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United States Government Accountability Office: 
GAO: 

Report to the Ranking Member, Committee on Veterans' Affairs, House of 
Representatives: 

December 2013: 

VA Nursing Homes: 

Reporting More Complete Data on Workload and Expenditures Could 
Enhance Oversight: 

GAO-14-89: 

GAO Highlights: 

Highlights of GAO-14-89, a report to the Ranking Member, Committee on 
Veterans’ Affairs, House of Representatives. 

Why GAO Did This Study: 

In fiscal year 2012, about $4.9 billion of VA’s $54 billion health 
care services budget was spent on nursing home care. To inform 
Congress of its budgeting priorities, VA prepares a budget 
justification, which is reviewed by OMB, that includes data on nursing 
home workload and expenditures in the three settings. VA also collects 
data on length of stay (long- and short-stay) and resident 
characteristics, including eligibility status, as VA is required to 
pay for mandatory veterans’ nursing home care and may pay for 
discretionary care as resources permit. These data are important for 
Congress to understand how funding is allocated for long- and short-
stay care and for residents in each setting. 

GAO was asked to examine VA’s nursing home program. Among other 
things, GAO examined (1) VA’s nursing home workload in each setting, 
by length of stay and resident characteristics; and (2) VA’s 
expenditures for nursing home care in each setting, by length of stay 
and resident characteristics. GAO analyzed VA nursing home workload 
and expenditure data, including fiscal year 2012, by setting, length 
of stay, and resident characteristics; and interviewed VA officials. 

What GAO Found: 

In fiscal year 2012, the Department of Veterans Affairs’ (VA) nursing 
home workload—-the average number of veterans receiving nursing home 
care per day—-was 36,250 across all of the three nursing home settings 
in which VA provided or paid for veterans’ nursing home care. The 
three settings include Community Living Centers (CLCs), which are VA-
owned and operated; community nursing homes with which VA contracts to 
provide care for veterans; and state veterans’ nursing homes, which 
are owned and operated by states. Over half (53 percent) of this 
workload was provided in state veterans’ nursing homes, 28 percent in 
CLCs, and 19 percent in community nursing homes. Nearly 90 percent of 
total workload was long-stay (91 days or more for residents with 
chronic conditions), and at least 75 percent of care provided in each 
of VA’s three settings was long-stay. In addition, 62 percent of VA’s 
total workload was provided to discretionary veterans (those veterans 
without certain levels of service-connected disabilities). 

In fiscal year 2012, VA spent $3.5 billion (71 percent) of its total 
nursing home expenditures on care provided in CLCs, 16 percent in 
state veterans’ nursing homes and 13 percent in community nursing 
homes. Seventy-five percent of total spending was for long-stay care, 
and at least 70 percent of spending in each setting was for long-stay 
care. About half of total VA spending was for discretionary veterans. 

Figure: Percentage of VA Nursing Home Workload and Expenditures for 
Long-Stay Care, by Setting, Fiscal Year 2012: 

[Refer to PDF for image: vertical bar graph] 

All settings; 
Long-stay workload: 88%; 
Long-stay expenditures: 75%. 

CLC; 
Long-stay workload: 76%; 
Long-stay expenditures: 70%. 

Community nursing home; 
Long-stay workload: 80%; 
Long-stay expenditures: 78%. 

State veterans' nursing home; 
Long-stay workload: 97%; 
Long-stay expenditures: 97%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

[End of figure] 

GAO found that VA does not provide nursing home workload and 
expenditure data by length of stay and resident characteristics in its 
budget justification, although the Office of Management and Budget 
(OMB) encourages agencies to provide such information to the maximum 
extent possible to justify staffing and other requirements and improve 
congressional decision making. As a result, VA does not provide 
complete information, which could hinder Congress’ budgeting and 
oversight of VA’s nursing home staffing and resource requirements. 

What GAO Recommends: 

To enhance congressional oversight of VA’s nursing home program, GAO 
recommends that VA supplement data currently included in its budget 
justification with workload and expenditures by length of stay and 
resident characteristics. VA concurred with GAO’s recommendation and 
stated it will provide these data upon release of its fiscal year 2015 
budget. 

View [hyperlink, http://www.gao.gov/products/GAO-14-89]. For more 
information, contact Vijay D’Souza at (202) 512-7114 or 
dsouzav@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Decisions Regarding Which Nursing Home Setting Is Used to Provide Care 
Are Decentralized, and Vary Based on Multiple Factors: 

State Veterans' Nursing Homes Provided Care for over Half of VA's 
Total Nursing Home Workload, and Workload in All Three Settings Was 
Mostly Long Stay: 

Most of VA's Nursing Home Spending Was for CLCs and Most Spending in 
All Three Settings Was for Long-Stay Care: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Percentage of Nursing Home Workload by Network and 
Setting, Fiscal Year 2012: 

Appendix II: Percentage of Nursing Home Workload by Network and Length 
of Stay, Fiscal Year 2012: 

Appendix III: Percentage of Nursing Home Workload by Network and 
Eligibility Status, Fiscal Year 2012: 

Appendix IV: Percentage of Nursing Home Workload by Network and 
Resident Age, Fiscal Year 2012: 

Appendix V: Percentage of Nursing Home Expenditures by Network and 
Setting, Fiscal Year 2012: 

Appendix VI: Percentage of Nursing Home Expenditures by Network and 
Length of Stay, Fiscal Year 2012: 

Appendix VII: Percentage of Nursing Home Expenditures by Network and 
Eligibility Status, Fiscal Year 2012: 

Appendix VIII: Percentage of Nursing Home Expenditures by Network and 
Resident Age, Fiscal Year 2012: 

Appendix IX: Comments from the Department of Veterans Affairs: 

Appendix X: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Percentage of VA Nursing Home Workload, by Setting and 
Resident Characteristics, Fiscal Year 2012: 

Table 2: Per Diem Expenditures, by Setting and Length of Stay, Fiscal 
Year 2012: 

Table 3: Composition of VA Community Living Center (CLC) Expenditures, 
Fiscal Year 2012: 

Table 4: Percentage of VA Nursing Home Expenditures by Resident 
Characteristics and Setting, Fiscal Year 2012: 

Figures: 

Figure 1: U.S. Veteran Population Projections, Fiscal Years 2010-2030: 

Figure 2: Percentage of VA Nursing Home Workload by Setting, Fiscal 
Year 2012: 

Figure 3: Percentage of VA Nursing Home Workload by Long-Stay and 
Short-Stay Care, Fiscal Year 2012: 

Figure 4: Percentage of VA Nursing Home Workload by Eligibility Status 
and Age, Fiscal Year 2012: 

Figure 5: Percentage of VA Total Nursing Home Expenditures by Setting, 
Fiscal Year 2012: 

Figure 6: Percentage of VA Nursing Home Expenditures by Setting and 
Length of Stay, Fiscal Year 2012: 

Figure 7: Percentage of VA Nursing Home Expenditures by Eligibility 
Status and Age, Fiscal Year 2012: 

Abbreviations: 

CLC: Community Living Center: 

OMB: Office of Management and Budget: 

VA: Department of Veterans Affairs: 

VHA: Veterans Health Administration: 

VISN: Veterans Integrated Service Network: 

[End of section] 

GAO:
United States Government Accountability Office: 
441 G St. N.W. 
Washington, DC 20548: 

December 20, 2013: 

The Honorable Michael H. Michaud: 
Ranking Member: 
Committee on Veterans' Affairs: 
House of Representatives: 

Dear Mr. Michaud: 

The Department of Veterans Affairs (VA) operates one of the largest 
health care delivery systems in the nation. In fiscal year 2012, VA 
served more than 6.3 million individuals through 21 health care 
networks at a total cost of nearly $54 billion.[Footnote 1] Of this, 
about $6.3 billion was spent on long-term care, including 
institutional long-term care provided in nursing homes, and 
noninstitutional long-term care provided in community settings. Most 
of VA's spending on long-term care was for nursing home care, which 
accounted for about 9 percent of total VA health care spending in 
fiscal year 2012.[Footnote 2] Nursing home care and long-term care 
overall are particularly important to VA, in part, because the 
proportion of the veteran population 65 and older--a vulnerable 
population that is the primary user of such care--is much larger than 
the proportion of individuals 65 and older in the general population. 
In fiscal year 2011, just over 40 percent of the veteran population 
was age 65 or older, compared to about 13 percent of the general 
population.[Footnote 3] In addition, long-term care services are 
necessary for some younger veterans. 

VA's nursing home program provides or pays for care in three settings. 
VA provides nursing home care in VA-owned and operated nursing homes 
known as Community Living Centers (CLC). VA also pays for care 
provided to veterans in community nursing homes, with which VA 
contracts to provide care to veterans. In addition, VA pays for all or 
part of the cost of care for veterans in state veterans' nursing 
homes, which are owned and operated by states.[Footnote 4] VA's 
nursing home care is broadly defined by length of stay--long-and short-
stay care. Long-stay care, which lasts for 91 days or more, is 
provided to residents who cannot be cared for at home because of 
severe chronic physical or mental limitations. Short-stay care, which 
lasts 90 days or less, includes more resource-intensive services, such 
as postacute care needed for residents recuperating from a stroke or 
hip replacement. 

VA provides nursing home services to veterans depending, in part, on 
their eligibility status--that is, whether the veteran is receiving 
care on a mandatory or discretionary basis. VA is required by law to 
provide nursing home care for two categories of veterans, known as 
mandatory veterans: (1) veterans who need nursing home care because of 
a service-connected disability,[Footnote 5] i.e., a condition related 
to their military service; and (2) veterans who need nursing home care 
and who also have a service-connected disability rated at 70 percent 
or greater.[Footnote 6] Additionally, VA may provide nursing home care 
to eligible veterans on a discretionary basis as capacity and 
resources permit.[Footnote 7] 

We previously found that VA did not collect data on veterans' 
eligibility status and length of stay for all three nursing home 
settings. Specifically, in 2004, we found that VA lacked such data for 
community nursing homes and state veterans' nursing homes, and 
concluded that gaps in VA data impeded VA's oversight of its nursing 
home program.[Footnote 8] In addition, in 2006, we found that VA did 
not compile information on key characteristics of nursing home 
residents--including age and eligibility status--and that VA needed 
this information to plan for nursing home care.[Footnote 9] We 
recommended that VA collect and report on these measures to improve on 
the completeness of data needed for VA's oversight. VA implemented 
these recommendations and now has such data for planning and budgetary 
purposes. 

Nursing home care is funded as part of VA's overall annual 
appropriation for health care services, and VA makes available 
resources for nursing home care in the context of competing demands 
for health services based on the fixed amount of appropriated funds. 
Although VA is required to provide nursing home care for mandatory 
veterans, it has considerable control over the amount the agency 
allocates for discretionary nursing home care. VA prepares an annual 
budget justification for Congress in support of the President's budget 
request. The budget justification provides Congress with information 
on what VA plans to achieve with the resources requested for nursing 
home care and other health care services. In its budget justification, 
VA reports on workload and expenditures for nursing home care and 
other health care services. For nursing home workload, VA reports 
average daily census (the average number of veterans in nursing home 
beds on any given day of the year) in each nursing home setting. VA 
reports expenditures in terms of total expenditures and per diem 
expenditures (average daily expenditures per resident) in each nursing 
home setting.[Footnote 10] VA's budget justification is reviewed by 
the Office of Management and Budget (OMB), which encourages agencies 
to provide information on workload and unit costs, such as per diem 
expenditures, in budget justifications to the maximum extent possible 
to justify staffing and other requirements.[Footnote 11] OMB states in 
guidance to agencies that providing more detailed information on 
federal programs and spending can improve congressional decision 
making.[Footnote 12] As a result, VA nursing home workload and 
expenditure data are important to Congress in providing oversight of 
budgeting and health care services, and understanding how the budget 
they approve is allocated for nursing home care by length of stay, 
mandatory and discretionary veterans, and age. In recent years, we 
have identified weaknesses regarding VA's inclusion and presentation 
of health care information in its budget justification, including 
nursing home care, and made recommendations to improve the information 
included and how it is presented.[Footnote 13] 

You asked us to conduct a review of VA's nursing home care provided in 
the three settings to better understand differences in spending and 
the type of care provided in each setting. In this report we examine: 
(1) the factors considered in deciding the nursing home setting in 
which veterans receive care; (2) VA's nursing home workload in each 
setting, by length of stay and resident characteristics; and (3) VA's 
expenditures for nursing home care in each setting, by length of stay 
and resident characteristics. 

