ANCOR | National Issues

Delivering on the Promise:

U.S. Department of Veterans Affairs

Self-Evaluation to Promote Community Living for People with Disabilities

Report to the President On Executive Order 13217

Department of Veterans Affairs

Executive Summary

The primary mission of the Department of Veterans Affairs (VA) is providing for the needs of veterans, offering them a range of compensation and pension benefits, vocational counseling and rehabilitation, health care and memorial services. In addition to these benefits, VA also administers education and home loan programs. President Abraham Lincoln’s pledge to “care for him who shall have borne the battle” is a constant reminder to VA employees that veterans are at the heart of our daily business.

Joining the Interagency Council as a voluntary partner enabled VA to conduct a full evaluation of our programs and services, identifying barriers to community access and developing an action plan to eliminate those barriers. Our Department self-evaluation resulted in the understanding that while we have already removed a significant number of barriers through changes in policies, Federal regulations and law, VA is still hindered in its ability to provide veterans with services necessary to allow them to remain in their homes and communities. While VA has identified the remaining barriers, we are still in process of reviewing these barriers and determining the appropriate action.

Veterans Benefits Administration

I. DESCRIPTION OF SERVICES

1. The Veterans Benefits Administration (VBA) provides disability compensation and pension to more than 2.7 million veterans each year. Disability compensation is a monetary benefit paid to veterans with service-connected disabilities. “Service connected” means that the disability was a result of disease or injury incurred or aggravated in line of duty during active service. Disability compensation is graduated according to the degree of the veteran’s disability.

2. Veterans with nonservice-connected disabilities may be eligible for VA pension programs, which provide income support to veterans with wartime service who become permanently and totally disabled as a result of nonservice-connected conditions. Pensions may also be paid to the survivors of wartime veterans. Entitlement to pension is subject to income limitations. In Fiscal Year (FY) 2001, VBA estimates paying $22 billion in disability compensation, survivor benefits and disability pension to 3.2 million people.

3. VBA offers additional programs to support the needs of disabled

veterans:

· Vocational Rehabilitation and Employment (VR&E) - The VR&E Program

provides comprehensive services and assistance necessary to enable veterans with service-connected disabilities and employment handicaps to become employable, and obtain and maintain stable, suitable employment. When the severity of a veteran’s disability prohibits suitable employment, the program offers services and assistance to enable the veteran to achieve maximum independence in daily living.

Program services may include evaluation of rehabilitation needs, employment services, medical and dental care, financial counseling, and where needed, education or training to develop marketable job skills. Veterans pursuing education or training may also receive a subsistence allowance.

In addition to administering the VR&E Program, VBA’s VR&E Service administers a program of education and training benefits for certain dependent children who have spina bifida as a result of a parent’s active service in Vietnam. The VR&E program also provides educational and vocational counseling for eligible service members, veterans, and dependents. This counseling service assists the participant in selecting educational or vocational goals and the facilities through which those goals may be reached.

· Aid and Attendance/Housebound Status - Disabled veterans in receipt of

service-connected compensation or nonservice-connected disability pension who are determined by VA to be housebound or in need of regular aid and attendance services are eligible for additional monetary compensation or pension. These additional funds can be used to pay for home care services received through home care agencies or provided by family members.

· Specially Adapted Homes - Veterans who are permanently and totally disabled due to service-related conditions are eligible for a grant of up to $43,000 to purchase or remodel a home to assist with accessibility and independence. Veterans who are permanently and totally disabled due to service-connected blindness in both eyes or loss of use of both hands are also eligible for a grant of up to $8,250 to adapt a home to assist with accessibility and independence. The VA awarded 590 new grants in FY 2000, totaling over $22.5 million in benefits.

· Automobiles - Veterans who have, through their service, lost hands, feet or vision may be eligible for $8,000 toward the purchase of a specially-adapted automobile.

· Clothing Allowance - Veterans who have service-connected disabilities requiring use of prosthetic or orthopedic appliances that wear out or tear clothing are eligible to receive annual clothing allowances.

