Veterans Care

VETERANS CARE

Since the 1970s, the U. S. Department of Veterans Affairs (VA) has responded to a vital demographic trend: Although the total number of veterans is declining, the proportion of older veterans is increasing dramatically. In addition, the proportion of older persons in the veteran population far exceeds the proportion of older persons in the U.S. population in general. Anticipating the needs of a rapidly aging veteran population, VA initiated a comprehensive, three-pronged plan encompassing clinical services, research, and education and training. In meeting the challenge of this aging imperative, VA has become recognized as a national leader in the development and implementation of innovative health care services for older persons (Cooley, Goodwin-Beck, and Salerno). This entry summarizes VA’s mission and health care service delivery structure; demographic trends in the veteran population; VA’s aging-related clinical programs, research, and health care provider education and training; and examples of emerging VA initiatives in aging.

Mission and service delivery structure

VA’s mission is to serve America’s veterans (individuals who have been honorably discharged from U. S. military service) in three major areas: health care, which is coordinated by the Veterans Health Administration (VHA); socioeconomic support and assistance, coordinated by the Veterans Benefits Administration; and burial services, coordinated by the National Cemetery Administration.

VHA operates the largest health care system in the nation, encompassing 172 hospitals, 132 nursing home care units, 40 domiciliaries, and over 600 outpatient clinics. VHA also contracts for care in non-VA hospitals and in community nursing homes, provides fee-for-service visits by non-VA physicians and dentists for outpatient treatment, and supports care in one hundred state veterans homes in forty-seven states.

Since 1995, VHA has undergone a major reorganization. There are twenty-two regional Veterans Integrated Service Networks (VISNs), each comprised of from five to eleven facilities. The VISN, rather than the individual medical center, is the basic planning and budgetary unit of health care delivery in the new VHA structure. VISNs are responsible for providing a coordinated continuum of care for veterans treated in each network of facilities and for supporting research and health profession education activities. Key domains of health care value in which VISN performance is measured include access to care, quality of care, patient satisfaction, patient functional status, and cost-effectiveness.

In addition, VHA has shifted from an inpatient, hospital bed-based system to outpatient, primary, and ambulatory care. There is increased emphasis on noninstitutional settings such as outpatient clinics, home-based services, and other ambulatory and community-based venues.

Demographic trends

In 2000, the median age of veterans was fifty-seven years (U. S. Department of Veterans Affairs), compared to only thirty-six years for the general U. S. population (Administration on Aging). Over 37 percent of the veteran population (9.5 million of the total 25.5 million veterans) was age sixty-five or older, compared to 13 percent of the general population. By 2020, nearly half of the entire veteran population (7.6 million, or 45 percent, of the total 16.9 million veterans) will be age sixty-five or older. Although most veterans are male, the number of female veterans is growing. In 2000, over 5 percent (1.4 million) of all veterans and 3 percent (325,000) of veterans age sixty-five or older were female. By 2020, over 9 percent (1.6 million) of all veterans and 4 percent (316,000) of veterans age sixty-five or older will be female. Among female veterans, the proportion age sixty-five or older was 23 percent in 2000 and is projected to be 20 percent in 2020. As in the general U.S. population, the ‘‘old-old’’ are the fastest-growing segment of the veteran population. By 2020, 6 percent of all veterans and 13 percent of veterans age sixty-five or older will be age eighty-five or older (1.1 million). Thus, VA will continue to encounter a very large group of potentially frail, older veterans in the next twenty years.

Clinical programs in aging

Typically, older persons have higher use of health care services, including increased number of physician visits, short-term hospital stays, number of days in the hospital, and greater need for long-term care services. Anticipating these needs, VA has developed a broad continuum of geriatrics and extended care services that are provided in a wide variety of settings, including home and the community, outpatient clinics, hospitals, and nursing homes. Together these programs provide preventive, acute, rehabilitative, and extended care on an outpatient and inpatient basis. Home- and community-based programs are emphasized, with coordinated use of hospital and nursing home programs. The shared purpose of these programs is to prevent or lessen the burden of disability on older, frail, chronically ill patients and their families, and to maximize each veteran’s functional independence.