To examine the factors considered in deciding the nursing home setting 
in which veterans receive VA care, we interviewed officials in the 
Veterans Health Administration's (VHA)[Footnote 14] Office of 
Geriatrics and Extended Care, which oversees CLCs and the community 
nursing home program, and officials from VHA's Chief Business Office, 
which has financial oversight of the state veterans' nursing home 
program, including oversight of veterans' eligibility for VA-funded 
nursing home care, and the amount paid by VA for these veterans. We 
discussed with these officials how the nursing home settings differ in 
terms of their organizational structure and the types of services 
typically offered at each setting. We also discussed VA's process for 
referring veterans for nursing home care, and the factors considered 
in deciding which nursing home setting will be used to provide care 
for eligible veterans. We reviewed relevant laws, regulations, and VA 
policies and procedures regarding the provision of nursing home care 
to veterans in CLCs, community nursing homes, and state veterans' 
nursing homes. 

To examine nursing home workload in each of VA's three nursing home 
settings, we analyzed data provided by VA on average daily census for 
fiscal years 2010-2012, the most recent data available at the time of 
our analysis, at the national level for each setting, and for each of 
the 21 networks.[Footnote 15] We analyzed average daily census by 
length of stay (short and long stays) and by resident characteristics--
age and eligibility status--at the national level and for each of the 
21 networks.[Footnote 16] We also assessed the extent to which VA 
reported nursing home workload data in its budget justification to 
Congress to the maximum extent possible to justify staffing and other 
requirements, as encouraged by OMB.[Footnote 17] In addition, we 
interviewed VA officials from the Office of Analytics and Business 
Intelligence, which is responsible for program analysis and reporting. 

To examine VA expenditures for nursing home care, we analyzed 
expenditure data provided by VA for each of the three nursing home 
settings from fiscal years 2010-2012, the most recent data available 
at the time of our analysis, at the national level and for each of the 
21 networks.[Footnote 18] We analyzed expenditure data by length of 
stay and resident characteristics at the national level and for each 
of the 21 networks.[Footnote 19] We also assessed the extent to which 
VA reported nursing home expenditure data in its budget justification 
to Congress to the maximum extent possible to justify staffing and 
other requirements.[Footnote 20] In addition to the officials noted 
above, we interviewed officials from VHA's Office of Finance, which is 
responsible, in part, for developing VA budget estimates. 

To assess the reliability of VA's workload and expenditure data we 
took several steps. We compared the data to the data contained in VA's 
annual budget justification.[Footnote 21] We also reviewed available 
documentation on the underlying data systems that VA used to generate 
the data. Additionally, we discussed with VA officials the methodology 
used to generate the data, and the comparability of the data across 
the three nursing home settings. We also conducted internal checks for 
logic and consistency of the data by comparing workload and 
expenditure data (broken out by length of stay and resident 
characteristics in each setting) to total workload and expenditures in 
each setting. We discussed and resolved any discrepancies we found 
with VA officials. We found the data reliable for the purposes of our 
engagement. 

We conducted this performance audit from May 2013 to December 2013 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

Nationwide, VA provides or pays for veterans' nursing home care in 
three settings: CLCs, community nursing homes, and state veterans' 
nursing homes.[Footnote 22] These settings vary in terms of their 
characteristics, as well as the cost of care that is covered for 
eligible veterans. 

VA provides nursing home care to veterans in 134 CLCs nationwide. CLCs 
are typically within or in close proximity to VA medical centers. VA 
requires CLCs to meet The Joint Commission's long-term care 
standards.[Footnote 23] VA covers the full cost of care provided to 
mandatory veterans in CLCs, while discretionary veterans may be 
required to pay a copayment depending on their income or other factors. 

In addition, VA contracts with approximately 2,500 community nursing 
homes to provide nursing home care to veterans. To participate in VA's 
nursing home program, community nursing homes generally must meet 
certain VA standards, including being state licensed and certified to 
participate in Medicare or Medicaid,[Footnote 24] and meet VA's own 
minimum care standards. VA also requires VA health care facilities to 
evaluate community nursing homes prior to contract award, and annually 
at renewal to ensure they are compliant with state and federal 
requirements, and are continuing to provide veterans an acceptable 
standard of care. VA pays community nursing homes per diem rates that 
are tiered based on the intensity of resources required to provide 
care.[Footnote 25] The homes may not bill any other payer for nursing 
home care provided to veterans. VA pays for the full cost of care for 
mandatory veterans, while discretionary veterans may be subject to a 
similar copayment as in CLCs depending on their income or other 
factors. However, VA is generally restricted by law from paying for 
more than 6 months of care for discretionary veterans.[Footnote 26] 
These veterans must therefore have other sources of payment, and, 
according to VA officials, most long-stay residents may enroll in 
Medicaid, have private long-term care insurance, or pay for care 
through out-of-pocket spending. 

VA also pays for all or part of veterans' care in 140 state veterans' 
nursing homes nationwide. For state veterans' nursing homes, VA pays 
at least a portion of the cost of providing nursing home care for 
eligible veterans in these homes, but does not control the admission 
process. Veterans are admitted based on eligibility criteria as 
established by state requirements. For state veterans' nursing homes 
to participate in VA's program, however, VA generally requires that at 
least 75 percent of the residents be veterans.[Footnote 27] In 
addition, VA requires state veterans' nursing homes to be certified by 
VA annually, and ensures compliance with its standards through surveys 
and audits.[Footnote 28] Each fiscal year, VA establishes the per diem 
rates paid to state veterans' nursing homes for care provided to 
veterans. For mandatory veterans, VA pays a higher per diem that 
covers the full cost of care, including medications.[Footnote 29] For 
discretionary veterans, VA pays the lesser of the basic per diem 
established by VA or one-half of the total daily cost of 
care.[Footnote 30] However, unlike community nursing homes, there is 
no restriction on the number of days for which VA may pay for care for 
discretionary veterans in state veterans' nursing homes. As part of 
VA's support and oversight of state veterans' nursing homes, VA 
medical centers of jurisdiction process and approve per diem 
reimbursements for the state veterans' nursing homes located in their 
geographic areas. In addition to paying some or all of the cost of 
providing nursing home care to veterans, VA supports state veterans' 
nursing homes by awarding grants to states for construction or 
renovation of facilities. These grants are awarded following VA's 
review and approval of proposals submitted by state officials. In 
addition to per diem payments and construction grants from VA, state 
veterans' nursing homes may receive payments from a number of 
different sources, including Medicare and Medicaid. 

While veterans of all ages may need VA nursing home care, the need for 
such care increases with age because elderly veterans are more likely 
to have functional or cognitive limitations that indicate a need for 
nursing home care.[Footnote 31] The overall number of elderly veterans 
is projected to peak in 2014 and decline thereafter (see figure 1). 
However, the percentage of elderly veterans is expected to remain 
relatively unchanged due to a decline in the overall veteran 
population. Although the need for VA nursing home care remains, for 
over a decade VA has highlighted the potential benefits of providing 
veterans with alternative options for long-term care--specifically, 
less costly home and community-based care--in an effort to lessen the 
need for more costly nursing home care. For example, in its 2014 
budget justification, VA proposed legislation that would authorize VA 
to pay for care in VA-approved medical foster homes for veterans who 
would otherwise need nursing home care. 

Figure 1: U.S. Veteran Population Projections, Fiscal Years 2010-2030: 

[Refer to PDF for image: line graph] 

Year: 2010; 
Veterans over 65: 9.21 million. 

Year: 2011; 
Veterans over 65: 9.42 million. 

Year: 2012; 
Veterans over 65: 9.61 million. 

Year: 2013; 
Veterans over 65: 9.71 million. 

Year: 2014; 
Veterans over 65: 9.73 million. 

Year: 2015; 
Veterans over 65: 9.66 million. 

Year: 2016; 
Veterans over 65: 9.51 million. 

Year: 2017; 
Veterans over 65: 9.37 million. 

Year: 2018; 
Veterans over 65: 9.19 million. 

Year: 2019; 
Veterans over 65: 9.02 million. 

Year: 2020; 
Veterans over 65: 8.87 million. 

Year: 2021; 
Veterans over 65: 8.73 million. 

Year: 2022; 
Veterans over 65: 8.6 million. 

Year: 2023; 
Veterans over 65: 8.46 million. 

Year: 2024; 
Veterans over 65: 8.34 million. 

Year: 2025; 
Veterans over 65: 8.22 million. 

Year: 2026; 
Veterans over 65: 8.11 million. 

Year: 2027; 
Veterans over 65: 8 million. 

Year: 2028; 
Veterans over 65: 7.88 million. 

Year: 2029; 
Veterans over 65: 7.76 million. 

Year: 2030; 
Veterans over 65: 7.61 million. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: This figure includes data on all veterans 65 and older, 
regardless of whether they receive health care from VA or non-VA 
providers. 

[End of figure] 

Decisions Regarding Which Nursing Home Setting Is Used to Provide Care 
Are Decentralized, and Vary Based on Multiple Factors: 

Decisions about the nursing home setting in which a veteran will 
receive care are decentralized to the local level because of several 
factors, including variability in the choice of available settings, 
the nursing home care services available, and admissions policies at 
each type of setting. In addition, veterans' nursing home service 
needs, eligibility status, and preferences about the location of care 
are considered in deciding the setting to choose. 

Decision Making Is Decentralized Due to Variation in Several Factors, 
Including Availability of Nursing Home Settings, Services, and 
Admissions Policies at Local Level: 

VA program officials told us that the decisions as to which nursing 
home setting would be used are decentralized to the local level 
because they are dependent upon several factors including the type of 
setting available in each community, and availability varies 
considerably across locations. For example, veterans in need of 
nursing home care in Augusta, Maine who wish to stay within about a 50-
mile radius may have the option of receiving care from several 
settings including 1 CLC, 12 community nursing homes and 2 state 
veterans' nursing homes, assuming availability of beds and resources. 
However, veterans in Saginaw, Michigan wishing to stay within a 
similar radius may have the option of receiving care from 1 CLC and 3 
community nursing homes, depending on the availability of beds and 
resources, since the only 2 state veterans' nursing homes are over 100 
miles away. 

In addition, VA officials told us that decisions about which setting 
is used are based upon veterans' specific nursing home service needs, 
and settings varied in the type of specific services offered. For 
example, officials told us that in certain geographic areas CLCs 
provide certain services that are not available in the community, such 
as dementia care, behavioral health services, and care for ventilator-
dependent residents. In other areas, however, officials told us that 
these specialized services might not be available in a CLC and instead 
might be available at a community nursing home. When an individual 
medical center has more than one CLC in its service area, each CLC may 
offer a unique set of services. Therefore, according to officials, the 
availability of different types of services in each nursing home 
setting depends largely on location. 

VA officials further told us that admissions policies are generally 
the same for all CLCs, but may vary for community nursing homes and 
state veterans' nursing homes. CLCs are required to provide care based 
on agency-wide policies; therefore, eligibility criteria and 
admissions policies are generally uniform across the country. An 
interdisciplinary team--including personnel such as a registered 
nurse, social worker, recreation therapist, medical provider, 
dietitian, and any other discipline(s) directly involved in the care 
of the resident--at the VA medical center of jurisdiction determines 
whether the veteran has a clinical need for nursing home care. This 
determination is to be based on a comprehensive clinical assessment of 
medical, nursing and therapy needs; level of functional impairment; 
cognitive status; rehabilitation needs; and special emphasis care 
needs, such as spinal cord injury or end-of-life care. Each CLC is 
required to use a standardized instrument that is used by all Centers 
for Medicare & Medicaid Services-certified nursing homes for 
assessment, treatment planning, and documentation and evaluation of 
care and services. Three key factors are considered at the time of 
admission: (1) the specific services to be provided; (2) whether the 
stay is short or long; and (3) the setting to which the resident will 
be discharged. 

