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Report to the Secretary of Veterans Affairs: United States Government Accountability Office: GAO: September 2004: VA Long-Term Care: More Accurate Measure of Home-Based Primary Care Workload Is Needed: GAO-04-913: GAO Highlights: Highlights of GAO-04-913, a report to the Secretary of Veterans Affairs: Why GAO Did This Study: The Department of Veterans Affairs (VA) provides a variety of long- term care services that includes nursing home care and noninstitutional care provided in community-based settings or in the homes of veterans. One important noninstitutional service is home-based primary care, which uses a multidisciplinary team approach involving VA health care providers and others such as social workers to treat veterans who are homebound. As part of GAO’s work for the Committee on Veterans’ Affairs, House of Representatives, to assess how VA meets veterans’ long-term care needs, GAO reviewed how VA measures workload for home- based primary care and five other noninstitutional services. What GAO Found: The amount of home-based primary care veterans receive is not accurately reflected in VA’s workload measurement for that service. VA measures home-based primary care workload using the number of days a veteran is enrolled in the program rather than the number of visits the veteran received. For example, if a veteran was enrolled in VA’s home- based primary care program for 1 week, and received two visits from VA providers that week, VA would calculate the workload using 7 days, rather than two visits. As a result, using enrolled days as the workload unit of measure overstates the amount of home-based primary care actually received by veterans. In fiscal year 2003, VA reported an average daily workload for home-based primary care of 8,370 using enrolled days; in contrast, GAO determined that using the number of visits results in a workload of 944. In addition, VA’s measurement of home-based primary care using enrolled days is inconsistent with the way it measures workload for the other noninstitutional long-term care services GAO reviewed. VA measures workload for these other services using the number of visits a veteran received. As a result, VA’s workload total for home-based primary care overstates that service’s use compared to other noninstitutional services VA provides. VA Noninstitutional Long-Term Care Workload, Fiscal Year 2003: [See PDF for image] Note: VA reports all noninstitutional care workload measures except home-based primary care in visits. [End of figure] What GAO Recommends: GAO recommends that VA measure and report the amount of home-based primary care services veterans receive by using visits. VA agreed that a more accurate measure of home-based primary care is needed but did not concur with GAO’s recommendation. However, VA plans to establish a combination of workload measures for home-based primary care and other long-term care programs in fiscal year 2005, including visits, which will be responsive to GAO’s recommendation. www.gao.gov/cgi-bin/getrpt?GAO-04-913. To view the full product, including the scope and methodology, click on the link above. For more information, contact Cynthia A. Bascetta at (202) 512-7101. [End of section] Contents: Letter: Results in Brief: Background: VA's Workload Measurement for Home-Based Primary Care Does Not Accurately Reflect the Amount of Care Received by Veterans: Conclusions: Recommendation for Executive Action: Agency Comments and Our Evaluation: Appendix I: Comments from the Department of Veterans Affairs: Table: Table 1: Selected VA Noninstitutional Long-Term Care Services: Figure: Figure 1: VA Noninstitutional Long-Term Care Workload, Fiscal Year 2003: Abbreviation: VA: Department of Veterans Affairs: United States Government Accountability Office: Washington, DC 20548: September 8, 2004: The Honorable Anthony J. Principi: Secretary of Veterans Affairs: Dear Mr. Secretary: The Department of Veterans Affairs (VA) provides a continuum of long- term care services that includes nursing home care and noninstitutional services provided in community-based settings or in the homes of veterans. One important noninstitutional service VA provides is home- based primary care, which uses a multidisciplinary team approach involving VA health care providers and others such as social workers to treat veterans who are homebound. Concerns about meeting veterans' long-term care needs in both institutional and noninstitutional settings have increased in part because the veteran population is aging. The number of veterans 85 years old and older, who are most in need of long-term care, is expected to increase from about 870,000 to 1.3 million over the next decade. Through its noninstitutional long- term care program, VA provides or pays for services that may help veterans remain at home and delay, or prevent, their need for nursing home care. As part of our work for the Committee on Veterans' Affairs, House of Representatives, to assess how VA met or addressed its long- term care workload needs from fiscal years 1998 through 2003, we reviewed how VA measures this workload for home-based primary care and other services.[Footnote 1] To conduct our review, we assessed veteran patient workload data for fiscal years 1998 through 2003. Because VA did not change how it measured workload for the noninstitutional services we reviewed from fiscal years 1998 through 2003, we focused on fiscal year 2003 for this report. We obtained data from VA on workload and information about how it is measured and we analyzed these data for six noninstitutional long-term care services: (1) home-based primary care, (2) adult day health care, (3) homemaker/home health aide, (4) skilled home health care, (5) home respite care, and (6) home hospice care.