Background For many veterans, long-term care is provided directly or purchased by VA. VA provides or pays for long-term care for eligible veterans enrolled in VA’s health care through a variety of programs, including institutional- based care like nursing homes and noninstitutional programs like home health care, which provides care to veterans in their own homes. VA Long-Term Care Programs VA provides or pays for long-term care—ranging from assistance with dressing and bathing to clinical care for spinal injuries or dementia— through a range of three institutional and 11 noninstitutional programs. Institutional programs, such as nursing homes, typically provide more acute skilled nursing care in a residential facility; noninstitutional programs, such as the Home-Based Primary Care program, provide care to veterans in their homes or communities. (See fig. 1 for a list of VA’s institutional and noninstitutional long-term care programs and app. I for brief descriptions of these programs.) Institutional Programs. VA provides or pays for eligible veterans to receive long-term care in three institutional programs that primarily provide skilled nursing care, such as for rehabilitation after surgery or for health issues or disabilities that require 24-hour care in a residential facility. These three programs include: VA Community Living Centers (VA-owned and -operated), Community Nursing Homes (publicly or privately owned and under contract with VA), and State Veterans Homes (state-owned and -operated homes approved and supported by VA). Noninstitutional Programs. VA provides or pays for eligible veterans to receive noninstitutional long-term care through 11 home or community- based programs, where most veterans receive long-term care. Several of VA’s noninstitutional programs provide personal care assistance to help veterans with activities of daily living—e.g., dressing, eating, bathing— that enable veterans to remain living at home, including the Homemaker Home Health Aide, Community Adult Day Health Care, and Respite Care programs. VAMCs evaluate veterans to determine the extent to which they can perform activities of daily living and to identify the available programs that would best meet their needs. In addition, VA’s noninstitutional programs include the Community Residential Care program where caregivers—in settings such as Medical Foster Homes where no more than three residents receive care—provide 24 hour care for veterans who cannot live alone because of medical or mental health conditions. Several of VA’s long-term care programs serve veterans with special needs. For example, some of these programs, such as certain Community Nursing Homes, Adult Day Health Care, and Hospice and Respite Care programs, have specially trained staff to serve veterans with dementia. The Spinal Cord Injury and Disability Home Care program and certain VA Community Living Centers are equipped to serve veterans needing ventilator care. In addition, some programs offer specific services for younger veterans, such as certain Adult Day Health Care programs. Eligibility for and Placement into VA Long- Term Care Programs All veterans enrolled in the VA health care system are eligible for VA’s basic medical benefits package, which includes certain institutional and noninstitutional long-term care services. A veteran’s eligibility for fully or partially covered nursing home care is determined by the veteran’s priority for care, which is generally based on the veteran’s service- connected disability status. Specifically, VA must cover the full cost of nursing home care for veterans who need this care for a service- connected disability and for veterans with service-connected disabilities rated at 70 percent or more. To the extent resources allow, VA may cover this nursing home care for certain other veterans, such as former prisoners of war and those awarded the Purple Heart. For all other veterans, VA may generally cover nursing home care to the extent resources and capacity allow and with the veteran’s agreement to share certain costs. Veterans’ placement in any particular institutional or noninstitutional long- term care program may depend on their clinical needs, disability ratings, preferences, and the availability of VA programs. When funds are limited, the agency may prioritize program placement based on veterans’ service- connected disability ratings. Decisions about which long-term care programs may be the best fit are made at the VAMC level between VA providers, veterans, and their families. VA providers may discuss a range of factors when making decisions about this care, such as health needs, the type of care provided in different programs, space availability, eligibility, and the veteran’s geographic preference. For facility-based programs, VAMC staff may also encourage veterans to take a tour of the prospective home. VA’s stated goal is to honor veterans’ preferences for care, including finding ways for veterans to age in their homes and communities instead of nursing homes. Selected Demographics of Veterans in Long-Term Care A diverse set of veterans receive care in VA’s long-term care programs. According to VA data for fiscal year 2018, 70 percent (370,821) of the veterans who received VA long-term care during the fiscal year