Admissions policies are generally standardized for community nursing 
homes, but may vary for state veterans' nursing homes based on state 
requirements. Community nursing homes are required to be certified for 
participation in the Medicare and Medicaid programs, and use the same 
standardized instrument for assessment, evaluation and treatment 
planning as CLCs. VA officials told us that community nursing homes 
are required to accept all eligible veterans referred by VA, subject 
to availability of beds and required resources. State veterans' 
nursing homes are not required to provide VA with documentation of 
their admissions policies. Since these homes are state-owned and 
operated entities they are subject to admissions and eligibility 
criteria that vary from state to state. For example, for admission, 
state veterans' nursing homes in Alabama require the veteran to have 
90 days of service, at least one day of which was wartime service. In 
contrast, state veterans' nursing homes in New York require the 
veteran to have only 30 days of active service, while homes in Florida 
do not require any wartime service. 

Veterans' Eligibility Status and Location Preferences Also Determine 
the Type of Setting Used: 

In addition to the type of available settings, the nursing home care 
services available, and admissions policies at each type of setting, 
VA officials told us that veterans' eligibility status, and 
preferences about remaining close to home and family or willingness to 
travel to a nursing home setting were important considerations. For 
example, a discretionary veteran with a preference for staying close 
to home might be a candidate for admission to a community nursing home 
or a state veterans' nursing home if a CLC was too far away. However, 
officials told us that because of the veteran's discretionary status, 
he or she would be informed of VA's restriction of coverage to only 
the first 180 days of care in the community nursing home, and staff 
would assist the veteran in obtaining Medicaid coverage. The veteran's 
eligibility status would be less important if admission was made to 
the state veterans' home since the restriction on length of coverage 
would not apply to this setting. However, officials emphasized that 
these considerations were made within the context of the availability 
of specific settings, specific services, and eligibility criteria and 
admissions policies across locations. Given the variability in these 
factors, veterans in two different communities with the same service 
needs, eligibility status and preferences might be admitted to 
different settings. 

State Veterans' Nursing Homes Provided Care for over Half of VA's 
Total Nursing Home Workload, and Workload in All Three Settings Was 
Mostly Long Stay: 

Of the three VA nursing home settings, state veterans' nursing homes 
provided care for just over half of VA's nursing home workload in 
fiscal year 2012. VA's total nursing home workload was primarily long 
stay that year. Most of the nursing home care that VA provided or paid 
for in fiscal year 2012 was for discretionary veterans and for 
residents ages 65 to 84 years old. In addition, veterans' eligibility 
status and age varied by setting. 

State Veterans' Nursing Homes Provided Care for over Half of VA's 
Nursing Home Workload in Fiscal Year 2012: 

State veterans' nursing homes accounted for 53 percent of the workload-
-measured by average daily census--for which VA provided or paid for 
care in fiscal year 2012. CLCs provided care for 28 percent of the 
total workload, and community nursing homes provided care for 19 
percent of the workload. (See figure 2.) In fiscal year 2012, the most 
recent year for which data were available, state veterans' nursing 
homes provided care to an average of 19,355 residents per day, out of 
the total average daily workload of 36,250 residents for whom VA 
provided or paid for nursing home care. This and other workload 
patterns we examined have been consistent in recent years based on VA 
data for fiscal years 2010-2012.[Footnote 32] 

Figure 2: Percentage of VA Nursing Home Workload by Setting, Fiscal 
Year 2012: 

[Refer to PDF for image: pie-chart] 

Total fiscal year 2012 workload: 36,250 residents per day; 
State veterans’ nursing homes: 53%; 
VA Community Living Centers: 29%; 
Community nursing homes: 19%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: The workload measure is the average daily census, which 
represents the average number of veterans residing in a nursing home 
on any given day of the year. Average daily census is calculated by 
dividing the total number of days of nursing home care provided in a 
year by the number of days in the year. In fiscal year 2012, the 
average daily census was 36,250 nursing home residents--9,991 in VA 
Community Living Centers, 6,904 in community nursing homes, and 19,355 
in state veterans' nursing homes. 

[End of figure] 

At the network level, the proportion of nursing home workload in each 
setting varied widely by network, particularly the range of workload 
in state veterans' nursing homes compared to the other settings. For 
example, state veterans' nursing homes comprised 74 percent of total 
VA nursing home workload in Veterans Integrated Service Network (VISN) 
16 (South Central VA Health Care Network), compared to 20 percent of 
the nursing home workload in VISN 21 (Sierra Pacific Network). (See 
appendix I for more information on nursing home workload by network 
and setting.) 

Workload in All Three Nursing Home Settings Was Primarily Long Stay: 

Overall, long-stay care accounted for nearly 90 percent of VA's total 
nursing home workload in fiscal year 2012 (31,750 of the 36,250 
residents for whom VA provided or paid for care each day), and long-
stay care accounted for at least three-quarters of all workload in 
each of VA's three nursing home settings. (See figure 3.) Of the three 
settings, state veterans' nursing homes had the largest proportion of 
long-stay workload (97 percent) compared to community nursing homes 
(80 percent) and VA's CLCs (76 percent). These patterns were 
consistent from fiscal year 2010 through fiscal year 2012. VA 
officials told us that they examine workload data by length of stay 
for planning purposes, but do not make these data available publicly. 

Figure 3: Percentage of VA Nursing Home Workload by Long-Stay and 
Short-Stay Care, Fiscal Year 2012: 

[Refer to PDF for image: stacked vertical bar graph] 

Nursing home setting: All settings; 
Long-stay care: 88%; 
Short-stay care: 12%. 

Nursing home setting: VA Community Living Centers; 
Long-stay care: 76%; 
Short-stay care: 24%. 

Nursing home setting: Community Nursing Homes; 
Long-stay care: 80%; 
Short-stay care: 20%. 

Nursing home setting: State Veterans' Nursing Homes; 
Long-stay care: 97%; 
Short-stay care: 3%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: The workload measure is the average daily census, which 
represents the average number of veterans residing in a nursing home 
on any given day of the year. Average daily census is calculated by 
dividing the total number of days of nursing home care provided in a 
year by the number of days in the year. In fiscal year 2012, the total 
average daily census was 36,250 nursing home residents--9,991 in VA 
Community Living Centers, 6,904 in community nursing homes, and 19,355 
in state veterans' nursing homes. 

[End of figure] 

For all of the networks, the majority of workload was long-stay. The 
proportion of long-stay workload ranged from 80 percent to 95 percent, 
with the lowest proportion of long-stay workload in VISN 18 (VA 
Southwest Health Care Network), VISN 21 (Sierra Pacific Network), and 
VISN 22 (Desert Pacific Healthcare Network), and the highest 
proportion of long-stay workload in VISN 3 (VA New York/New Jersey 
Veterans Healthcare Network). (See appendix II for information on 
workload by network and length of stay.) 

VA officials said that they thought long-stay care (measured by 
average daily census) accounted for a high proportion of CLC workload 
because CLCs provide a number of long-stay programs for veterans who 
are unable to access certain nursing home services in other settings. 
For example, according to VA officials, some CLCs offer specialized 
long-stay programs for residents with dementia or spinal cord 
injuries, and may also serve residents with mental or behavioral 
health conditions who are not eligible for nursing home care in other 
settings. 

Discretionary Veterans and Veterans Age 65 to 84 Accounted for Most of 
VA's Nursing Home Workload: 

Nearly two-thirds (62 percent) of VA's nursing home care in fiscal 
year 2012 was provided to discretionary veterans, while just over one-
third (35 percent) was provided to mandatory veterans. When examined 
by age group, nursing home residents 65 through 84 years of age 
comprised a larger proportion of the workload than other age groups, 
amounting to 45 percent of VA's nursing home workload. Residents age 
85 and older amounted to 37 percent, and those under 65 years of age 
amounted to 16 percent. (See figure 4.) 

Figure 4: Percentage of VA Nursing Home Workload by Eligibility Status 
and Age, Fiscal Year 2012: 

[Refer to PDF for image: 2 pie-charts] 

Total fiscal year 2012 workload: 36,250 residents per day: 

Eligibility status: 
Discretionary veterans: 62%; 
Mandatory veterans: 35%; 
Unknown: 4%. 

Age: 
Under 65 years old: 16%; 
65 to 84 years old: 45%; 
85 years and older: 37%; 
Unknown: 2%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: The workload measure is the average daily census, which 
represents the average number of veterans residing in a nursing home 
on any given day of the year. Average daily census is calculated by 
dividing the total number of days of nursing home care provided in a 
year by the number of days in the year. 

[End of figure] 

At the network level, workload by resident characteristics generally 
mirrored overall patterns. Workload for most networks was largely 
discretionary, with discretionary care comprising at least half of the 
workload in 20 of VA's 21 networks. Discretionary workload ranged from 
40 percent of total workload in VISN 21 (Sierra Pacific Network) to 69 
percent of total workload in VISN 7 (VA Southeast Network) and VISN 3 
(VA New York/New Jersey Veterans Healthcare Network). (See appendix 
III for information on workload by network and eligibility status.) In 
addition, residents 65 through 84 years of age comprised similar 
proportions of workload in each network. Specifically, the proportion 
of workload for residents 65 through 84 years of age ranged from 42 
percent in VISN 1 (VA New England Healthcare System), VISN 3 (VA New 
York/New Jersey Veterans Healthcare Network), VISN 15 (VA Heartland 
Network), and VISN 21 (Sierra Pacific Network) to 50 percent in VISN 6 
(VA Mid-Atlantic Health Care Network) and VISN 11 (Veterans in 
Partnership). (See appendix IV for information on workload by network 
and resident age.) 

Veterans' Eligibility Status and Age Varied by Setting: 

The proportion of nursing home workload by veterans' eligibility 
status--mandatory veterans compared to discretionary veterans--varied 
widely by setting. State veterans' nursing homes provided the highest 
proportion of discretionary care compared to the other nursing home 
settings--84 percent of workload in state veterans' nursing homes was 
for care provided on a discretionary basis, compared to 48 percent of 
workload in CLCs and just 18 percent in community nursing homes. 
Conversely, community nursing homes provided the highest proportion of 
mandatory care (82 percent of workload), followed by CLCs (52 percent) 
and state veterans' nursing homes (9 percent). (See table 1.) 

Table 1: Percentage of VA Nursing Home Workload, by Setting and 
Resident Characteristics, Fiscal Year 2012: 

Resident characteristics: Eligibility status; Discretionary; 
Percentage of VA nursing home workload: 
VA Community Living Centers: 48%; 
Community nursing homes: 18%; 
State veterans' nursing homes: 84%. 

Resident characteristics: Eligibility status; Mandatory; 
Percentage of VA nursing home workload: 
VA Community Living Centers: 52%; 
Community nursing homes: 82%; 
State veterans' nursing homes: 9%. 

Resident characteristics: Eligibility status; Total; 
Percentage of VA nursing home workload: 
VA Community Living Centers: Age: 100%; 
Community nursing homes: Age: 100%; 
State veterans' nursing homes: Age: 93%[A]. 

Resident characteristics: Age; Under 65; 
Percentage of VA nursing home workload: 
VA Community Living Centers: 27%; 
Community nursing homes: 24%; 
State veterans' nursing homes: 8%. 

Resident characteristics: Age: 65-84; 
Percentage of VA nursing home workload: 
VA Community Living Centers: 49%; 
Community nursing homes: 46%; 
State veterans' nursing homes: 43%. 

Resident characteristics: Age: 85 and older; 
Percentage of VA nursing home workload: 
VA Community Living Centers: 24%; 
Community nursing homes: 30%; 
State veterans' nursing homes: 46%. 