[Footnote 2] In doing our work, we tested the reliability of the data and determined they were adequate for our purposes. We conducted our review from January 2003 through August 2004 in accordance with generally accepted government auditing standards. Results in Brief: VA's workload measurement of home-based primary care services does not accurately reflect the amount of care veterans receive. VA measures home-based primary care workload using the number of days a veteran is enrolled in the program rather than the number of visits received by a veteran. For example, if a veteran was enrolled in VA's home-based primary care program for 1 week, and received two visits from VA providers that week, VA would calculate the workload using 7 days, rather than two visits. As a result, the use of enrolled days as the unit of measure for home-based primary care overstates the services actually received by veterans. Specifically, VA reported an average daily workload for home-based primary care of 8,370 using enrolled days in fiscal year 2003; in contrast, we determined that using the number of visits results in a workload of 944. In addition, VA's measurement of home-based primary care using enrolled days is inconsistent with the way VA measures workload for the five other noninstitutional long-term care services we reviewed. For these other services, VA measures workload using the number of visits a veteran received. Because the number of visits is a more accurate measure of the home-based primary care services veterans receive than enrolled days, we are recommending that VA use visits to measure and report the amount of home-based primary care services veterans receive. In commenting on a draft of this report, VA agreed that a more accurate measure of home-based primary care is needed but did not concur with our recommendation. However, VA plans to establish a combination of workload measures for home-based primary care and other long-term care programs in fiscal year 2005, including visits, which will be responsive to our recommendation. This will provide useful information to Congress and other stakeholders for assessing the amount of home- based primary care services veterans receive from VA. Background: VA provides noninstitutional services as an important part of its continuum of long-term care. VA provides these services to veterans in their own homes or in community settings using both its own employees and other providers available through contracts. Veterans may prefer such services, which allow them to remain in their homes or in other settings that are less restrictive than institutions. We reviewed six of the noninstitutional services that VA provides or pays for. (See table 1.) VA reported workload measures for these noninstitutional care services in appropriations requests and testimony to Congress.[Footnote 3] Table 1: Selected VA Noninstitutional Long-Term Care Services: Service: Home-based primary care; Description: Primary health care, delivered by a physician-directed interdisciplinary team of staff including nurses, to homebound (often bedbound) veterans for whom visits to an outpatient clinic are not practical; Care providers: VA providers. Service: Homemaker/home health aide; Description: Personal care, such as grooming, housekeeping, and meal preparation services, provided in the home to veterans who would otherwise need nursing home care; Care providers: Contracted providers. Service: Adult day health care; Description: Health maintenance and rehabilitative services provided to frail elderly veterans in an outpatient setting during part of the day; Care providers: VA and contracted providers. Service: Skilled home health care; Description: Medical services provided to veterans at home; Care providers: Contracted providers. Service: Home respite care; Description: Services provided at home to temporarily relieve the veteran's caregiver from the burden of caring for a chronically disabled veteran in the home; Care providers: Contracted providers. Service: Home hospice care; Description: Services provided at home to veterans whose primary goal of treatment is comfort rather than cure for an advanced disease that is life-limiting; Care providers: Contracted providers. Source: VA. [End of table] VA's Workload Measurement for Home-Based Primary Care Does Not Accurately Reflect the Amount of Care Received by Veterans: VA's workload measurement for home-based primary care does not accurately reflect the amount of care received by veterans. VA measures home-based primary care workload using the number of days the veteran is enrolled in the program to receive these services, including weekends. Veterans do not, however, typically receive a home-based primary care visit every day they are enrolled in the program. For example, if a veteran was enrolled in VA's home-based primary care program for 1 week, and received two visits from VA providers that week, VA would calculate the workload using 7 days, rather than two visits. VA officials told us that VA used the number of enrolled days to measure access to home-based primary care. While the number of enrolled days may provide a measure of access it does not provide an accurate measure of the services veterans receive. Measuring workload on the basis of number of visits veterans receive is a more accurate measure of VA's provision of this service. To more accurately reflect the services veterans received, we measured VA's workload for home-based primary care using number of visits as the unit of measure. Using this method, we determined that the average daily workload for VA's home-based primary care in fiscal year 2003 was 944. VA, however, reported an average daily workload for home-based primary care that year of 8,370 based on enrolled days. The use of enrolled days as a workload measure overstates the amount of home-based primary care services veterans received by a factor of 9 to 1. Moreover, the way VA measures home-based primary care workload is inconsistent with the way it measures workload for the five other noninstitutional long-term care services we reviewed.