Home and Community-Based Services

As the U.S. veteran population ages, long-term care will make up an increasingly large share of VA health care expenditures. Home and community-based services allow veterans to "age in place" while receiving the care and support they need. These services also provide a significant cost savings over institutional care facilities, such as nursing homes. As these types of programs expand, it will be important to ensure that they meet the needs of veterans and their caregivers and that they are available to all veterans who would benefit from them.

Most older adults prefer to "age in place" rather than enter a nursing home for long-term care. As the U.S. population ages, demand is increasing for home and community-based services (HCBS) that allow older adults and people with chronic illnesses or disabilities to live independently. Examples include home health aide services, adult day programs, and assisted living. These services can enable people who require assistance with activities of daily living to remain in their homes and communities. To honor aging and disabled veterans' preferences to receive long-term care in the least restrictive setting possible, the U.S. Department of Veterans Affairs (VA) will need to improve access to these services and how they are delivered.

The Home and Community-Based Services Landscape: Regardless of Veteran Status, Many Older Adults Lack Access

Long-term services and supports in the United States are paid through a combination of Medicaid funding, state and local public programs, VA funding (for eligible veterans and other beneficiaries), out-of-pocket spending, and very limited private insurance (Colello, 2022; Werner and Konetzka, 2022). Although Medicare covers post-acute care services, such as skilled nursing facility care and skilled home health care, this coverage is usually limited in duration and not intended as a primary source of long-term support.

State Medicaid programs are the country's largest payers for these services and supports (Colello, 2022). Aside from VA, Medicaid is the only source of coverage for many types of HCBS, given that these services are not typically covered by private insurance or Medicare. Older adults must "spend down" their assets to become eligible for Medicaid-sponsored long-term services and supports. Historically, this funding has been biased toward institutional settings because federal law requires state Medicaid programs to cover institutional long-term services and supports, but the same requirements do not exist for HCBS (Christ and Keane, 2021). Over the past 25 years, Medicaid policy reforms have sought to "rebalance" spending on long-term services and supports to allow individuals with cognitive or functional limitations to remain in their homes and communities rather than entering a nursing home. However, access to Medicaid HCBS (and the type and scope of services available) still varies widely across and within states. Many states provide Medicaid HCBS through waivers with capped enrollment, resulting in waitlists when the number of people seeking services exceeds available capacity (Burns, Watts, and Ammula, 2022).

VA provides or pays for long-term care for more than 500,000 veterans each year (U.S. Government Accountability Office [GAO], 2020). All veterans enrolled in VA health care are eligible for the basic medical benefits package, which includes long-term care services. Eligible veterans are assigned to one of eight priority groups based on such factors as military service history, disability rating, and income. Priority status determines the financial contributions a veteran makes toward their own care. Congruent with nationwide rebalancing efforts, VA policies have emphasized a shift from institutional care to HCBS (GAO, 2020; Biko et al., 2023). For veterans, HCBS are provided through a combination of VA and purchased care from community providers, as shown in the box. Although the more costly institutional care still accounts for the majority of VA's total spending on long-term services and supports, enrollment in HCBS programs is growing much faster than enrollment in institutional programs (GAO, 2020).

Regardless of veteran status, many older adults face barriers to accessing HCBS. Many individuals do not qualify for public benefits but lack the financial resources to pay out of pocket for these services. Medicaid and VA benefits typically cover only a limited number of service hours. Most veterans enrolled in VA health care do not receive Medicaid benefits and therefore lack access to non-VA supplemental services or supports (Wang et al., 2021). Notably, older adults experiencing cognitive decline may not qualify for HCBS programs that use activities of daily living performance to determine service eligibility (Garfield et al., 2015). Another frequent barrier to HCBS placement is insufficient availability of local HCBS providers, particularly in rural areas (Miller et al., 2019). Widespread shortages of direct care workers, greatly exacerbated by the COVID-19 pandemic, have contributed to HCBS provider closures in nearly all states (Watts, Burns, and Ammula, 2022). Both VA and non-VA HCBS providers face challenges hiring and retaining sufficient direct care staff, contributing to program waitlists (Burns, Watts, and Ammula, 2022; GAO, 2020). For the majority of community-dwelling older adults with cognitive or functional limitations, informal (unpaid) assistance from family or friends remains the predominant source of support (Christ and Keane, 2021).

Pressing Issues

As the veteran population ages, VA will face challenges meeting demand for home and community-based services.