Resident characteristics: Age: Total; 
Percentage of VA nursing home workload: 
VA Community Living Centers: 100%; 
Community nursing homes: 100%; 
State veterans' nursing homes: 97%[B]. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: The workload measure is the average daily census, which 
represents the average number of veterans residing in a nursing home 
on any given day of the year. Average daily census is calculated by 
dividing the total number of days of nursing home care provided in a 
year by the number of days in the year. 

[A] Total percentage for veterans' eligibility status in state 
veterans' nursing homes does not add up to 100 because 7 percent of 
data on eligibility status are missing for this setting. 

[B] Total percentage for veterans' age in state veterans' nursing 
homes does not add up to 100 because 3 percent of data on age are 
missing for this setting. 

[End of table] 

The proportion of workload by age group also varied among the three 
settings. Of the three settings, state veterans' nursing homes had the 
highest proportion of workload for veterans age 85 and older. State 
veterans' nursing homes also had the smallest proportion of workload 
for residents under age 65, who constituted less than a tenth of the 
workload. CLCs and community nursing homes had about the same 
proportions of workload for each age group, and in contrast to state 
veterans' nursing homes, they had higher proportions of workload for 
residents under age 65 (27 and 24 percent of workload, respectively, 
compared to 8 percent). 

These patterns indicate that the characteristics of resident 
populations varied distinctly across settings. A higher proportion of 
workload in state veterans' nursing homes was for discretionary and 
older veterans than in the other two settings. In addition, while 
workload in CLCs and community nursing homes had a similar age 
distribution of residents, community nursing homes had a higher 
proportion of workload for mandatory veterans than CLCs. 

VA officials told us that, at the national level, they rely on 
workload data for planning and budgeting purposes, especially to 
ensure that there are adequate resources to serve mandatory veterans. 
Officials said that reviewing the mix of mandatory versus 
discretionary veterans is particularly important since VA is required 
to serve the needs of mandatory veterans. VA officials told us that 
age data are also becoming important because VA now has a cohort of 
younger residents, and VA needs to be attuned to these population 
changes to ensure the required services are available. However, VA 
does not currently publish data on nursing home workload disaggregated 
by length of stay and resident characteristics in its budget 
justification. As a result, VA is not providing workload data on 
nursing home care provided or paid for to the maximum extent possible 
as encouraged by OMB guidance to justify staffing and other 
requirements. Congressional stakeholders therefore have incomplete 
information on the type of workload (long-stay or short-stay) being 
provided in each nursing home setting, as well as how settings differ 
in eligibility status and age of residents they serve. The lack of 
such information could hinder congressional budgeting and program 
decision making and oversight regarding VA's staffing and resource 
requirements for providing nursing home care. 

Most of VA's Nursing Home Spending Was for CLCs and Most Spending in 
All Three Settings Was for Long-Stay Care: 

Just under three-quarters of VA's total nursing home expenditures in 
fiscal year 2012 were for care provided in CLCs. In addition, per diem 
expenditures in CLCs--i.e., the average daily cost per resident--were 
significantly higher than the per diem expenditures in community 
nursing homes and state veterans' nursing homes. Over half of VA's 
nursing home spending was for discretionary care and nearly half of 
spending was for veterans age 65 to 84. However, spending by 
eligibility status and age cohort varied by VA nursing home setting. 

Nearly Three-Quarters of Total Spending Was for CLCs and CLC Per Diem 
Expenditures Were Considerably Higher than Per Diem Expenditures in 
Other Settings: 

In fiscal year 2012, VA spent more for care provided in CLCs than in 
the other two settings combined. Seventy-one percent ($3.5 billion) of 
VA's total expenditures was spent on care provided in CLCs (see figure 
5), although CLCs accounted for 28 percent of the total workload. 
Conversely, VA spent 16 percent (about $800 million) for nursing home 
care in state veterans' nursing homes, although state veterans' 
nursing homes accounted for 53 percent of VA's nursing home workload. 
The share of VA expenditures in each setting and other expenditure 
patterns we examine below remained relatively unchanged between fiscal 
years 2010-2012.[Footnote 33] 

Figure 5: Percentage of VA Total Nursing Home Expenditures by Setting, 
Fiscal Year 2012: 

[Refer to PDF for image: pie-chart] 

Total fiscal year 2012 expenditures: $4.9 billion; 
VA Community Living Centers: 71%; 
State veterans’ nursing homes: 16%; 
Community nursing homes: 13%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

[End of figure] 

Similar to workload, the proportion of VA nursing home expenditures 
accounted for by each setting varied widely by network. For example, 
nearly 90 percent of VA's expenditures in VISN 5 (VA Capitol Health 
Care Network) were for care provided in CLCs, whereas in VISN 19 
(Rocky Mountain Network) just 48 percent of expenditures were for care 
provided in CLCs. (See appendix V for more information on nursing home 
expenditures by network and setting.) 

In addition to CLCs accounting for most of VA's total nursing home 
expenditures, the per diem expenditure in CLCs was considerably higher 
than that for community nursing homes and state veterans' nursing 
homes, as also reported in VA's annual budget justification. 
Specifically, while the per diem expenditure across all settings in 
fiscal year 2012 was $370, the per diem expenditure in CLCs was nearly 
4 times higher than for community nursing homes, and about 8 times 
higher than for state veterans' nursing homes--$953 compared to $244 
and $113, respectively.[Footnote 34] (See table 2.) We also found that 
the per diem expenditure for CLCs was substantially higher than the 
per diem expenditure for community nursing homes and state veterans' 
nursing homes, regardless of the resident's length of stay. Although 
the short-stay per diem expenditure in CLCs ($1,167) was substantially 
more than the per diem expenditure for long stays ($884), both were 
considerably higher than the per diem expenditures for community 
nursing homes and state veterans' nursing homes. 

Table 2: Per Diem Expenditures, by Setting and Length of Stay, Fiscal 
Year 2012: 

Nursing home setting: VA Community Living Centers; 
All stays: $953; 
Short stays: $1,167; 
Long stays: $884. 

Nursing home setting: Community nursing homes; 
All stays: $244; 
Short stays: $265; 
Long stays: $239. 

Nursing home setting: State veterans' nursing homes[A]; 
All stays: $113; 
Short stays: $113; 
Long stays: $113. 

Nursing home setting: All settings; 
All stays: $370; 
Short stays: $732; 
Long stays: $318. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: The per diem expenditure is the average expenditure per resident 
per day (total expenditures divided by the total days of care). 

[A] VA pays state veterans' nursing homes a per diem that is generally 
about one-third the total cost of care, and VA data show that state 
veterans' nursing homes overwhelmingly serve discretionary veterans. 
VA pays the same per diem for short-and long-stay care in state 
veterans' nursing homes, although it pays a higher per diem for 
mandatory veterans. 

[End of table] 

VA officials told us that they have not done any studies comparing the 
reasons for differences in per diem expenditures across settings 
because such expenditures are not comparable. However, VA officials 
provided us with a breakdown of the various components of total and 
per diem expenditures in CLCs. (See table 3.) VA officials indicated 
that "core" CLC expenditures, which account for about 40 percent of 
total CLC per diem expenditures, would be comparable to the care that 
VA pays for in community nursing homes and state veterans' nursing 
homes. In addition to these core expenditures, VA's expenditures for 
CLCs in fiscal year 2012 included direct care expenditures for 
physicians and other medical personnel staffing, indirect care 
expenditures for education and research, and overhead expenditures 
related to VA national programs, among others. In particular, VA 
officials noted that CLCs are often located in or within close 
proximity to a VA medical center, and that the facility expenditures 
alone for CLCs are generally higher than those of community nursing 
homes and state veterans' nursing homes, which are generally stand-
alone facilities. In fiscal year 2012, for example, the per diem 
expenditure for CLC facility costs alone was $234, roughly comparable 
to the entire per diem that VA paid for veterans to receive care in 
community nursing homes that year. VA officials also told us that 
while the amount of nursing staff in community nursing homes is 
similar to that of CLCs, the skill level may not be as high. For 
example, CLCs may hire more licensed and registered nurses due to the 
needs of the residents in CLCs. VA officials also told us that 
expenditures for emergency medical care would not be included in the 
community nursing home per diem expenditures, but that these 
expenditures are included for CLC residents. In addition, while the 
cost of routine medications is covered under the community nursing 
home per diem, any high-cost medications are not, although they are 
accounted for in the overall expenditures for operating the community 
nursing home program. Officials also noted that per diem expenditures 
for state veterans' nursing homes only represent a portion of the 
total expenditures for care, with the remainder being paid for by the 
state and the veteran. 

Table 3: Composition of VA Community Living Center (CLC) Expenditures, 
Fiscal Year 2012: 

Cost category: Direct care; Core CLC[A]; 
Total expenditures: $1.363 billion; 
Per diem expenditures: $373. 

Cost category: Direct care; Physician; 
Total expenditures: $91 million; 
Per diem expenditures: $25. 

Cost category: Direct care; Physician extender[B]; 
Total expenditures: $27 million; 
Per diem expenditures: $7. 

Cost category: Direct care; Social worker/Psychologist; 
Total expenditures: $36 million; 
Per diem expenditures: $10. 

Cost category: Direct care; CLC rehabilitation services; 
Total expenditures: $36 million; 
Per diem expenditures: $10. 

Cost category: Direct care; Outpatient clinic use; 
Total expenditures: $88 million; 
Per diem expenditures: $24. 

Cost category: Direct care; Pharmacy; 
Total expenditures: $174 million; 
Per diem expenditures: $48. 

Cost category: Direct care; Prosthetics; 
Total expenditures: $23 million; 
Per diem expenditures: $6. 

Cost category: Indirect care; Education; 
Total expenditures: $6 million; 
Per diem expenditures: $2. 

Cost category: Indirect care; Research; 
Total expenditures: $19 million; 
Per diem expenditures: $5. 

Cost category: Indirect care; Administrative; 
Total expenditures: $277 million; 
Per diem expenditures: $76. 

Cost category: Indirect care; Facilities[C]; 
Total expenditures: $854 million; 
Per diem expenditures: $234. 

Cost category: Overhead; Capital obligations; 
Total expenditures: $398 million; 
Per diem expenditures: $109. 

Cost category: Overhead; National overhead; 
Total expenditures: $95 million; 
Per diem expenditures: $26. 

Cost category: Total--all cost categories; 
Total expenditures: $3.486 billion[D]; 
Per diem expenditures: $953 million[D]. 

Source: Department of Veterans Affairs (VA). 

[A] Includes services such as nursing, food delivery, hospice, and 
respiratory therapy. 

[B] Includes nurse practitioners and physician assistants. 

[C] Includes indirect costs that are not attributable to specific 
patient care, such as rent, operating and maintenance costs for 
buildings, equipment, and utilities. 

[D] Totals for all cost categories do not equal the sum of each of the 
categories due to rounding. 

[End of table] 

VA Spent More in All Three Settings on Long-Stay Care than Short-Stay 
Care: 

The majority of VA's spending for nursing home care in fiscal year 
2012--$3.7 billion, or 75 percent--was on long-stay care. Long-stay 
care accounted for most of VA's expenditures in each nursing home 
setting, and accounted for all but a small percentage of spending in 
state veterans' nursing homes. (See figure 6.) Although VA officials 
said they examine data on nursing home spending by length of stay for 
planning and budgeting purposes, VA does not include such data in its 
budget justification. 

Figure 6: Percentage of VA Nursing Home Expenditures by Setting and 
Length of Stay, Fiscal Year 2012: 

[Refer to PDF for image: stacked vertical bar graph] 

Nursing home setting: All settings; 
Long-stay care: 75%; 
Short-stay care: 25%. 

Nursing home setting: VA Community Living Centers; 
Long-stay care: 70%; 
Short-stay care: 30%. 

Nursing home setting: Community Nursing Homes; 
Long-stay care: 78%; 
Short-stay care: 22%. 

