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community resources.

Furthermore, each medical district has assigned a

senior level professional as a community service coordinator for the

district. Although this is sound planning, the execution of the program is difficult. Each veteran has distinct personal habits and values and differs as to family support, socioeconomic status, work skills and interests, living arrangements, and the extent of the disability. Consequently assisting a veteran to utilize profitably available resources is always a time-consuming and complex effort. It is my opinion that a small amount of additional money is needed by the Department of Medicine and Surgery of the Veterans Administration to further promote demonstration projects concerned with the integration of community resources with the Veterans Administration health care services. Programs addressing these problems would be beneficial both to the Veterans Administration and to our entire health care system.

To find practical solutions to this coordination and maximum use of resoruces, the Veterans Administration has sponsored a major conference, and it is anticipated that the papers at this conference will serve as a base for further development of a range of options for coordinating and linking services between the Veterans Administration and the community. This same problem will be given additional attention at a long-term care planning conference which will take place in Washington DC in

September, 1984.

I am convinced

I would like to emphasize to the Senate Committee on Veterans Affairs that the coordination of accessing and utilizing the existing resources is a major problem particularly in the area of long term care. that the Veterans Administration can make an enormous contribution to the citizens of the United States by expanding their efforts in this area. I believe that the Department of Medicine and Surgery should be commended for their efforts and be encouraged to vigorously expand their programs.

Chairman SIMPSON. Our next witness is Dr. Wetle. Please pro

ceed.

Dr. WETLE. Thank you, sir. I am Terrie Wetle. I am an assistant professor at Harvard Medical School in the Division of Health Policy Research and Education. In addition to that I am the associate director of Harvard's Geriatric Education Center and I am a former director of the program in long-term care at the Department of Epidemiology and Public Health of Yale Medical School. My testimony today is based upon the work of a collaborative project between Harvard's Division of Health Policy Research and Education and Boston's VAOPC GRECC. The goal of this project has been to explore the use of VA and community-based resources to better serve the elderly. In addition to 10 background papers, that I have here but am not going to read to you today, the major product of our project is a set of options for integration of VA and community-based resources.

The process has been multidisciplinary, soliciting both VA and non-VA perspectives and has included a conference which brought together representatives of the various Federal agencies serving the elderly, staff from relevant congressional committees, local service providers and planners, and academicians involved in gerontology and health policy.

Although the project is not yet completed and the options are currently under review by the VA's Central Office, I would like to share with you a few of the specific findings and suggestions for enhanced linkages between the VA and other providers of care to elders in the community.

Our work is based on several observations. The Veterans' Administration is certainly the Nation's largest single coordinated healthcare system. It is a major provider of geriatric institutional-based care, but has only begun to emphasize community-based services. It is also recognized that elderly veterans are quite likely to have multiple entitlements and eligibilities, including VA benefits, medicare, medicaid, Social Security, and services under title III of the Older Americans Act, and others. To ensure the availability of the broad array of services required by the elderly I think it is imperative that the VA develop and improve linkages with communitybased providers.

The options that we suggest take into account the special health and illness behaviors of elders, as well as the existing organization of VA and non-VA services, the importance of both medical and social services in caring for elders and the barriers to coordination and collaboration among individual services and the two-service systems.

The options that we offer address the following objectives: To increase the availability of community resources for veterans; to support family care which maintains elderly veterans in their homes and, therefore, saves the expense of institutional-based services; to expand noninstitutional services; and to expand and develop care management systems.

We believe that the first step is the increased coordination of planning efforts at the local community level and this includes increased VA participation in the local health service agencies and State health coordinating councils. This would involve an expan

sion of the MEDIPP process to include more emphasis on long-term

care.

We also believe implementation of this option requires coodination at the Federal level with agreements between, the Veterans' Administration, the Administration on Aging, and other relevant Federal agencies.

We think there are three options available to implement this sort of linkage. The first model is exchange of inkind services and expertise, recognizing that in many locations, both the VA and the community, provide services or have expertise which is in short supply in other aspects of the community sector.

We believe the VAMC hospital administrators should be given responsibility for negotiating interagency agreements and that there should be incentives available to VAMC's for taking part in them, including the recognition of such sharing arrangements in performance appraisals and changes in the formula for allocating budgets to take into account inhome and outpatient services.