4. These compensatory and rehabilitation benefits allow millions of disabled veterans to live independently and to maximize their potential.

II. ELIMINATED BARRIERS

· VR&E has begun new initiatives to reduce or eliminate barriers in identifying needed vocational rehabilitation services, delivering the needed services, and breaking down employment barriers experienced by people with disabilities.

· Separation Physicals - VA has partnered with the Department of Defense to

streamline the compensation claims process through conducting one physical

examination for all military personnel separating from active duty that serves as the

military separation physical and the VA compensation physical. This change in

policy has reduced duplication, resulting in one physical exam rather than two, and

allowed claims for VA service-connected disabilities to be processed more quickly.

· relocation of VR&E staff to be more proximate to the veteran population;

· use of contract service providers to augment VR&E staff and to help reduce the workload and expedite rehabilitation evaluations;

· use of portable computer and video teleconferencing tools that allow case managers to do their jobs virtually anywhere; and,

· use of “distance learning,” such as the Internet, as avenues for training and employment that have not been previously available.

· Employment Assistance - The vocational rehabilitation and employment for service-disabled veterans is a job-focused program to help eligible, service-disabled veterans prepare for, obtain and maintain suitable employment. In some cases, the veteran possesses adequate job skills and needs assistance in marketing those skills. In other cases, due to the lack of developed job skills or the handicapping aspects of the veteran’s disabilities, the veteran is assisted in choosing a viable occupation and an Individualized Written Rehabilitation Plan (IWRP) of services is developed. Necessary services often include training or education, and VR&E provides for all authorized expenses of school, including tuition, books, and fees. A veteran may be ready to go to work, but may need assistance with effective job-hunting. VR&E has participated in the following programs or initiatives:

· The Disabled Transition Assistance Program (TAP) briefings conducted at selected military discharge sites can assist service members who may need rehabilitation services and are pending discharge or medical retirement. In many cases, service members can begin working on the objectives of the rehabilitation plan prior to their separation or medical discharge.

· Through the assistance of our partner agencies and stakeholders, service-disabled veterans are identified and assisted in obtaining suitable employment, or exploring the option of self-employment.

· The Employment Specialist Pilot Program, which works with employers on the advantages of hiring vocational rehabilitation graduates and which examines job market trends. Trend data are used to assist veterans in selecting viable vocational goals and in tailoring training programs to meet the current and projected needs of employers.

· Case Management of VR&E Services – Each veteran participating in a VR&E program is assigned a case manager to coordinate the services the veteran receives and to follow the veteran from onset of services through placement in suitable employment. To facilitate case management, the VR&E Service has:

· Developed and deployed a state-of-the-art electronic case management system that tracks the veteran’s progress in his/her program, authorizes required tuition, books, fees, supplies and equipment for the veteran, and expedites payments to the vendors.

· Developed and implemented a streamlined system that allows case managers to provide the right services at the right time, on an individualized basis, while reducing or eliminating work processes which are not sufficiently productive.

III. REMAINING BARRIERS

· Backlog of unprocessed claims - Currently, VBA has a backlog of 661,000 claims for 2.7 million veterans and survivors. The latest caseload numbers to be published the budget is 2.3 million in FY 01 and 02 and 2.4 in FY 03.

· Secretary Principi has established a team at the Cleveland VBA Regional Office that will focus initially on the longest pending claims and the claims of the oldest veterans.

· The Secretary has instructed the Veterans Health Administration (VHA) to work in cooperation with VBA to quickly schedule and complete physical and psychological examinations as part of the compensation and claims process.

