VA Responds to the Needs of Aging Veterans
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.
Shift to Home- and Community-Based Care
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:
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.
Trends Point to Research Needs
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.