Several innovative home- and communitybased services are offered. These include Home-Based Primary Care (HBPC), which provides in-home primary medical care to veterans with chronic illnesses. A home-based, interdisciplinary treatment team prescribes medical, nursing, social, rehabilitation, and dietetic regimens and provides training in supportive care to the patient and family caregivers. In addition, VA’s homemaker/home health aide program enables selected patients who meet criteria for nursing home placement to remain at home through the provision of personal care services purchased by VA from public and private agencies in the community, with case management provided directly by VA staff. VA also offers Adult Day Health Care, which provides health maintenance and rehabilitation services to veterans in a congregate, outpatient setting during daytime hours. This program uses a medical model of services, which in some circumstances may be a substitute for nursing home care. Another communitybased program is Community Residential Care/ Assisted Living, in which private homes provide room, board, personal care, and general healthcare supervision, at the veteran’s expense. Veterans in this program do not require hospital or nursing home care, but because of health conditions, they are not able to live independently and have no suitable support system to provide needed care. All residential care homes are regularly inspected by a multidisciplinary team of VA staff, and veterans in this program receive monthly visits from VA health care professionals who monitor the care provided in the home.

VA Domiciliaries are residential rehabilitation and health maintenance centers for veterans who do not require hospital or nursing home care but are unable to live independently because of medical or psychiatric disabilities. Veterans receive medical and psychiatric care, rehabilitative assistance, and other therapeutic interventions on an outpatient basis from the host hospital, while residing in the structured, therapeutic, homelike environment of the domiciliary. There are specialized, interdisciplinary treatment programs for rehabilitation of head trauma, stroke, mental illness, chronic alcoholism, heart disease, and a wide range of other disabling conditions. For some veterans, domiciliary care can help prepare for return to independent or semi-independent community living.

In the area of geriatric assessment, VA pioneered the concept of the Geriatric Evaluation and Management (GEM) program, which includes inpatient units, outpatient clinics, and consultation services. An interdisciplinary health care team provides comprehensive, multidimensional evaluations for a targeted group of older patients with multiple acute and chronic diseases, functional impairments, and psychosocial problems.

For veterans in need of skilled nursing care and related medical services, there are VA hospital–based nursing home care units. These units employ an interdisciplinary care approach to meet the multiple physical, social, psychological, and spiritual needs of patients. Many also provide sub-acute and post-acute care.

All VA facilities have a hospice consultation team, which coordinates a hospice and palliative care program of pain management, symptom control, and other medical services to terminally ill veterans, as well as bereavement counseling to their families. In addition, VA provides respite care to relieve spouses or other caregivers from the burden of caring for a chronically disabled veteran at home. Respite is provided for planned, brief periods of care in a variety of settings, including the veteran’s home, community nursing home, or VA hospital or nursing home.

Veterans with Alzheimer’s disease or other dementias participate in the full range of VA services, including in-home, community-based, and institutional-based acute and extended care services. In addition, some VA facilities have developed specialized inpatient or outpatient dementia services for diagnosis; management of comorbid medical, emotional, and behavioral problems; or palliative care. Programs for family caregivers of persons with dementia include support groups and caregiver education.

Research in aging

VHA is one of the nation’s largest research organizations, with a research appropriation from Congress of $316 million in 1999.

A cornerstone of VA’s response to its ‘‘aging imperative’’ is the Geriatric Research, Education and Clinical Center (GRECC) program, which began in 1975. As centers of excellence in geriatrics, GRECCs’ mission is to improve the health and care of older veterans through research, training and education, and the development and evaluation of innovative models of care. GRECCs are widely recognized as having provided leadership in geriatrics and gerontology, both within VA and throughout the nation (Goodwin and Morley). In 2000, there were twenty GRECCs across the VA system, each with a specific programmatic focus (e.g., osteoarthritis and osteoporosis; stroke rehabilitation, neurobiology and management of dementia; prostate disease; falls and instability; exercise in frail elderly; end of life care).

VA also funds a wide range of aging-related research, including basic biomedical, applied clinical, rehabilitation, and health services topics, as well as cooperative studies involving multiple VA sites. Aging is one of nine designated research areas used to prioritize VA research funding. In addition to individual investigator awards, VA supports aging research at Health Services Research and Development Centers of Excellence and at Rehabilitation Research and Development Centers. In 1999, VA provided $19.9 million for 150 aging-related research projects. VA investigators received another $33.8 million from non-VA sources to support another 339 aging-related research projects.

