SENATORS

ROBERT B. MENSCH Chairman JAMES R. BREWSTER Vice Chairman MICHELE BROOKS THOMAS McGARRIGLE CHRISTINE TARTAGLIONE JOHN N. WOZNIAK REPRESENTATIVES

ROBERT W. GODSHALL Secretary JAKE WHEATLEY Treasurer STEPHEN E. BARRAR JIM CHRISTIANA SCOTT CONKLIN PETER SCHWEYER EXECUTIVE DIRECTOR

PHILIP R. DURGIN

Pennsylvania’s Current and Future Need for Long-term Care

Services for Veterans

Conducted Pursuant to Senate Resolution 2015-171

May 2016

Legislative Budget and Finance Committee

A JOINT COMMITTEE OF THE PENNSYLVANIA GENERAL ASSEMBLY Offices: Room 400 Finance Building, 613 North Street, Harrisburg

Mailing Address: P.O. Box 8737, Harrisburg, PA 17105-8737 Tel: (717) 783-1600 • Fax: (717) 787-5487 • Web: http://lbfc.legis.state.pa.us

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Table of Contents

Page

Report Summary .......................................................................................... S-1

I. Introduction ....................................................................................... 1

II. The Impact of Pennsylvania’s Changing Veterans Population on State Veterans’ Homes ................................................................. 3

A. How Many Veterans in Each County Are Waiting to Be Placed in a State Veterans’ Care Facility? ................................................................ 3

B. How Many Veterans in Pennsylvania Are Eligible for Care From the Department of Military and Veterans Affairs and the United States Department of Veterans Affairs? ............................................................ 7

C. What Is the Average Cost Per Day of the Care and Treatment for a Veteran at State-owned Veterans’ Care Facilities? ................................ 14

D. What Is the Average Cost Per Day for the Care and Treatment for a Veteran at a Privately-owned Health Care Facility? ............................... 17

E. How Many Veterans Will Need Care Over the Next 10 Years Within This Commonwealth? ............................................................................ 18

F. A Summary of Other States and Their Respective Programs That Allow for Public-Private Partnerships With the United States Department of Veterans Affairs to Offer Additional Care for Veterans. .. 21

G. What Types of Health and Medical Care Need to Be Provided and How Is It Expected to Change Over the Next 10 Years? ....................... 23

H. What Types of Veterans Will Need to Be Served Over the Next 10 Years and How Will That Population of Veterans Be Different From Traditional Populations of Veterans Based on Age, Sex, and Conditions to Be Treated? ...................................................................... 25

I. Additional Opportunities That Exist to Enhance and Improve the Care for Veterans at Either a State-owned or Privately-owned Facility. .......... 26

III. Appendices ........................................................................................ 33

A. Senate Resolution 2015-171 ................................................................... 34

B. Number of State Veterans’ Homes Per State .......................................... 37

C. State Veterans’ Home Program: FY 16 Per Diem Rates for Selected Veterans Under Pub.L. 112-154, Section 105 ......................................... 38

D. Response to This Report......................................................................... 41

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Summary and Recommendations

Senate Resolution 171 directs the Legislative Budget and Finance Committee to assess Pennsylvania’s changing veterans’ population, its impact on Pennsylva-nia’s six State Veterans’ Homes, and how private facilities might be used to supple-ment the services provided at the homes.

We found: As of the end of March 2016, the Pennsylvania Department of Military

and Veterans Affairs (DMVA) had a waiting list of 223 individuals waiting for a State Veterans’ Home bed, 107 of whom were veterans and 116 non-veterans. DMVA also reported having 236 vacant beds at the state veter-ans’ facilities. If nonveterans and personal care beds are taken out of the equation, then there are 99 veterans waiting for a bed, with 163 nursing home (skilled/dementia) beds available. The reason the State Veterans’ Homes have both a waiting list and vacant beds is primarily due to loca-tion; most veterans on the waiting list live in the southeastern, northwest-ern, or southwestern corners of the state, and most empty beds are at the Hollidaysburg Veterans’ Home (Huntington County). Also, DMVA has been undergoing construction projects that have temporarily increased the number of vacant beds.

Although the number of veterans aged 65 and older living in Pennsylvania is projected to decrease by 36 percent over the next 20 years (from 473,382 in 2015 to 301,182 in 2035), the number of veterans aged 85 and older will increase by 8 percent, from 82,833 in 2015 to 89,078 in 2035. It is not a straight-line increase, however, as the number of Pennsylvania veterans aged 85 and older will decrease somewhat until 2025, followed by an in-crease between 2025 and 2035 as the Vietnam veteran generation begins to attain octogenarian status.

Population Trend of PA Veterans Aged 65+

-

100,000

200,000

300,000

400,000

500,000

2015 2020 2025 2030 2035

65-74 75-84 85+ Total aged 65+

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The need for additional nursing home and personal care beds for veterans aged 85 plus will, however, be more than offset by the much lower number of veterans in the 65-84 year old category, which will drop by 46 percent, from 391,000 in 2015 to 212,000 in 2035.

We estimate the number of Pennsylvania veterans aged 65 and older needing a nursing home or personal care bed will drop over the next 20 years as follows:

Estimated Number of Pennsylvania Veterans Aged 65+

Needing a Nursing Home or Personal Care Bed

2015 2025 2035 PA Vets Aged 65+ Needing Nursing Home Care .................. 14,871 12,625 11,071 PA Vets Aged 65+ Needing Personal Home Care ................ 7,371 6,291 5,331

These estimates are based on national studies on the nursing home and per-sonal care home needs of U.S. citizens (not just veterans) in various age groups and on estimates of the number of persons living in nursing homes and personal care homes in Pennsylvania (see page 8).

When originally created, State Veterans’ Homes were intended to serve veterans in financial need. Today, DMVA uses a first come, first served approach for admissions, using financial need only as a measure to deter-mine the ability to pay. However, veterans with financial net worth of over $80,000 must pay the full cost of care (i.e., both the veteran and state portion). We estimate the number of Pennsylvania veterans aged 65 and older with a financial net worth of less than $80,000 (and therefore eligi-ble for state assistance at a State Veterans’ Home) to be as follows:

2015 PA Vets Aged 65+ Needing Nursing Home Care with Net Worth Below $80,000 ................................................ 2,633

PA Vets Aged 65+ Needing Personal Home Care with Net Worth Below $80,000 ............................................... 1,305

Pennsylvania’s State Veterans’ Homes currently have a capacity of 1,246

nursing home/dementia beds and 362 personal/domiciliary care beds. Some of the veterans needing nursing home or personal home care will, however, qualify for care at a U.S. Department of Veterans Affairs (USDVA) facility. The USDVA has 662 Community Living Center (nurs-ing home) beds in six different facilities across Pennsylvania and contracts for approximately 575 additional nursing home beds through its Commu-nity Nursing Home program. The USDVA also provides for personal

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home/domiciliary care for veterans with specific needs. Additionally, some low-income veterans will qualify for nursing home care through the Medi-caid (Medical Assistance) program.

Despite acknowledging a future surplus of nursing home beds at the State Veterans’ Homes (when USDVA beds are factored in), a 2009 report com-missioned by the DMVA recommended three new State Veterans’ Homes be built to address the maldistribution of beds geographically. The three areas in which they recommended new homes be build are northcentral, southcentral, and Lehigh Valley/Reading.

The DMVA believes the demand for State Veterans’ Home beds has been limited due largely to a lack of marketing and the lack of a State Veterans’ Home in some regions of the Commonwealth, particularly the southcen-tral region. The DMVA has submitted a proposal, which was included in the FY 2007-08 Capital Budget, to build a new State Veterans’ Home in either Dauphin or Lebanon County. The total estimated cost of the pro-ject is $87 million dollars. The USDVA share (65 percent) would be ap-proximately $56.5 million and the state share (35 percent) would be $30.4 million). Such funds, however, have not yet been authorized.

The DMVA has also submitted a Capital Budget request for $22.9 million (to be matched with federal funds of $42.6 million) to construct, furnish, and equip a new 200-bed Community Living Center (nursing home) facil-ity to replace the Hollidaysburg Veterans’ Home. The current Hol-lidaysburg home, with a capacity of 339 nursing/dementia beds, is an adapted State Hospital originally constructed in the early 1950s.

Pennsylvania’s six State Veterans’ Homes have an average per diem cost of $350. The basic State Veterans’ Home per diem rate paid by the USDVA for nursing home care is $103.61, resulting in unreimbursed costs of $246, of which approximately $175 is paid for by the Commonwealth, with the remainder paid for by other sources such as Medicaid and USDVA Aid and Attendance payments to residents. In percentage terms, the USDVA pays approximately 27 percent of the average per diem, and the DMVA (General Fund) approximately 45 percent, with the veteran and other sources paying approximately 28 percent.

Actual expenditures for Pennsylvania’s State Veterans’ Homes totaled $184.2 million in FY 2014-15; $82.4 million state, $68.5 million federal, and $33.2 million in augmentations (includes items such as federal veter-ans Aid and Attendance payments to residents, third-party insurance re-imbursements, and estate collections). By FY 2016-17, state costs are pro-jected to increase by 27 percent, to $104.7 million. The DMVA notes that over the past several years it has undertaken a variety of cost-saving measures, particularly with regard to right-sizing staffing at the homes and reducing overtime and workers’ compensation costs, with cost savings

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totaling $22.1 million for the three-year period FY 2011-12 through FY 2013-14.

The USDVA is mandated to provide nursing home care to veterans with a service-connected disability rating of 70 percent or greater. In 2014, Pennsylvania was home to about 30,700 such veterans. The USDVA also provides nursing home care to less disabled veterans on a discretionary basis, mostly through State Veterans’ Homes.

The USDVA contracts with private nursing homes to provide a portion of their long-term care nursing services. In 2012, the USDVA provided care to about 575 veterans in 76 private community nursing homes across Pennsylvania at an average cost of $303 per day. Pennsylvania’s average (unweighted) Medicaid rate for a private nursing home is $201 per day.

We did not find any states that have developed public-private partner-ships with the USDVA to provide nursing home care to veterans in pri-vate nursing homes as an alternative to a State Veterans’ Home.

Additional opportunities to improve care for veterans needing nursing or per-

sonal home levels of care include: Adult Day Health Care. Adult Day Health Care is a program funded by the

USDVA that veterans can go to during the day for social activities, peer support, companionship, recreation, and certain medical services. The DMVA reported it is considering establishing an Adult Day Health Care (ADHC) program at several of the State Veterans’ Homes, depending on the funds allocated to this program by the USDVA.

New Construction. A new 32-bed dementia care unit was opened at the

Pennsylvania Soldiers’ and Sailors’ Home (Erie) in 2007, and a new 120-bed Com-munity Living Center was opened at the Southeastern Veterans’ Center (Spring City) in 2012. Additionally, the DMVA has submitted a request for $22.9 million in state funds (to be matched by $42.6 million in federal funds) to construct and fur-nish a new 200-bed Community Living Center (nursing home) facility to replace the Hollidaysburg Veterans’ Home. A new State Veterans’ Home, to be located in either Dauphin County or Lebanon County, was included in the FY 2007-08 Capital Budget, but these funds have not yet been authorized.

Converting Personal Care Beds to Skilled Care Beds. The DMVA has con-verted personal care beds to skilled nursing beds at several State Veterans’ Homes, and in FY 2017-18, the Delaware Valley Veterans Home (DVVH) is scheduled to transition to 100 percent skilled care.

Improving the Quality of Care at the Existing State Veterans’ Homes. One

Pennsylvania State Veteran’s Home (Gino Merli) received a rating of 2 stars out of 5 in the most recent U.S. Department of Health and Human Services review, and one

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received a rating of only 1 star (Southeastern). While it was not within the scope of this study to conduct an operational review of the State Veterans’ Homes, there would appear to be opportunities for improvement in the operations of at least sev-eral of the homes.

Privatizing some or all operations at the State Veterans’ Homes. Several

states have privatized some or all of the operations of their State Veterans’ Homes. While the DMVA has taken some steps toward privatizing some services (e.g., ther-apy, some medical services, barber/beautician, and transportation), there would ap-pear to be opportunities to achieve savings through the privatization of at least some additional functions (e.g., financial billing, food service, laundry, and addi-tional nursing services).

Recommendations

We recommend: 1. The DMVA take the lead in contacting the USDVA regarding piloting a

PACE program in Pennsylvania. PACE (Program of All-Inclusive Care for the Elderly) is a Medicare option that helps the elderly (both veterans and nonveterans) to live independently instead of in a nursing home.1 The USDVA has partnered with PACE providers in several states to pro-vide services to veterans.

In Pennsylvania, AlbrightLIFE worked with the Lebanon VA to provide PACE services to Pennsylvania veterans. The individual we spoke with at AlbrightLIFE noted that providing care to veterans through the PACE program cost about $3,300 a month, compared to $8,000-$10,000 a month for nursing home care. She also noted, however, that the parameters the USDVA placed on their pilot program were very restrictive (they could only serve veterans with a 100 percent service-connected disability), and they no longer receive funding from the Lebanon VA to offer this service.

2. The DMVA consider privatizing more of the functions performed at State

Veterans’ Homes. Some states, such as California and Oregon, appear to have had success in privatizing all or key (e.g., financial billing and food service) State Veterans’ Home functions. The DMVA has privatized some limited services (e.g., transportation, barber/beautician, and some medical services). A detailed review of what additional functions, if any, could be performed more efficiently at the State Veterans’ Homes was, however, beyond the scope of this study.

                                                            1 This is different from the PACE (Pharmaceutical Assistance Contract for the Elderly) program most Pennsyl-vanians are familiar with.

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We recommend the DMVA contact at least several states that have privat-ized some or all of the operations of their State Veterans’ Homes and con-duct a preliminary assessment to identify those additional functions that appear most promising in terms of potential savings if privatized. We rec-ommend the DMVA conduct a more formal assessment of the most prom-ising possibilities and, depending on the outcomes, solicit bids from pri-vate companies to undertake these functions.

3. The DMVA consider creating a pilot program to assess the feasibility of providing services in private nursing homes. The USDVA contracts with private nursing homes when a veteran needs services that USDVA facili-ties cannot provide or when no nearby USDVA facility is available. We recommend the DMVA explore the feasibility of establishing a similar pro-gram in areas of Pennsylvania not served by a State Veterans’ Home (northcentral, southcentral, and/or Lehigh Valley/Reading). Current USDVA rules prevent the USDVA from paying private nursing homes the per diem paid to State Veterans’ Homes ($104), so to be affordable, the target rate for providing such care would need to be no more than $246 per day. Though significantly lower than the current average per diem rate of $350 at the State Veterans’ Homes, $246 is well above the average Medicaid rate of $201 per day paid to Pennsylvania nursing home provid-ers in 2014. Due to the potential demand (and therefore potentially high costs), we recommend the pilot program initially be limited to perhaps two or three nursing homes, simply to test the feasibility of the concept. Such a modest pilot could be paid for without incurring new General Fund obli-gations if savings could be generated, for example, through the privatiza-tion of certain State Veterans’ Home functions (see the above recommen-dation) and re-directed toward this program. DMVA should also assess the feasibility of leasing part or all of an exist-ing nursing home to provide additional beds in underserved areas of the Commonwealth. The USDVA’s Office of General Counsel has informed us that, if a state leases space in a private nursing home, the USDVA could recognize the leased space as a state home if the home meets all USDVA requirements.