An estimated 80 percent of veterans will have some need for long-term services and supports in their lifetime (Hartronft, 2021). In VA, demand is growing rapidly, driven by an aging veteran population and a growing number of veterans with service-connected disabilities (VA, 2023). Vietnam-era veterans are increasingly driving this demand, with most reaching age 75 or older by 2026 (VA, 2023). As shown in the figure, VA expenditures for long-term care are projected to reach $14.3 billion by 2037, and HCBS will account for a growing share of this cost (GAO, 2020).

Billions of dollars

Fiscal year	Institutional programs	Non-institutional programs	Total
2017	$4.4	$2.5	$6.9
2022	$5.1	$3.5	$8.6
2027	$6.0	$4.5	$10.5
2032	$6.9	$5.8	$12.7
2037	$7.5	$6.8	$14.3

Share of long-term care spending

Fiscal year	Institutional programs	Non-institutional programs
2017	63%	37%
2022	59%	41%
2027	57%	43%
2032	54%	46%
2037	53%	47%

SOURCE: GAO, 2020.

VA's goal is to honor veterans' preferences by allowing them to receive long-term care at home or in the least restrictive setting possible. Expanding access to HCBS is one of the major priorities outlined in VA's strategic plan for geriatrics and extended care (VA, 2022a). However, VA faces several key challenges in meeting the escalating demand for long-term services and supports, which were summarized in a 2020 GAO report:

• National health care workforce shortages limit the capacity of long-term care programs. VA officials have reported shortages of geriatricians and palliative care providers, as well as widespread shortages of direct care workers. These shortages have resulted in waitlists for some programs, such as Home-Based Primary Care.
• Geographic alignment of care is an ongoing challenge, particularly for the 2.8 million veterans living in rural areas, where access to services is often limited. Geographic shifts in the veteran population have led to a misalignment of services with demand as the veteran population has decreased in the Northeast and increased in the South.
• VA faces challenges finding appropriate long-term care services for veterans with specialty care needs, such as for dementia, behavioral health issues, and ventilator support. GAO outlined several recommendations for VA to develop measurable goals to address these challenges, some of which it has already implemented.

Budgetary pressures at VA medical centers can also limit access to HCBS. Veterans' placement in VA HCBS programs is contingent on available resources and can depend on veterans' preferences, clinical needs, level of disability, program availability, and other factors (GAO, 2020; Miller et al., 2019). These budgetary pressures can lead to restricted geographic service areas, limited hours of service, and a cap on the number of veterans served (Miller et al., 2019). In some cases, veterans have no choice but to enter a nursing home.

Operating under these limitations, VA staff might need to link veterans to supplemental community resources, such as services paid by Medicaid and through the Older Americans Act (Pub. L. 89-73). However, the availability of such services varies by location, and many veterans do not meet the criteria for Medicaid coverage (Miller et al., 2019).

Recent legislative action has highlighted opportunities to improve VA care access and delivery.

Expand support for veteran caregivers.

Many veterans with long-term care needs rely on support from informal caregivers to remain in their homes and communities. Nearly a decade ago, family caregivers provided an estimated $14 billion in uncompensated care to veterans each year (Ramchand et al., 2014), and that amount is likely much higher now. The VA Caregiver Support Program offers two types of resources to support these caregivers' health and well-being:

• The Program of General Caregiver Support Services provides skills training, peer support, respite care, and referrals to mental health counseling.
• The Program of Comprehensive Assistance for Family Caregivers provides caregivers with a monthly stipend, access to health insurance, and a travel stipend. Eligibility for this program was initially limited to caregivers of post-9/11 veterans (those who had served since September 11, 2001), but legislation extended eligibility to veterans of all eras starting in October 2022 (VA, 2022b).

Recent legislation has proposed improvements to these programs and more resources to support veterans' caregivers. Key features of the Elizabeth Dole Home Care Act include improved support for caregivers who are ineligible for these programs or who were discharged from them, respite care for caregivers who are enrolled in home care programs, and a website to disseminate information on VA HCBS programs and help veterans and caregivers determine their eligibility (S.B. 141, 2023).

Provide flexibility for veterans to self-direct their care.

The Veteran-Directed Care Program gives veterans the option to decide what services they use. Eligible veterans receive a budget to choose their own care providers as an alternative to receiving services from VA. In some cases, family members can be paid to provide care. Self-directed care is a promising approach to maximizing veterans' choice of services and care settings, and this option could be particularly appealing to veterans in rural and underserved areas with limited access to VA facilities or VA-contracted private-sector care providers.