were aged 65 or older. (See fig. 2.) In addition, 91 percent (480,299) of those who received this care had served in the military prior to September 11, 2001. Lastly, according to VA data for fiscal year 2018, 55 percent (291,197) of veterans receiving long-term care had some level of service- connected disabilities. VA Planning for Long-Term Care VA’s planning for veterans’ long-term care is informed by broader strategic planning by VA and the VHA and then operationalized by GEC at the program level. Veterans Integrated Service Networks (VISN) then implement GEC strategies for their regions and VAMCs implement and manage the various programs. VA, through the Assistant Secretary for Enterprise Integration’s office, sets a strategic plan that identifies agency-wide goals. For example, VA’s fiscal year 2018 through 2024 strategic plan identifies a goal that veterans “choose VA for easy access, greater choices, and clear information to make informed decisions,” and the plan notes that VA should “understand veterans’ needs throughout their lives to enhance their choices and improve customer experiences.” VA develops its agency-wide strategic plan every four years. VHA, through its Office of Policy and Planning, identifies strategies within VA’s health care system to address VA’s agency-wide goals. For example, VHA’s fiscal year 2018 through 2019 strategy, operationalizing VA’s goal for veteran choice, is to “honor veterans’ preferences by offering home and community based care to prevent unwanted nursing home care.” VHA strategic planning occurs every two years according to VA officials. VHA’s Office of Enrollment and Forecasting uses the EHCPM to project the utilization of and cost for care across most of VA’s health care programs 20 years into the future, including most long-term care programs. GEC’s strategic planning operationalizes VA and VHA goals and strategies for long-term care at the program level. For example, to achieve VA’s goal of veteran choice and VHA’s strategy of honoring veteran preferences, GEC developed a model to identify veterans at the highest risk of needing nursing home care. According to GEC officials, the GEC strategic planning process generally occurs annually. VISNs are responsible for managing and overseeing VAMCs within their regions where long-term care is delivered, with a GEC point of contact at each VISN who can address GEC issues as they arise, according to VA officials. VAMCs within each VISN are, according to VA officials, responsible for the management of individual long-term care programs, including oversight of long-term care programs’ quality of care. As previously noted, VAMCs also have a role in guiding decisions about individual veterans’ long-term care placement. Other health care systems nationwide are also planning to meet the growing demand for long-term care and have developed strategies to address future long-term care challenges. For example, some state agencies, which provide long-term care through Medicaid, have developed strategies to help aging citizens live in their communities by enhancing community-based services and developing the workforce to provide care. VA has a federal Geriatrics and Gerontology Advisory Group to share knowledge with other long-term care providers and to advise the Secretary and Under Secretary for Health on all matters related to geriatrics and gerontology for the care of veterans. Utilization of and Spending for VA Long-Term Care Have Increased in Recent Years and Are Projected to Increase Utilization of VA Long- Term Care Increased from Fiscal Years 2014 through 2018 Our analysis of VA data shows that the number of veterans receiving care in one or more of the VA long-term care programs increased 14 percent from fiscal years 2014 through 2018, from 464,071 to 530,327 veterans. The data also show that utilization increased more for noninstitutional programs than for institutional programs. Specifically by program type, VA data show that the number of veterans receiving institutional long-term care increased 8 percent during these years, from 97,124 to 105,151, while the number receiving noninstitutional care increased 16 percent, from 395,736 to 459,783. VA officials told us that the agency is continuing to expand veterans’ access to noninstitutional care programs because institutional care is more costly than home- or community-based care, and because veterans prefer to delay or reduce the amount of nursing home care they receive. Our analysis showed that utilization of long-term care—in terms of various VA workload units—also generally increased from fiscal years 2014 through 2018. The average daily census increased for two of VA’s three institutional programs—Community Nursing Homes increased by 26 percent from 7,771 to 9,808 and State Veterans Homes increased by 1 percent from 23,176 to 23,423. Five of the 11 noninstitutional programs experienced increases in their workload over this period, ranging from 8 percent to 48 percent. For example, the number of VA clinic stops (one type of VA workload unit) in the Homemaker Home Health Aid program—which served approximately 23 percent of the veterans receiving noninstitutional long-term care in fiscal year 2018—increased 48 percent from 8.3 million to 12.3 million clinic stops. (See app. II