4. If a decision is made to construct a new State Veterans’ Home in south-central Pennsylvania, the DMVA consider contracting out management of that home to a private entity. Managing a large facility such as a State Veterans Home with unionized, Civil Service employees is challenging, es-pecially with regard to hiring and maintaining the personnel required to provide medical services. While transitioning management of an existing State Veterans’ Home to a private firm presents difficulties that may ren-der it infeasible, the opening of a new veterans’ home would not require the same type of difficult actions, such as furloughing existing employees.

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If DMVA is then not satisfied with the private operator, it could seek a new contractor or transition some or all of the operations to state employ-ees.

5. The DMVA initiate a joint effort to identify veterans who are currently in

a Pennsylvania nursing home or who are nearing a stage in life when they might need nursing home care services to ensure they are receiv-ing all the federal veteran benefits to which they are entitled. Many vet-erans are unaware of all the benefits they can receive through the USDVA or are discouraged by the complicated requirements to receive these bene-fits. The Aid and Attendance and Housebound Improved Pension benefit, which can cover the costs of caregivers in the home or be used for assisted living or a nursing home, are two of these lesser-known benefits. We rec-ommend the DMVA work with the Departments of Aging, Health, and Human Services and the Commonwealth’s various veterans service organ-izations to identify veterans who may be eligible for these and other fed-eral benefits and to initiate an outreach program to work with these veter-ans to obtain these benefits. While most of the benefit of this effort would probably accrue to individual veterans, the Commonwealth could also stand to benefit financially as the result of additional federal dollars com-ing into the state or veterans receiving services at home that allow them to postpone entering a nursing home. The DMVA has indicated its sup-port for such a program, provided that sufficient additional funding, per-haps through the Lottery Fund, is allocated to the effort.

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I. Introduction

Senate Resolution 2015-171 called on the Legislative Budget and Finance Committee to conduct a study relating to the feasibility and cost-effectiveness of uti-lizing privately-owned veterans care facilities to augment the Commonwealth’s six state-owned veterans care facilities. (See Appendix A).

Study Objectives

As described in the resolution, the study objectives were to include:

1. The number of veterans in each county waiting to be placed in state veterans care facilities.

2. The number of veterans in Pennsylvania eligible for care from the Department of Military and Veterans Affairs and the United States Department of Veterans Affairs.

3. The average cost per day of the care and treatment for a veteran at State-owned veterans care facilities.

4. The average cost per day of the care and treatment for a veteran at a privately owned health care facility.

5. The projected number of veterans who will need care over the next 10 years within this Commonwealth.

6. A summary of other states and their respective programs that allow for public-private partnerships with the United States Department of Veterans Affairs to offer additional care for veterans.

7. The types of health and medical care to be provided and how it is expected to change over the next 10 years.

8. The types of veterans to be served over the next 10 years and how the population of veterans may be different from traditional populations of veterans based on age, sex, and conditions to be treated.

9. Any additional opportunities that exist to enhance and improve the care for veterans at either a State-owned or privately owned facility.

Methodology

Much of the statistical information in this report on the number and age of

Pennsylvania veterans comes from the United States Department of Veterans Af-fairs (USDVA). Descriptive information on the services available to veterans and the eligibility requirements for those services also comes from the USDVA. Addi-tional information on the nature and future costs of veterans care was obtained through reports by the U.S. Government Accountability Office and the Congres-sional Budget Office, among others.

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The Pennsylvania Department of Military and Veterans Affairs also contrib-uted information regarding each of the study objectives and provided information specific to Pennsylvania’s six State Veterans’ Homes.

Although the report projects the future number of Pennsylvania veterans that may need nursing home or personal home care, we do not project the number of nursing home or personal care home beds that might be needed to serve these veter-ans. This is largely because of the significant difference between the average length of stay at a State Veterans’ Home (900 days) compared to the statewide average length of stay at all nursing homes (139 days). Projecting the number of beds needed would require a policy decision on whether new beds would reflect the prac-tices and policies of State Veterans’ Homes (long-term lengths of stay) or the poli-cies and practices of private nursing homes (much shorter lengths of stay).

Acknowledgements We would like to thank the Pennsylvania Department of Military and Veter-ans Affairs for the cooperation and assistance they provided during this study.

Important Note

This report was developed by Legislative Budget and Finance Committee staff. The release of this report should not be construed as indicating that the Committee members endorse all the report’s findings and recommendations. Any questions or comments regarding the contents of this report should be di-rected to Philip R. Durgin, Executive Director, Legislative Budget and Finance Com-mittee, P.O. Box 8737, Harrisburg, Pennsylvania 17105-8737.

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II. The Impact of Pennsylvania’s Changing Veterans Popula-tion on State Veterans’ Homes

This chapter is organized around the nine specific issues listed in Senate Resolu-tion 171.

A. How Many Veterans in Each County Are Waiting to Be Placed in a State Veterans’ Care Facility?

The Commonwealth’s six veterans’ homes have a capacity of 1,022 nursing

care beds, 224 dementia beds, and 362 personal/domiciliary care beds (see Table 1).

Table 1

State Veterans’ Home Capacity

Name Nursing/Dementia Beds Personal Care/Domiciliary Beds

Delaware Valley Veterans’ Home ................. 130 41

Gino J. Merli Veterans’ Center ...................... 196 0

Hollidaysburg Veterans’ Home...................... 339 167

Pennsylvania Soldiers’ and Sailors’ Home ... 107 100

Southeastern Veterans’ Center ..................... 238 54

Southwestern Veterans’ Center .................... 236 0

Total ............................................................ 1,246 362 Source: DMVA (as of March 2016).

As of the end of March 2016, the Pennsylvania Department of Military and

Veterans Affairs (DMVA) had 236 vacant beds at the state veterans’ facilities. DMVA expects the number of vacant beds to continue to grow in some homes due to deaths of our older veterans. Statewide, at the end of March 2016, the waiting lists total 223 individuals waiting to be placed in a veterans’ home, 107 of whom are vet-erans and 116 nonveterans. Table 2 shows the waiting list by county for those where county information is known.

Over the past 18 months, DMVA noted that waiting lists have increased due

to several factors. The Southwestern Veterans’ Center (SWVC) has been undergo-ing a major construction project that required vacating of an entire unit to allow for the refurbishment of the veterans’ home. Post construction inspections and clear-ance were required from both Department of Health and VA agencies. The South-eastern Veterans’ Center (SEVC) added 54 beds to the compliment, which also re-quired certification from regulatory agencies.

The Commonwealth’s veterans’ homes have three distinct levels of care;

Skilled Nursing, Dementia, and Personal Care. If Personal Care is taken out of the

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Table 2

PA Bureau of Veterans’ Homes (Veterans Only) Waiting List (as 3/25/16)*

County Vet S/Da Vet PCb County Vet S/Da Vet PCb

Adams ...................... 0 0 Lackawanna (SVH) ... 2 0

Allegheny (SVH) ....... 21 0 Lancaster ................... 1 0

Armstrong ................. 1 0 Lawrence ................... 0 0

Beaver ...................... 1 0 Lebanon ..................... 0 0

Bedford ..................... 0 0 Lehigh ........................ 0 0

Berks......................... 2 0 Luzerne ...................... 0 0

Blair (SVH) ................ 0 0 Lycoming ................... 0 0

Bradford .................... 0 0 McKean ..................... 0 0

Bucks ........................ 9 0 Mercer ....................... 0 0

Butler ........................ 0 0 Mifflin ......................... 0 0

Cambria .................... 0 0 Monroe ...................... 0 0

Cameron ................... 0 0 Montgomery ............... 5 3

Carbon ...................... 0 0 Montour ..................... 0 0

Centre ....................... 0 0 Northampton .............. 0 0

Chester (SVH) .......... 2 2 Northumberland ......... 0 0

Clarion ...................... 0 0 Perry .......................... 0 0

Clearfield .................. 0 0 Philadelphia (SVH) .... 13 0

Clinton ...................... 0 0 Pike ............................ 1 0

Columbia .................. 0 0 Potter ......................... 0 0

Crawford ................... 0 0 Schuylkill .................... 0 0

Cumberland .............. 0 0 Snyder ....................... 0 0

Dauphin .................... 0 0 Somerset ................... 0 0

Delaware .................. 2 0 Sullivan ...................... 0 0

Elk ............................. 0 0 Susquehanna ............ 0 0

Erie (SVH) ................ 20 0 Tioga .......................... 0 0

Fayette ...................... 0 0 Union ......................... 0 0

Forest........................ 0 0 Venango .................... 0 0

Franklin ..................... 0 0 Warren ....................... 1 0

Fulton ........................ 0 0 Washington ................ 1 0

Greene ...................... 1 0 Wayne ....................... 0 0

Huntingdon ............... 0 0 Westmoreland ........... 2 0

Indiana ...................... 0 0 Wyoming .................... 0 0

Jefferson ................... 0 0 York ........................... 0 0

Juniata ...................... 0 0 Total ...................... 85 5 ______________ * Counties with (SVH) after county name have a State Veterans’ Home within their border. a Vet S/D = Veteran Requiring Skilled or Dementia Care. b Vet PC = Veteran Requiring Personal Care. Source: Pennsylvania Department of Military and Veterans Affairs.

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equation, then there are 99 veterans waiting for a bed with 163 open skilled/demen-tia beds currently available, giving a variance of 64 surplus beds. The DMVA re-ports that current vacant beds are being filled at both SEVC and SWVC following renovations in those facilities. Current Gino J. Merli Veterans’ Center (GJMVC) vacancies are due largely to preparation for a major renovation project that will begin in July 2016. There are also 107 non-veterans in need of beds.1

The DMVA notes that, even though there are waiting lists, beds are availa-

ble.2 It may not be the home of first or even second choice, but a bed is always of-fered. The variables include: location of the home or applicant, applicant’s choice, gender, and level of care required. However, the location of the veterans’ home is often the most identified issue noted, as many times a veteran will not accept a bed, for example, at the Hollidaysburg Veterans’ Home if his family lives too far away and would not be able to visit due to transportation issues. So reducing the waiting list depends more on the location of the bed than on the overall number of beds statewide. Exhibit 1 shows the location of the State Veterans’ Homes and Exhibit 2 shows the county of residence for Pennsylvania veterans aged 65 and older.

Exhibit 1

Location of Pennsylvania Veterans’ Homes

  Source: Developed by LB&FC staff using information from the DMVA.

                                                            1 The USDVA limits the number of nonveterans (e.g., spouses, surviving spouses, and Gold Star parents) at State Veterans’ Homes to 25 percent of the bed occupants. Nonveterans also include those who served in the National Guard or Reserves but did not serve on active duty. 2 While most Pennsylvania State Veteran’s Homes have occupancy rates in excess of 95 percent, the occupancy rate in Hollidaysburg is only 68 percent.  

Southwestern Veterans'

CenterHolidaysburg

Veterans' Home

Pennsylvania Soldiers' and Sailors' Home

Gino J. Merli Veterans'

Center

Delaware Valley Veterans' Home

Southeastern Veterans'

Center

Exh

ibit

2

6

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B. How Many Veterans in Pennsylvania Are Eligible for Care From the Department of Military and Veterans Affairs and the

United States Department of Veterans Affairs? The veteran population in Pennsylvania as of September 2015 is estimated at

916,638 as per the U.S. Department of Veterans Affairs (USDVA). However, not all of these veterans are eligible for nursing home or domiciliary/personal home care.

Veterans Eligible for DMVA Care at a State Veterans’ Home. Under Chapter

7 of Title 51, admittance to a State Veterans’ Home is potentially available to all Pennsylvania residents3 who have served in the armed forces of the United States or the Pennsylvania military forces, who were discharged under honorable condi-tions, and who can demonstrate a financial and medical need for admission.4 The veterans’ ability to pay for services is not, however, a qualifying factor for admission into a State Veterans’ Home.5 The DMVA calculates what sources of income are available to the veteran and bases the veteran’s portion to pay for care off that dol-lar amount. An admissions committee at the home determines the level of care, but its decisions may be appealed.

To estimate the number of Pennsylvania veterans that may need the services

offered by the Commonwealth’s State Veterans’ Homes, we multiplied the number of veterans in the various age groups shown below by the rates of institutionaliza-tion in a nursing home or residential care facility (RFC) as reported by the Congres-sional Budget Office. As shown in Table 3, using this methodology we estimate ap-proximately 13,642 Pennsylvania veterans aged 65 and older are currently in need of nursing home care, and approximately 5,398 Pennsylvania veterans aged 65 and older are currently in need of residential care.

                                                            3 Veterans must be a bona fide Pennsylvania resident or, if living in another state, must have listed Pennsylva-nia as their home of record when they enlisted. 4 Certain veterans, such as those with mental health or severe behavioral issues, contagious diseases, or a his-tory of alcoholism, may not be eligible. 5 DMVA reports that, although there are no income level thresholds for the homes, veterans with over $80,000 in assets may be required to pay the full cost of care until assets are below that level. Once assets are below $80,000, then the monthly maintenance fee is based solely on the resident’s monthly income.

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Table 3

Estimate of PA Veterans Requiring Nursing Home or Residential Care

2015

Age PA Veterans % Residing in a Nursing Home

# Requiring Nursing

Home Care % Residing in

an RCF

# Requiring Residential

Care

65-74 ..... 245,357 1.00% 2,454 0.30% 736

75-84 ..... 145,191 2.40% 3,485 1.10% 1,597

85+ ........ 82,833 9.30% 7,703 3.70% 3,065

Total .... 473,381 13,642 5,398 Source: Developed by LBFC staff from U.S. Department of Veterans Affairs and Congressional Budget Office data.

We also estimated the number of veterans who might need nursing home

care based on the number of Pennsylvanians aged 65 and older who are currently in nursing home care. In 2012, Pennsylvania had 2.0 million citizens aged 65 and older and, according to the Pennsylvania Health Care Association, 88,000 nursing home beds. Approximately 80,000 of these beds were filled, for an average occu-pancy rate of 91 percent. Based on national statistics, about 85 percent of these beds are filled with someone aged 65 or older, yielding a rate of 34 filled beds per 1,000 persons aged 65 or older. Using the rate of 34 filled beds, 16,100 veterans aged 65 and older can be expected to need nursing home care. Averaging these two estimates (13,642 and 16,100) yields an estimated 14,871 Pennsylvania veterans aged 65 and older needing nursing home care in 2015.

