The Department of Veterans Affairs (VA) offers numerous options for extended-care services to eligible veterans, providing them and their families abundant flexibility in making choices about their care. These options fall into two general categories: home- and community-based services, which help chronically ill or disabled veterans remain in their homes, and the residential or nursing home option.

The home- and community-based options include adult day health care, home-based primary care, homemaker and home health aide care, hospice, palliative care, respite care, skilled home health care, telehealth care, and veteran-directed care. Veterans can simultaneously receive more than one of these services, with these choices offering veterans a range of alternatives to support their desire to receive care at home.

Most CLCs are located within VA medical centers, although some are in separate buildings on the medical center campus while others are completely detached to serve a wider geographical area.

The residential and nursing home category includes community residential care in settings such as group living homes or medical foster home care, which serve as options for veterans who qualify for nursing home care but prefer an alternative residential setting and who are able to pay for these VA-monitored programs.

For eligible veterans whose needs require nursing home care, VA-contracted community nursing homes serve a significant number. Two other options are VA community living centers (CLCs) and state veterans homes (SVHs).

For some, the thought of a nursing home evokes images of an institutional facility with doors on either side of a hallway, a rigid care schedule, and an uninviting place for residents’ family and friends to visit. However, within the VA and around the country, that picture is changing to a more homelike physical environment and a veteran-centered care model.

The CLCs, owned and operated by the VA, demonstrate the organization’s commitment to transform its nursing home care.

According to Lisa Minor, RN, MSSL, director, Facility-Based Program Operations, Veterans Health Administration (VHA) Office of Geriatrics and Extended Care, the VA’s 134 CLCs are located across the country in every state except Alaska, Rhode Island, Utah, and Vermont, with operating beds numbering approximately 13,391. Last year, Minor said, the VA treated 41,344 unique veterans in the CLCs.

Most CLCs are located within VA medical centers, although some are in separate buildings on the medical center campus while others are completely detached to serve a wider geographical area.

“The VA has been keeping pace with changes in nursing home care in the community at large,” explained Marianne Shaughnessy, Ph.D., CRNP, director of Facility-Based Programs Policy, VHA Office of Geriatrics and Extended Care. “In the late 1990s and early 2000s, a trend emerged toward creating more homelike atmospheres in community nursing homes. This movement became known as cultural transformation. In 2005, the VA committed to this movement,” she said, and changed the designation from VA nursing home care units to VA CLCs.

“The cultural transformation movement is characterized by moving from traditional nursing homes, which were designed to look and function like institutions, into more residential environments,” Shaughnessy said. “The interiors were redesigned to create a more homelike atmosphere with comfortable living spaces and communal dining areas and kitchens, because these are the centers of activity in most homes.”

Because most CLCs are within existing medical centers, transforming the facilities from institutional to more homelike requires renovation in some cases and new construction in others. This utilizes the “small house” model, incorporating small groups of living units with common central spaces.

The movement went beyond changing the physical structure, Shaughnessy added, extending into care practices redesigned to revolve around the veteran’s preferences. “Mealtimes are flexible, and snacks and drinks are available throughout the day. Activities, therapy, and sleep schedules are built around the veteran’s choices. The focus is on the veteran and providing care in his or her home, rather than a veteran residing in an institution where schedules are dictated by the institution.”

Shaughnessy emphasized, “We really make an effort to involve the veterans and their families in care planning. The veterans have a voice. Their families have a voice. They have choices, and we work with them to honor their choices around the care that they’re receiving.”

Dr. Mark Heuser, FACP, associate chief of staff, Geriatrics and Extended Care at W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina, described multiple services available to veterans at CLCs, categorized as short-stay programs of 90 days or fewer and long-stay programs of more than 90 days.

Although SVHs are not required to adhere to the design guidelines that the VA has adopted for the CLCs, Minor noted that several states have adopted a model that resembles a more homelike and less institutional facility.

“The goal of the CLC is to maximize the veteran’s physical and cognitive functioning,” said Heuser, adding that in some cases, with physical therapy, for example, or an adjustment of medications, “a veteran can actually reach a higher level of functioning than when he or she came in.”

Short-stay programs include hospice and palliative care for veterans with life-ending diseases. This can also involve respite care, when “veterans on home hospice may come into our facility to give their caregiver a break or rest from their daily care,” Heuser said. “Or they may come from home hospice to the CLC hospice for a pain crisis or other crisis, for treatment of their symptoms, often then returning to home hospice.”

Other short-stay programs include: rehabilitation, for example, following a hip fracture; skilled nursing care, for treatments such as wound care or IV antibiotics; dementia care when exacerbated by associated acute problems, such as recent hospitalization for urinary tract infection; continuing care short stay, such as for weakness following hospitalization to build stamina and endurance; and geriatric evaluation and management.

Long-stay programs, Heuser said, include dementia care. “A veteran that has dementia and requires assistance with activities of daily living [ADL] – bathing, transferring, toileting, grooming, feeding – and meets [VA service-connected] eligibility criteria would be eligible to stay in a VA community living center for an indefinite period of time,” he said.