Veterans Health Administration

The Veterans Health Administration (VHA) operates 172 medical centers, more than 800 ambulatory care clinics, 135 137 nursing homes, 43 domiciliaries, 206 readjustment counseling centers and 73 comprehensive home care programs. VHA has a comprehensive array of services for disabled veterans, including state-of-the-art treatment for spinal cord injury, blind rehabilitation, chronic mental illness, traumatic brain injury, amputations, brain dysfunction, post-traumatic stress disorder (PTSD), and substance abuse. Nine VHA research centers of excellence conduct studies emphasizing wheelchair design and technology, brain rehabilitation, spinal cord injury and multiple sclerosis, early detection of hearing loss, orientation techniques for blind persons, amputation prevention and joint replacement. In addition, VHA has the largest network of homeless assistance programs in the country. The primary objective of VHA’s programs is to achieve the maximum independence for veterans by restoring lost function or decreasing the impact of their disabilities. VHA has a Central Office position of Coordinator for Special Disability Programs.

For most of its 70-year history, VA was primarily an inpatient, facility-based system. In the 1990s, the health care industry in America changed dramatically, with demands for lower costs, greater accountability and higher quality. The basic system of health care delivery was reformed from hospital-centered care to managed, patient-centered primary care and necessary specialty care. Beginning in 1995, VHA began a fundamental transformation, developing into the largest integrated health care system in the Nation. Inpatient wards were closed as care shifted to ambulatory settings and primary care models. The number of bed days of care per 1,000 users of acute care facilities was reduced by 21 percent between FY 1995 and FY 1996. Since 1995, VA has eliminated more than 6,000 inpatient beds and established over 2,000 psychosocial residential rehabilitation beds. Lengths of inpatient admissions were drastically reduced, the bulk of care was provided in outpatient clinics, and VA began to expand home-based services.

I. DESCRIPTION OF SERVICES

1. Health Care Benefits - VA provides a comprehensive package of outpatient and inpatient services.

Primary Health Care assure that one team of providers oversees all of the health care services provided to veterans in their panels. Primary care providers offer the full range of services, including preventive care and treatment for acute and chronic medical conditions. The advantage to the veteran is that she/he is seen by the same provider or team of providers at every visit, allowing for the development of longer term treatment relationships. The primary care team members have longitudinal experience in caring for the veteran, reducing the need to recapture the same medical information and history at each visit and allowing providers to quickly recognize changes in health status.

By October 1996, 97 percent of VHA facilities had developed primary care teams; all VHA facilities had such teams as of FY 2001. Each veteran receiving care in VHA is now assigned to a primary care team and a primary care provider. The interdisciplinary primary care team typically includes physicians, physician assistants, nurse practitioners, registered nurses, licensed practical nurses, social workers and clerical staff. Additional services are provided by registered dietitians, pharmacists, psychologists and chaplains.

Each veteran followed by a primary care provider and team receives a comprehensive biopsychosocial assessment, which identifies health, mental health, and psychosocial needs and problems. For example, veterans identified who have suffered sexual trauma are referred for mental health treatment services if they choose.

The assessment process is designed to identify veterans who are at high medical or psychosocial risk. High-risk criteria include the following:

· chronic, unstable medical or psychiatric condition;

· catastrophic illness or injury;

· frail elderly;

· suspected abuse or neglect;

· incompetent or in need of a payee, guardian or conservator

· homeless with no apparent fixed or temporary shelter; and,

· unable to care for self (physically, emotionally or mentally).

Nurse and social worker case managers are assigned to primary care teams to work closely with high risk veterans, many with disabilities, to assure that their special needs are met. Case managers typically conduct thorough assessments of their patients, including home visits to determine the need for home equipment and home and community services and for assessing the safety of the home environment, the ability of the veteran to perform activities of daily living, and the availability of support systems.

Case managers provide a variety of supportive and psychosocial services to allow disabled veterans to remain in their homes and in the community in the least restrictive environment, addressing health and psychosocial problems early to prevent unnecessary admissions to hospitals or institutions. Case managers maintain frequent contact with the veteran and family members, building strong relationships and serving as the liaison for the veteran and family with the VHA medical facility and with community agencies. They make referrals for additional services from VA, from other governmental programs and from community agencies and track the appropriateness and quality of those services. Case managers offer patient and family education as well as counseling services.

b. Preventive services, including immunizations, screening tests, and health education and training classes, are available to all enrolled veterans.

Diagnostic and treatment services determined to be necessary for the care of veteran patients are provided.