Similarly, in 2012, Pennsylvania had approximately 46,500 licensed personal

care home beds, of which 93.3 percent (based on national figures) can be expected to be occupied by someone aged 65 or older. Using this same percentage for Pennsyl-vania and assuming an occupancy rate of 91 percent (the same as nursing homes), yields a rate of approximately 19.7 filled beds per 1,000 persons aged 65 and older.6 Applying this figure (19.7) to Pennsylvania’s 473,381 older veterans yields an esti-mated 9,344 Pennsylvania veterans who may need a personal care bed in 2015. Av-eraging these two estimates (5,398 and 9,344) yields an estimated 7,371 Pennsylva-nia veterans aged 65 and older needing a personal care bed in 2015.

Pennsylvania’s State Veterans’ Homes were originally intended to serve vet-

erans who can demonstrate a financial need for such care. The DMVA indicated they do not now use an income test for eligibility for admission, but veterans with over $80,000 in assets are to pay for the full cost of care until their assets are below

                                                            6 “Assisted Living” homes and personal care homes were one and the same in Pennsylvania prior to 2011.

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that level. Once assets are below $80,000, then the monthly maintenance fee is based solely on the resident’s monthly income.

To estimate how many Pennsylvania veterans aged 65 and older have assets

of less than $80,000, and would therefore be eligible to receive financial assistance as soon as they moved into a State Veterans’ Home, we reviewed the latest (2013) survey information provided by the Federal Reserve on median net worth by age of the head of household. This survey found that the median (meaning half of re-spondents had more and half had less) net worth of families (both veteran and non-veteran) with heads of households between ages 65 to 74 is $232,100. For families with heads of households aged 75 and older, their median net worth is $194,800.

These numbers suggest that the large majority of veterans aged 65 and older

would not immediately qualify for state aid should they decide to move into a veter-ans’ home.7 To develop a rough estimate of how many Pennsylvania veterans are likely to have assets below $80,000, we assumed a straight-line relationship for per-sons with net worth between $0 and $232,100 ($194,800 for persons aged 75 and older). This methodology resulted in an estimate that 17 percent of veterans be-tween the ages of 65 to 74 have assets below $80,000, and 21 percent of veterans aged 75 and older have assets below $80,000.

Table 4 shows our estimate of the potential number of Pennsylvania veterans

who would be eligible for state assistance in a State Veterans’ Home based on these estimates.8

Table 4

Veteran Nursing Home and Personal/Domiciliary Care Needs Versus Current State Veterans’ Home Capacity

Nursing Personal/Domiciliary Care

Estimated Veteran Population Needing Care ............... 14,871 7,371

Estimated Number of Veterans Needing Care With Net Worth Below $80,000 ............................................. 2,633 1,305

State Veterans’ Home Beds .......................................... 1,246 362 Source: Developed by LB&FC staff.

Table 4 shows what would appear to be a significant unmet need for both

nursing and personal care beds at the State Veterans’ Homes. However, there                                                             7 DMVA noted that about 145 veterans are currently in “full pay” status, so the overwhelming majority of veter-ans staying at a State Veterans Home do receive state assistance. 8 It should be noted that nonveterans (e.g., spouses, surviving spouses, and Gold Star parents) are also eligible to live in State Veterans’ Homes. The USDVA limits the number of such nonveterans to 25 percent of the bed occupants. Our estimates only pertain to veterans.

10

are several reasons why this conclusion should be viewed with caution. First, as described below, many of these veterans will likely qualify for nursing home or dom-iciliary care under the USDVA. The USDVA currently has 662 Community Living Center (nursing home) beds and 321 domiciliary care beds in Pennsylvania. Addi-tionally, approximately 575 veterans received services in 2014 through the USDVA’s Community Nursing Home program, and an unknown number receive as-sistance though the Community Residential Care program.

Other factors, such as location (discussed above), also enter into the decision

as to whether or not to enter a State Veterans’ Home. For low income veterans, Medicaid (Medical Assistance) is another option available to pay for nursing home care.9

Veterans Eligible for USDVA Care. The USDVA provides nursing home and

domiciliary care for some veterans and makes these services available to other vet-erans on a discretionary basis. Specifically, the USDVA is required by law to pro-vide nursing home care to any veteran who needs it because of a service-connected disability and to any veteran who needs it if the veteran has a service-connected disability rated at 70 percent or greater, even if the illness that requires nursing home care is not service-connected. Some degree of nursing home service is also provided to veterans with 60 percent service-connected disability ratings who are either unemployable or who have been determined by VA to be permanently and to-tally disabled.

As of November 2014, Pennsylvania was home to about 30,700 veterans with a service-connected disability rating of 70 percent or higher.10 If any of these veter-ans needed nursing home care, it is likely they would qualify to receive mandatory services through a USDVA program.

The USDVA also provides nursing home care to veterans on a discretionary basis, as resources permit, with certain veterans having higher priority, such as vet-erans who require care following a hospitalization.11 Most of the nursing home care provided to veterans is through such optional services, which include State Veter-ans’ Homes. For discretionary veterans not in a State Veterans’ Home, the USDVA is generally restricted by law from paying for more than 6 months of such care, and

                                                            9 Available to veterans with annual incomes below about $26,000 and who have less than $8,000 in resources. For Medically Needy Only, the income limit is $425 per month after deducting medical expenses. Some property does not count toward the resource limit. In Pennsylvania, your home is exempt up to an equity value of $543,000 (2014), so long as you live in it, intend to return to it, or if your spouse or dependent lives in it. One vehicle is also excluded from the resource calculation. 10 American Community Survey (2014) conducted by the University of New Hampshire’s Institute on Disability. 11 Other priority categories include having been prisoners of war, having been exposed to toxic chemicals in Vi-etnam or in the American occupation of Hiroshima and Nagasaki, having served in World War I, World War II, Vietnam, or the Korean conflict and/or receiving a VA pension that is not adequate to cover the cost of nursing home care.

11

nonservice-connected veterans could be subject to long-term care co-payments.12 Any nursing home care that is approved by the USDVA must be provided in a USDVA facility or a contracted nursing home.

Veterans Eligible for Nursing Home Care at a USDVA Facility. Nursing home care is provided at VA facilities through Community Living Centers (CLCs). CLCs are designed to resemble home as much as possible. There are activities for veter-ans of all ages. Veterans are allowed to decorate their rooms and keep pets. Veter-ans may stay for a short time or, in rare instances, for the rest of their life. It is a place where veterans can receive nursing home level of care, which includes help with activities of daily living (e.g., bathing and getting dressed) and skilled nursing and medical care.

There are more than 130 CLCs nationwide, most of which are located near VA hospitals. Pennsylvania is home to six CLCs, at Butler, Pittsburgh, Lebanon, Wilkes-Barre, Coatesville, and Philadelphia (see Table 5). VISN4, our regional VA healthcare network, reports that none of Pennsylvania’s USDVA CLCs have a wait-ing list.

Table 5

Nursing Home Beds* at USDVA Community Living Centers in Pennsylvania

Center Beds

Butler ................................. 60

Pitt/Heinz III ....................... 114

Lebanon ............................ 79

Wilkes-Barre ...................... 105

Coatesville ......................... 169

Philadelphia ....................... 135

Total ................................ 662 ____________ * Includes dementia beds. Source: U.S. Department of Veterans Affairs.

CLCs provide both short-stay (90 days or less) and long-stay (more than 90 days) services. Nationally, almost 94 percent of the residents admitted to CLCs in fiscal year 2010 were short-stay. Short-stay care in CLCs includes skilled nursing care, rehabilitation, restorative care, maintenance care for those awaiting alterna-tive placement, hospice, and respite care. The remaining admissions, about 6 per-cent, were long-stay. Long-stay care includes dementia care, maintenance care, and care for those with spinal cord injury and disorders. A copay may be charged for CLC care based on VA service-connected disability status and financial information.

                                                            12 Unlike for 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.

12

Veterans Eligible for Domiciliary Care at a USDVA Facility. Domiciliary care, as provided by the USDVA, is a residential rehabilitation program that provides short-term rehabilitation and long-term health maintenance to veterans who require min-imal medical care as they recover from medical, psychiatric, or psychosocial prob-lems. Most domiciliary patients return to the community after a period of rehabili-tation.

Domiciliary care is provided at 43 USDVA-operated facilities across the coun-

try. (State homes also operate 49 domiciliaries in 33 states.) In Pennsylvania, dom-iciliary care is provided at two USDVA facilities: Butler (56 beds) and Coatesville (265 beds). The USDVA also provides a number of psychiatric residential rehabili-tation programs, including ones for veterans coping with post-traumatic stress dis-order, transitional residences for homeless chronically mentally ill veterans, and veterans recovering from substance abuse.

Veterans Eligible for Contracted (Private) Nursing and Domiciliary Care. In addi-tion to CLCs, the USDVA contracts with approximately 2,500 private community nursing homes across the country to provide nursing home care to veterans. The USDVA will only pay for community nursing home care if the veteran meets the eli-gibility criteria involving service-connected status, level of disability, and income.

To participate in the USDVA’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 and meet VA’s minimum care standards. The USDVA evaluates community nursing homes prior to awarding a contract, and annually at renewal, to ensure they are compliant with state and fed-eral requirements and provide veterans with an acceptable standard of care.

The USDVA pays community nursing homes per diem rates that are tiered based on the intensity of resources required to provide care. The homes may not bill any other payer for nursing home care provided to veterans. Nationally, of the vet-erans receiving USDVA-funded nursing care, about 35 percent are in a CLC, 15 per-cent in a private nursing home with a VA contract, and 55 percent in a State Veter-ans’ Home. (See Appendix B for a list of the number of veterans homes in the vari-ous states.)

Table 6 shows that community nursing homes largely serve veterans with

mandatory eligibility status, whereas State Veterans’ Homes largely serve veterans with a discretionary eligibility status. Table 7 shows the average per diem expendi-tures at these various facilities in 2012.

13

Table 6

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

Resident Characteristics VA Community Living Centers

Community Nursing Homes

State Veterans’ Nursing Homes

Eligibility Status:

Discretionary .................. 48% 18% 84%

Mandatory ..................... 52 82 9

Total ............................ 100% 100% 93% Source: VA Nursing Homes, U.S. Government Accountability Office, December 2013.

Table 7

Per Diem Expenditures, by the USDVA, by Setting and Length of Stay, Fiscal Year 2012 Nursing Home Setting

All Stays Short Stays Long Stays

VA Community Living Centers ....... $953 $1,167 $884

Community Nursing Homes ........... 244 265 239

State Veterans’ Nursing Homes .... 113 113 113

All Settings (Weighted Average) .... 370 732 318 Source: VA Nursing Homes, U.S. Government Accountability Office, December 2013.

The USDVA also assists veterans who need residential care through the

Community Residential Care program. This program provides room, board, limited personal care, and self-care supervision to veterans who do not require hospital or nursing home care but are not able to live independently because of medical or psy-chiatric conditions, and who have no family to provide care. This type of care takes place in a number of settings including Assisted Living facilities, Personal Care Homes, Family Care Homes, Group Living Homes, and Psychiatric Community Res-idential Care Homes. These facilities—about 1,300 of them across the country—are inspected and approved by USDVA medical center staff, but are chosen by the vet-eran.

Veterans pay for the cost of these living arrangements from their VA compen-

sation, VA pension (including the Aid and Attendance supplement), Social Security, or other retirement or income sources. USDVA’s contribution is limited to the cost of administration and clinical services, which include inspection of the home and pe-riodic visits to the veteran by USDVA health care professionals. Medical care is provided to the veteran primarily on an outpatient basis at USDVA facilities. Pri-marily focused on psychiatric patients in the past, this program will be increasingly focused on older veterans with multiple chronic illnesses that can be managed in the home under proper care and supervision.

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C. What Is the Average Cost Per Day of the Care and Treatment for a Veteran at State-owned Veterans’ Care Facilities?

Actual expenditures for Pennsylvania’s State Veterans’ Homes totaled $184.2

million in FY 2014-15; $82.4 million state, $68.5 million federal, and $33.2 million in augmentations (includes items such as federal veterans Aid and Attendance pay-ments to residents, third-party insurance reimbursements, and estate collections). State costs are expected to increase to $91.9 million in FY 2015-16 and $104.7 mil-lion in FY 2016-17, a 27 percent increase over the two-year period. The number of veterans served is also projected to increase, but only by 11 percent (from 1,367 to 1,518). Total expenditures for the various institutions are presented in Table 8.

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Table 8

Costs to Operate PA State Veterans’ Homes ($000s)

Institution FY 2014-15

Hollidaysburg Veterans Home

State Funds ................................... $24,024

Federal Funds ............................... 20,254

Augmentations ............................... 9,205

Total ........................................... $53,483 Erie Soldiers and Sailors Home

State Funds ................................... $ 8,350

Federal Funds ............................... 8,153

Augmentations ............................... 4,165

Total ........................................... $20,668 Southeastern Veterans Center

State Funds ................................... $11,685

Federal Funds ............................... 11,101

Augmentations ............................... 5,266

Total ........................................... $28,052 Gino J. Merli Veterans Center

State Funds ................................... $ 8,786

Federal Funds ............................... 10,978

Augmentations ............................... 5,060

Total ........................................... $24,824 Southwestern Veterans Center

State Funds ................................... $14,189

Federal Funds ............................... 9,113

Augmentations ............................... 5,182

Total ........................................... $28,484 Delaware Valley Veterans Home

State Funds ................................... $ 8,022

Federal Funds ............................... 8,908

Augmentations ............................... 4,363

Total ........................................... $21,293 Source: Pennsylvania Department of Military and Veterans Affairs FY 2016-17 Budget Request.

16

Table 9 shows the cost per day to care for veterans in the six State Veterans’ Homes and four personal care home sites.

Table 9

Costs Per Day at Pennsylvania’s State Veterans’ Homes

Pennsylvania State Veterans’ Home Cost

Per Daya Less VA

Per Diemb Total Cost Per Dayc

Delaware Valley Veterans’ Home - Skilled Care .............. $339 $103.61 $235.39

Gino Merli Veterans’ Center - Skilled Care ...................... $320 $103.61 $216.39

Hollidaysburg Veterans’ Home - Skilled Care .................. $385 $103.61 $281.39

PA Soldiers’ and Sailors’ Home - Skilled Care ................ $365 $103.61 $261.39

Southeastern Veterans’ Center - Skilled Care ................ $369 $103.61 $265.39

Southwestern Veterans’ Center - Skilled Care ................ $320 $103.61 $216.39

Average - Skilled Care ................................................. $350 $246

Delaware Valley Veterans’ Home - Personal Care .......... $161 $44.72 $117.28

Hollidaysburg Veterans’ Home - Personal Care .............. $193 $44.72 $148.28

PA Soldiers’ and Sailors’ Home - Personal Care ............. $159 $44.72 $154.28

Southeastern Veterans’ Center - Personal Care ............. $193 $44.72 $148.28

Average - Personal Care .............................................. $177 $142 _______________ a Based on costs of care for the period July 1, 2012, to June 30, 2013. b Rates for FFY 2016. c Approximately 70 percent are General Fund monies to DMVA, the remaining 30 percent are augmenta-tions.