Nursing home setting: State Veterans' Nursing Homes; 
Long-stay care: 97%; 
Short-stay care: 3%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

[End of figure] 

Similarly, at the network level, the majority of expenditures for all 
networks were for long-stay care. The proportion of expenditures for 
long-stay care ranged from 62 percent for VISN 18 (VA Southwest Health 
Care Network) to 90 percent for VISN 3 (VA New York/New Jersey 
Veterans Healthcare Network). (See appendix VI for information on 
expenditures by network and length of stay.) 

Over Half of VA's Nursing Home Spending Was for Discretionary Care and 
Just Under Half Was for Veterans Age 65 to 84: 

Overall, discretionary care accounted for just over half (52 percent 
or $2.5 billion) of all VA nursing home spending--a slightly lower 
proportion than workload, of which discretionary care comprised 62 
percent. Just under half (47 percent or $2.3 billion) was spent on 
care for residents age 65 to 84. About one-quarter was spent on 
residents under age 65 and about the same percent for residents age 85 
and over. (See figure 7.) 

Figure 7: Percentage of VA Nursing Home Expenditures by Eligibility 
Status and Age, Fiscal Year 2012: 

[Refer to PDF for image: 2 pie-charts] 

Total fiscal year 2012 expenditures: $4.9 billion: 

Eligibility status: 
Discretionary veterans: 52%; 
Mandatory veterans: 47%; 
Unknown: 1%. 

Age: 
Under 65 years old: 25%; 
65 to 84 years old: 47%; 
85 years and older: 27%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: Percentages may not add up to 100 due to rounding. 

[End of figure] 

At the network level, total expenditures by eligibility status varied 
by network, with the proportion of spending for discretionary care 
ranging from 37 percent in VISN 6 (VA Mid-Atlantic Health Care 
Network) to 61 percent in VISN 15 (VA Heartland Network) and VISN 23 
(VA Midwest Health Care Network). (See appendix VII for information on 
expenditures by network and eligibility status.) Spending by age group 
did not vary as substantially between networks, however. Specifically, 
the proportion of spending for residents 65 through 84 ranged from 45 
percent in VISN 1 (VA New England Healthcare System), VISN 15 (VA 
Heartland Network), and VISN 19 (Rocky Mountain Network), to 51 
percent in VISN 6 (VA Mid-Atlantic Health Care Network). (See appendix 
VIII for information on expenditures by network and resident age.) 

Spending by Veterans' Eligibility Status and Age Varied across 
Settings: 

Similar to workload, spending for discretionary care varied widely by 
setting, with state veterans' nursing homes having the highest 
proportion of their total spending (84 percent) for discretionary care 
compared to the other two settings (50 percent in CLCs and 18 percent 
in community nursing homes). (See table 4.) Also, state veterans' 
nursing homes had the highest proportion (46 percent) of their total 
spending for residents age 85 and older, and the lowest proportion (8 
percent) on residents under age 65. CLCs and community nursing homes 
had similar proportions of their total spending on care for residents 
in each age group. 

Table 4: Percentage of VA Nursing Home Expenditures by Resident 
Characteristics and Setting, Fiscal Year 2012: 

Resident characteristics: Eligibility status; Discretionary; 
Percentage of VA nursing home expenditures: 
VA Community Living Centers: 50%; 
Community nursing homes: 18%; 
State veterans' nursing homes: 84%. 

Resident characteristics: Eligibility status; Mandatory; 
Percentage of VA nursing home expenditures: 
VA Community Living Centers: 50%; 
Community nursing homes: 82%; 
State veterans' nursing homes: 9%. 

Resident characteristics: Eligibility status; Total; 
Percentage of VA nursing home expenditures: 
VA Community Living Centers: Age: 100%; 
Community nursing homes: Age: 100%; 
State veterans' nursing homes: Age: 93%[A]. 

Resident characteristics: Age; Under 65; 
Percentage of VA nursing home expenditures: 
VA Community Living Centers: 29%; 
Community nursing homes: 25%; 
State veterans' nursing homes: 8%. 

Resident characteristics: Age; 65-84; 
Percentage of VA nursing home expenditures: 
VA Community Living Centers: 49%; 
Community nursing homes: 46%; 
State veterans' nursing homes: 43%. 

Resident characteristics: Age; 85 and older; 
Percentage of VA nursing home expenditures: 
VA Community Living Centers: 22%; 
Community nursing homes: 29%; 
State veterans' nursing homes: 46%. 

Resident characteristics: Age; Total; 
Percentage of VA nursing home expenditures: 
VA Community Living Centers: 100%; 
Community nursing homes: 100%; 
State veterans' nursing homes: 97%[B]. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

[A] Total percentage for spending by veterans' eligibility status in 
state veterans' nursing homes does not add up to 100 because 6 percent 
of data on eligibility status are missing for this setting, and 
because of rounding. 

[B] Total percentage for spending by veterans' age in state veterans' 
nursing homes does not add up to 100 because 3 percent of data on age 
are missing for this setting. 

[End of table] 

Similar to workload data, VA program officials told us that they rely 
on expenditure data by length of stay and resident characteristics for 
planning and budgeting purposes. This type of analysis is important 
given the significant differences in short-and long-stay per diem 
expenditures, particularly for CLCs, as well as differences in per 
diems that VA pays for mandatory and discretionary veterans in state 
veterans' nursing homes. In addition, according to officials, 
expenditure data on community nursing homes are especially important 
from a program perspective since VA looks at unit costs to help in 
rate negotiations. However, VA does not currently include expenditure 
data disaggregated by length of stay and resident characteristics in 
its budget justification, and therefore does not provide information 
on unit costs to the maximum extent possible as encouraged by OMB to 
justify staffing and other requirements. As a result, congressional 
stakeholders have incomplete information on the budget that is 
approved for VA nursing home care, including the proportion of 
expenditures that is allocated for long-stay and short-stay care, as 
well as expenditures by resident characteristics. The lack of such 
information could hinder congressional budgeting and program oversight 
regarding VA's staffing and resource requirements for providing 
nursing home care. 

Conclusions: 

VA now has key data on workload and expenditures for its three nursing 
home settings that were lacking in the past, and VA officials told us 
that they use these data for budgeting and planning purposes. Our 
analysis of these data show that the nursing home care that VA 
provides or pays for is primarily for long-stay care of 90 days or 
more for residents with chronic physical and mental limitations across 
all three nursing home settings, rather than short-stay care for 
residents with postacute care needs. Most of VA's nursing home 
workload is for discretionary care, rather than mandatory care, and 
more care is provided for residents 65 to 84 years of age than for 
other age groups, though these patterns vary by setting. As VA 
determines budget estimates and plans for future care needs, these 
data provide a foundation for understanding the type of care provided, 
the characteristics of the residents receiving it, and differences 
among the three settings. 

We believe that having and using the key workload and expenditure data 
that we analyzed in this report provides VA with more complete data to 
better inform its budget estimates and conduct program oversight than 
in the past. VA is to be commended for collecting and using the 
information to improve its decision making. However, VA only includes 
data on total nursing home workload, total expenditures, and per diem 
expenditures by the three nursing home settings in its budget 
justification and does not include workload or expenditures 
disaggregated by length of stay or resident characteristics to the 
maximum extent possible to justify staffing and other requirements. As 
a result, Congress does not have complete nursing home data on 
workload and expenditures by the three settings. The lack of such 
information could hinder congressional decision making and oversight 
of budgeting of VA nursing home care staffing and resource needs for 
care, which accounts for a significant portion of VA's health care 
budget and serves a vulnerable population. 

Recommendation for Executive Action: 

To provide more complete data for Congress, we recommend that the 
Secretary of Veterans Affairs supplement nursing home workload and 
expenditure data currently included in VA's budget justification with 
the following information: 

* Average daily census by length of stay and resident characteristics, 
including veterans' eligibility status and age. 

* Total expenditures and per diem expenditures by length of stay and 
resident characteristics, including veterans' eligibility status and 
age. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to VA for comment. In its written 
comments--reproduced in appendix IX--VA concurred with our 
recommendation and stated that it will provide supplemental data on 
both nursing home workload and expenditures by length of stay and 
resident characteristics upon release of its fiscal year 2015 budget. 
VA stated that it would provide data for state veterans' nursing homes 
to the extent the data are available. 

We are sending copies of this report to the Secretary of Veterans 
Affairs, and appropriate congressional committees. In addition, the 
report will be available at no charge on the GAO website at 
[hyperlink, http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact Vijay D'Souza at (202) 512-7114, or dsouzav@gao.gov. Contact 
points for our Offices of Congressional Relations and Public Affairs 
are on the last page of this report. GAO staff who made major 
contributions to this report are listed in appendix X. 

Sincerely yours, 

Signed by: 

Vijay A. D'Souza: 
Acting Director, Health Care: 

[End of section] 

Appendix I: Percentage of Nursing Home Workload by Network and 
Setting, Fiscal Year 2012: 

[Refer to PDF for image: stacked horizontal bar graph] 

Veterans Integrated Service Network (VISN): 

VISN 16: South Central; 
VA Community Living Center: 13%; 
Community nursing home: 13%; 
State veterans' nursing home: 74%. 

VISN 15: Heartland; 
VA Community Living Center: 13%; 
Community nursing home: 16%; 
State veterans' nursing home: 71%. 

VISN 3: New York/New Jersey; 
VA Community Living Center: 33%; 
Community nursing home: 1%; 
State veterans' nursing home: 66%. 

VISN 7: Southeast; 
VA Community Living Center: 24%; 
Community nursing home: 14%; 
State veterans' nursing home: 62%. 

VISN 4: VA Healthcare – VISN 4; 
VA Community Living Center: 32%; 
Community nursing home: 10%; 
State veterans' nursing home: 58%. 

VISN 12: Great Lakes; 
VA Community Living Center: 26%; 
Community nursing home: 17%; 
State veterans' nursing home: 57%. 

VISN 23: Midwest; 
VA Community Living Center: 22%; 
Community nursing home: 22%; 
State veterans' nursing home: 56%. 

VISN 9: Mid South; 
VA Community Living Center: 20%; 
Community nursing home: 24%; 
State veterans' nursing home: 56%. 

VISN 1: New England; 
VA Community Living Center: 20%; 
Community nursing home: 24%; 
State veterans' nursing home: 56%. 

VISN 19: Rocky Mountain; 
VA Community Living Center: 15%; 
Community nursing home: 32%; 
State veterans' nursing home: 53%. 

VISN 20: Northwest; 
VA Community Living Center: 18%; 
Community nursing home: 29%; 
State veterans' nursing home: 53%. 

VISN 18: Southwest; 
VA Community Living Center: 29%; 
Community nursing home: 19%; 
State veterans' nursing home: 52%. 

VISN 11: Veterans in Partnership; 
VA Community Living Center: 36%; 
Community nursing home: 19%; 
State veterans' nursing home: 45%. 

VISN 6: Mid-Atlantic; 
VA Community Living Center: 42%; 
Community nursing home: 16%; 
State veterans' nursing home: 42%. 

VISN 10: Ohio; 
VA Community Living Center: 36%; 
Community nursing home: 23%; 
State veterans' nursing home: 41%. 

VISN 8: Sunshine; 
VA Community Living Center: 41%; 
Community nursing home: 19%; 
State veterans' nursing home: 40%. 

VISN 17: Heart of Texas; 
VA Community Living Center: 35%; 
Community nursing home: 27%; 
State veterans' nursing home: 38%. 

VISN 2: Upstate New York; 
VA Community Living Center: 50%; 
Community nursing home: 13%; 
State veterans' nursing home: 37%. 

VISN 5: Capitol; 
VA Community Living Center: 55%; 
Community nursing home: 11%; 
State veterans' nursing home: 34%. 

VISN 22: Desert Pacific; 
VA Community Living Center: 29%; 
Community nursing home: 47%; 
State veterans' nursing home: 24%. 

VISN 21: Sierra Pacific; 
VA Community Living Center: 51%; 
Community nursing home: 29%; 
State veterans' nursing home: 20%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Notes: The workload measure is the average daily census, which 
represents the average number of veterans residing in a nursing home 
on any given day of the year. Average daily census is calculated by 
dividing the total number of days of nursing home care provided in a 
year by the number of days in the year. Percentage totals for each 
VISN may not equal 100 due to rounding. 