In previous evaluations, veterans and family caregivers who participated in the Veteran-Directed Care Program appreciated the flexibility to choose caregivers, scheduling, and services that fit their needs, and caregivers reported reduced stress (Mahoney et al., 2019; Milliken, Mahoney, and Mahoney, 2016). Enrollment in the Veteran-Directed Care Program, compared with VA-paid personal care services, has been associated with a lower likelihood of nursing home admission, as well as fewer acute care admissions and emergency department visits among rural veterans (Yuan et al., 2022). Although the Veteran-Directed Care Program is not yet available across all regions, President Biden signed an executive order in April 2023 calling for the program's expansion to all VA medical centers by the end of fiscal year 2024 (White House, 2023).

Invest in long-term care workforce recruitment and retention.

VA HCBS programs have been affected by widespread shortages of health care workers, including geriatrics and palliative care providers. Recent legislation has proposed modifications to VA policies to improve health care workforce recruitment and retention. The VA Clinician Appreciation, Recruitment, Education, Expansion, and Retention Support (CAREERS) Act of 2023 (S.B. 10, 2023) would modernize the VA pay system for physicians and other health care providers, authorize recruitment and retention bonuses for health care professionals, expand VA's rural interdisciplinary team training program, and allow VA to waive pay limitations if necessary to recruit and retain critical health care personnel. The legislation would also increase VA workforce data reporting requirements for greater public transparency and would require VA to study barriers and facilitators to hiring and retaining long-term care staff.

Explore options for VA to provide assisted living services.

Assisted living is a less costly alternative to nursing home care that would allow aging veterans to live with greater independence. VA does not currently pay for assisted living services for veterans. The Expanding Veterans' Options for Long Term Care Act (S.B. 495, 2023) would require VA to implement a pilot program to provide assisted living services to eligible veterans and evaluate the quality and cost of that care. The pilot program would include six geographically diverse Veterans Integrated Service Networks (VISNs) with at least two sites located in rural areas and two being state veterans homes (VA facilities that provide nursing home, residential care, and adult day care services). Providing options for assisted living will ensure that veterans have access to appropriate levels of care.

Directions for Future Research

As a growing number of veterans enroll in VA HCBS programs, there are many opportunities to expand the research base in this area.

Determine what types of home and community-based services can meet the needs of veterans with dementia.

People with dementia generally require a higher level of caregiver support and supervision than other long-term care users, but home- and community-based alternatives to nursing homes are often limited (GAO, 2020). Further research is needed to determine the type and scope of services that this population requires, as well as the caregiver support that would allow veterans with dementia to remain in their communities. One promising model is VA's Caregivers of Older Adults Cared for at Home (COACH) program, which provides individualized training and support for home-based caregivers of veterans with dementia who are experiencing behavioral challenges or functional decline (Davagnino, 2016).

Evaluate models of community-based long-term care delivery that address both medical and social needs.

VA has developed multiple innovative, evidence-based models of HCBS delivery to support veterans with complex medical and social needs and their caregivers (McConnell, Xue, and Levy, 2022). Some programs, such as Home-Based Primary Care, are widely available; others, such as the COACH program, are offered in a limited number of VA medical centers. Key elements of these programs include interprofessional teams and individualized interventions to address both medical and psychosocial needs. Continued evaluation of how best to implement and scale up these models of care can help aging veterans remain in their communities and enjoy an improved quality of life while alleviating the burden on informal caregivers.

Assess person-centered outcomes for veterans who receive HCBS.

In addition to evaluating the cost-effectiveness and health outcomes of VA HCBS programs, assessments of person-centered outcomes—such as quality of life and experiences with care—can inform quality-improvement efforts. Relevant domains could include community participation, communication with care providers, service coordination, and adequacy of service hours. It is also important to understand how contextual factors, such as veterans' access to informal caregiving, affect these outcomes.

Examine intersectional demographic data on veterans who would benefit from home and community-based services to identify gaps in access.

Congressional testimony from Minority Veterans of America highlighted the barriers that many women and minority veterans face in accessing HCBS, including difficulty navigating VA benefits and programs (Minority Veterans of America, 2021). In particular, very little is known about the use of VA long-term services and supports by women veterans. Evaluating intersectional demographic data on VA health care enrollees who do and do not use HCBS—that is, assessing individuals across multiple characteristics, such as age, gender, race/ethnicity, period of service, and disability rating—would help VA identify gaps in access for specific groups of veterans and inform strategies to address these gaps.

References

Related Content

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  RAND Epstein Family Veterans Policy Research Institute

  Sep 30, 2025

Topics

• Long-Term Care
• Nursing Homes
• Older Adults
• Patient-Centered Care
• People with Disabilities
• Veterans Health Care