Source: Pennsylvania Department of Military and Veterans Affairs.

Per diem rates for all State Veterans’ Homes as reported by the USDVA for FFY 2016 are shown in Appendix C. The appendix shows the average per diems for Pennsylvania’s six veterans homes (all of which are considered urban) to be $387.06, slightly below the national average of $395.10 for all 93 State Veterans’ Homes located in urban areas.13

The DMVA notes that over the past several years it has undertaken a variety of cost-saving measures, particularly with regard to right-sizing staffing at the homes and reducing overtime and workers’ compensation costs. DMVA estimates that over the three-year period from FY 2011-12 through FY 2013-14, these and other efforts at the State Veterans’ Homes have resulted in cost savings to the Gen-eral Fund of approximately $22.1 million.

                                                            13 Per diem rates do not, however, directly reflect actual costs. Rather, they are based largely on the prevailing wages in a given region, such that the higher the area’s wage index, the higher the per diem rate. As a result, the rates are less about the efficiency of a home’s operations and more about the estimated cost of services in the region.

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D. What Is the Average Cost Per Day for the Care and Treatment for a Veteran at a Privately-owned Health Care Facility?

Private Nursing Homes. As noted above, in addition to providing assistance

to veterans living in State Veterans’ Homes and through USDVA-owned and oper-ated Community Living Centers, veterans can also receive services in privately owned facilities through the USDVA’s Community Nursing Home program. Under this program, USDVA health care facilities establish contracts with community nursing homes, including privately-owned facilities, to meet the nursing home needs of veterans who require long-term nursing home care in their own commu-nity, thereby allowing them to remain close to their families.

The contract allows the USDVA to place a patient in a nursing home when

the home agrees to accept the patient at a previously established price. Eligibility for nursing home admission via the Community Nursing Home program is the same as for Community Living Centers (described above). As a consequence, only a small percentage of PA veterans (less than five percent) qualify for the Community Nurs-ing Home program.

According to PA Department of Health reports, in 2013 the USDVA con-

tracted with 76 community nursing homes across Pennsylvania to provide 79,925 days of care, with per diem rates that varied from $176 to $735, with an average per diem of $303.14 In addition, ancillary costs may be placed on the veterans residing in private nursing homes that are not covered by the USDVA.

Pennsylvania’s Medicaid (Medical Assistance) nursing home rates as of Octo-

ber 2015 are $235.40 per day (weighted average), with a target rate of $200.79. Rates range from $147 to $439.

Private Personal/Domiliciary Care Homes. As discussed above, the USDVA also assists veterans who need residential care through the Community Residential Care program. However, this does not include financial assistance, and veterans are expected to pay for the cost of these living arrangements from their VA compen-sation, VA pension, Social Security, or other retirement or income sources.

According to a 2015 Genworth Financial cost of care survey, the average cost

of assisted living in Pennsylvania is about $117 per day, or $42,660 annually. This cost, which is slightly below the national average ($118 per day), represents the base cost for a one-bedroom assisted living unit in Pennsylvania.

                                                            14 These 79,925 days of care would provide services to approximately 575 veterans, based on the Pennsylvania average stay of 139 days in 2014. 

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E. How Many Veterans Will Need Care Over the Next 10 Years Within This Commonwealth?

As Table 10 and Exhibit 3 show, Pennsylvania is currently home to about 473,400 veterans aged 65 and older. This number will shrink to about 380,000 by 2025 and to slightly over 300,000 by 2035.

Table 10

Estimated Number of PA Veterans Aged 65+

2015 2020 2025 2030 2035

65-74 .............. 245,357 199,567 133,913 127,399 112,350

75-84 .............. 145,191 146,847 178,528 142,735 99,753

85+ ................. 82,833 76,658 68,498 73,918 89,078

Total 65+ ...... 473,382 423,073 380,939 344,052 301,182 Source: U.S. Department of Veterans Affairs

As can be seen from Table 10 and Exhibit 3, although the total number of vet-erans aged 65 and older drops by 36 percent between 2015 and 2035, the number of veterans aged 85 and older, the age group most likely to need care, increases by 8 percent.

Veterans Needing Nursing Home Beds. Table 11 shows an estimate of how many Pennsylvania veterans aged 65 and older will need a nursing home or resi-dential care bed in 2025 and 2035 based on current national rates.

Table 11

Estimate of PA Veterans Requiring Nursing Home or Residential Care

2025

Age PA Veterans % Residing in a Nursing Home

# Requiring Nursing Home

Care % Residing in

an RCF

# Requiring Residential

Care

65-74 ..... 133,913 1.00% 1,339 0.30% 402

75-84 ..... 178,528 2.40% 4,285 1.10% 1,964

85+ ........ 68,498 9.30% 6,370 3.70% 2,534

Total .... 380,939 11,994 4,900

2035

Age PA Veterans % Residing in a Nursing Home

# Requiring Nursing Home

Care % Residing in

an RCF

# Requiring Residential

Care

65-74 ..... 112,350 1.00% 1,124 0.30% 337

75-84 ..... 99,753 2.40% 2,394 1.10% 1,097

85+ ........ 89,078 9.30% 8,284 3.70% 3,296

Total .... 301,181 11,902 4,730 Source: Developed by LB&FC staff from U.S. Department of Veterans Affairs and Congressional Budget Office data.

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2020

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19

20

Using Pennsylvania-specific data (i.e., 34 filled beds per 1,000 persons 65 and older for nursing homes and 19.7 filled beds per 1,000 persons 65 and older for per-sonal care homes), we estimate approximately 13,257 Pennsylvania veterans aged 65 and older will need a nursing home bed by 2025, dropping to 10,240 by 2035.

We averaged these two estimates to arrive at an estimated 12,625 Pennsylva-nia veterans aged 65 and older will need a nursing home bed in 2025 and 11,071 in 2035.15

This drop in demand was also cited in a 2009 report conducted by First Ches-

apeake Group, a healthcare consulting firm selected by the PA Department of Mili-tary and Veterans Affairs to conduct an assessment on the need and feasibility of additional veterans’ homes within Pennsylvania. The report, citing a standard of 2.5 nursing home beds per 1,000 veterans, concluded that by 2019, Pennsylvania would have a surplus of 293 veterans’ home beds and by 2029, the surplus will have increased to 737 (assuming Pennsylvania maintained its 1,164 existing beds).16 The report also found, however, that the veterans’ nursing home beds are not well dis-tributed geographically and therefore, recommended that three new State Veterans’ Homes (Northcentral, Southcentral, and Lehigh Valley/Reading) be built.

Personal Care Bed Needs. Similarly, Table 11 shows approximately 4,900

Pennsylvania veterans aged 65 and older will need a personal care bed in 2025, fall-ing to 4,730 in 2035. Using the Pennsylvania estimate of 19.7 filled beds per 1,000 persons aged 65 and older, approximately 7,682 Pennsylvania veterans will need a personal care bed in 2025. By 2035, this number drops to 5,933. We averaged these two estimates to arrive at an estimated 6,291 Pennsylvania veterans aged 65 and older will need a nursing home bed in 2025, and 5,331 in 2035.

The First Chesapeake Group found a similar downward trend in demand and

concluded that, while Pennsylvania is not facing a surplus of personal care and domiciliary care beds for veterans, the net demand for personal care and domiciliary care beds in Pennsylvania’s State Veterans’ Homes will fall from 959 in 2014 to 710 in 2019 and to 354 in 2029.17

                                                            15 It should be noted that our estimate is for the number of veterans who are likely to need a nursing or personal care bed, not the number of beds that might be needed to serve these veterans. Determining the number of beds needed requires an estimate of the average length of stay (i.e., one bed may have more than one occupant during the year). The average length of stay for all nursing home beds in Pennsylvania was 139 days in 2014. How-ever, the average length of stay at Pennsylvania’s State Veterans’ Homes is about 900 days, or 6.5 times longer than the statewide average. Before being able to estimate the possible number of beds that might be needed, a determination would need to be made as to whether the beds are to provide “typical” nursing home care (i.e., relatively short-term care) or the more extended lengths of stay common in State Veterans’ Homes. 16 Includes 932 existing USDVA beds. The report found, however, that the veterans’ nursing home beds are not well distributed geographically and therefore, recommends the building of three new State Veterans’ Homes (Northcentral, Southcentral, and Lehigh Valley/Reading). 17 Includes 265 existing USDVA personal care beds.

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F. A Summary of Other States and Their Respective Programs That Allow for Public-Private Partnerships With the United States Depart-

ment of Veterans Affairs to Offer Additional Care for Veterans.

While the U.S. Department of Veterans Affairs has undertaken various ef-forts to establish public-private partnerships to better serve veterans, these part-nerships have generally focused on services to help veterans transition to civilian life, including enhanced employment opportunities, or providing inpatient or outpa-tient care at private medical facilities, rather that public-private partnerships to improve long-term care services.

PACE. The USDVA has, however, conducted several pilot projects with

PACE (Program of All-Inclusive Care for the Elderly) providers, including in Mon-tana and Florida. PACE—not to be confused with the Pennsylvania PACE (Phar-maceutical Assistance Contract for the Elderly) program—is a Medicare option that allows the elderly (both veterans and nonveterans) to live independently on their own instead of in a skilled nursing home. In Pennsylvania, the PACE program is known as LIFE (Living Independence for the Elderly), and all PACE providers in Pennsylvania have the name ‘LIFE’ in their name. The first programs were imple-mented in Pennsylvania in 1998.

LIFE is based on a managed care model that provides a comprehensive all-

inclusive package of medical and supportive services. To be eligible for LIFE, you must:

be age 55 or older,

meet the level of care needs for a skilled nursing facility or a special reha-bilitation facility,

meet the financial requirements as determined by your local County As-sistance Office or be able to privately pay,

reside in an area served by a LIFE provider, and

be able to be safely served in the community as determined by a LIFE pro-vider.

Funding for the PACE/LIFE program comes from both Medicaid and Medi-

care. While VA social workers can help veterans determine if they qualify for PACE, PACE is not a VA program. The program provides all the care and services covered by Medicare and Medicaid, as authorized by the interdisciplinary team, as well as additional medically-necessary care and services not covered by Medicare and Medicaid. LIFE provides coverage for prescription drugs, doctor care, transpor-tation, home care, checkups, hospital visits, and even nursing home stays whenever necessary. For individuals who do not qualify for Medicaid, private funds are re-quired.

22

Once enrolled in LIFE, the amount the client pays each month does not change no matter what care and services the client might need. Clients may, how-ever, be held financially responsible for care received outside the program that is not approved by the LIFE interdisciplinary team.

There have been several pilot program attempts where PACE organizations

have partnered with the USDVA and local VA organizations to provide PACE ser-vices to veterans, including a partnership between the Lebanon VA and Albright-LIFE. This program involved the Lebanon VA obtaining a grant to support veter-ans who had a 100 percent service-connected disability and who were eligible for nursing home level of care. AlbrightLIFE, however, was able to identify only a very few candidates who met these requirements.

When we spoke to an AlbrightLIFE official in January 2016, she noted that

they still provide services to one individual identified under the grant, but that the grant has since expired and that individual is now a private pay client. The Al-bright official expressed disappointment that this effort was not successful, noting that the cost to provide services to the veterans through the LIFE program is about $3,300 a month, compared to $8,000-$10,000 a month for nursing home care.

VA Montana, part of the USDVA health care network, was awarded funding for two Home and Community-Based Services pilot programs, includes PACE ser-vices at the Billings VA Clinic. As part of this program, Montana veterans were able to receive PACE services without having to enroll in Medicaid (thereby protect-ing the veterans’ assets and income). VA Montana reported that the demand for PACE services from veterans in the Billings area exceeded their expectations and that they doubled the size of the program (from 15 to 30). However, due to the loss of Montana State PACE funding, the Billings Clinic PACE program was forced to cease operations on July 1, 2011. The Miami Veterans Healthcare System similarly partnered with a PACE provider in Miami to provide a model of care to help keep lower-income veterans liv-ing independently. The target population was underserved veterans who are Medi-care eligible, but have incomes that are too high to qualify for Medicaid.

Medical Foster Homes. The Medical Foster Home Program (MFH) is a vol-

untary VA program that offers long-term care in a home-like setting. Under MFH, the veteran receives a furnished private room with a caregiver that lives in the home and provides hands-on daily care. Care includes medication management, personal care (e.g., dressing, grooming, bathing), meals, laundry, and cleaning. MFH currently operates through 73 VA sites in 36 states (including the Lebanon and Coatesville VAs), with a goal of expanding to 10 more states within two years. Eventually, the VA hopes to introduce the program to all 153 of the agency’s medi-cal centers.

23

Other States. We also contacted the two states that do not operate a state nursing home for veterans (Alaska and Wyoming), one state (Delaware) that only recently built a State Veterans’ Home, and Ohio, a state similar in population to Pennsylvania but that operates only two State Veterans’ Homes, to determine if they have undertaken efforts to provide nursing home care through public-private partnerships.

Alaska operates the Alaska Veterans & Pioneers Home which provides domil-

icary, but not skilled nursing services. The administrator of this facility said that they provided more extensive care that would be typical of a domilicary facility, but that they do not provide higher level skilled care. Alaska does not have any other arrangements with private nursing facilities to assist veterans who need this level of care.

Wyoming also provides domilicary care, but veterans in need of skilled nurs-

ing services must go to a USDVA facility (Wyoming has two), the Wyoming Retire-ment Center (a state-owned nursing home which also provides services to nonveter-ans), or to a private provider. Wyoming does not, however, have any public-private partnership arrangements to assist veterans who need this level of care.

Delaware did not have a State Veterans’ Home until 2007. The official we

spoke with indicated that they did not have any special arrangements with private nursing homes and, until the home was built, veterans that wanted VA-assisted nursing home care in Delaware had to go to the USDVA facility in Wilmington.

Ohio, which has two state veterans’ homes with a total of 595 nursing home

beds, reported that it has no alternative program for veterans that may not want to go to either of these homes.

G. What Types of Health and Medical Care Need to Be Provided

and How Is It Expected to Change Over the Next 10 Years?

The DMVA expects to see more veterans with Post Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI). They also expect to see more veterans with loss of limb(s), as more veterans from current conflicts (Vietnam and forward) are surviving injuries that they would not have survived in previous conflicts. The DMVA also expects to see a greater numbers needing services for mental illness and drug addiction.