for more information on veterans’ utilization of institutional and noninstitutional long-term care by program.) According to VA, veterans’ use of VA long-term care programs increased during fiscal years 2014 through 2018 for several reasons, including that a large number of Vietnam veterans are aging and that more veterans are receiving higher service-connected disability ratings. We found the number of veterans who served on or after 9/11 and received VA long- term care to have increased at a faster rate than the overall number of veterans who received this care, from fiscal year 2014 through 2018. VA Spending for Long- Term Care Increased 33 Percent from Fiscal Years 2014 through 2018 Our analysis of VA data shows that VA’s spending for long-term care— which VA reports as obligations—increased 33 percent, from $6.8 billion in fiscal year 2014 to $9.1 billion in fiscal year 2018. Furthermore, over this time period institutional program obligations declined as a proportion of total obligations, from 74 percent to 67 percent, while the proportion of noninstitutional program obligations rose from 26 percent to 33 percent. (See fig. 3.) Looking at VA’s three institutional programs, our analysis shows VA’s obligations for these programs increased 21 percent from fiscal years 2014 through 2018, from $5.0 billion to $6.1 billion. The highest share of obligations for institutional care over this time period was for the VA Community Living Centers program, which increased 11 percent, from $3.3 billion to $3.7 billion. This percentage increase was less than the increases for the Community Nursing Homes program (49 percent) and the State Veterans Homes program (33 percent); however, costs for these last two programs are significantly lower than for the other institutional program. VA obligations for its 11 noninstitutional long-term care programs increased 66 percent, from $1.8 to $2.9 billion, between fiscal years 2014 and 2018. Noninstitutional programs with the highest share of obligations during that period included the Homemaker Home Health Aide, Home-Based Primary Care, Purchased Skilled Home Care, and Home Telehealth programs. Noninstitutional programs with the highest obligation increases included the Homemaker Home Health Aide (109 percent) and Purchased Skilled Home Care (164 percent) programs. However, two noninstitutional programs saw obligations decline during these years, including the State Home Adult Day Health Care program with a 59 percent decrease, and the Community Residential Care program with a 10 percent decrease. (See app. II for more information on VA’s obligations for institutional and noninstitutional long-term care by program.) VA Projects Utilization of VA Long-term Care to Increase from Fiscal Years 2017 through 2037 VA projects utilization of long-term care will increase for most of the programs included in VA’s EHCPM from fiscal years 2017 through 2037. For the two institutional programs included in the EHCPM, VA projects that utilization based on workload units (average daily census) will increase by 80 percent for the Community Nursing Homes program but will decrease by 10 percent for the Community Living Centers program. For the 10 noninstitutional programs included in the EHCPM, VA projects that utilization based on workload units (which differ by program) will increase for nine of the 10 programs—with increases ranging from 1 percent to 95 percent. For example, the number of VA clinic stops for the Homemaker Home Health Aide program is projected to increase 84 percent. (See app. III for more information on projected utilization for institutional and noninstitutional long-term care by program.) VA reports that these projections are based on expected increases in the number of veterans who will rely on VA for their long-term care needs through fiscal year 2037. According to VA officials, these projected increases are due to a variety of factors, including that VA plans to continue expanding the availability of home- and community- based care, and plans to provide care to an increasing number of aging veterans and veterans rated in the highest service-connected disability groups. For example, VA data show that the proportion of long-term care provided to veterans with service-connected disabilities is projected to increase from 60 percent to 78 percent of utilization from fiscal year 2017 to 2037, and the proportion of this care provided to post-9/11 deployed combat veterans is projected to increase from 1 percent to 6 percent of all long- term care utilization during these years. Further, VA officials told us that the agency has planned to expand veterans’ access to noninstitutional care when appropriate, and they have integrated these assumptions into the EHCPM. VA Projects Expenditures for Long-Term Care to Increase from Fiscal Year 2017 through 2037, with Noninstitutional Programs Accounting for an Increased Share of Expenditures VA projects that increases in overall demand for long-term care for veterans will result in future expenditure increases for the programs included in VA’s EHCPM. Specifically, VA’s model projects expenditures will more than double from fiscal years 2017 through 2037, increasing from $6.9 billion to $14.3 billion (107 percent). VA projects that its expenditures