Necessary surgical procedures are provided. Over the last five years, VHA has offered more outpatient surgery, in many cases eliminating the need for inpatient admission.

Comprehensive inpatient and outpatient mental health and substance abuse treatment services are available. Veterans assigned to primary care teams are routinely screened for depression and referred for treatment.

Home health care services such as home-based primary care and homemaker and home health aide services, are available.

Respite, hospice care and palliative care are offered for inpatients and outpatients.

Urgent and limited emergency care services are provided in some VA facilities.

VHA provides all medically necessary drugs, pharmaceuticals and supplies for enrolled veterans. Nonservice-connected veterans are subject to a small co-payment, generally much less than private insurance plans. VA physicians prescribe atypical antipsychotics and other medications to enhance functioning of seriously mentally ill veterans, allowing them to remain in the community with their symptoms under control.

2. Specialty Services:

· Spinal Cord Injury and Disorders Treatment - Services include acute inpatient, rehabilitation, outpatient, and home-based care as well as annual health examinations and all medically necessary equipment and supplies. Each VHA facility has a spinal cord injury coordinator who oversees the services provided to veterans with spinal cord injury. There are 23 VHA spinal cord injury centers across the country. The goal of spinal cord injury and disorders rehabilitation is to allow veterans to live independently or with supportive community services when independent living is not realistic.

· Blind Rehabilitation - The Blind Rehabilitation Service provides programs to enhance the quality of life for eligible blinded veterans through identification, treatment, education and research programs. This is accomplished through Visual Impairment Services Team Coordinators at every VHA facility; 10 VHA Blind Rehabilitation Centers; and 20 Blind Rehabilitation Outpatient Specialists located nationwide and in Puerto Rico. These programs and services assist visually impaired veterans in adapting to community living.

· Traumatic Brain Injury (TBI) - Services include evaluation and referral to a VHA TBI center, which is accredited by the Commission on Accreditation of Rehabilitation Facilities. TBI centers provide comprehensive assessment, acute rehabilitation and neurobehavioral management, outpatient services, referrals for community-based support care and all medically necessary equipment and supplies. There are four VHA TBI centers, 22 supporting network centers and 26 TBI coordinators who facilitate referrals and coordination of services.

· Mental Health - Services include acute inpatient, outpatient, rehabilitation and residential mental health treatment. Mental Health services are comprehensive and offer substance abuse treatment and specialty treatment for post-traumatic stress disorder.

· Homeless Veterans – VA provides a wide range of services for homeless veterans. VA staff conduct outreach to area homeless shelters, network with community agencies to facilitate referral of veterans to VA facilities, and organize annual stand-down events across the country. VA also assists homeless veterans with accessing medical and other VA benefits and services. Case management services are offered, as well as all necessary medical and mental health treatment services. Several different types of residential care and transitional living options are available. In addition, non-profit organizations and local governments may apply for grants under the VHA Homeless Grant and Per Diem Program to construct, acquire or remodel buildings for housing or service centers for homeless veterans. Organizations and agencies awarded such grants may be eligible to receive per diem payments from VHA for homeless veterans receiving services.

3. Home and Community Services:

· Contract Nursing Home Program - Each day, VHA pays for skilled nursing care in contract community nursing homes for more than 3,600 veterans. Each VHA facility has a community nursing home program coordinator who oversees appropriate community placements, monthly nursing and social work visits to veterans in nursing homes, and annual inspections of each nursing home under contract. The care provided to each veteran is closely monitored.

· VA Nursing Home Care - There are 137 nursing homes operated in VHA facilities. Many of these nursing homes have a rehabilitative mission, with the goal of returning veterans to the community with maximum functioning and supportive services.

· State Veterans Homes in Partnership with VA – VA provides per diem payments for veterans residing in state veterans homes.

· Contract Adult Day Health Care Program (CADHC) - VHA pays for adult day health care services in the community for veterans who would otherwise be placed in institutions. CADHC allows veterans to remain in their homes and allows caregivers to work outside the home, knowing that the veteran is under the care of health care professionals for up to eight hours per day, five days per week.