A second model for the VA and the community is to develop joint programs and coordinate existing programs. This, for example, could include a recognition by the VA and State medicaid agencies of their mutual interest in both the placement of veterans in community services as well as in nursing homes and it would include an involvement of VA in coordination with the ongoing national long-term care channeling projects.

Finally, we believe that the VAMC's should have an opportunity and the resources available on a flexible basis to pool their funding with the community-based agencies to develop new services which either agency may not have the resources or the impetus to develop on its own.

We have a precedent for this in the authorization of construction funds for State nursing home programs, which appears to be both efficacious and efficient for the VA. We recommend that such programs serve both older veterans and nonveterans, increasing the likelihood of enthusiastic community participation on both parts.

I will not go into a description of our suggestions for supportive services for family providers. That is provided in some detail in my written testimony.

Chairman SIMPSON. Thank you very much, doctor.

[The prepared statement of Terrie Wetle, Ph.D., assistant professor, Division of Health Policy Research and Education, Harvard University Medical School, Cambridge, MA, follows:]

PREPARED STATEMENT OF TERRIE WETLE, PH.D., ASSISTANT PROFESSOR, DIVISION OF HEALTH
POLICY RESEARCH AND EDUCATION, HARVARD UNIVERSITY MEDICAL SCHOOL, CAMBRIDGE, MA

My testimony today is based upon the work of a collaborative project between Harvard's Division of Health Policy Research and Education and Boston's VAOPC GRECC The goal of this project has been to explore the use of VA and community based resources to better serve the elderly. In addition to ten background papers, the major product of this project has been a set of options for integration of VA and community resources. The process has been multidisciplinary, soliciting VA and non-VA perspectives and included a conference which brought together representatives of the various federal agencies serving the elderly, staff from relevant Congressional committees, local service providers and planners, and academicians involved in gerontology and health policy.

Although the project is not yet completed and the options are currently under review by the Veterans Administration, I would like to briefly share with you our preliminary findings and suggestions for enhanced linkages between the VA and other providers of care to elders in the community. The Comments I offer are not intended to represent the official views of the Veterans Administration, but rather those of the faculty and staff of the Harvard Project on VA/community Resources and the Older Veteran.

Our work has been based on several initial observations. The Veterans Administration is the nation's largest single coordinated health care system. Although the VA is a major provider of insititutionally based geriatric care, there has been far less emphasis on community based services. The VA faces a clear geriatric imperative not only because of increases in absolute numbers of elder veterans, but because the mix of services by the elderly differs from that of other age groups. It is also recognized that the majority of veterans have multiple elligibilities and entitlements including VA benefits, Medicare, Medicaid, Social Security, and services provided under the Older Americans Act. To ensure the availability of the broad array of services required by elder veterans the VA must develop and improve linkages with community based providers.

The options suggested here take into account the special health and illness behaviors of elders, the existing organization of VA and non-VA services, the importance of both medical and social services in caring for elders and the barriers to coordination and collaboration among individual services and the two service systems. The options address the following objectives,

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to increase the availability of community resources to veterans

to support family care which maintains veterans at home

O to expand non-institutional services, and

O to expand and develop care management.

The options also address the themes of education, research and the targeting of services.

1

:

VA/COMMUNITY RESOURCES
AND THE OLDER VETERAN

VA/COMMUNITY OPTIONS FOR SERVING THE ELDER VETERAN

OPTION 1

Increase the Availability of Community Resources by

OPTION 2

OPTION 3

OPTION 4

4018h

a. greater coordination of planning efforts
b. increased sharing of VA/Community resources

Support Family Care to Aid in Maintaining Veterans at Home by

a.
b.

supportive services to family care providers
direct services to supplement family care

Expand Non-institutional Services by

a.

b.

C.

expanding Housebound Benefits for non-service connected to allow for purchase of non-VA services expanding current Disability Pension program to allow for purchase of non-VA services

expanding definition of medical services to include home-health and home-help services

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3.

Education

a.

b.

VA Geriatric Education Centers
Faculty development

C. Health Education/Health Promotion modules

Research

a.

Evaluation of health delivery programs as primary HSR&D
activity.

b. Removing barriers for HSR&D demonstrations of joint
VA/Community projects.

c.

Prospective study of functional assessment and surveillance of high risk elders.

Targeting

a.

b.

Programs targeted to veterans at greatest risk of high
utilization and long term institutionalization
Simplification of eligibility criteria

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