[End of figure] 

[End of section] 

Appendix II: Percentage of Nursing Home Workload by Network and Length 
of Stay, Fiscal Year 2012: 

[Refer to PDF for image: stacked horizontal bar graph] 

Veterans Integrated Service Network (VISN): 

VISN 3: New York/New Jersey; 
Short-stay workload: 5%; 
Long-stay workload: 95%. 

VISN 16: South Central; 
Short-stay workload: 7%; 
Long-stay workload: 93%. 

VISN 7: Southeast; 
Short-stay workload: 8%; 
Long-stay workload: 92%. 

VISN 1: New England; 
Short-stay workload: 11%; 
Long-stay workload: 89%. 

VISN 15: Heartland; 
Short-stay workload: 11%; 
Long-stay workload: 89%. 

VISN 4: VA Healthcare – VISN 4; 
Short-stay workload: 11%; 
Long-stay workload: 89%. 

VISN 12: Great Lakes; 
Short-stay workload: 11%; 
Long-stay workload: 89%. 

VISN 19: Rocky Mountain; 
Short-stay workload: 12%; 
Long-stay workload: 88%. 

VISN 17: Heart of Texas; 
Short-stay workload: 13%; 
Long-stay workload: 87%. 

VISN 9: Mid South; 
Short-stay workload: 13%; 
Long-stay workload: 87%. 

VISN 23: Midwest; 
Short-stay workload: 13%; 
Long-stay workload: 87%. 

VISN 2: Upstate New York; 
Short-stay workload: 13%; 
Long-stay workload: 87%. 

VISN 5: Capitol; 
Short-stay workload: 13%; 
Long-stay workload: 87%. 

VISN 11: Veterans in Partnership; 
Short-stay workload: 15%; 
Long-stay workload: 85%. 

VISN 10: Ohio; 
Short-stay workload: 16%; 
Long-stay workload: 84%. 

VISN 8: Sunshine; 
Short-stay workload: 16%; 
Long-stay workload: 84%. 

VISN 20: Northwest; 
Short-stay workload: 17%; 
Long-stay workload: 83%. 

VISN 6: Mid-Atlantic; 
Short-stay workload: 17%; 
Long-stay workload: 83%. 

VISN 18: Southwest; 
Short-stay workload: 20%; 
Long-stay workload: 80%. 

VISN 21: Sierra Pacific; 
Short-stay workload: 20%; 
Long-stay workload: 80%. 

VISN 22: Desert Pacific; 
Short-stay workload: 20%; 
Long-stay workload: 80%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: The workload measure is the average daily census, which 
represents the average number of veterans residing in a nursing home 
on any given day of the year. Average daily census is calculated by 
dividing the total number of days of nursing home care provided in a 
year by the number of days in the year. 

[End of figure] 

[End of section] 

Appendix III: Percentage of Nursing Home Workload by Network and 
Eligibility Status, Fiscal Year 2012: 

[Refer to PDF for image: stacked horizontal bar graph] 

Veterans Integrated Service Network (VISN): 

VISN 7: Southeast; 
Discretionary workload: 69%; 
Mandatory workload: 27%; 
Unknown: 4%. 

VISN 3: New York/New Jersey; 
Discretionary workload: 69%; 
Mandatory workload: 29%; 
Unknown: 2%. 

VISN 12: Great Lakes; 
Discretionary workload: 68%; 
Mandatory workload: 30%; 
Unknown: 2%. 

VISN 15: Heartland; 
Discretionary workload: 68%; 
Mandatory workload: 25%; 
Unknown: 7%. 

VISN 23: Midwest; 
Discretionary workload: 68%; 
Mandatory workload: 30%; 
Unknown: 2%. 

VISN 4: VA Healthcare – VISN 4; 
Discretionary workload: 67%; 
Mandatory workload: 30%; 
Unknown: 3%. 

VISN 16: South Central; 
Discretionary workload: 66%; 
Mandatory workload: 29%; 
Unknown: 5%. 

VISN 11: Veterans in Partnership; 
Discretionary workload: 64%; 
Mandatory workload: 36%; 
Unknown: 0%. 

VISN 10: Ohio; 
Discretionary workload: 61%; 
Mandatory workload: 37%; 
Unknown: 2%. 

VISN 18: Southwest; 
Discretionary workload: 61%; 
Mandatory workload: 37%; 
Unknown: 2%. 

VISN 1: New England; 
Discretionary workload: 60%; 
Mandatory workload: 35%; 
Unknown: 5%. 

VISN 9: Mid South; 
Discretionary workload: 59%; 
Mandatory workload: 36%; 
Unknown: 5%. 

VISN 19: Rocky Mountain; 
Discretionary workload: 58%; 
Mandatory workload: 37%; 
Unknown: 5%. 

VISN 20: Northwest; 
Discretionary workload: 58%; 
Mandatory workload: 40%; 
Unknown: 2%. 

VISN 8: Sunshine; 
Discretionary workload: 56%; 
Mandatory workload: 42%; 
Unknown: 2%. 

VISN 2: Upstate New York; 
Discretionary workload: 55%; 
Mandatory workload: 43%; 
Unknown: 2%. 

VISN 6: Mid-Atlantic; 
Discretionary workload: 52%; 
Mandatory workload: 46%; 
Unknown: 2%. 

VISN 5: Capitol; 
Discretionary workload: 50%; 
Mandatory workload: 41%; 
Unknown: 9%. 

VISN 17: Heart of Texas; 
Discretionary workload: 50%; 
Mandatory workload: 47%; 
Unknown: 3%. 

VISN 22: Desert Pacific; 
Discretionary workload: 50%; 
Mandatory workload: 50%; 
Unknown: 0%. 

VISN 21: Sierra Pacific; 
Discretionary workload: 40%; 
Mandatory workload: 50%; 
Unknown: 10%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Notes: The workload measure is the average daily census, which 
represents the average number of veterans residing in a nursing home 
on any given day of the year. Average daily census is calculated by 
dividing the total number of days of nursing home care provided in a 
year by the number of days in the year. Percentage totals for each 
VISN may not equal 100 due to rounding. 

[End of figure] 

[End of section] 

Appendix IV: Percentage of Nursing Home Workload by Network and 
Resident Age, Fiscal Year 2012: 

[Refer to PDF for image: stacked horizontal bar graph] 

Veterans Integrated Service Network (VISN): 

VISN 6: Mid-Atlantic; 
Under 65 years old: 16%; 
65-84 years old: 50%; 
85 years and older: 34%; 
Unknown: 0. 

VISN 11: Veterans in Partnership; 
Under 65 years old: 26%; 
65-84 years old: 50%; 
85 years and older: 24%; 
Unknown: 0. 

VISN 7: Southeast; 
Under 65 years old: 15%; 
65-84 years old: 48%; 
85 years and older: 36%; 
Unknown: 0. 

VISN 22: Desert Pacific; 
Under 65 years old: 24%; 
65-84 years old: 48%; 
85 years and older: 28%; 
Unknown: 0. 

VISN 20: Northwest; 
Under 65 years old: 19%; 
65-84 years old: 48%; 
85 years and older: 33%; 
Unknown: 0. 

VISN 18: Southwest; 
Under 65 years old: 13%; 
65-84 years old: 48%; 
85 years and older: 39%; 
Unknown: 0. 

VISN 17: Heart of Texas; 
Under 65 years old: 16%; 
65-84 years old: 48%; 
85 years and older: 36%; 
Unknown: 0. 

VISN 23: Midwest; 
Under 65 years old: 16%; 
65-84 years old: 47%; 
85 years and older: 37%; 
Unknown: 0. 

VISN 8: Sunshine; 
Under 65 years old: 15%; 
65-84 years old: 46%; 
85 years and older: 38%; 
Unknown: 0. 

VISN 16: South Central; 
Under 65 years old: 15%; 
65-84 years old: 46%; 
85 years and older: 37%; 
Unknown: 2%. 

VISN 9: Mid South; 
Under 65 years old: 15%; 
65-84 years old: 45%; 
85 years and older: 39%; 
Unknown: 1%. 

VISN 10: Ohio; 
Under 65 years old: 21%; 
65-84 years old: 45%; 
85 years and older: 34%; 
Unknown: 1%. 

VISN 4: VA Healthcare – VISN 4; 
Under 65 years old: 16%; 
65-84 years old: 45%; 
85 years and older: 37%; 
Unknown: 3%. 

VISN 19: Rocky Mountain; 
Under 65 years old: 16%; 
65-84 years old: 44%; 
85 years and older: 39%; 
Unknown: 1%. 

VISN 12: Great Lakes; 
Under 65 years old: 19%; 
65-84 years old: 44%; 
85 years and older: 36%; 
Unknown: 0. 

VISN 5: Capitol; 
Under 65 years old: 23%; 
65-84 years old: 44%; 
85 years and older: 26%; 
Unknown: 7%. 

VISN 2: Upstate New York; 
Under 65 years old: 12%; 
65-84 years old: 43%; 
85 years and older: 45%; 
Unknown: 0. 

VISN 3: New York/New Jersey; 
Under 65 years old: 10%; 
65-84 years old: 42%; 
85 years and older: 47%; 
Unknown: 1%. 

VISN 21: Sierra Pacific; 
Under 65 years old: 23%; 
65-84 years old: 42%; 
85 years and older: 24%; 
Unknown: 10%. 

VISN 15: Heartland; 
Under 65 years old: 12%; 
65-84 years old: 42%; 
85 years and older: 44%; 
Unknown: 1%. 

VISN 1: New England; 
Under 65 years old: 13%; 
65-84 years old: 42%; 
85 years and older: 42%; 
Unknown: 4%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Notes: The workload measure is the average daily census, which 
represents the average number of veterans residing in a nursing home 
on any given day of the year. Average daily census is calculated by 
dividing the total number of days of nursing home care provided in a 
year by the number of days in the year. Percentage totals for each 
VISN may not equal 100 due to rounding. 

[End of figure] 

[End of section] 

Appendix V: Percentage of Nursing Home Expenditures by Network and 
Setting, Fiscal Year 2012: 

[Refer to PDF for image: stacked horizontal bar graph] 

Veterans Integrated Service Network (VISN): 

VISN 5: Capitol; 
VA Community Living Center: 89%; 
Community nursing home: 5%; 
State veterans' nursing home: 5%. 

VISN 21: Sierra Pacific; 
VA Community Living Center: 84%; 
Community nursing home: 12%; 
State veterans' nursing home: 4%. 

VISN 2: Upstate New York; 
VA Community Living Center: 83%; 
Community nursing home: 8%; 
State veterans' nursing home: 9%. 

VISN 11: Veterans in Partnership; 
VA Community Living Center: 81%; 
Community nursing home: 9%; 
State veterans' nursing home: 10%. 

VISN 3: New York/New Jersey; 
VA Community Living Center: 80%; 
Community nursing home: 1%; 
State veterans' nursing home: 19%. 

VISN 6: Mid-Atlantic; 
VA Community Living Center: 80%; 
Community nursing home: 9%; 
State veterans' nursing home: 11%. 

VISN 8: Sunshine; 
VA Community Living Center: 80%; 
Community nursing home: 11%; 
State veterans' nursing home: 9%. 

VISN 17: Heart of Texas; 
VA Community Living Center: 80%; 
Community nursing home: 10%; 
State veterans' nursing home: 10%. 

VISN 4: VA Healthcare – VISN 4; 
VA Community Living Center: 77%; 
Community nursing home: 7%; 
State veterans' nursing home: 16%. 

VISN 10: Ohio; 
VA Community Living Center: 76%; 
Community nursing home: 14%; 
State veterans' nursing home: 10%. 

VISN 12: Great Lakes; 
VA Community Living Center: 74%; 
Community nursing home: 9%; 
State veterans' nursing home: 17%. 

VISN 18: Southwest; 
VA Community Living Center: 70%; 
Community nursing home: 13%; 
State veterans' nursing home: 16%. 

VISN 7: Southeast; 
VA Community Living Center: 68%; 
Community nursing home: 13%; 
State veterans' nursing home: 20%. 