· Homemaker/Home Health Aide Program - VHA offers homemaker and home health aide services to disabled veterans, allowing them to remain in their homes even when their caregivers are unable to provide for all of their care.

· Respite and Contract Respite Programs - VHA offers up to 30 days per year of respite care services to veterans. VA nursing homes and intermediate care units have designated respite beds, and many VHA facilities offer contract respite services in community nursing homes for veterans with special needs. The respite services allow caregivers to take vacations and have a break from the pressures of providing 24-hour care to a disabled loved one.

· Caregiver Support Services - VHA offers caregiver support, including facilitated support groups, information and education, and counseling services. Such supportive services assist caregivers in keeping disabled veterans in their homes.

· Home-Based Primary Care (HBPC) - There are 73 HBPC programs in VHA facilities nationwide. Physicians, nurse practitioners, registered nurses, social workers, dietitians and occupational and physical therapists comprise the HBPC teams. Each week, several team members make home visits to disabled veterans enrolled in the program. They provide medical care, nursing and dietary instruction, home evaluations, psychosocial interventions and case management services. Nearly 15,000 veterans received care through HBPC programs in FY 2000. The average number of veterans receiving such care on any given day is 7,312.

· Hospice Services - VHA offers in-home and medical center hospice and palliative care services for terminally ill veterans.

· Community Residential Care - VHA assists veterans with the financial means to pay for residential or board and care services in finding an appropriate facility. VHA social workers negotiate rates with community residential care operators to assure veterans pay reasonable rates. VHA teams conduct annual inspections of each facility.

· Domiciliaries - VHA operates 43 domiciliaries, which function as intermediate treatment and transitional living facilities for disabled veterans.

· Transitional Residential Rehabilitation and Treatment Programs - VHA has a variety of residential rehabilitation programs for veterans, most of whom are homeless and have a mental illness or disability. One hundred three Psychiatric Residential Rehabilitation Treatment Programs provide residential treatment and/or transitional housing services to approximately 15,000 veterans suffering from substance use disorders, post-traumatic stress disorder or other serious mental illnesses, and many of whom are also homeless. VHA contracts with over 250 halfway houses and community-based residential treatment programs to provide residential care for over 4,500 homeless veterans each year. In addition, under the Homeless Providers Grant and Per Diem Program, VHA offers grants to state and local governments, nonprofit organizations and Indian tribal governments to help develop transitional, supportive housing programs for homeless veterans.

From FYs 1994-2000, VHA offered $53 million in grants to help establish approximately 5,000 supportive housing beds. In FY 2000, 2,326 beds were operational, and VHA provided per diem payments to offset the costs of these programs. Over 3,500 homeless veterans were served in these community-based supportive housing programs in FY 2000.

· Partial Hospitalization and Day Treatment Programs - These programs are designed to provide comprehensive psychiatric rehabilitation services that allow veterans with serious mental illnesses to remain in community settings and to improve their quality of life.

· Home Improvement and Structural Alterations Grants - Prosthetic and Sensory Aids Service provides a grant of up to $4,100 for veterans with service-connected disabilities for access and necessary alterations to a disabled veteran’s home to enable continuation of medical services. Nonservice-connected disabled veterans may be eligible for a maximum of $1,200.

· Compensated Work Therapy (CWT) - As part of transitioning veterans into the community, VHA offers 100 CWT programs serving 14,000 veterans each year. CWT allows veterans to learn job skills and to earn wages, some for the first time in years. CWT generates more than $30,000,000 in income each year for veterans from its agreements with participating companies. Upon having demonstrated their abilities, graduates of the program go on to regular employment. CWT also provides treatment in a transitional residential model, where veterans work in CWT and live in one of 40 transitional residences located at one of 30 VHA medical centers. The program is authorized by law to charge participants a fee from their CWT earnings. The fee is used to support operating and maintenance costs for the residences.