These expectations match the national projections done by the Congressional

Budget Office and the U.S. Department of Veterans Affairs. The CBO notes that veterans from recent conflicts will represent a fast-growing share of enrollees for VA health care over the next decade. However, the share of VA’s resources devoted to

24

the care of those veterans is projected to remain small through 2020, in part be-cause they are younger and healthier than other veterans served by VA.18 As the OCO (Overseas Contingency Operations, which includes Operation Iraqi Freedom, Operation New Dawn, and Operation Enduring Freedom in Afghanistan) veterans age, however, CBO expects that their costs will be similar to those of other older veterans who use VA’s health care services.

The CBO also found that the use of VA’s medical services by OCO veterans is

greatest in the months immediately after they enroll and then declines sharply in the next several months for most categories of service. The CBO attributes this de-cline primarily to veterans who find civilian employment or, in the case of reserv-ists, who return to work and decide to use private health care providers for most or all of their care.

The VA notes that, in the past, reliance on the VA system was often driven by a lack of health insurance—a driver that is now diminishing under the Affordable Care Act and various state initiatives. The VA believes these trends, combined with historical VHA problems, requires it to reconsider whether it should aim to be the comprehensive provider for all veterans’ health needs or should emphasize more limited centers providing specialized care, such as the National Intrepid Center of Excellence for traumatic brain injury and psychological health. If it focuses on spe-cialized care, veterans will need to use non-VHA health care networks for the ma-jority of their health care needs.19

Specifically with regard to long-term care, we found that the USDVA is at-tempting to evolve its approach to geriatrics and extended care from an institution-ally focused model (nursing home care) to one that includes a continuum of home and community-based extended care services. One of VHA’s strategic objectives in this area is to expand home and community-based care while retaining its three nursing home programs (VA-operated homes, VA-contracted community nursing homes, and State Veterans’ Homes).20

However, the GAO reported in 2009 that the USDVA had not done a good

job in assessing future demands for long-term care for either institutional or non-institutional long-term care services. For institutional services, the GAO found de-ficiencies regarding the USDVA’s ability to assess the extent to which veterans in the future will be seeking care for short-stay post-acute needs versus long-stay chronic needs. The GAO also found that the VA lacked the baseline data from which to estimate future demand for nursing home care in its various long-term care settings. The GAO also found the USDVA’s cost assumptions regarding its

                                                            18 Future Costs of Veterans’ Health Care, Congressional Budget Office, October 2010. 19 Brett P. Giroir, M.D., and Gail R. Wilensky, Ph.D., Reforming the Veterans Health Administration — Beyond Palliation of Symptoms, New England Journal of Medicine 2015; 373:1693-1695, October 29, 2015. 20 VHA Vision 2010, written in 2003.

25

ability to provide non-institutional long-term care services to be unrealistic, con-cluding that the “VA’s long-term care spending estimates are questionable bench-marks for congressional budget deliberations.”21 These uncertainties make is particularly difficult for states to assess the ex-tent to which there may be gaps in veterans’ long-term care services.

H. What Types of Veterans Will Need to Be Served Over the Next 10 Years and How Will That Population of Veterans Be Different From

Traditional Populations of Veterans Based on Age, Sex, and Conditions to Be Treated?

The USDVA projects that the total number of veterans (all ages) living in

Pennsylvania will steadily decline over the next 20 years, from 916,638 in 2015 to 720,630 in 2025 and to 567,456 in 2035, or a 38 percent decline over the 20-year pe-riod. As show in Exhibit 3, Pennsylvania is currently home to about 473,400 veter-ans aged 65 and older. This number will shrink to about 390,000 by 2025 and to slightly over 300,000 by 2035, a 36 percent decline over the 20-year period. Alt-hough the absolute number of Pennsylvania veterans aged 65 and older will decline over the next 10 years, as a percentage of Pennsylvania’s total veterans’ population they will increase slightly, from 52 percent of the total Pennsylvania veteran popu-lation in 2015 to 54 percent in 2025.

Female veterans currently comprise about 8 percent of Pennsylvania’s total

veteran population. Most female veterans (59 percent) are under age 55, whereas only 29 percent of Pennsylvania’s male veterans are under age 55. Therefore, as the veteran population ages, an increasingly larger percentage of older veterans will be women, increasing from 15,048 (3 percent of all veterans aged 65 and older) to 22,024 (6 percent of all veterans aged 65 and older). While still a small minority, this could affect operations at the State Veterans’ Homes, where currently the large majority (about 88 percent) of the resident population is male.22 This ratio is con-siderably different than the ratio of males to females in all Pennsylvania nursing homes, which is about 32 percent males and 68 percent females.

Additionally, the conditions to be treated may change somewhat as wide-spread use of body armor and recent advances in battlefield medicine have enabled many soldiers to survive what might otherwise have been fatal injuries. The large majority of returning service members, however, are in good health, with 85 percent

                                                            21 VA Health Care: Long-Term Care Strategic Planning and Budgeting Need Improvement (GAO-09-145), 2009. 22The spouse of a veteran may become a resident with the veteran if the spouse has been married to the veteran for at least two years prior to application for membership and is otherwise eligible. The surviving spouse of a deceased eligible veteran is also eligible to be admitted to a state veterans’ home, as long as the spouse has not remarried.

26

of returning OCO troops reporting their health status as excellent, very good, or good.

Two medical conditions that troops develop in theater have received wide-

spread attention: Posttraumatic Stress Disorder (PTSD) and Traumatic Brain In-jury (TBI). PTSD is an anxiety disorder induced by exposure to a traumatic event and is characterized by symptoms that include re-experiencing the traumatic event, hyperarousal (such as irritability or exaggerated startle response), and diminished responsiveness to or avoidance of stimuli associated with the trauma. TBI is an in-jury to the head arising from sudden trauma to the brain, resulting in a decreased level of consciousness, amnesia, or neurological or intracranial abnormalities. TBI is classified at the time of the injury as mild, moderate, or severe. Almost 90 per-cent of the service members diagnosed with that type of injury have a mild case, and the vast majority are expected to recover within one year after the injury.

Estimates of the prevalence of PTSD or symptoms of PTSD among those per-sonnel generally range between 5 percent and 25 percent, depending on the study’s methodology and the population it sampled. Less is known about the prevalence of TBI among that population. Recent studies indicate that between 19 percent and 23 percent of service members and veterans who have deployed to Iraq or Afghani-stan may have had TBI, depending on the study’s methodology and the population it sampled.

The CBO notes, however, that none of the studies of the prevalence of either PTSD or TBI are definitive. Most studies surveyed subgroups of deployed person-nel, such as Army infantry, and then extrapolated the results to the general de-ployed population, which is a problematic methodology. Also, the survey instru-ments used to screen for a possible case of PTSD or TBI either have not been vali-dated or do not produce highly accurate estimates of those conditions.

I. Additional Opportunities That Exist to Enhance and Improve the Care for Veterans at Either a State-owned or

Privately-owned Facility.

Adult Day Health Care. Adult Day Health Care (ADHC) is a program funded by the USDVA where veterans can go during the day for social activities, peer sup-port, companionship, and recreation. The program also helps veterans who need skilled services, case management, and help with activities of daily living, such as bathing, dressing, fixing meals, or taking medicines. Health services, such as care from nurses, therapists, social workers, and others may also be available, as can respite care for a family caregiver.

The program may be provided at VA medical centers, State Veterans Homes, or community organizations. ADHC programs also facilitate greater use of the

27

PACE program, as many of the medical and social services needed for PACE can be provided though an ADHC program. The DMVA reported it is considering estab-lishing an ADHC program at several State Veterans’ Homes, depending on the funds allocated to this program by the USDVA.

New Construction. The USDVA assists states for construction of new state

veterans’ homes and for significant renovations of existing facilities at a cost not to exceed 65 percent of the project cost. These funds, which are only available to state-owned facilities, are contingent, however, upon sufficient federal funding of the State Extended Care Facilities Grant Program.

A new 32-bed dementia care unit was opened at the Pennsylvania Soldiers’ and Sailors’ Home (Erie) in 2007, and a new 120-bed Community Living Center was opened at the Southeastern Veterans’ Center (Spring City) in 2012.

Additionally, the DMVA has submitted a request for $22.9 million in state funds (to be matched by $42.6 million in federal funds) to construct, furnish, and equip a new 200-bed Community Living Center (nursing home) facility to replace the Hollidaysburg Veterans Home. The Hollidaysburg Home was constructed in the early 1950s as a State Hospital. The new replacement facility would be designed in accordance with the Community Living Center (CLC) concept as per the U.S. De-partment of Veterans Affairs’ guidelines.

The FY 2007-08 Capital Budget also provided for a new $87 million veterans’

home to be constructed in either Dauphin or Lebanon County. The USDVA share (65 percent) would be approximately $56.5 million and the state share (35 percent) would be $30.4 million. The funds, however, have not yet been authorized for this project.

Converting Personal Care Beds to Skilled Care Beds. The DMVA notes that

the veteran homes’ waiting lists clearly represent a greater need for skilled beds across the Commonwealth. Most recently, Gino J. Merli Veterans Center (GJMVC) and Southwestern Veterans Center (SWVC) converted their personal care beds to skilled nursing beds and, in FY 2017-18, the Delaware Valley Veterans Home (DVVH) is scheduled to transition to 100 percent skilled care.

The DMVA also notes that while skilled bed conversions necessitate a higher

standard of care with higher staffing requirements that increase expenditures, they also yield increased federal reimbursement and revenue. When converting GJMVC and SWVC, the DMVA was able to utilize existing vacancies to meet these in-creased staffing needs. However, with the conversation at DVVH, DMVA antici-pates needing to request additional personnel beginning FY 2017-18.

Improving the Quality of Care at the Existing State Veterans’ Homes. As

shown in Exhibit 4, three of Pennsylvania’s six State Veterans’ Homes received at

28

rating of either 4 or 5 (out of 5) stars, one received a rating of 3 stars, one received a rating of 2 stars, and one received a rating of only 1 star. While it was not within the scope of this study to conduct a review of the operations of the State Veterans’ Homes, there would appear to be opportunities for improvement in the operations of at least several of the homes.

Exhibit 4

Pennsylvania State Veterans’ Home Ratings

Hollidaysburg Veterans

Home

Delaware Valley

Veterans Home

Gino J Merli

Veterans Center

Pennsylvania Soldiers and

Sailors Home

Southeastern Pennsylvania

Veterans Center

Southwestern Veterans Center

Health Inspection

Rating 3 4 1 2 1 4

Quality Rating

2 5 4 2 4 3

Staffing Rating

5 5 5 5 1 5

RN Staffing Rating

5 5 5 5 2 5

Overall Rating

4 out of 5 Stars

5 out of 5 Stars

2 out of 5 Stars

3 out of 5 Stars

1 out of 5 Stars

5 out of 5 Stars

Date of Standard

Health Inspection

3/26/15 1/29/15 9/25/15 11/6/15 10/29/15 12/12/14

Source: Developed by LB&FC staff using U.S. Department of Health and Human Services ratings.

Privatizing Some or All Operations at the State Veterans’ Homes. Many

states have privatized some or all of the operations of their State Veterans’ Homes. California contracted out the management of one of its State Veterans’

Homes (Barstow) after it lost its federal certification in July 2000, but only for the period from January 2001 through October 2001. California also contracts out cer-tain specific services, such as the financial billing function, food service, laundry, and specialty medical services, at various State Veterans’ Homes.

29

In a 2003 report analyzing the pros and cons of privatizing, the California Legislative Analyst’s Office (LAO) noted that average annual costs for skilled nurs-ing residents in the private sector range from $40,000 to $45,000, whereas average annual costs for nursing residents in the state’s veterans’ homes range from $110,000 to $130,000. Citing “significant legal constraints involved in replacing civil service employees with privately contracted staff,” the LAO did not, however, recommend further privatization of California’s veterans’ homes.

Oregon owns its two state veterans’ homes, but contracts their operations out to an outside contractor (dietary and housekeeping services are provided under sep-arate contracts), retaining only two state employees at each home. (The USDVA re-quires that each veterans home have at least one state employee to oversee the home.) Montana, which owns two state veterans’ homes, operates one with state employees and contracts operations of the other to a private firm.

A 2003 report by the Mackinac Center for Public Policy found additional pri-vatization efforts as shown in Exhibit 5:

Exhibit 5

Michigan Privatization Report

Illinois. The Illinois Veterans’ Home in Anna is managed under contract by the Tutera Group, of Kansas City, Mo.

Utah. The state of Utah currently has one veterans’ home. It is managed by the for-profit firm, Traditions Health Care, Inc. Utah currently is planning two more veterans’ homes. No determination has been made as to whether or not it will be operated under contract.

South Carolina. The Campbell State Veterans’ Nursing Home in Anderson S.C. is man-aged by Health Management Resources, Inc.

Maryland. Health Management Resources, Inc. manages the Charlotte Hall Veterans’ Home in St. Mary’s County, Maryland.

Texas. The Lone Star State outsources management of all four of its veterans’ homes. There are two more homes being built, one for McAllen and one for El Paso. It has not yet been determined whether or not these will be privately managed. One of the four ex-isting Texas homes is managed by the Wilson County Memorial Hospital District. The other three are run by the private, for-profit firm, “Care Inns of Texas, Ltd.” of San Anto-nio, Texas.

North Carolina. The state’s single veterans’ home is managed by Priva-Trends, which also manages a home in Georgia. The state is building a second home now, which is due to open in the fall of 2003, but there is no word on whether or not it will be privately managed.

Georgia. The Georgia War Veterans Home is run by Priva-Trends, a subsidiary of UHS Pruitt, of Toccoa, Georgia. Priva-Trends has helped lower the cost of providing daily care to veterans by 40 percent to 44 percent, depending on the type of patient care.

Source: LaFaive, Michael D., Michigan Privatization Report – Veterans’ Homes: Privatization Could Mean Lower Costs, Better Service, Mackinac Center for Public Policy, November 20, 2003.

30

Mackinac estimated that if Michigan could save 40 percent by competitively contracting management of its two veterans’ home operations—which it notes is less than was saved in Georgia—the state would save more than $20 million annu-ally.23

The DMVA reported that they have successfully privatized transportation

and barber/beautician services at all six veterans’ homes, and some psychological and medical therapy services at some facilities. The DMVA also reported they had tried privatizing pharmacy operations, but that that effort was unsuccessful. DMVA reported it is also looking into privatizing dietary and housekeeping services as possible cost saving approaches.

Another advantage to privatization is that it can avoid some of the difficulties

inherent in operating a large facility with unionized, Civil Service workers. In par-ticular, the DMVA stated it has had difficulty attracting, hiring, and retaining qual-ified medical personnel, who are essential when operating a large nursing home. Restrictions on who can be hired, delays in the hiring process, and not being able to offer competitive salaries were among the issues cited.