Education and training in aging

VA conducts the nation’s largest coordinated education and training effort for health care professionals, with over 100,000 health profession students receiving clinical training in VA facilities annually, including the GRECCs and other geriatrics and extended care settings described above. VA’s creation of a physician fellowship program in geriatric medicine in the 1970s played a significant role in the later recognition of geriatric medicine as a specialty in the United States (Goodwin and Morley). In addition, VA has developed a wide range of other fellowships and specialty training in geriatrics for psychiatrists, dentists, nurses, psychologists, and other associated health professions. VA also pioneered the concept and practice of interdisciplinary team training in geriatrics. In addition to student training, VA also provides aging-related continuing education for professional staff from VA and the community on a regular basis.

New initiatives in aging

In 2000, an area of intense focus within VA was the integration of primary care, geriatrics, and mental health. One initiative is the Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) project, in which elderly patients with symptoms of depression, anxiety, and substance abuse in VA medical and surgical hospital settings are evaluated by an interdisciplinary psychogeriatric team and followed by care coordinators on an outpatient basis. Preliminary results indicate cost savings from fewer hospital days for patients managed in this way. A second initiative is the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISMe) project, a four year controlled study cosponsored by VA and the U. S. Department of Health and Human Services. Eleven sites, including five VA-funded sites, will compare two models for delivering mental health and substance abuse services to older adults in primary care settings: One model uses an integrated team of primary care and mental health/ substance abuse professionals, and the other uses referrals to specialty mental health/substance abuse care. A key question to be examined is under what conditions are integrated or referral models most effective in terms of access, treatment adherence, patient outcomes, and cost. A third initiative in this area is the VA’s Primary Care Multidisciplinary Education Committee (PCMEC). In 2000, PCMEC identified over twenty-five innovative and promising models of integrated primary care, mental health, and geriatrics at VA facilities. A variety of educational activities will be developed to evaluate and disseminate best practices from these model programs.

Other innovative projects are underway in the area of dementia care. One is the Chronic Care Networks for Alzheimer’s Disease (CCN/ AD) project, co-sponsored by the National Chronic Care Consortium and the Alzheimer’s Association. VA’s Upstate New York Healthcare Network (VISN 2) is among seven partnerships of health care organizations and Alzheimer’s Association chapters that are testing new, integrated approaches to serving persons with dementia and their families through networks of primary, acute, and long-term care. A set of clinical tools has been developed to facilitate dementia diagnosis and care management in the CCN/AD study sites. A second dementia project is Advances in Home-Based Primary Care for End of Life in Advancing Dementia (AHEAD). Begun in 2000, this project will involve approximately fifteen VA HBPC teams using a rapid cycle change process to improve end of life care at home for individuals with dementia.

In 2000, other significant initiatives were underway as part of the implementation of Public Law 106–117, the Veterans Millennium Healthcare and Benefits Act, which was passed by Congress in November 1999. This major legislation includes numerous provisions related to VA long-term care services, such as inclusion of certain noninstitutional extended care services in the medical benefits package and specification of priority groups for nursing home care.

Conclusion

As VA enters the new millennium, health care needs of older veterans remain a high priority. Through its early and continued response to a demographic aging imperative, VA has demonstrated leadership in geriatric research, clinical program development, and professional education. VA’s health care network structure presents great opportunities for comprehensive, coordinated care and evaluation of innovative service delivery models. Lessons learned from VA’s past and future aging initiatives will benefit veterans and their families as well as all older Americans.

Susan G. Cooley Judith A. Salerno

See also Geriatric Medicine; Long-term Care.

BIBLIOGRAPHY

Administration on Aging. ‘‘Resident Population of the United States: Estimates by Age.’’ 2000. Based on 1990 U. S. Census. Available on the World Wide Web at www.aoa.gov

Cooley, S. G.; Goodwin-Beck, M. E.; and Salerno, J. A. ‘‘United States Department of Veterans Affairs Health Care for Aging Veterans.’’ In Geriatric Programs and Departments Around the World. Edited by B. Vellas, J. P. Michel, and L. Z. Rubenstein. New York: Springer Publishing Co., 1998. Pages 183–198.

Goodwin, M., and Morley, J. E. ‘‘Geriatric Research, Education and Clinical Centers: Their Impact in the Development of American Geriatrics.’’ Journal of the American Geriatrics Society 42 (1994): 1012–1019.

Kizer, K. W. ‘‘Geriatrics in the VA: Providing Experience for the Nation.’’ Journal of American Medical Association 275, no. 17 (1996): 1303.

U.S. Department of Veterans Affairs. Vet Pop 2000. (version 2.07, 30 September 2000) [Data file]. Available on the World Wide Web at www.va.gov