Long-stay programs also include: continuing care for veterans who have normal cognition but require assistance with ADL due to physical issues, such as spinal cord injury or severe arthritis; or mental health recovery, for veterans who have chronic mental illness and are unable to live in a community setting.

Emphasizing the transformation from institution to become more veteran centered and homelike, Minor said, “The CLC is where they live; whether they come for short stay or long stay, that is their home for that time period. They don’t come to live where we work. We actually work where they live.”

Regarding CLC eligibility, Shaughnessy said, “Generally, the VA is responsible to provide or pay for long-term nursing home care for veterans that require that level of care and have a 70 percent service-connected disability, or a 60 percent service-connected disability and are unemployable. Veterans can qualify for short-term rehabilitation in a VA CLC if they require such care for a service-connected condition. And veterans who do not meet the criteria may also be admitted for short- or long-stay services if the resources allow at the site. We encourage veterans and their families to consult with the VA health care team to talk about available options.”

State veterans homes provide another nursing home option for veterans. These 156 facilities, located in all states and Puerto Rico, are state owned, operated, and managed, and the VA must formally recognize and certify SVHs to participate in the program and ensure they meet VA standards. Similar to the CLCs, these facilities provide short- and long-term skilled nursing care and rehabilitation.

According to Minor, SVHs provide one or more of three separate programs: nursing home (148 programs, 25,685 beds); domiciliary care (54 programs, 5,894 beds); and adult day health care (three programs, 109 participant slots).

Each state determines eligibility and admission criteria for its facilities, although, Minor said, “There are some overarching federal regulations that determine who is eligible. But the state sets their admission criteria.”

Although SVHs are not required to adhere to the design guidelines that the VA has adopted for the CLCs, Minor noted that several states have adopted a model that resembles a more homelike and less institutional facility.

To assist in navigating the numerous choices, Shaughnessy highlighted the shared decision-making portion of the VA’s Geriatrics and Extended Care Services website that helps educate veterans, family members, and caregivers about what options are available for home- and community-based services as well as residential care facilities. Detailed worksheets, available to download, assist with considerations about the type and amount of care that’s needed, as well as the veteran’s preferences. “It also provides them with questions that they can take with them to their next health care visit so they can have an informed discussion with their doctor,” Shaughnessy said. “A great thing about the shared decision-making site is that it also provides questions for families to speak with each other about what the veteran’s preferences are. Sometimes those conversations with families can be difficult to start, but it’s worked into this information on the website so nicely that it hopefully will initiate some of those conversations among the veteran and family members before they even get to the VA. Our goal is to honor the veteran’s wishes for care that they receive and the setting in which they receive it.”

Minor echoed that concept. “Veterans have many choices for long-term care services and support,” she said. “Our goal is to provide the right services at the right time in the right setting.”

Shaughnessy addressed future trends and the scope of need for VA nursing home services. “Current estimates suggest that the number of veterans who are going to require nursing home care at some point in their lives is expected to reach 1 million by 2023. And as the Vietnam-era cohort ages, the VA is providing services to this growing group,” she said.

“If we can create a safety net for veterans utilizing home- and community-based resources and residential care programs, that would be a significant goal in the next decade.”

“This group of veterans was the first to benefit from a shifting paradigm in trauma care called ‘scoop and run,’ which decreased transit time to a trauma care setting,” Shaughnessy continued. “While the casualty rates dropped, many veterans returned with significant physical disability. Further, the group was not generally welcomed home after their service, so many have suffered psychological trauma and never sought formal treatment. Over the years, these veterans may have received care at local VA medical centers or through private insurers. However, as they age, their health care needs are growing, and the VA estimates a significant number will seek out extended care services from the VA.”

Minor identified this trend as a future challenge. “Regarding the cohort of Vietnam veterans and the complex issues that this veteran group has, and the CLC program, we’re trying to evolve to meet the needs of our veterans. And with that group aging over the next five to 10 years, we expect that many of these men and women are going to require extended care resources to manage these complex medical, cognitive, and psychosocial issues. We’re preparing to help the veterans meet these challenges with additional training and innovative programs to identify and build on strengths to help them live as they would wish to. But that’s also one of our challenges, because these veterans are complex in so many areas. We have to evolve to be able to care for them.”

Given that challenge, Shaughnessy emphasized the importance of continuing to develop services for veterans who live in the community. “If we can create a safety net for veterans utilizing home- and community-based resources and residential care programs, that would be a significant goal in the next decade,” she said.

Shaughnessy reinforced the value of the VA’s commitment to cultural transformation, recognizing that “veterans who are living in extended care settings become an extended family. They share a common bond and a common experience; it doesn’t matter what era they’re from. They value the camaraderie that comes with being with other veterans and being in a place that honors them and their service. Adding that cultural transformation aspect and creating more homelike atmospheres goes right along with the extended family that’s already there,” she said, concluding, “I feel that it’s our responsibility to provide the best quality care that we can for these veterans who have served their country honorably, and treat them with the dignity, respect, and love that they’ve earned.”

This article was first published in the Veterans Affairs & Military Medicine Outlook 2018 Spring publication.