for its institutional programs will be higher than for its noninstitutional programs, reaching $7.5 billion and $6.8 billion, respectively, by fiscal year 2037. However, VA also projects that the proportion of expenditures for institutional long-term care will decrease from 63 percent to 53 percent, as the share for noninstitutional programs increases. (See fig. 4.) While VA expenditures are projected to increase for all long-term care programs included in the EHCPM from fiscal years 2017 through 2037, the size of these projected increases vary by program. For example, VA projects its expenditures for institutional programs to increase 71 percent overall over this time period, with the VA Community Living Centers program projected to increase 50 percent and the Community Nursing Homes program to increase 149 percent. VA projects that its expenditures for noninstitutional programs will increase 168 percent over this time, with the largest projected increases including the Community Adult Day Health Care (240 percent), Home Respite Care (231 percent), and the Homemaker Home Health Aide (212 percent) programs. (See app. III for more information on projected expenditures for institutional and noninstitutional long-term care by program.) The projected expenditures for care provided to veterans with service- connected disabilities are projected to represent a growing percent of VA’s long-term care expenditures, increasing from 64 percent to 79 percent of expenditures for this care from fiscal years 2017 through 2037. VA projects that its expenditures for care provided to veterans with service-connected disabilities will increase 156 percent during this period, from $4.4 billion to $11.3 billion, while expenditures for care provided to veterans without service-connected disabilities will increase only 19 percent, from $2.5 billion to $3.0 billion. In addition, VA projects that the proportion of spending for long-term care provided to post-9/11 deployed combat veterans will rise from 1 percent to 7 percent during these years, from $89 million to $981 million, as that cohort of veterans ages. VA Has Identified Several Key Challenges to Meeting the Demand for Long-Term Care, but Lacks Measurable Goals for Addressing Them As VA works to meet veterans’ growing demand for long-term care, it faces a number of key challenges: workforce shortages, geographic alignment of care, and difficulty meeting veterans’ needs for specialty care. (See table 1.) These challenges, which VA has identified, are similar to challenges faced by other health care systems. However, while VA’s GEC—the office that manages VA long-term care programs—is aware of these challenges, as of November 2019 GEC’s strategic planning has not identified measurable goals for addressing them. Addressing workforce shortages. According to VA, the agency faces challenges hiring the staff needed to meet veterans’ demand for long-term care, a challenge that is likely to grow as demand for care is projected to increase in coming years. We have previously reported on workforce shortages in key positions—such as nursing assistants and home health aides—that are critical for supporting long-term care programs and affect health care systems beyond VA. Within VA, the Healthcare Analysis and Information Group (HAIG) report found that 80 percent of VA community living centers had, at the time of the report, current vacancies for nursing assistant or health technician positions. These workforce challenges have led to waitlists for some long-term care programs. For example, VA officials told us staffing challenges were the key factor creating a waitlist of 1,780 veterans for the Home-Based Primary Care program. (The HAIG report found 65 percent of VA facilities cited staffing as a barrier to expanding Home- Based Primary Care.) GEC officials recognize these workforce challenges and told us they have developed some workforce strategies such as offering geriatrics training to rural primary care providers through GEC’s Geriatric Scholars Program. Aligning care geographically. According to VA, the agency faces challenges aligning its provided or purchased long-term care with where veterans live. VA data show that 2.8 million VA-enrolled veterans lived in rural areas as of 2018, and that veteran populations have shifted to different geographic regions. Providing long-term care in rural areas is a challenge experienced by other health care systems; for example, a report from the Rural Policy Research Institute identified challenges with providing long-term care in rural areas, including “more limited access to services and support” and the “absence of an adequate workforce and infrastructure.” VA officials also told us that veterans moving from one region to another presents demand and capacity challenges. For example, officials told us that veterans have moved away from the Northeast and to the South, and that VA now has too many long-term care beds in the Northeast and too few in the South. VA officials acknowledged the challenge of aligning care with where veterans live and pointed to telehealth, where veterans can receive care remotely, and to Veteran Directed Care program, which provides veterans with a budget to manage their own care, as approaches that could provide care to