OIF) and Operation Enduring
Freedom (OEF), who do not want to live in
an institutional setting but cannot live independently
at home.
While the increased availability of home- and
community-based services has had the desired
effect of reducing inpatient demand,
VA is still experiencing significant need for
nursing home services. In addition to its own
nursing home facilities, VA contracts with
CMS-certified community nursing homes to
provide care for veterans. Typically, a veteran
is placed in a community nursing home
on a short-term VA contract, ultimately
transitioning to Medicaid for long-term
care. VA also has a nationwide program
with state homes, paying a per diem for each
day a veteran is a resident of a state home.
Advances in the application of technology
to care delivery, such as wireless devices and
the Internet, also play a role in meeting the
needs of the aging patient population.
Home telehealth offers significant potential
to veterans, particularly in overcoming time
and distance barriers in rural areas. One example
is VA’s teleretinal imaging program,
launched in 2007. The program offers initial
screening for eye disease to veterans with
diabetes. Under this program, retinal images
are taken in primary care settings and sent
to an image reading center where they are
evaluated by an eye care specialist.
The rapidly aging veteran population poses
several important research opportunities.
The satisfaction of veterans and families with
the care they receive in home- and community-
based settings is largely unknown. In
addition, the impact of care provision in
these newer settings in reducing emergency
room and hospital usage is an important potential
consequence that we need to better
understand. And while we know, in general,
that home- and community-based settings
are less expensive than inpatient settings, we
do not have data on the relative cost of care
across these care settings.
While VA has successfully negotiated with
pharmaceutical manufacturers to get their best
prices, the cost of drugs continues to rise. It
is quite common for individuals over 65 to
have multiple medications. Unfortunately,
clinical trials typically do not include the elderly,
so we suffer from limited data on the
safety and efficacy of drugs for this population.
Patient access to information on the Internet
has had quite an impact. Some of this
information is quite reliable and timely, but
other information is dangerous and inaccurate.
VA could play a larger role in sorting
this out for veterans. My HealtheVet offers
an important opportunity for veterans to
add information on their conditions and for
providers to monitor their patients.
Finally, while VA has relatively limited authority
to provide support to caregivers, we
can offer training to family members and
other caregivers. Research on the most effective
training modalities for caregivers
would be helpful.
- The Congressionally mandated benefit provided nursing
home benefits for veterans classified as P1A, meaning
any veteran with a 70 percent or greater service-connected
disability, or who requires nursing home care
specifically because of a service-connected disability.
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