· Senior Companion/Peer Counseling Services - Homebound, disabled and frail elderly veterans benefit from enrollment in senior companion programs and from receipt of peer counseling services. Senior companions and peer counselors visit veterans in their homes to provide emotional support, recreational activities, and friendship. They also alert VHA primary care team members of concerns about the veteran’s health and well-being.

· Durable Medical Equipment, Prosthetic Devices and Orthopedic Appliances - Veterans found to have a medical need for such equipment, devices and appliances can receive them from VHA. These items include hospital beds, regular and motorized wheelchairs, motorized lifts, adaptive equipment for automobiles and vans, home safety equipment, home oxygen, artificial limbs, etc.

4. Access to Services:

· Community-Based Outpatient Clinics - In an effort to assure easy access to health care, VHA has established a network of community-based outpatient clinics (CBOCs). The CBOCs allow veterans to receive care in their communities rather than traveling great distances to VHA medical centers. These access points have allowed an additional 500,000 veterans to receive VA health care services. VHA operates more than 800 facility and community-based outpatient clinics, which offer primary care services, management of acute and chronic illnesses and conditions, and referrals for subspecialty care. Many CBOCs provide mental health services and referrals for specialty mental health care. Eighty-seven percent of all veterans who are enrolled live within 30 miles of a point of service.

· Beneficiary Travel - VA pays mileage for use of personal vehicles and for ambulances and wheelchair vans for some veterans receiving outpatient care from VHA facilities. This financial assistance helps low income, disabled veterans receive needed health care services.

· Disabled American Veterans (DAV) Transportation Services - The DAV has entered into agreements with VHA to provide wheelchair vans and drivers to ferry veterans to VHA facilities for medical appointments and care. Without such services, many of these disabled veterans would be forced into institutional settings or would forgo needed health care services.

5. Consumer and Stakeholder Involvement:

VA continually seeks to involve veterans, family members, advocacy groups, veterans service organizations and other stakeholders in all plans for providing services and health care to veterans. Most VHA facilities hold regular formal meetings with veterans

organizations to keep them informed, listen and respond to their input and concerns and involve them in planning activities. On the national level, there are a variety of consumer task forces and panels that meet regularly with top VA officials. VHA Mental Health officials have worked with a National Mental Health Consumer Liaison Council that includes community mental health organizations, veterans service organizations and Substance Abuse and Mental Health Services Administration. The partnership has resulted in the development of many locally-affiliated mental health consumer councils at VHA medical centers.

II. ELIMINATED BARRIERS

1. Reduced Admissions and Lengths of Stay:

· Restructuring VA health care and opening community-based outpatient clinics have allowed VA to treat more veterans closer to home at less cost.

· Primary care and case management have reduced unnecessary admissions and lengths of admissions for persons with physical and mental disabilities.

· Ambulatory surgery and other procedures have reduced unnecessary admissions.

· Veterans living in VHA long-term care settings (psychiatric units, nursing home care units and domiciliaries) have been provided with the equipment, community-based services and medications to allow them to reside in a less restrictive environment.

2. Homemaker, Home Health Aide, Respite and Adult Day Health Care Services:

· The ability of VHA to provide or pay for these services has allowed countless numbers of veterans to remain in their homes rather than be placed in institutions.

3. Mental Health Services:

· Mental Health Intensive Case Management Programs - Previously called intensive psychiatric community care, these programs are designed to help veterans who are frequently admitted or who are frequent walk-in patients live more successfully in the community. The programs utilize intensive case management services with a low staff to veteran ratio using evidence-based assertive community treatment principles.

4. The Veterans Health Care Eligibility Reform Act of 1996 (Public Law

104-262):

· Made Eligibility the Same for Hospital and Outpatient Care - VHA facilities no longer have to admit veterans in order to make them eligible for outpatient care and medical and prosthetic equipment.

· Clarified VA’s Authority to Furnish Preventive Services to Veterans Not Otherwise Receiving Care - Prior to passage of this legislation, VHA could only provide outpatient care to nonservice-connected veterans as follow-up to inpatient treatment. There had been no previous authority for VHA to provide preventive and primary care services.