Provide Services in Private Nursing Homes. The USDVA contracts with pri-

vate nursing homes when a veteran needs services USDVA facilities cannot provide or when no nearby USDVA facility is available. Generally, contracted beds are re-served for “mandatory” veterans, meaning veterans with a 70 percent or greater service-connected disability.

Current USDVA rules, however, would prevent the USDVA from paying pri-

vate nursing homes the per diem paid to State Veterans’ Homes ($104). So to be af-fordable, the target rate for providing such care would need to be no more than $246 per day. Though significantly lower than the current per diem rate of $350 at the State Veterans’ Homes, $246 is well above the average Medicaid rate of $201 per day paid to Pennsylvania nursing home providers in 2014.

One possibility that would allow USDVA per diem payments would be for the

Commonwealth to lease some or all of a private nursing home. The USDVA’s Office of General Counsel informed us that “if a State leases space in a private nursing home, the VA could recognize the leased space as a State home if the home meets all VA requirements.”

                                                            23 Michigan did privatize nursing aides in 2011 as part of an effort to save $4 million in operating costs. How-ever, a February 2016 report by the Michigan Auditor General documented numerous instances in which the private contractor hired to provide residential care aides failed to adequately staff the home. The contracted workers also failed to conduct required location and fall alarm checks designed to ensure the safety of residents, but they nonetheless reported that the checks had occurred. After the audit was made public, the director of the Michigan Veterans Affairs Agency resigned.

31

Ensuring Veterans Are Receiving All the Services to Which They Are Enti-tled. While the VA provides a wide range of commonly-known benefits and services for its veterans—such as health care, education support through the GI Bill, and home loans—they also provide many lesser-known benefits to veterans, their family members, and survivors.

Some of the federal benefits that are often overlooked by older veterans and their families include:

Veterans' Pension: This is available to limited-income veterans aged 65 and older or who are totally disabled, provided they served at least 90 days of active mil-itary service. At least one of those days of service must be during a period of war (stateside or overseas). Many veterans of wartime service are unaware that if they are 65 or older and on a limited income they may qualify for a VA Pension even though they are not disabled. Single surviving spouses of such veterans are also eli-gible.

Aid and Attendance (A&A): Of particular importance to this study, this little known benefit can help veterans and their spouses pay for in-home care, an assisted living facility, or nursing home care. It pays up to $1,949 per month, in addition to the monthly pension benefits. To qualify, the veteran must be 65 or older (or per-manently disabled), have served during wartime and meet certain financial and medical requirements (e.g., needing assistance with basic everyday living tasks like eating, bathing, or dressing). Being blind or in a nursing home or assisted living fa-cility for mental incapacity also qualifies. Annual income as a couple (minus medi-cal and long-term care expenses) cannot exceed $23,396, $19,736 for a single vet-eran, or $12,681 for a surviving spouse. Assets must be less than $80,000, exclud-ing a home and car.

Housebound: Like A&A, Housebound benefits are paid in addition to monthly pension benefits and may not be paid without eligibility to pension. A veteran may be eligible for Housebound benefits when:

the veteran has a single permanent disability evaluated as 100-percent disabling and, due to such disability, he/she is permanently and substan-tially confined to his/her immediate premises, or,

the veteran has a single permanent disability evaluated as 100-percent disabling and, another disability, or disabilities, evaluated as 60 percent or more disabling.

A veteran cannot receive both Aid and Attendance and Housebound benefits at the same time.

32

Hospice Benefit: Hospice care is now a covered benefit for all enrolled veter-ans.

Burial Benefits: Regardless of income and assets, this benefit provides all vet-erans, spouses, and dependents a free burial at a national cemetery and a free grave marker. Funeral or cremation costs are not covered, but some veterans may qualify for a $300 funeral allowance and $300 for a plot if they choose to be buried in a pri-vate cemetery.

Death Pension: This is available to low-income surviving spouses and de-pendents of wartime veterans whose death was not related to military service.

The DMVA and Commonwealth veterans organizations attempt to inform veterans of these programs, but many veterans are still not aware of the benefits to which they are entitled. This is particularly true of veterans who may already be in a nursing home or who have limited ability to travel to a veterans outreach center.

33

III. Appendices

34

APPENDIX A

PRIOR PRINTER'S NO. 1195 PRINTER'S NO. 1294

THE GENERAL ASSEMBLY OF PENNSYLVANIA

SENATE RESOLUTION No. 171 Session of

2015

INTRODUCED BY ARGALL, VULAKOVICH, EICHELBERGER, FONTANA,

GREENLEAF, BREWSTER, BARTOLOTTA, FOLMER, SABATINA, SCARNATI, WARD, ALLOWAY, BROWNE AND STEFANO, JULY 23, 2015

SENATOR VULAKOVICH, VETERANS AFFAIRS AND EMERGENCY PREPAREDNESS,

AS AMENDED, SEPTEMBER 30, 2015

A RESOLUTION

Directing the Legislative Budget and Finance Committee to conduct a study relating to the feasibility and cost-effectiveness of utilizing privately owned veterans care facilities to augment the Commonwealth's six State-owned veterans care facilities.

WHEREAS, There is increased demand for quality care for

veterans across this Commonwealth; and

WHEREAS, Costs to PROVIDE OR subsidize veterans care from

taxpayers could be offset by utilizing the private sector care

facilities; and

WHEREAS, The United States Department of Veterans Affairs

currently partners with several privately owned or managed

health care facilities to provide quality health care to

veterans; and

WHEREAS, The privately managed health care facilities may

further assist the Department of Military and Veterans Affairs

35

Appendix A (Continued)

to provide necessary care to veterans and their families;

therefore be it

RESOLVED, That the Senate direct Legislative Budget and

Finance Committee to conduct a study relating to the cost-

effectiveness and opportunities for the Department of Military

and Veterans Affairs to partner with privately managed health

care facilities to provide added care for veterans in

Pennsylvania; and be it further

RESOLVED, That the study include:

(1) The number of veterans in each county waiting to be

placed in State veterans care facilities.

(2) The number of veterans in Pennsylvania eligible for

care from the Department of Military and Veterans Affairs and

the United States Department of Veterans Affairs.

(3) The average cost per day of the care and treatment

for a veteran at State-owned veterans care facilities.

(4) The average cost per day of the care and treatment

for a veteran at a privately owned HEALTH care facility.

(5) The projected number of veterans who will need care

over the next 10 years within this Commonwealth.

(6) A summary of other states and their respective

programs that allow for public-private partnerships with the

United States Department of Veterans Affairs to offer

additional care for veterans.

36

Appendix A (Continued)

(7) The types of health and medical care to be provided

and how it is expected to change over the next 10 years.

(8) The types of veterans to be served over the next 10

years and how the population of veterans may be different

from traditional populations of veterans based on age, sex

and conditions to be treated.

(9) Any additional opportunities that exist to enhance

and improve the care for veterans at either a State-owned or

privately owned facility;

and be it further

RESOLVED, That in compiling this report the Legislative

Budget and Finance Committee seek input from the Department of

Military and Veterans Affairs, United States Department of

Veterans Affairs and any other groups or individuals who may

have information relevant to this study; and be it further

RESOLVED, That the Legislative Budget and Finance Committee

report its findings and recommendations to the Senate no later

than six months after the adoption of this resolution.

37

APPENDIX B

Number of State Veterans Homes Per State

State

Total Per State

State

Total Per State

Alabama ........................ 4 Nebraska ............................... 4

Alaska ........................... 1 Nevada .................................. 1

Arizona .......................... 2 New Hampshire ..................... 1

Arkansas ....................... 2 New Jersey ............................ 3

California ....................... 8 New Mexico ........................... 2

Colorado ........................ 5 New York ............................... 5

Connecticut ................... 1 North Carolina ....................... 4

Delaware ....................... 1 North Dakota ......................... 1

Florida ........................... 8 Ohio ....................................... 2

Georgia ......................... 2 Oklahoma .............................. 7

Hawaii ........................... 1 Oregon .................................. 1

Idaho ............................. 3 Pennsylvania ....................... 6

Illinois ............................ 4 Puerto Rico ............................ 1

Indiana .......................... 1 Rhode Island ......................... 1

Iowa ............................... 1 South Carolina ....................... 3

Kansas .......................... 2 South Dakota ......................... 1

Kentucky ....................... 4 Tennessee ............................. 5

Louisiana ....................... 5 Texas ..................................... 8

Maine ............................ 6 Utah ....................................... 4

Maryland ....................... 1 Vermont ................................. 1

Massachusetts .............. 2 Virginia .................................. 3

Michigan ........................ 2 Washington ........................... 5

Minnesota...................... 5 West Virginia ......................... 2

Mississippi ..................... 6 Wisconsin .............................. 3

Missouri ......................... 7 Wyoming ............................... 1

Montana ........................ 2

Source: Developed by LB&FC staff from information obtained from the Senior Veterans Alliance.

AP

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Station 

Facility Nam

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Add

ress 

City 

State 

Co

unty 

Urban

/Rural

RUG IV

 Average

1

Physician 

Expe

nse*

112‐15

4 PE

R DIEM 

521 

Bill Nichols State Veterans Home 

1784 ELKAHATCHEE RD 

ALEXANDER

 CITY 

AL 

TALLAPOOSA

 Rural 

$ 317.12

$ 

3.85

$ 

320.96

521 

William F. Green State Veterans Home 

300 FAULKNER DR 

BAY M

INETTE 

AL 

BALD

WIN 

Urban 

$ 327.62

$ 

3.85

$ 

331.47

521 

Colonel R

obert L. Howard State Veterans Home 

7054 VETERANS PARKWAY 

PELL CITY 

AL 

ST CLA

IR 

Urban 

$ 354.34

$ 

3.85

$ 

358.19

521 

Floyd

 E. Tut Fann Veterans Home 

2701 M

ERIDIAN ST N 

HUNTSV

ILLE 

AL 

MADISON 

Urban 

$ 367.16

$ 

3.85

$ 

371.00

564 

Fayetteville

 Veterans Home 

1125 NORTH COLLEGE AVENUE 

FAYETTEVILLE 

AR 

WASH

INGTON 

Urban 

$ 361.50

$ 

3.85

$ 

365.35

644 

Arizona State Veterans Home 

4141 N 3RD ST 

PHOENIX 

AZ 

MARICOPA 

Urban 

$ 411.68

$ 

3.85

$ 

415.52

678 

Arizona State Veterans Home ‐ Tucson 

555 EAST AJO

 WAY 

TUCSO

N 

AZ 

PIM

A 

Urban 

$ 371.89

$ 

3.85

$ 

375.74

570 

Veterans Home of California, Fresno 

2811 W

 CALIFO

RNIA AVE 

FRESN

O 

CA 

FRESN

O 

Urban 

$ 431.32

$ 

3.95

$ 

435.27

605 

Veterans Home of California 

100 VETERANS PKWY 

BARSTOW 

CA 

SAN BER

NARDINO 

Urban 

$ 450.13

$ 

3.95

$ 

454.08

612 

Veterans Home of California, Redding 

3400 KNIGHTON RD 

REDDING 

CA 

SHASTA 

Urban 

$ 538.87

$ 

3.95

$ 

542.82

662 

Veterans Home of California 

180 CALIFO

RNIA DR 

YOUNTVILLE 

CA 

NAPA 

Urban 

$ 564.89

$ 

4.07

$ 

568.96

664 

Veterans Home of California 

700 E NAPLES CT 

CHULA

 VISTA 

CA 

SAN DIEGO 

Urban 

$ 460.60

$ 

3.95

$ 

464.55

691 

Veterans Home of California 

800 BRINGHAM AVENUE 

WEST LOS ANGELES 

CA 

LOS ANGELES 

Urban 

$ 477.43

$ 

3.95

$ 

481.38

741 

Walsenburg Colorado State Veterans Home 

23500 US HIGHWAY 160 

WALSENBURG 

CO 

HUERFA

NO 

Rural 

$ 396.13

$ 

3.85

$ 

399.98

741 

Fitzsimons Home 

1919 QUENTIN ST 

AURORA 

CO 

ADAMS 

Urban 

$ 408.73

$ 

3.85

$ 

412.57

741 

Rifle Colorado State Veterans Home 

851 E 5TH ST 

RIFLE 

CO 

GARFIELD

 Rural 

$ 396.13

$ 

3.85

$ 

399.98

741 

Homelake Colorado State Veterans Center 

3749 SHERMAN AVE 

HOMELA

KE (Monte Vista) 

CO 

RIO GRANDE 

Rural 

$ 396.13

$ 

3.85

$ 

399.98

741 

Florence Colorado State Veterans Nursing Home 

903 M

OORE DR 

FLORENCE 

CO 

FREMONT 

Rural 

$ 396.13

$ 

3.85

$ 

399.98

689 

State Veterans Home 

287 W

EST STREET 

ROCKY HILL 

CT 

HARTFO

RD 

Urban 

$ 434.14

$ 

3.94

$ 

438.07

460 

Delaware Veterans Home 

100 DELA

WARE VETERANS DRIVE 

MILFO

RD 

DE 

SUSSEX 

Urban 

$ 383.96

$ 

3.89

$ 

387.85

516 

Douglas T. Jacobson State Veterans Home 

21281 GRAYTON TER 

PORT CHARLO

TTE 

FL 

CHARLO

TTE 

Urban 

$ 378.83

$ 

3.85

$ 

382.68

520 

Clifford Chester Sims State Veterans Home 

4419 TRAM RD 

SPRINGFIELD

 (Panama City) 