veterans in rural areas with limited access to VA provided or purchased care. GEC officials have also identified potential strategies to address the issue; for example, GEC’s strategic planning includes a proposal to expand telehealth geriatrics services to reach more veterans, although officials told us this effort is currently unfunded. Further, VA officials from the Office of Policy and Planning said an ongoing market assessment project will provide information that will help VA align its provided and purchased care with where veterans live to better meet veteran needs. Meeting needs for specialty care. According to VA, the agency faces challenges meeting some specialty care needs for veterans in long-term care. Specifically, it can be difficult to find appropriate long- term care settings for veterans with dementia, behavioral issues, and for veterans requiring a ventilator. Meeting specialty care needs is also a challenge for other health care systems; for example, a 2017 study from the RAND Corporation found that the U.S. health system does not have sufficient capacity to care for a growing number of people with Alzheimer’s disease. Challenges in providing this type of care are not new for VA. For example, in 2013 we reported that VA officials told us that while “in certain geographic areas [community living centers] 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 “these specialized services might not be available in a [community living center] and instead might be available at a community nursing home.” As previously mentioned, VA has developed some programs to provide specialty care (e.g. VA’s Spinal Cord Injury and Disability Care program and the agency’s efforts to educate home caregivers on how to better serve veterans with dementia). While GEC recognizes and has taken some steps to address the challenges it faces in meeting the demand for long-term care, our review of GEC’s most recently approved strategic planning document from March 2019 shows that GEC has not established measurable goals for its efforts to address these three key challenges. GEC has not established measurable goals for its efforts to address workforce shortages, such as specific staffing targets necessary to address the waitlist for the Home-Based Primary Care program, or defining the number of rural providers it expects to train through the Geriatrics Scholar program. GEC has not established measurable goals for its efforts to address the geographic alignment of care, such as specific targets for providing long-term care within the Home Telehealth and Veteran Directed Care programs. GEC has not established measurable goals for its efforts to address difficulties meeting veterans’ needs for specialty care, such as specific targets for the number of available ventilators or the number of caregivers educated to help veterans with dementia. According to GAO’s body of work on effectively managing performance under the Government Performance and Results Act of 1993 (GPRA), as enhanced by the GPRA Modernization Act of 2010, federal agencies should clarify and clearly define measurable outcomes for each strategic objective and assess progress towards those goals. VA officials told us that competing priorities, including implementation of the VA MISSION Act of 2018, have affected GEC’s ability to effectively address challenges to meeting veterans’ long-term care needs. Without measurable goals, however, VA is limited in its ability to better plan for and understand progress towards addressing the challenges it faces meeting veterans’ long-term care needs. As VA works to address these challenges, it does so along with other health care systems, and VA has opportunities for leveraging outside experience through VA’s Geriatrics and Gerontology Advisory Group. For example, the Advisory Group recently acknowledged workforce challenges and recommended that VA “devise strategies to create incentives and identify and remove barriers” for the recruiting and retaining the health care workforce needed to care for VA’s growing geriatric veteran population. In addition to the key challenges that VA and many other health care systems face, VA has identified, but has not planned to take steps to fully address, challenges at the VAMC level that affect its ability to meet veterans’ long-term care needs. Specifically, VA has identified issues with inconsistency in the management of the 14 long-term care programs at the VAMC level that could lead to inefficient and inequitable decisions about long-term care across VA. While VA has identified the steps it can take to address these issues, it has not implemented these steps. First, VA identified that VAMCs do not have a consistent approach to managing VA’s 14 long-term care programs. GEC officials told us that fragmentation of the long-term care programs within the VAMCs—that is, where programs could be run by one or more departments within the VAMC, for example the Nursing department or the Social Work department at VAMCs where there are not GEC staff—hinders standardization and the ability to get veterans the right care. Similarly, the HAIG report found that VAMCs organize their long-term care programs differently and recommended that to “efficiently, reliably, and equitably serve veterans” VA align GEC