[Footnote 4] For these other services, VA measures workload using the number of visits a veteran received from a health care provider rather than the number of days the veteran was enrolled in the program. In fiscal year 2003, VA's use of enrolled days to measure home-based primary care workload resulted in that service having the largest workload (46 percent) in comparison to the five other noninstitutional services. In contrast, when using visits to measure the home-based primary care workload, home-based primary care constituted 9 percent of all noninstitutional care services and its workload was smaller than the workload for homemaker/home health aide, adult day health care, or skilled home health care. (See fig. 1.) Figure 1: VA Noninstitutional Long-Term Care Workload, Fiscal Year 2003: [See PDF for image] Note: VA reports all noninstitutional care workload measures except home-based primary care in visits. [End of figure] Conclusions: VA's use of enrolled days to measure home-based primary care workload does not accurately measure the amount of this service that veterans receive and overstates its usage compared with other noninstitutional care services. VA reported that in fiscal year 2003 the average daily workload for home-based primary care, based on enrolled days, was 8,370. Measured in visits, however, we determined that the average daily workload for home-based primary care was 944. Inaccurate measurement and overstated usage of home-based primary care, as reported by VA, makes it difficult for decision makers to know the amount of care VA is providing with the resources it is expending. Using the number of visits instead of the number of enrolled days to measure home-based primary care workload would provide a more accurate measure of the amount of home-based primary care services that veterans receive and would provide a more appropriate comparison of home-based primary care with other noninstitutional long-term care services. Recommendation for Executive Action: Because the number of visits is a more accurate measure of the home- based primary care services veterans receive than enrolled days, we recommend that you direct the Under Secretary for Health to use visits to measure and report the amount of home-based primary care services veterans receive. Agency Comments and Our Evaluation: In commenting on a draft of this report, VA agreed that a more accurate measure of home-based primary care is needed but did not concur with our recommendation to use visits to measure and report the amount of home-based primary care services veterans receive. However, VA plans to establish a combination of workload measures for home-based primary care and other long-term care programs in fiscal year 2005, including visits, which will be responsive to our recommendation. VA stated that it did not concur with our recommendation because using the number of visits alone, rather than incorporating ancillary work such as reviewing laboratory and other test results, does not entirely represent home-based primary care workload. VA stated that it made a deliberate decision to convert from using the number of visits received to the number of enrolled days as the primary workload measure because this would promote more efficient and comprehensive management of the patient population. However, VA's use of enrolled days as a workload measure for home-based primary care services provides a misleading picture of VA's noninstitutional long-term care services. This measure overstates the amount of services veterans received because VA measures home-based primary care workload using the number of days the veteran is enrolled in the program to receive these services, including weekends. Veterans do not, however, typically receive a home-based primary care visit every day they are enrolled in the program. Using enrolled days may be useful for management of a population in need of such services, as VA states, but not as a measure of the amount of services veterans received. VA states that in fiscal year 2005 it will begin reporting two other workload measures in addition to enrolled days, the number of patients treated and the number of visits veterans receive. We believe that reporting the number of patients treated will provide useful information on the number of veterans receiving home-based primary care but still will not accurately measure the amount of such care veterans receive. We believe that measuring and reporting the number of visits veterans receive, as VA said it will do, will be responsive to our recommendation. This will provide useful information to Congress and other stakeholders for assessing the amount of home-based primary care services veterans receive from VA. If VA chooses to also include in its home-based primary care measure the amount of ancillary work involved in delivering such care, this could provide a more comprehensive workload measure. However, based on a discussion with VA officials, VA cannot currently provide data on the amount of ancillary work involved with delivering home-based primary care. VA's written comments are in appendix I. We are sending copies of this report to the House Committee on Veterans' Affairs; other interested congressional committees; and other interested parties. This report is also available at no charge on GAO's Web site at http://www.gao.gov. If you have questions about this report, please contact me at (202) 512-7101 or James Musselwhite at (202) 512-7259. Also contributing to this report were Cheryl A. Brand, Janet L. Overton, and Thomas A. Walke. Sincerely yours, Signed by: Cynthia A. Bascetta, Director, Health Care--Veterans' Health and Benefits Issues: [End of section] Appendix I: Comments from the Department of Veterans Affairs: THE SECRETARY OF VETERANS AFFAIRS: WASHINGTON: August 11, 2004: Ms. Cynthia A. Bascetta: Director: Health Care Team: U. S. Government Accountability Office: 441 G Street, NW: Washington, DC 20548: Dear Ms. Bascetta: The Department of Veterans