FL 

BAY 

Urban 

$ 366.82

$ 

3.85

$ 

370.67

546 

Alexander Sandy Ninger Veterans Nursing Home 

8401 W

 CYPRESS DR 

PEM

BROKE PINES 

FL 

BROWARD 

Urban 

$ 396.97

$ 

3.85

$ 

400.81

573 

Clyde E. Lassen State Veterans Nursing Home 

4650 STATE ROAD 13 

SAINT AUGUSTINE 

FL 

ST. JOHNS 

Urban 

$ 377.63

$ 

3.85

$ 

381.48

673 

Baldomero Lopez Veterans Nursing Home 

6919 PARKWAY BLV

D 

LAND O LAKES 

FL 

PASC

O 

Urban 

$ 374.79

$ 

3.85

$ 

378.64

675 

Emory L. Bennett Veterans Nursing Home 

1920 M

ASO

N AVE 

DAYTONA BEA

CH 

FL 

VOLU

SIA 

Urban 

$ 361.95

$ 

3.85

$ 

365.79

509 

Georgia W

ar Veterans Home 

1120 15TH ST 

AUGUSTA 

GA 

RICHMOND 

Urban 

$ 385.71

$ 

3.85

$ 

389.56

557 

Georgia W

ar Veterans Home 

VINSO

N HIGHWAY 

MILLEDGEVILLE 

GA 

BALD

WIN 

Rural 

$ 331.69

$ 

3.85

$ 

335.53

459 

Yukio Okutsu State Veterans Home 

1180 W

AIANUENUE AVENUE 

HILO 

HI 

HAWAII 

Rural 

$ 429.32

$ 

3.86

$ 

433.17

636 

Iowa Veterans Home 

1301 SUMMIT ST 

MARSH

ALLTOWN 

IA 

MARSH

ALL 

Rural 

$ 358.96

$ 

3.85

$ 

362.81

531 

Idaho State Veterans Home 

320 COLLINS RD 

BOISE 

ID 

ADA 

Urban 

$ 384.51

$ 

3.85

$ 

388.36

668 

Idaho State Veterans Home 

821 21ST AVE 

LEWISTON 

ID 

NEZ PERCE 

Urban 

$ 393.07

$ 

3.85

$ 

396.91

741 

Idaho State Veterans Home 

1957 ALVIN RICKEN DR 

POCATELLO 

ID 

BANNOCK 

Urban 

$ 395.07

$ 

3.85

$ 

398.92

578 

Illinois Veterans Home 

1015 OCONOR AVE 

LA SALLE 

IL 

LA SALLE 

Rural 

$ 361.08

$ 

3.85

$ 

364.93

578 

Illinois Veterans Home 

1 VETERANS DR 

MANTENO 

IL 

KANKAKEE 

Urban 

$ 368.41

$ 

3.85

$ 

372.26

636 

Illinois Veterans Home 

1710 N 12TH ST 

QUINCY 

IL 

ADAMS 

Rural 

$ 361.08

$ 

3.85

$ 

364.93

657 

Illinois Veterans' Home 

792 N M

AIN ST 

ANNA 

IL 

UNION 

Rural 

$ 361.08

$ 

3.85

$ 

364.93

583 

Indiana Veterans Home 

3851 N RIVER RD 

WEST LAFA

YETTE 

IN 

TIPPECANOE 

Urban 

$ 400.01

$ 

3.85

$ 

403.85

589 

Kansas Veterans Home 

1220 NORTH VIKING BOULEVARD 

WINFIELD

 KS 

COWLEY 

Rural 

$ 338.79

$ 

3.85

$ 

342.64

589 

Kansas Soldiers Home 

E. TRAIL STREET 

FORT DODGE 

KS 

GRAY 

Rural 

$ 338.79

$ 

3.85

$ 

342.64

596 

Thomson‐Hood Veterans Center 

100 VETERANS DR 

WILMORE 

KY 

JESSAMINE 

Urban 

$ 371.59

$ 

3.85

$ 

375.43

596 

Eastern Kentucky Veterans Center 

200 VETERANS DR 

HAZA

RD 

KY 

PERRY 

Rural 

$ 340.30

$ 

3.85

$ 

344.14

657 

Western Kentucky Veterans Center 

926 VETERANS DR 

HANSO

N 

KY 

HOPKINS 

Rural 

$ 340.30

$ 

3.85

$ 

344.14

TBD 

TBD 

TBD 

RADCLIFF 

KY 

HARDIN 

Urban 

$ 331.49

$ 

3.85

$ 

335.34

502 

SW Louisiana W

ar Veterans Home 

1610 EVANGELINE RD 

JENNINGS 

LA 

ACADIA 

Rural 

$ 318.48

$ 

3.85

$ 

322.33

629 

Louisiana W

ar Veterans Home 

4739 HIGHWAY 10 

JACKSO

N 

LA 

EAST FELICIANA 

Urban 

$ 349.19

$ 

3.85

$ 

353.03

629 

SE Louisiana W

ar Veterans Home 

4080 W

 AIRLINE HWY 

RESERVE 

LA 

ST. JOHN THE BAPTIST PARISH 

Urban 

$ 365.62

$ 

3.85

$ 

369.47

667 

N.E. Louisiana W

ar Veterans Home 

6700 HIGHWAY 165 N 

MONROE 

LA 

OUACHITA 

Urban 

$ 337.59

$ 

3.85

$ 

341.44

                                                            

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Util

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the

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.

38

Ap

pen

dix

C (

Co

nti

nu

ed)

  Station 

Facility Nam

e 

Add

ress 

City 

State 

Co

unty 

Urban

/Rural

RUG IV

 Average

Physician 

Expe

nse*

112‐15

4 PE

R DIEM 

667 

Northwest Louisiana W

ar Veterans Home 

3130 ARTHUR RAY TEAGUE PARKWAY 

BOSSIER CITY 

LA 

BOSSIER PARISH 

Urban 

$ 355.34

$ 

3.85

$ 

359.19

523 

Soldier's Home in

 Chelsea 

91 CREST AVE 

CHELSEA 

MA 

SUFFOLK

 Urban 

$ 487.58

$ 

3.91

$ 

491.49

631 

Soldiers Home in

 Holyoke

 110 CHERRY ST 

HOLYOKE 

MA 

HAMPDEN 

Urban 

$ 409.95

$ 

3.91

$ 

413.86

688 

Charlotte Hall V

eterans Home 

29449 CHARLO

TTE HALL RD 

CHARLO

TTE HALL 

MD 

ST. MARY'S 

Rural 

$ 366.24

$ 

3.90

$ 

370.14

402 

Bango

r Home 

44 HOGAN RD 

BANGOR 

ME 

PENOBSCOT 

Urban 

$ 398.89

$ 

3.85

$ 

402.74

402 

Caribou Home 

163 VAN BUREN RD 

CARIBOU 

ME 

AROOSTOOK 

Rural 

$ 360.78

$ 

3.85

$ 

364.62

402 

South Paris Home 

477 HIGH ST 

SOUTH PARIS 

ME 

OXFO

RD 

Rural 

$ 360.78

$ 

3.85

$ 

364.62

402 

Scarborough Home 

290 US ROUTE 1 

SCARBOROUGH 

ME 

CUMBERLA

ND 

Urban 

$ 405.24

$ 

3.85

$ 

409.09

402 

Augu

sta Home 

310 CONY RD 

AUGUSTA 

ME 

KENNEBEC 

Rural 

$ 360.78

$ 

3.85

$ 

364.62

515 

Grand Rapids Home for Veterans 

3000 M

ONROE AVE NE 

GRAND RAPIDS 

MI 

KENT 

Urban 

$ 371.11

$ 

3.85

$ 

374.96

585 

D.J. Jacobetti H

ome for Veterans 

425 FISHER ST 

MARQUETTE 

MI 

MARQUETTE 

Rural 

$ 358.07

$ 

3.85

$ 

361.92

437 

Minnesota Veterans Home 

1821 N PARK ST 

FERGUS FA

LLS 

MN 

OTTER TAIL 

Rural 

$ 375.90

$ 

3.85

$ 

379.75

438 

Minnesota Veterans Home 

1300 N KNISS AVE 

LUVERNE 

MN 

ROCK 

Rural 

$ 375.90

$ 

3.85

$ 

379.75

618 

Minnesota Veterans Home 

45 BANKS BLV

D 

SILVER BAY 

MN 

LAKE 

Rural 

$ 375.90

$ 

3.85

$ 

379.75

618 

Minnesota Veterans Home 

5101 M

INNEHAHA AVE 

MINNEAPOLIS 

MN 

HENNEPIN 

Urban 

$ 435.08

$ 

3.85

$ 

438.93

589 

Missouri Veterans Home 

620 N JEFFERSO

N ST 

SAINT JAMES 

MO 

PHELPS 

Rural 

$ 340.02

$ 

3.85

$ 

343.86

589 

Missouri Veterans Home 

111 EUCLID 

CAMERON 

MO 

CLINTON 

Urban 

$ 388.22

$ 

3.85

$ 

392.07

589 

Missouri Veterans Home 

1300 VETERANS RD 

WARRENSB

URG 

MO 

JOHNSO

N 

Rural 

$ 340.02

$ 

3.85

$ 

343.86

589 

Missouri Veterans Home 

1 VETERANS WAY 

MEXICO 

MO 

AUDRAIN 

Rural 

$ 340.02

$ 

3.85

$ 

343.86

657 

Missouri Veterans Home 

2400 VETERANS MEMORIAL DR 

CAPE GIRARDEA

U 

MO 

CAPE GIRARDEA

U 

Urban 

$ 364.98

$ 

3.85

$ 

368.83

657 

Missouri Veterans Home 

10600 LEWIS AND CLA

RK BLVD 

SAINT LOUIS 

MO 

ST. LO

UIS 

Urban 

$ 382.48

$ 

3.85

$ 

386.33

657 

Missouri Veterans Home 

600 N M

AIN ST 

MOUNT VERNON 

MO 

LAWRENCE 

Rural 

$ 340.02

$ 

3.85

$ 

343.86

586 

Mississippi V

eterans Home 

3261 HIGHWAY 49 

COLLINS 

MS 

COVINGTON 

Rural 

$ 331.33

$ 

3.85

$ 

335.17

586 

Mississippi V

eterans Home 

4607 LINDBERGH DR 

JACKSO

N 

MS 

HINDS 

Urban 

$ 346.46

$ 

3.85

$ 

350.30

586 

Mississippi V

eterans Home 

310 AUTUMN RIDGE DR 

KOSCIUSKO 

MS 

ATTALA

 Rural 

$ 331.33

$ 

3.85

$ 

335.17

614 

Mississippi V

eterans Home 

120 CENTER RIDGE RD 

OXFO

RD 

MS 

LAFA

YETTE 

Rural 

$ 331.33

$ 

3.85

$ 

335.17

741 

Montana Veterans Home 

400 VETERNS DR 

COLU

MBIA FALLS 

MT 

FLATHEAD 

Rural 

$ 381.23

$ 

3.85

$ 

385.07

741 

Eastern M

ontana Veterans Home 

2000 M

ONTANA AVE 

GLENDIVE 

MT 

DAWSO

N 

Rural 

$ 381.23

$ 

3.85

$ 

385.07

558 

North Carolina Veterans Home ‐ Kingston 

2150 HULL ROAD 

KINSTON 

NC 

LENOIR 

Rural 

$ 346.46

$ 

3.85

$ 

350.30

565 

North Carolina Veterans Home 

214 COCHRAN AVE 

FAYETTEVILLE 

NC 

CUMBERLA

ND 

Urban 

$ 346.46

$ 

3.85

$ 

350.30

637 

North Carolina Veterans Home ‐ Black M

ountain 

62 LAKE EDEN ROAD 

BLACK M

OUNTA

IN 

NC 

BUNCOMBE 

Urban 

$ 364.01

$ 

3.85

$ 

367.85

659 

North Carolina Veterans Home for W.G. Hefner 

1601 BRENNER AVE 

SALISB

URY 

NC 

ROWAN 

Urban 

$ 377.38

$ 

3.85

$ 

381.23

437 

North Dakota Veterans Home 

1400 ROSE ST 

LISB

ON 

ND 

RANSO

M 

Rural 

$ 331.02

$ 

3.85

$ 

334.86

636 

Thomas Fitzgerald Veterans Home 

15345 W

 MAPLE RD 

BELLEVUE (Omaha) 

NE 

DOUGLA

S Urban 

$ 391.40

$ 

3.85

$ 

395.24

636 

Grand Island Veterans Home 

2300 W

 CAPITAL AVE 

GRAND ISLAND 

NE 

HALL 

Urban 

$ 367.71

$ 

3.85

$ 

371.56

636 

Norfolk Veterans Home 

1700 N VICTORY RD 

NORFO

LK 

NE 

MADISON 

Rural 

$ 360.05

$ 

3.85

$ 

363.90

741 

Western Nebraska Veterans Home 

1102 W

 42ND ST 

SCOTTSB

LUFF 

NE 

SCOTTS BLU

FF 

Rural 

$ 360.05

$ 

3.85

$ 

363.90

608 

New Hampshire Veterans Home 

139 W

INTER ST 

TILTON 

NH 

BELKNAP 

Rural 

$ 404.35

$ 

3.85

$ 

408.20

460 

New Jersey Memorial H

ome 

524 N W

EST BLV

D 

VINELA

ND 

NJ 

CUMBERLA

ND 

Urban 

$ 426.06

$ 

3.94

$ 

430.00

561 

Paramus Veterans Home 

1 VETERANS WAY 

PARAMUS 

NJ 

BERGEN 

Urban 

$ 485.71

$ 

4.00

$ 

489.71

561 

Menlo Park Veterans Memorial H

ome 

132 EVERGREEN RD 

MENLO

 PARK (Edison) 

NJ 

MIDDLESEX 

Urban 

$ 485.71

$ 

4.00

$ 

489.71

501 

New M

exico Veterans Center 

992 S BROADWAY ST 

TRUTH OR CONSEQUENCES 

NM 

SIERRA 

Rural 

$ 361.78

$ 

3.85

$ 

365.62

501 

New M

exico State Veterans Home 

120 CALLE EL CASTRO 

FORT BAYA

RD 

NM 

GRANT 

Rural 

$ 361.78

$ 

3.85

$ 

365.62

593 

Nevada Veterans Nursing Home 

100 VETERANS MEMORIAL DR 

BOULD

ER CITY 

NV 

CLA

RK 

Urban 

$ 461.16

$ 

3.86

$ 

465.03

528 

New York State Veterans' Home at Batavia 

220 RICHMOND AVE 

BATAVIA 

NY 

GENESEE 

Rural 

$ 354.37

$ 

3.85

$ 

358.21

528 

New York State Veterans' Home at Oxford 

4211 STATE HIGHWAY 220 

OXFO

RD 

NY 

CHENANGO 

Rural 

$ 354.37

$ 

3.85

$ 

358.21

620 

New York State Veterans' Home at Montrose 

2090 ALBANY POST RD 

MONTROSE

 NY 

WESTCHESTER 

Urban 

$ 485.71

$ 

3.85

$ 

489.55

630 

St. Albans Veterans Home 

17850 LINDEN BLV

D 

JAMAICA 

NY 

QUEENS 

Urban 

$ 485.71

$ 

4.05

$ 

489.75

632 

Long Island State Veterans Home 

STONY BROOK 100 PARTRIOTS RD 

STONY BROOK 

NY 

SUFFOLK

 Urban 

$ 485.88

$ 

4.02

$ 

489.90

539 

Southern Ohio Veterans Home 

2003 VETERANS BLVD 

GEORGETOWN 

OH 

BROWN 

Urban 

$ 387.58

$ 

3.85

$ 

391.42

541 

Ohio Veterans Home 

3416 COLU

MBUS AVE 

SANDUSKY 

OH 

ERIE 

Rural 

$ 356.04

$ 

3.85

$ 

359.88

623 

Oklahoma Veterans Center 

3001 W

 BLU

E STARR DR 

CLA

REMORE 

OK 

ROGERS 

Urban 

$ 341.89

$ 

3.85

$ 

345.73

623 

Oklahoma Veterans Center 

HIGHWAY 63A 

TALIHINA 

OK 

LE FLO

RE 

Rural 

$ 337.23

$ 

3.85

$ 

341.08

635 

Oklahoma Veterans Center 

1015 S COMMERCE ST 

ARDMORE 

OK 

CARTER 

Rural 

$ 337.23

$ 

3.85

$ 

341.08

635 

Oklahoma Veterans Center 

1776 E ROBINSO

N ST 

NORMAN 

OK 

CLEVELA

ND 

Urban 

$ 369.41

$ 

3.85

$ 

373.26

635 

Oklahoma Veterans Center 

2326 E GORE BLV

D 

LAWTON 

OK 

COMANCHE 

Urban 

$ 329.85

$ 

3.85

$ 

333.69

39

Ap

pen

dix

C (

Co

nti

nu

ed)