programs “at all VISNs and eventually VAMCs nationwide.” GEC strategic planning documents outline a goal of alignment within the VISNs, and officials said alignment has been established within the VISNs. However, VA officials told us that, as of October 2019, they had not taken action to pursue VAMC-level alignment with a GEC point of contact at each VAMC that could provide consistency across long-term care programs at the VAMC level. Second, GEC has developed a tool to improve the consistency with which VAMCs determine the amount of services needed for veterans based on their specific health issues. However, as of October 2019, VA has not required the tool be used in all VAMCs. VA has identified that VAMCs do not have a consistent approach to determining the amount of noninstitutional long-term care services veterans need. VA officials told us that, as of October 2019, VAMCs used different methods to assess the amount of noninstitutional long-term care services veterans need—for example, how many hours of in-home care veterans need. As a result, decisions about the amount of services veterans receive may vary by VAMC. The HAIG report recommended that VA use a standardized approach to ensure the “balance of noninstitutional care programs, program reliability, and equity of resource distribution.” GEC officials said the tool they developed is currently being used by some VAMCs, and they expect VA will require the tool to be used by all VAMCs sometime in the next year. However, VA has not set time frames for this requirement. One of VA’s performance goals is to provide highly reliable and integrated care and support and excellent customer service. Furthermore, federal internal controls dictate that federal agencies should exercise oversight responsibility, for example by overseeing the remediation of deficiencies as appropriate and providing direction to management on appropriate time frames for correcting these deficiencies. Although VA has identified steps it can take to improve consistency in long-term care programs, according to officials, it has not prioritized their implementation. Without a reliably consistent approach to administering long-term care programs across its VAMCs, VA may not consistently and equitably meet veteran preferences and needs. Conclusions VA currently faces difficult challenges meeting the demand for long-term care. These challenges—such as addressing workforce shortages, aligning care geographically, and meeting specialty care needs—are likely to intensify as veterans’ demand for long-term care grows. However, a lack of measurable goals in the strategic planning efforts of VA’s GEC, which has the lead responsibility for managing VA’s 14 long- term care programs, affects VA’s ability to appropriately plan for and understand its progress towards addressing long-term care challenges. In addition to these key challenges, VA has identified, but not yet fully addressed, inconsistencies in the management of the 14 long-term care programs at the VAMC level. These inconsistencies in determining both the best program for veterans and the amount of noninstitutional care veterans need can lead to inefficient and inequitable experiences with VA’s long-term care programs. Recommendations for Executive Action We are making the following three recommendations to VA: The Secretary of VA should direct GEC leadership to develop measurable goals for its efforts to address key long-term care challenges: workforce shortages, geographic alignment of care, and difficulty meeting veterans’ needs for specialty care. (Recommendation 1) The Secretary of VA should direct GEC leadership to set time frames for and implement a consistent GEC structure at the VAMC level. (Recommendation 2) The Secretary of VA should direct GEC leadership to set time frames for and implement a VAMC-wide standardization of the tool for assessing the noninstitutional program needs of veterans. (Recommendation 3) Agency Comments We provided a draft of this report to VA for review and comment. In its comments, reproduced in appendix IV, VA concurred with our three recommendations and identified actions it is taking to implement them. Specifically, VA said that it will: (1) take steps to incorporate measurable goals and defined timelines into its strategies to meet the long-term care challenges; (2) work to establish a time frame for the execution of a uniform GEC structure at the VAMC level; and (3) work to establish a time frame for the execution of a VAMC-wide standardized tool for evaluating non-institutional care needs for veterans. VA also provided technical comments that we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretary of the Department of Veterans Affairs, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at silass@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix V. Appendix I: Department of Veterans Affairs’ (VA) Institutional and Noninstitutional Long- Term Care Program Descriptions VA provides or pays for long-term services and supports, or long-term care, for eligible veterans through a range of three institutional and 11 noninstitutional programs. VA covers the full or partial cost of nursing home care for eligible veterans who require skilled nursing home care in an institutional program. Specifically, VA