Affairs (VA) has reviewed the Government Accountability Office's (GAO) draft report, VA LONG TERM CARE: More Accurate Measure of Home-Based Primary Care Workload is Needed, (GAO- 04-913). VA acknowledges the need for a more sophisticated and accurate primary workload measurement methodology for the Veterans Health Administration's (VHA) Home-Based Primary Care (HBPC) initiative. However, VA does not concur in your recommendation to measure and report the amount of home-based primary care services veterans receive by using visits because the number of visits does not adequately represent the amount of ancillary work that goes into this type of care. VHA has made a deliberate decision to convert from the number of visits to the number of enrolled days of care as the primary workload measurement methodology because it promotes more efficient and comprehensive management of this patient population. Moreover, VHA is establishing a combination of measures to reduce undesired incentives from any one workload measure. To assure consistency across all VHA long-term care programs, VHA will implement this methodology for all other home and community based care programs beginning in FY 2005. The enclosure details the Department's reasons for not concurring in GAO's recommendation. VA appreciates the opportunity to comment on your draft report and my staff would be happy to discuss this further at your convenience. Sincerely yours, Signed by: Anthony J. Principi: Enclosure: Enclosure: THE DEPARTMENT OF VETERANS AFFAIRS COMMENTS TO GAO DRAFT REPORT: VA LONG TERM CARE: More Accurate measure of Home-Based Primary Care Workload is Needed (GAO-04-913): Because visits is a more accurate measure of home based primary care services that veterans receive than enrolled days, GAO recommends that the Secretary of Veterans Affairs direct the Under Secretary for Health to measure and report the amount of home based primary care services veterans receive by using visits. Do Not Concur - VA does not concur with GAO's recommendation to use the number of visits received by the veteran in Home-Based Primary Care (HBPC) because the number of visits does not adequately represent the amount of ancillary work that goes into this type of care. Home-Based Primary Care is an alternative to nursing home care. In contrast to skilled nursing care, which is fee-based per hour of care, HBPC furnishes continuous coverage. Supporting this distinction, the Joint Commission on Accreditation of Healthcare Organizations requires that during orientation to HBPC, patients be given materials that provide clear instructions on how to reach staff between visits, any time of the night or day. Accordingly, most of the effort in effective HBPC patient management involves time that is not captured by the number of visits. Much of the time used in caring for these patients is in tasks such as coordinating care with VA and community services, facilitating medication management, meeting with members of the interdisciplinary team, reviewing laboratory and other test results, telephone conversations with the patients, their families and caregivers, and the travel time to and from home visits. To the best of VA's knowledge, the Department's HBPC program is not replicated in the private sector. Services most closely resembling the HBPC program might be Medicare's Hospice Program, which is paid for on a per-diem basis and reflects the fact that the interdisciplinary hospice care team provides continuous oversight and support even if no patient visit occurred. VA acknowledges the need for a more sophisticated and accurate primary workload measurement methodology for the HBPC initiative and across all VA's long-term care programs. VA believes a combination of measures, which will be implemented in FY 2005, will better serve veterans than would any single measure. These measurements are: 1) days of care (census of enrolled patients); 2) number of patients treated; and 3) number of visits. Each of these measures serves a different purpose and allows different aspects of VHA's long-term care programs to be monitored. VA focuses on number of enrolled days of care as the key workload measure for HBPC to encourage comprehensive longitudinal care. This approach is successful in managing persons with complex, chronic, progressively disabling conditions. To eliminate the incentive to enroll and maintain a large patient population that requires little effort from the home-care team, VA provides oversight by requiring ongoing review of eligibility criteria, periodic quality management assessments, and compliance with accreditation standards. [End of section] FOOTNOTES [1] See GAO, VA Long-Term Care: Changes In Service Delivery Raise Important Questions, GAO-04-425T (Washington, D.C.: Jan. 28, 2004). [2] Combining workload for each of these services is not a measure of the number of unique veterans receiving these services because a patient may receive more than one noninstitutional long-term care service in the same day. [3] House Committee on Veterans' Affairs, Statement of the Under Secretary for Health, Department of Veterans Affairs, VA's Long-Term Care Programs, 108th Congress, 2nd session, January 28, 2004; House Subcommittee on Health, Committee on Veterans' Affairs, Statement of the Under Secretary for Health, Department of Veterans Affairs. VA's Long-Term Care Programs, 108th Congress, 1st session, May 22, 2003; Department of Veterans Affairs, Fiscal Year 2004 Budget Submission: Medical Programs Volume 2 of 5 Final (Washington, D.C.: March 2003), 2- 148; and Department of Veterans Affairs, Fiscal Year 2002 Budget Submission: Medical Programs, Volume 2 of 6 (Washington, D.C.: April 2001), 2-101. [4] VA refers to measures of workload for the six services we reviewed as average daily census. GAO's Mission: The Government Accountability Office, the investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. 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