  Station 

Facility Nam

e 

Add

ress 

City 

State 

Co

unty 

Urban

/Rural

RUG IV

 Average

Physician 

Expe

nse*

112‐15

4 PE

R DIEM 

635 

Oklahoma Veterans Center 

HIGHWAY 183 S 

CLINTON 

OK 

CUSTER 

Rural 

$ 337.23

$ 

3.85

$ 

341.08

635 

Oklahoma Veterans Center 

200 E FAIRLA

NE 

SULPHUR 

OK 

MURRAY 

Rural 

$ 337.23

$ 

3.85

$ 

341.08

648 

Orego

n State Veterans Home 

700 VETERANS DR 

THE DALLES 

OR 

WASC

O 

Rural 

$ 406.08

$ 

3.85

$ 

409.92

TBD 

TBD 

TBD 

SALEM 

OR 

POLK

 Urban 

$ 423.38

$ 

3.85

$ 

427.23

TBD 

TBD 

TBD 

SALEM 

OR 

MARION 

Urban 

$ 423.38

$ 

3.85

$ 

427.23

648 

Edward C. Allw

orth Orego

n Veterans' Home 

600 N 5TH ST 

LEBANON 

OR 

LINN 

Urban 

$ 424.50

$ 

3.85

$ 

428.34

503 

Hollidaysburg Veterans Home 

ROUTE 220 M

EADOWS INTERSECTI 

HOLLIDAYSB

URG 

PA 

BLA

IR 

Urban 

$ 415.36

$ 

3.85

$ 

419.20

542 

Southeastern Pennsylvania Veterans Center 

1 VETERANS DR 

SPRING CITY 

PA 

CHESTER 

Urban 

$ 410.98

$ 

3.85

$ 

414.83

562 

Pennsylvania Soldiers and Sailors Home 

560 E 3RD ST 

ERIE 

PA 

ERIE 

Urban 

$ 341.02

$ 

3.85

$ 

344.87

642 

Delaware Valley State Home 

2701 SOUTHAMPTON RD 

PHILADELPHIA 

PA 

PHILADELPHIA 

Urban 

$ 434.78

$ 

3.93

$ 

438.70

646 

Southwestern Veterans Center 

7060 HIGHLA

ND DR 

PITTSB

URGH 

PA 

ALLEGHENY 

Urban 

$ 363.76

$ 

3.85

$ 

367.60

693 

Northeastern Pennsylvania Veterans Center 

401 PENN AVE 

SCRANTON 

PA 

LACKAWANNA 

Urban 

$ 356.43

$ 

3.85

$ 

360.27

672 

Casa Del V

eterano 

CARR.592 

JUANA DIAZ 

PR 

JUANA DIAZ 

Urban 

$ 244.31

$ 

3.85

$ 

248.16

650 

Rhode Island Veterans Home 

480 M

ETACOM AVE 

BRISTOL 

RI 

BRISTOL 

Urban 

$ 420.40

$ 

3.93

$ 

424.33

534 

The Veterans Victory House 

2461 SIDNEYS ROAD 

WALTERBORO 

SC 

COLLETON 

Rural 

$ 354.23

$ 

3.85

$ 

358.07

544 

Richard M

. Campbell Veterans Nursing Home 

4605 BELTON HWY 

ANDERSO

N 

SC 

ANDERSO

N 

Urban 

$ 375.74

$ 

3.85

$ 

379.58

544 

E. Roy Stone, Jr. War Veterans Pavilio

n 

2200 HARDEN ST 

COLU

MBIA 

SC 

RICHLA

ND 

Urban 

$ 358.27

$ 

3.85

$ 

362.11

568 

Michael J. Fitzmaurice Veterans Home 

2500 M

INNEKAHTA AVE 

HOT SPRINGS 

SD 

FALL RIVER 

Rural 

$ 348.38

$ 

3.85

$ 

352.22

TBD 

Clarksville Veterans' Home 

TBD 

CLA

RKSV

ILLE 

TN 

MONTGOMERY 

Urban 

$ 332.97

$ 

3.85

$ 

336.82

614 

Tennessee State Veterans Home 

2865 E M

AIN ST 

HUMBOLD

T 

TN 

GIBSO

N 

Rural 

$ 328.79

$ 

3.85

$ 

332.64

621 

The Ben Atchley State Veterans Home 

1 VETERANS WAY 

KNOXVILLE 

TN 

KNOX 

Urban 

$ 334.17

$ 

3.85

$ 

338.01

626 

Tennessee State Veterans Home 

345 COMPTON RD 

MURFR

EESB

ORO 

TN 

RUTHERFO

RD 

Urban 

$ 372.92

$ 

3.85

$ 

376.77

504 

Ussery‐Roan

 Texas State Veterans Home 

1020 TASC

OSA

 ROAD 

AMARILLO

 TX 

POTTER/RANDALL 

Urban 

$ 352.75

$ 

3.85

$ 

356.60

519 

Lamun‐Lusk‐San

chez State Veterans Home 

1809 N US HIGHWAY 87 

BIG SPRING 

TX 

HOWARD 

Rural 

$ 340.97

$ 

3.85

$ 

344.81

549 

Clyde W

. Cosper State Veterans Home 

1300 SEVEN OAKS RD 

BONHAM 

TX 

FANNIN 

Rural 

$ 340.97

$ 

3.85

$ 

344.81

549 

Watkins‐Logan‐Garrison Texas State Veterans Home 

11466 HONOR LANE 

TYLER 

TX 

SMITH 

Urban 

$ 356.57

$ 

3.85

$ 

360.41

671 

Frank M. Tejeda State Veterans Home 

200 VETERANS DR 

FLORESV

ILLE 

TX 

WILSO

N 

Urban 

$ 365.87

$ 

3.85

$ 

369.72

674 

William Courtney State Veterans Home 

1901 S 1ST ST 

TEMPLE 

TX 

BELL 

Urban 

$ 377.16

$ 

3.85

$ 

381.00

740 

Alfredo Gonzales Texas State Vet Home 

301 E YUMA AVE 

MCALLEN 

TX 

HIDALG

O 

Urban 

$ 349.07

$ 

3.85

$ 

352.92

756 

Ambrosia Gullen Texas State Veterans Home 

9650 KENWORTHY ST 

EL PASO

 TX 

EL PASO

 Urban 

$ 348.32

$ 

3.85

$ 

352.17

741 

George E. Wahlen Ogden Veterans Home 

1102 NORTH 1200 W

EST OGDEN 

OGDEN 

UT 

WEBER 

Urban 

$ 381.70

$ 

3.85

$ 

385.55

741 

Central U

tah Veterans Home 

1551 NORTH M

AIN STREET 

PAYSO

N 

UT 

UTAH 

Urban 

$ 391.84

$ 

3.85

$ 

395.69

741 

Southern Utah Veterans Home 

160 NORTH 200 EAST STREET 

IVINS 

UT 

WASH

INGTO

N  COUNTY

 Urban 

$ 392.90

$ 

3.85

$ 

396.75

741 

Utah State Veterans Nursing Home 

700 FOOTHILL BLV

D 

SALT LAKE CITY 

UT 

SALT LAKE 

Urban 

$ 389.17

$ 

3.85

$ 

393.01

652 

Sitter & Barefoot Veteran Care Center 

1601 BROAD ROCK BLV

D. 

RICHMOND 

VA 

RICHMOND 

Urban 

$ 393.01

$ 

3.85

$ 

396.86

658 

Virginia Veterans Care Center 

4550 SHENANDOAH AVE NW 

ROANOKE 

VA 

ROANOKE 

Urban 

$ 380.56

$ 

3.85

$ 

384.40

405 

Verm

ont Veterans Home 

325 NORTH ST 

BENNINGTON 

VT 

BENNINGTON 

Rural 

$ 394.29

$ 

3.85

$ 

398.14

663 

Washington Soldiers Home 

1301  O

RTING/KAPOWSIN HIGHWAY 

ORTING 

WA 

PIERCE 

Urban 

$ 452.69

$ 

3.85

$ 

456.54

663 

Retsil Washington State Veterans Home 

1141 BEACH DRIVE 

RETSIL 

WA 

KITSA

P 

Urban 

$ 433.86

$ 

3.85

$ 

437.70

TBD 

TBD 

TBD 

WALLA W

ALLA 

WA 

WALLA W

ALLA 

Urban 

$ 449.04

$ 

3.85

$ 

452.89

668 

Washington Veterans Home 

222 E 5TH AVE 

SPOKANE 

WA 

SPOKANE 

Urban 

$ 459.60

$ 

3.85

$ 

463.45

607 

Wisconsin Veterans Home 

N 2665 CTH QQ 

KING 

WI 

WAUPACA 

Rural 

$ 372.12

$ 

3.85

$ 

375.96

618 

Wisconsin Veterans Home Chippewa Falls 

2175 EAST PARK AVENUE 

CHIPPEWA FALLS 

WI 

CHIPPEW

A/EAU  CLAIR 

Urban 

$ 394.74

$ 

3.85

$ 

398.58

695 

Wisconsin Veterans Home‐‐Union Grove

 21425 SPRING ST # D 

UNION GROVE 

WI 

RACINE 

Urban 

$ 422.94

$ 

3.85

$ 

426.78

540 

West Virginia Veterans Home 

ONE FREEDOMS WAY 

CLA

RKSB

URG 

WV 

HARRISON 

Rural 

$ 329.88

$ 

3.85

$ 

333.72

* Notes: 

1) The Physician Expense rate is calculated by taking the National Practice Expense Hourly Rate (PE‐HR) for All Physicians. 

2) The PE‐HR rate is then multiplied by the PW GPCI (Physician W

ork ‐Geographic Practice Cost Index) based on County and State of the State home 

3) The adjusted PE‐HR (from note 2) is then multipied by 12 and the divided to get a daily rate. 

4) The National PE‐HR of $116.96 for Calendar Year 2015 is used in calculating the Fiscal Year 2016 per diem rates. 

5) The Calendar Year 2015 PE‐HR rate will be not be adjusted after the new 2016 calendar year rates are published. 

6) Both the PE‐HR for all physicians and the PW GPCI rates can be found on the CMS web site. 

  Source:  U.S. D

epartm

ent of Military Affairs. 

40

41

APPENDIX D

Response to This Report

COMMOIYWEALTH OF PENNSYLVANIADEPARTMENT OF MILITARY AND VETERANS AFFAIRS

THE ADruTANT GENERALBUILDING S-O-47

FORT INDIANTOWN GAPANNVILLE. PENNSYLVANIA 17 OO3 -5002

Mav 12.2016

Mr. Philip R. DurginExecutive DirectorLegislative Budget and Finance CommitteePost Office Box 8737Harrisburg, PA 1 7105 -8737

Dear Mr. Durgin:

Thank you for the opportunity to review the report on Pennsylvania's Cunent and FutureNeedfor Long-term Care Services for Veterans Study conducted pursuant to Senate Resolution2015-17I. We are appreciative of the Legislative Budget and Finance Committee's interest onthe current and future care of our aging Veterans.

The study focused on two specific areas: (1) the assessment of the Veteran populationand the impacts on our six Veterans' Homes and (2) how private facilities might be used tosupplement services.

The Department of Military and Veterans Affairs (DMVA) provides residential care toVeterans as one of the three tiers of the U.S. Department of Veterans Affairs (USDVA). Thefirst two tiers mentioned in the study include Veterans who choose and have the means to affordprivate care facilities and those who have a service-connected disability to qualify for USDVACommunity Living Centers. Our six State Veterans' Homes are open to all Veterans regardlessof financial or disability qualification, which provides a safety net for Veterans who may notqualiff for other Veteran programs. Currently, of our 1,389 residents, only 44 are 100% disabledand may qualify for alternative care. Although the Veteran population may fluctuate, it isimperative that DMVA provide Veterans that may not qualiff for other services a home wherethey can receive the respect and care they have earned.

DMVA is continually working to improve the quality of care through effrciencies andreducing costs. The USDVA approves the number of authorized beds and we receivereimbursement for the number of residents we serve. As part of our partnership with theUSDVA, nearly half of the budget for our six state Veterans' Homes comes from the federalgovernment through annually prescribed per diem rates, based on their qualifuing level of care.Therefore, all facilities used to care for Veterans under our licensure must meet or exceed federaland state regulatory requirements. Additionally, facility construction projects and improvementsinclude a35%o state and 65Yo federal funding share, which are subject to annual state and federalbudget allocations. These constraints make it difficult to augment services to the private sector.

DMVA has and continues to seek cost savings without reducing the quality of care. Thishas been demonstrated over the past few years through implementation of numerous initiatives,to include; staffing standardization, reduction in authorized overtime, medication administrationmodifications, procurement strategies, and contracting options that have allowed DMVA tosubstantially realize cost-savings. DMVA has privatized physical and occupational therapyservices at all six Veterans' Homes and continues to examine other areas where pivatization willreduce costs without negatively affecting the continuum and quality of care. However,contracting does not always produce cost savings or efficiencies, as was recognized during apilot program to privatize pharmacy operations utilizing commonwealth employees proved to bemore beneficial than contracted services.

DMVA is adjusting and seeking resources to adapt to the changing Veteran populationwithin the construct developed by the USDVA. First, we are adjusting the types of services weoffer in our Veterans' Homes by reducing personal care beds and increasing skilled nursing anddementia care. Secondly, in order to facilitate short-term, daily medical adult day care for thoseVeterans living in their personal homes, we a.re seeking resources to pilot Medical Adult DayHealth Care as an annex to our existing Homes levels of care. Building on the anticipatedsuccess in this area with additional resources, we hope to further expand and provide VeteranDay Care Services for those who do not require medical care but would benefit from life skilland recreational assistance. Our goal is to assist Veterans throughout the aging process byensuring they are receiving eamed benefits that further extend and enhance their quality of life aselder residents.

Again, thank you for the opportunity to review the Current and Future Needfor Long-term Care Services for Veterans Study. We look forward to meeting with the Legislative Budgetand Finance Committee on May 18, 20l6,to further discuss the study and address any questions.

Sincerely,

Anthony J.

Brigadier General, PennsylvaniaAir National Guard

Acting Adjutant General