VISN 22: Desert Pacific; 
VA Community Living Center: 67%; 
Community nursing home: 26%; 
State veterans' nursing home: 8%. 

VISN 9: Mid South; 
VA Community Living Center: 61%; 
Community nursing home: 19%; 
State veterans' nursing home: 20%. 

VISN 1: New England; 
VA Community Living Center: 60%; 
Community nursing home: 21%; 
State veterans' nursing home: 19%. 

VISN 23: Midwest; 
VA Community Living Center: 59%; 
Community nursing home: 18%; 
State veterans' nursing home: 24%. 

VISN 20: Northwest; 
VA Community Living Center: 58%; 
Community nursing home: 24%; 
State veterans' nursing home: 18%. 

VISN 15: Heartland; 
VA Community Living Center: 55%; 
Community nursing home: 13%; 
State veterans' nursing home: 32%. 

VISN 16: South Central; 
VA Community Living Center: 50%; 
Community nursing home: 12%; 
State veterans' nursing home: 38%. 

VISN 19: Rocky Mountain; 
VA Community Living Center: 48%; 
Community nursing home: 25%; 
State veterans' nursing home: 27%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: Percentage totals for each VISN may not equal 100 due to 
rounding. 

[End of figure] 

[End of section] 

Appendix VI: Percentage of Nursing Home Expenditures by Network and 
Length of Stay, Fiscal Year 2012: 

[Refer to PDF for image: stacked horizontal bar graph] 

Veterans Integrated Service Network (VISN): 

VISN 3: New York/New Jersey; 
Short-stay expenditures: 10%; 
Long-stay expenditures: 90%. 

VISN 7: Southeast; 
Short-stay expenditures: 14%; 
Long-stay expenditures: 86%. 

VISN 5: Capitol; 
Short-stay expenditures: 17%; 
Long-stay expenditures: 83%. 

VISN 16: South Central; 
Short-stay expenditures: 18%; 
Long-stay expenditures: 82%. 

VISN 2: Upstate New York; 
Short-stay expenditures: 19%; 
Long-stay expenditures: 81%. 

VISN 19: Rocky Mountain; 
Short-stay expenditures: 19%; 
Long-stay expenditures: 81%. 

VISN 1: New England; 
Short-stay expenditures: 22%; 
Long-stay expenditures: 78%. 

VISN 4: VA Healthcare – VISN 4; 
Short-stay expenditures: 22%; 
Long-stay expenditures: 78%. 

VISN 9: Mid South; 
Short-stay expenditures: 25%; 
Long-stay expenditures: 75%. 

VISN 21: Sierra Pacific; 
Short-stay expenditures: 25%; 
Long-stay expenditures: 75%. 

VISN 17: Heart of Texas; 
Short-stay expenditures: 25%; 
Long-stay expenditures: 75%. 

VISN 6: Mid-Atlantic; 
Short-stay expenditures: 27%; 
Long-stay expenditures: 73%. 

VISN 10: Ohio; 
Short-stay expenditures: 27%; 
Long-stay expenditures: 73%. 

VISN 8: Sunshine; 
Short-stay expenditures: 29%; 
Long-stay expenditures: 71%. 

VISN 11: Veterans in Partnership; 
Short-stay expenditures: 30%; 
Long-stay expenditures: 70%. 

VISN 22: Desert Pacific; 
Short-stay expenditures: 30%; 
Long-stay expenditures: 70%. 

VISN 23: Midwest; 
Short-stay expenditures: 30%; 
Long-stay expenditures: 70%. 

VISN 12: Great Lakes; 
Short-stay expenditures: 30%; 
Long-stay expenditures: 70%. 

VISN 15: Heartland; 
Short-stay expenditures: 30%; 
Long-stay expenditures: 70%. 

VISN 20: Northwest; 
Short-stay expenditures: 32%; 
Long-stay expenditures: 68%. 

VISN 18: Southwest; 
Short-stay expenditures: 38%; 
Long-stay expenditures: 62%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

[End of figure] 

[End of section] 

Appendix VII: Percentage of Nursing Home Expenditures by Network and 
Eligibility Status, Fiscal Year 2012: 

[Refer to PDF for image: stacked horizontal bar graph] 

Veterans Integrated Service Network (VISN): 

VISN 15: Heartland; 
Discretionary expenditures: 61%; 
Mandatory expenditures: 36%; 
Unknown: 3%. 

VISN 23: Midwest; 
Discretionary expenditures: 61%; 
Mandatory expenditures: 38%; 
Unknown: 1%. 

VISN 16: South Central; 
Discretionary expenditures: 60%; 
Mandatory expenditures: 37%; 
Unknown: 2%. 

VISN 12: Great Lakes; 
Discretionary expenditures: 59%; 
Mandatory expenditures: 40%; 
Unknown: 1%. 

VISN 18: Southwest; 
Discretionary expenditures: 58%; 
Mandatory expenditures: 41%; 
Unknown: 1%. 

VISN 11: Veterans in Partnership; 
Discretionary expenditures: 58%; 
Mandatory expenditures: 42%; 
Unknown: 0. 

VISN 10: Ohio; 
Discretionary expenditures: 58%; 
Mandatory expenditures: 42%; 
Unknown: 1%. 

VISN 7: Southeast; 
Discretionary expenditures: 55%; 
Mandatory expenditures: 44%; 
Unknown: 2%. 

VISN 8: Sunshine; 
Discretionary expenditures: 53%; 
Mandatory expenditures: 47%; 
Unknown: 1%. 

VISN 19: Rocky Mountain; 
Discretionary expenditures: 52%; 
Mandatory expenditures: 46%; 
Unknown: 2%. 

VISN 22: Desert Pacific; 
Discretionary expenditures: 51%; 
Mandatory expenditures: 48%; 
Unknown: 0. 

VISN 20: Northwest; 
Discretionary expenditures: 50%; 
Mandatory expenditures: 49%; 
Unknown: 1%. 

VISN 9: Mid South; 
Discretionary expenditures: 50%; 
Mandatory expenditures: 48%; 
Unknown: 2%. 

VISN 17: Heart of Texas; 
Discretionary expenditures: 50%; 
Mandatory expenditures: 49%; 
Unknown: 1%. 

VISN 4: VA Healthcare – VISN 4; 
Discretionary expenditures: 49%; 
Mandatory expenditures: 50%; 
Unknown: 1%. 

VISN 1: New England; 
Discretionary expenditures: 47%; 
Mandatory expenditures: 51%; 
Unknown: 2%. 

VISN 21: Sierra Pacific; 
Discretionary expenditures: 46%; 
Mandatory expenditures: 52%; 
Unknown: 2%. 

VISN 5: Capitol; 
Discretionary expenditures: 43%; 
Mandatory expenditures: 56%; 
Unknown: 1%. 

VISN 2: Upstate New York; 
Discretionary expenditures: 42%; 
Mandatory expenditures: 57%; 
Unknown: 1%. 

VISN 3: New York/New Jersey; 
Discretionary expenditures: 41%; 
Mandatory expenditures: 59%; 
Unknown: 1%. 

VISN 6: Mid-Atlantic; 
Discretionary expenditures: 37%; 
Mandatory expenditures: 63%; 
Unknown: 0. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: Percentage totals for each VISN may not equal 100 due to 
rounding. 

[End of figure] 

[End of section] 

Appendix VIII: Percentage of Nursing Home Expenditures by Network and 
Resident Age, Fiscal Year 2012: 

[Refer to PDF for image: stacked horizontal bar graph] 

Veterans Integrated Service Network (VISN): 

VISN 6: Mid-Atlantic; 
Under 65 years old: 26%; 
65-84 years old: 51%; 
85 years and older: 23%; 
Unknown: 0. 

VISN 17: Heart of Texas; 
Under 65 years old: 27%; 
65-84 years old: 50%; 
85 years and older: 23%; 
Unknown: 0. 

VISN 16: South Central; 
Under 65 years old: 22%; 
65-84 years old: 49%; 
85 years and older: 28%; 
Unknown: 1%. 

VISN 22: Desert Pacific; 
Under 65 years old: 28%; 
65-84 years old: 49%; 
85 years and older: 23%; 
Unknown: 0. 

VISN 18: Southwest; 
Under 65 years old: 22%; 
65-84 years old: 49%; 
85 years and older: 29%; 
Unknown: 0. 

VISN 7: Southeast; 
Under 65 years old: 25%; 
65-84 years old: 48%; 
85 years and older: 26%; 
Unknown: 0. 

VISN 20: Northwest; 
Under 65 years old: 26%; 
65-84 years old: 48%; 
85 years and older: 26%; 
Unknown: 0. 

VISN 11: Veterans in Partnership; 
Under 65 years old: 30%; 
65-84 years old: 48%; 
85 years and older: 22%; 
Unknown: 0. 

VISN 8: Sunshine; 
Under 65 years old: 24%; 
65-84 years old: 48%; 
85 years and older: 28%; 
Unknown: 0. 

VISN 9: Mid South; 
Under 65 years old: 25%; 
65-84 years old: 47%; 
85 years and older: 27%; 
Unknown: 0. 

VISN 21: Sierra Pacific; 
Under 65 years old: 28%; 
65-84 years old: 47%; 
85 years and older: 23%; 
Unknown: 2%. 

VISN 10: Ohio; 
Under 65 years old: 29%; 
65-84 years old: 47%; 
85 years and older: 23%; 
Unknown: 0. 

VISN 23: Midwest; 
Under 65 years old: 25%; 
65-84 years old: 47%; 
85 years and older: 28%; 
Unknown: 0. 

VISN 12: Great Lakes; 
Under 65 years old: 28%; 
65-84 years old: 47%; 
85 years and older: 24%; 
Unknown: 0. 

VISN 2: Upstate New York; 
Under 65 years old: 19%; 
65-84 years old: 46%; 
85 years and older: 35%; 
Unknown: 0. 

VISN 5: Capitol; 
Under 65 years old: 33%; 
65-84 years old: 46%; 
85 years and older: 20%; 
Unknown: 1%. 

VISN 3: New York/New Jersey; 
Under 65 years old: 19%; 
65-84 years old: 46%; 
85 years and older: 35%; 
Unknown: 0. 

VISN 4: VA Healthcare – VISN 4; 
Under 65 years old: 25%; 
65-84 years old: 46%; 
85 years and older: 28%; 
Unknown: 1%. 

VISN 15: Heartland; 
Under 65 years old: 23%; 
65-84 years old: 45%; 
85 years and older: 31%; 
Unknown: 1%. 

VISN 1: New England; 
Under 65 years old: 19%; 
65-84 years old: 45%; 
85 years and older: 35%; 
Unknown: 1%. 

VISN 19: Rocky Mountain; 
Under 65 years old: 22%; 
65-84 years old: 45%; 
85 years and older: 32%; 
Unknown: 1%. 

Source: GAO analysis of Department of Veterans Affairs (VA) data. 

Note: Percentage totals for each VISN may not equal 100 due to 
rounding. 

[End of figure] 

[End of section] 

Appendix IX: Comments from the Department of Veterans Affairs: 

Department of Veterans Affairs: 
Washington, DC 20420: 

December 2, 2013: 

Mr. Vijay D'Souza: 
Acting Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, NW Washington, DC 20548: 

Dear Mr. D'Souza: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, "VA Nursing Homes: 
Reporting More Complete Data on Workload and Expenditures Could 
Enhance Oversight" (GAO-14-89). VA generally agrees with GAO's 
conclusions and concurs with GAO's recommendation to the Department.
The enclosure specifically addresses GAO's recommendation and provides 
technical comments to the draft report. VA appreciates the opportunity 
to comment on your draft report. 

Sincerely, 

Signed by: 

Jose D. Riojas: 
Chief of Staff: 

Enclosure: 

Department of Veterans Affairs (VA) Response to Government 
Accountability Office (GAO) Draft Report: "VA Nursing Homes: Reporting 
More Complete Data on Workload and Expenditures Could Enhance 
Oversight" (GAO-14-89): 

GAO Recommendation: To provide more complete data for Congress, we 
recommend that the Secretary of Veterans' Affairs supplement nursing 
home workload and expenditure data currently included in VA's budget 
justification with the following information: 

Recommendation 1: Average daily census by length of stay and resident 
characteristics, including veterans' eligibility status and age. 