covers the full cost of nursing home care for veterans who need this care for a service-connected disability—which is an injury or disease that was incurred or aggravated while on active duty—and for veterans with service-connected disabilities rated at 70 percent or more. To the extent resources allow, VA may cover this care for certain other veterans, such as former prisoners of war and those awarded the Purple Heart. For all other veterans, VA may cover nursing home care to the extent resources and capacity allow and with the veteran’s agreement to share certain costs. (See table 2 for more information about these programs.) In addition, all veterans enrolled in the health care system are eligible for VA’s basic medical benefits package, which covers, among other things, a comprehensive array of medically necessary home- and community- based health services. While a veteran’s priority for care generally determines whether these services are provided at full or partial cost, the VA may not charge a copay for home hospice care and may waive copays for home telehealth services. (See table 3 for more information about these programs.) A veteran’s placement in a particular program may depend on their clinical needs, preferences, and the availability of VA funding and programs. Appendix II: Utilization and Obligations for Department of Veterans Affairs’ (VA) Long- Term Care Programs, Fiscal Years 2014 to 2018 Subtotal institutional programs Noninstitutional programs (workload units in thousands) Homemaker Home Health Aide 9,999 8,328 11,136 Home-Based Primary Care 1,671 1,755 1,599 Purchased Skilled Home Care Home Telehealth payment for a Home Hospice Care program visit from a community provider. The units for each program may differ. VA officials told us that these data do not include non-veterans and may differ from data included in VA’s congressional budget justification for a variety of reasons, including the timing of when they looked at the data, the inclusion of additional data, and that VA used a standard definition of services for all years. In addition to these programs, VA may provide stipends or other services to caregivers for veterans who were seriously injured in the line of duty through the Caregiver Support program. Disabled veterans may also be eligible for increased compensation benefits from the Veterans Benefits Administration. Program Institutional programs VA Community Living Centers Community Nursing Homes Appendix III: Projected Utilization and Expenditures for Department of Veterans Affairs’ (VA) Long-Term Care Programs, Fiscal Years 2017 through 2037 Appendix III: Projected Utilization and Expenditures for Department of Veterans Affairs’ (VA) Long-Term Care Programs, Fiscal Years 2017 through 2037 these data do not include non-veterans and may differ from data included in VA’s budget request for a variety of reasons, including the timing of when they looked at the data, the inclusion of additional data, and that VA used a standard definition of services for all years. Program Institutional programs VA Community Living Centers Appendix IV: Comments from the Department of Veterans Affairs Appendix V: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments Sharon M. Silas, (202) 512-7114 or silass@gao.gov In addition to the contact named above, Karin Wallestad (Assistant Director), Luke Baron (Analyst-In-Charge), Kye Briesath and Corinne Quinones made key contributions to this report. Also contributing were Laurie Pachter, Vikki Porter, Jennifer Rudisill, and Selah Myers. Related GAO Reports Veterans Affairs: Sustained Leadership Attention Needed to Address Long-Standing Workforce Problems, GAO-19-720T (Washington, D.C.: Sept. 18, 2019). Veterans Health Care: VA Needs to Improve Its Allocation and Monitoring of Funding, GAO-19-670 (Washington, D.C.: Sept. 23, 2019). VA Health Care: Actions Needed to Improve Family Caregiver Program, GAO-19-618 (Washington, D.C.: Sept. 16, 2019). Veterans Health Care: Opportunities Remain to Improve Appointment Scheduling within VA and through Community Care, GAO-19-687T (Washington, D.C.: July 24, 2019). VA Health Care: Estimating Resources Needed to Provide Community Care, GAO-19-478 (Washington, D.C.: June 12, 2019). VA Real Property: Improvements in Facility Planning Needed to Ensure VA Meets Changes in Veterans’ Needs and Expectations, GAO-19-440 (Washington, D.C.: June 13, 2019). VA Nursing Home Care: VA Has Opportunities to Enhance Its Oversight and Provide More Comprehensive Information on Its Website, GAO-19-428 (Washington, D.C.: July 3, 2019). Long-Term Care Workforce: Better Information Needed on Nursing Assistants, Home Health Aides, and Other Direct Care Workers, GAO-16-718 (Washington, D.C.: Aug. 16, 2016). VA Mental Health: Clearer Guidance on Access Policies and Wait-Time Data Needed, GAO-16-24 (Washington, D.C.: Oct. 28, 2015). VA Nursing Homes: Reporting More Complete Data on Workload and Expenditures Could Enhance Oversight, GAO-14-89 (Washington, D.C.: Dec. 20, 2013). Older Americans: Continuing Care Retirement Communities Can Provide Benefits, but Not Without Some Risk, GAO-10-611 (Washington, D.C.: June 21, 2010). VA Health Care: Long-term Care Strategic Planning and Budgeting Need Improvement, GAO-09-145 (Washington, D.C.: Jan. 23, 2009).