Providing Care to Older Adults in the Department of Veterans Affairs: Lessons for Us All

The VA's mission-driven commitment to the veterans it serves is one of the most significant aspects of the system. The United States Department of Veterans Affairs (VA) operates the nation's largest integrated healthcare system, which is administered by the Veterans Health Administration (VHA). The VHA, the Veterans Benefits Administration (VBA) and the National Cemetery Administration (NCA), comprise the three major components of the VA. The VA was originally established by Congress in 1930 as the Veterans Administration. The agency's name changed to the Department of Veterans Affairs when the VA was elevated to cabinetlevel status in 1989. The VA healthcare system provides care to veterans at more than 150 hospitals, more than 900 community-based outpatient clinics (CBOC), 134 nursing homes (now called community living centers), and 271 readjustment counseling centers (also known as vet centers). The large number of CBOCs within the VHA reflects the VA's emphasis over the last two decades on promoting non-institutional care and service access and reducing re-hospitalizations. In fiscal year (FY) 2009 (October 1, 2008, through September 30, 2009), approximately 8 million veterans were enrolled in the VHA, and approximately 5.5 million veterans received care at VA medical centers and clinics. The VHA is a major provider of care to older adults; approximately 45 percent of veterans enrolled in care in the VHA are at least 65 years of age. In FY 2009, the VHA provided care to more than 2.3 million veterans ages 65 or older. Care for older veterans is anticipated to become an increasing focus of the VHA, largely because of the aging of the Vietnam era cohort of veterans. The VHA provides a broad continuum of general primary care and specialty care services, as well as a comprehensive spectrum of geriatric and extended care services that includes both institutional and (increasingly) non-institutional services. Institutional services are provided in community living centers (CLC), community nursing homes, and state veterans homes. The VA's non-institutional geriatric and extended care services include a number of innovative and highly effective programs, including home-based primary care, purchased skilled homecare, adult day healthcare, homemaker and home health aide services, home respite care, home hospice care, and community residential care. Several of these programs are discussed in this issue. In FY 2009, 59 percent of the VA's total extended care patient population received care in non-institutional or enriched housing settings. The experiences of the VHA can provide numerous lessons for providing high-quality care to older adults for other healthcare systems and the nation at large. The VHA has been internationally recognized as a leader in providing high-quality care. In fact, according to a study by the RAND Corporation, VA patients consistently received better care than consumers of non-VA services (Asch et al., 2004). Superior findings for the VHA were observed for screening, diagnosis, treatment, and follow-up care. Moreover, the VHA's superior performance relative to the private sector on multiple measures of healthcare quality, safety, cost-effectiveness, and satisfaction has been the focus of increasing attention among journalists and the popular press (Gerencher, 2010) in recent years and was the topic of Phillip Longman's 2007 book, Best Care Anywhere: Why VA Healthcare Is Better Than Yours (2d ed., 2010). Defining Characteristics of the VA Healthcare System Numerous factors, including structural, technological, clinical, and mission-oriented factors, contribute to the VHA's performance and recognition as a leader in providing highquality care. First, unlike private insurers, the VHA provides care that is mission-driven and is directly linked with its commitment to honor and to serve those who have served this country. Moreover, unlike other payers and providers of healthcare services, the VHA provides care to veterans for life; this provides an even greater incentive for the VHA to provide high-quality care and to keep veterans healthy, and results in providers having a lifetime relationship and unique bond with the patients for whom they care. …