VA Comment: Concur. VA will provide supplemental information using 
actual data for long term care settings. Information for State Homes 
will be provided to the extent which data is available. Target 
Completion Date: Upon release of Fiscal Year 2015 Budget. 

Recommendation 2: Total expenditures and per diem expenditures by 
length of stay and resident characteristics, including veterans' 
eligibility status and age. 

VA Comment: Concur. VA will provide supplemental information using 
actual data for long term care settings. Information for State Homes 
will be provided to the extent which data is available. Target 
Completion Date: Upon release of Fiscal Year 2015 Budget. 

[End of section] 

Appendix X: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Vijay D'Souza, Acting Director, Health Care, (202) 512-7114, 
dsouzav@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, James C. Musselwhite, 
Assistant Director; Iola D'Souza; Linda Galib; Drew Long; and Hemi 
Tewarson made key contributions to this report. 

[End of section] 

Related GAO Products: 

Veterans' Health Care Budget: Improvements Made, but Additional 
Actions Needed to Address Problems Related to Estimates Supporting 
President's Request, [hyperlink, 
http://www.gao.gov/products/GAO-13-715] (Washington, D.C.: Aug. 8, 
2013). 

Veterans' Health Care: Improvements Needed to Ensure That Budget 
Estimates Are Reliable and That Spending for Facility Maintenance Is 
Consistent with Priorities, [hyperlink, 
http://www.gao.gov/products/GAO-13-220] (Washington, D.C.: Feb. 22, 
2013). 

Veterans' Health Care Budget: Better Labeling of Services and More 
Detailed Information Could Improve the Congressional Budget 
Justification, [hyperlink, http://www.gao.gov/products/GAO-12-908] 
(Washington, D.C.: Sept. 18, 2012). 

Veterans' Health Care Budget Estimate: Changes Were Made in Developing 
the President's Budget Request for Fiscal Years 2012 and 2013, 
[hyperlink, http://www.gao.gov/products/GAO-11-622] (Washington, D.C.: 
Jun. 14, 2011). 

Veterans' Health Care: VA Uses a Projection Model to Develop Most of 
Its Health Care Budget Estimate to Inform the President's Budget 
Request, [hyperlink, http://www.gao.gov/products/GAO-11-205] 
(Washington, D.C.: Jan. 31, 2011). 

VA Health Care: Long-Term Care Strategic Planning and Budgeting Need 
Improvement, [hyperlink, http://www.gao.gov/products/GAO-09-145] 
(Washington, D.C.: Jan. 23, 2009). 

VA Long-Term Care: Data Gaps Impede Strategic Planning for and 
Oversight of State Veterans' Nursing Homes, [hyperlink, 
http://www.gao.gov/products/GAO-06-264] (Washington, D.C.: March 31, 
2006). 

VA Long-Term Care: Trends and Planning Challenges in Providing Nursing 
Home Care to Veterans, [hyperlink, 
http://www.gao.gov/products/GAO-06-333T] (Washington, D.C.: Jan. 9, 
2006). 

VA Long-Term Care: Oversight of Nursing Home Program Impeded by Data 
Gaps, [hyperlink, http://www.gao.gov/products/GAO-05-65] (Washington, 
D.C.: Nov. 10, 2004). 

[End of section] 

Footnotes: 

[1] VA's national health care system consists of regional health care 
networks known as Veterans Integrated Service Networks (VISN). These 
networks have budget and management responsibilities that include 
allocating budgetary resources for and managing their VA nursing home 
care programs. 

[2] The proportion of VA long-term care resources spent on nursing 
homes--over 75 percent--is similar to that spent for nursing home care 
more generally. The Congressional Budget Office estimated that, of the 
$191 billion spent on long-term care services in 2011, about $134 
billion (70 percent) was spent on institutional care provided in 
skilled nursing facilities and nursing homes. See Congressional Budget 
Office: Rising Demand for Long-Term Services and Supports for Elderly 
People (Washington D.C.: June 2013). 

[3] See VA National Center for Veterans Analysis and Statistics, 
Projected Veterans Population 2010 to 2040, and U.S. Census Bureau, 
2011 American Community Survey 1-year estimates. 

[4] In addition to paying for all or some of the cost of care for 
eligible veterans, VA is generally authorized to pay up to 65 percent 
of the costs of construction of state veterans' nursing homes. 

[5] A service-connected disability is an injury or disease that was 
incurred or aggravated while on active duty. VA classifies veterans 
with service-connected disabilities according to the extent of their 
disability. These classifications are expressed in terms of 
percentages--for example, the most severely disabled veteran would be 
rated as having a service-connected disability of 100 percent. 
Percentages are assigned in increments of 10 percent. 

[6] See 38 U.S.C. § 1710A (a), (d). Unless reauthorized by Congress, 
this provision will terminate on December 31, 2013. VA officials also 
informed us that mandatory veterans also include veterans who have a 
service-connected disability rating of total disability based on 
individual unemployability. Although this group is not listed 
specifically in legislation, VA officials told us that these veterans 
are, by definition, included in the categories of veterans for whom VA 
is required by law to pay the full cost of nursing home care. 

[7] See 38 U.S.C. § 1710 (a). 

[8] GAO, VA Long-Term Care: Oversight of Nursing Home Program Impeded 
by Data Gaps, [hyperlink, http://www.gao.gov/products/GAO-05-65] 
(Washington, D.C.: Nov.10, 2004). 

[9] VA Long-Term Care: Data Gaps Impede Strategic Planning for and 
Oversight of State Veterans' Nursing Homes, [hyperlink, 
http://www.gao.gov/products/GAO-06-264] (Washington, D.C.: Mar.31, 
2006). 

[10] In this report, we use the term expenditures to refer to 
obligations, which VA reports in its budget justification. Obligations 
refer to a definite commitment creating a legal liability to make 
payments immediately or in the future. An obligation is incurred, for 
example, when an agency awards a contract to a private entity. 

[11] OMB Circular A-11, Section 51, Basic Justification Materials 
(Washington, D.C.: Jul. 26, 2013). 

[12] OMB Circular A-11, Section 200, Overview of the Federal 
Performance Framework (Washington, D.C.: Jul. 26, 2013). 

[13] See GAO, VA Health Care: Long-Term Care Strategic Planning and 
Budgeting Need Improvement, [hyperlink, 
http://www.gao.gov/products/GAO-09-145] (Washington, D.C.: Jan. 23, 
2009); and GAO, Veterans' Health Care Budget: Improvements Made, but 
Additional Actions Needed to Address Problems Related to Estimates 
Supporting President's Request, [hyperlink, 
http://www.gao.gov/products/GAO-13-715] (Washington, D.C.: Aug. 8, 
2013). 

[14] VHA administers VA's health care system. 

[15] We use average daily census as our workload measure in this 
report because it is the workload measure that VA uses in its budget 
justification when reporting on nursing home care. 

[16] Data on certain resident characteristics were missing for a small 
percentage of workload data for state veterans' nursing homes in 
fiscal year 2012--specifically, 7 percent of data on eligibility 
status, and 3 percent of data on age, were missing for state veterans' 
nursing homes. Across all settings combined, this resulted in 
eligibility status missing for 4 percent, and age missing for 2 
percent, of the workload data for fiscal year 2012. 

[17] OMB Circular A-11, Section 51, Basic Justification Materials. 

[18] Our analysis showed that workload and expenditure trends were 
generally consistent over the 3-year period, therefore, we focused our 
review on fiscal year 2012 data. 

[19] Similar to workload data, data on certain resident 
characteristics were missing for a small percentage of expenditure 
data for state veterans' nursing homes in fiscal year 2012--
specifically, 6 percent of data on eligibility status, and 3 percent 
of data on age, were missing for state veterans' nursing homes. Across 
all settings combined, this resulted in eligibility status missing for 
1 percent, and age missing for less than 1 percent, of the expenditure 
data for fiscal year 2012. 

[20] OMB Circular A-11, Section 51, Basic Justification Materials. 

[21] The proportions of workload accounted for by each nursing home 
setting are generally consistent with the workload data that VA 
publishes in its annual budget justification. 

[22] Most veterans do not receive their nursing home care from the VA 
program but instead receive it from other providers. For veterans who 
do not receive their nursing home care from the VA program, care is 
financed by programs such as Medicaid, Medicare, private health or 
long-term care insurance, or out-of-pocket spending by the residents. 

[23] See Veterans Health Administration Handbook 1142.01, Criteria and 
Standards for VA Community Living Centers (Aug. 13, 2008). The Joint 
Commission is an independent organization that accredits and certifies 
health care organizations and programs in the United States. 

[24] Medicare is the federal health insurance program for people age 
65 and older, individuals under age 65 with certain disabilities, and 
individuals diagnosed with end-stage renal disease. Medicaid is a 
federal-state program that provides health care coverage to certain 
categories of low-income individuals. 

[25] VA generally determines its per diem rates to community nursing 
homes in part by using Resource Utilization Groups to classify 
residents based on their treatment needs and the resources needed to 
provide that care. The eight groups used by VA include residents who 
are clinically complex, with behavioral and cognitive performance 
issues, and those with reduced physical functioning. 

[26] Nursing home care can be extended beyond the 6 months in certain 
limited circumstances, such as for a period up to 45 days when the 
need for care continues to exist and the veteran's eligibility for a 
public assistance program has been temporarily delayed. See 38 U.S.C. 
§ 1720, 38 C.F.R. § 17.60. 

[27] The percentage of the facility residents eligible for care in 
state veterans' nursing homes must be at least 75 percent veterans; 
however, if the facility was constructed or renovated solely with non-
VA funds the veteran percentage need only be more than 50 percent. 

[28] About two-thirds of state veterans' nursing homes participating 
in VA's nursing home program are also Medicare-or Medicaid-certified. 

[29] VA is required by law to enter into either contracts or provider 
agreements with state veterans' nursing homes to pay for mandatory 
veterans' care. Under contract, VA pays state veterans' nursing homes 
either a negotiated rate or, upon request by homes that were serving 
veterans as of August 2012, a rate based on reimbursement levels in 
effect at that time. Under provider agreements, VA pays state 
veterans' nursing homes using a formula identified in federal 
regulations that reflects prevailing rates payable in the homes' 
respective geographic locations. See 38 C.F.R. § 51.41. 

[30] See 38 C.F.R. § 51.40. Federal regulations define the basic per 
diem as the lesser of (i) half of the cost of care for each day the 
veteran is in the facility or (ii) the basic per diem rate for the 
fiscal year established by VA. 

[31] Functional limitations are physical problems that limit a 
person's ability to perform routine daily activities, such as eating, 
bathing, dressing, paying bills, and preparing meals. Cognitive 
limitations are losses in mental acuity that may also restrict a 
person's ability to perform such activities. Institutionalization in a 
nursing home is more common at older ages--in 2010, about 1 in 8 
people age 85 or older resided in institutions, compared with 1 
percent of people ages 65 to 74. See Congressional Budget Office: 
Rising Demand for Long-Term Services and Supports for Elderly People 
(Washington D.C.: June 2013). 

[32] As a result, we focus our workload analysis in this report on 
fiscal year 2012. 

[33] As a result, we focus our expenditure analysis in this report on 
fiscal year 2012. 

[34] The average per diem that VA paid through its community nursing 
home program was generally similar to the average national per diem 
for nursing home care purchased in a community setting. The national 
average per diem for a semi-private room (which is what VA officials 
told us that VA covers for veterans admitted to community nursing 
homes) in 2012 was $222. See MetLife Mature Market Institute, "Market 
Survey of Long-Term Care Costs: The 2012 MetLife Market Survey of 
Nursing Home, Assisted Living, Adult Day Services, and Home Care 
Costs" (New York, NY; November 2012). 

[End of section] 

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