· Eliminated Certain Restrictions on Furnishing Prosthetics for Nonservice-Connected Disabilities to Veterans Receiving Outpatient Care - Inpatient admissions were no longer required for eligibility.

· Required VA to Establish an Annual Patient Enrollment System - VHA established seven enrollment categories, based on special disability groups and income. Enrollment in FY 2001 grew to 5.26 million veterans, approximately 20 percent of the total veteran population.

· Required VA to Maintain its Capacity to Treat Veterans Requiring Specialized Treatment or Rehabilitation - The treatment of disabled veterans continues to be the foundation of VHA health care services. This section of the law required VA to maintain its capacity in special emphasis programs. VHA identified twelve special emphasis programs:

· Blind rehabilitation

· Geriatrics and long-term care

· Homelessness

· Persian Gulf Veterans programs

· Post-traumatic stress disorder

· Preservation Amputation Care and Treatment

· Prosthetics

· Readjustment counseling services

· Seriously mentally ill

· Spinal cord injury and disorders

· Substance abuse treatment

· Women veterans programs

· Authorizes VA to contract with community providers for the sharing of health care services - This has allowed VHA to establish contract community-based clinics in regions of the country with insufficient veteran populations to support a VA-staffed clinic.

5. Veterans Millennium Health Care and Benefits Act of 2001 (Public

Law 106-117):

· Provides Mandatory Nursing Home Eligibility for Service-Connected Veterans - Requires VA to provide or pay for nursing home care for veterans who are rated 70 percent or more disabled and those needing nursing home care for a service-connected condition.

· Requires VA to provide an extended care benefits package that includes both institutional and non-institutional benefits, such as adult day health care, community nursing home care, domiciliary care, geriatric evaluation and respite care.

· Requires VA to provide alternatives to institutional care for elderly and disabled veterans.

· Changed the previous six-month limitation on adult day health care services for some disabled veterans to an indefinite benefit based on the needs of the veteran.

· Requires VA to maintain the level of services and staffing in long-term care programs provided nationally in VHA facilities during Fiscal Year 1998.

· Authorizes VA to fund pilot programs for the provision of all-inclusive care for elderly veterans.

· Authorizes VA to fund a pilot program for the provision of assisted living services.

· Establishes a special eligibility category for VA health care for veterans awarded the Purple Heart.

6. The Veterans Benefits and Health Care Improvement Act (Section
221 of Public Law 106-419):

· Authorizes VA to provide temporary lodging services for veterans and those providing familial support. This gives VHA statutory authority to provide or to pay for temporary lodging for veterans living too far to commute to the closest VHA facility for outpatient care and procedures.

· Authorizes VA to accept, maintain and operate Fisher Houses, donated to the Department by the Fisher House Foundation to temporarily lodge family members of hospitalized veterans.

III. REMAINING BARRIERS

1. Community Services:

· Limited community resources in rural communities - For disabled veterans living in rural parts of the country, the necessary community services may not exist to allow them to remain in their homes. Even if VA is willing to pay for homemaker and home health aide and adult day health care services, if no high quality community agencies are available to provide the care, the veteran suffers. Adequate mental health services in the community may not exist to allow seriously mentally ill veterans to reside in the community.

· Transportation - Transportation to VHA facilities continues to be problematic in rural parts of the country, despite the Disabled American Veterans transportation network. Some veterans in these areas have no means of private transportation, even if they are eligible for VA beneficiary travel reimbursement.

· Availability of geropsychiatric services - As seriously mentally ill veterans age, their overall health can deteriorate and they can develop health care problems associated with old age (dementia, Alzheimer’s disease, etc.). These veterans with both physical and mental health disabilities are in need of specially structured environments and services to assure their health, safety and well-being. There is a paucity of geropsychiatric services available both within and outside VHA.

· Mental Health in CBOCs - Some VHA community-based outpatient clinics (CBOCs) do not offer basic mental health services. Recently the Assistant Deputy Under Secretary for Health has required that all facilities submit plans for the provision of mental health services to veterans receiving care in CBOCs in fiscal year 2002.