How VA Has Advanced the Care of Aging Veterans and What Lies Ahead
Welcome to the Fall issue of HSR&D's FORUM, which focuses on aging Veterans. On behalf of the Office of Geriatrics and Extended Care, we are pleased to offer comment and issues for thought for VA researchers in the field of aging, and those whose research touches the lives of Veterans aging with chronic conditions.
The Office of Geriatrics and Extended Care (GEC) is responsible for the oversight and monitoring of institutional and non-institutional care programs for aging Veterans. VHA provides a spectrum of services to aging Veterans unparalleled in the community. A multitude of GEC programs are available to aging Veterans in most VA facilities around the country; these services range from outpatient geriatric evaluations and adult day care services to home care and institutional care options.
The number of aging Veterans continues to rise as Vietnam-era Veterans are now reaching Medicare-eligibility age. Almost 9 million Veterans are enrolled in VA for health care and 47 percent of those are over 65 years of age. Those Veterans will age into their advanced years with complex medical, cognitive, and psychological issues.
In the early 1970s, VA faced a similar crisis as aging WWII Veterans streamed into the system seeking care in their later years. About the same time, the science of gerontology began to emerge, revealing the aging process and management of frail older persons to be a unique area of inquiry. The National Institute on Aging was established in 1974, and shortly thereafter VHA established the Geriatric Research, Education and Clinical Center (GRECC) Program. GRECCs were designed to be geriatric centers of excellence that would give visible focus to VA's commitment to aging Veterans and that would create a critical mass of experts to lead the way in quality research, enhanced education, and clinical innovation in the care and treatment of older Veterans.1 VA strategically located GRECC Centers, enabling them to partner with academic institutions that were emerging as geriatric research centers, in line with VA's pre-existing relationships with academic medical centers nationwide. The first 10 GRECCs opened between 1975 and 1980, and 11 more opened between 1980 and 1985; an additional 13 GRECCs opened between 1985 and 2000. Over time, some of the GRECCs consolidated efforts or closed, and at present 20 GRECCs are in operation throughout the United States.
The influence of the GRECC program on the advancement of aging research, geriatric training, and clinical care for Veterans has been substantial over the past 44 years. Advances in the biology of aging, including mechanisms underlying dementia, heart disease, renal disease, metabolic syndrome, osteoporosis, and rehabilitation medicine can be directly attributed to GRECCs.2 Development of clinical care models addressing transitional care, hospice and palliative care, dementia care, and physical activity/exercise for healthy aging have been demonstrated in GRECCs and exported to VHA and the public for years. GRECC educators have built one of the largest initiatives to train a geriatric workforce for the future as part of their mandate to provide education to health care trainees in the unique care needs of older adults. GeriScholars is a VA GEC program that provides training and support for VA employees to strengthen their skills in meeting the needs of older adults; this program has provided training experiences for over 5,800 VA employees across the spectrum of health care disciplines.
VHA faces a number of challenges in the next decade, including a growing number of aging Veterans who have dealt with physical and psychological issues dating back to their service years. The Veterans with the highest levels of service-related disabilities are known as Priority 1a, and this number is expected to increase from 500,000 to over 1 million in the next 10 years. VHA is required to provide or pay for nursing home care for this group if it is needed. This challenge will be compounded by the decrease in numbers of a specifically trained and geriatric certified workforce across all disciplines of care.
GEC has successfully launched many programs designed to provide assistance to honor Veterans' preferences to remain at home in their advanced years. Home-based primary care sends the resources to Veterans' homes to deliver needed services. Adult day care programs allow for socialization and also meet health care needs. Medical Foster Homes let Veterans live with families in their homes and provide a welcome alternative to nursing home placement. Homemaker and home health aide programs allow Veterans to receive needed personal care at home, and the new Veteran-Directed Care Program allows them to hire family members to meet personal caregiving needs. These programs, together with GRECC initiatives emphasizing exercise, nutrition, and cognitive and social stimulation have demonstrated success in delaying or eliminating the need for institutional care. VHA's nursing homes, known as Community Living Centers (CLCs), have recently entered the public reporting sphere with CLC Compare, similar to CMS' Nursing Home Compare. Since initial reporting began last year, quality ratings have significantly improved and as of the last reporting period, almost all VA CLCs have improved in readiness and quality measures that exceed average levels for nursing homes in the community.
Finally, VHA is also working hard to reach Veterans living in rural areas who do not have easy access to VA or other health care services and who prefer to age in place. These challenges arise at the same time VA is modernizing and developing integrated clinical service lines as part of the effort to become a high-reliability organization. Electronic health record modernization will also help address these challenges by accelerating advances in care outcomes using telehealth technology.
While we've come a long way in the past 40 years, there is still a long way to go. The environment is ripe for continued investigations into biological mechanisms associated with aging and chronic illness, as well as preventive strategies and targeted interventions to improve functional health and overall well-being. The changes underway in modernizing VA systems and services allow investigators to look ahead to advancing how, when, and where VA health care is received; these changes will also permit investigators to measure the effectiveness of programs and models of care designed to honor Veterans' preferences in their later years. The Office of Geriatrics and Extended Care looks forward to working with our research colleagues as we meet our mission "To care for him who shall have borne the battle and for his widow and his orphan."