The Changing Dynamics of Providing Health Care to Older Veterans in the 21^st Century: How Do We Best Serve Those Who Have Borne the Battle?

The Veterans Health Administration (VA) is the largest provider of health-care services to older adults in the United States. Almost half (47%) of the 9 million veterans who currently receive health care through the VA are aged 65 and older (Greenstone et al., 2019), with close to 1.2 million ≥85 years. Similar to the aging U.S. population, as veterans age, they are at higher risk for developing chronic conditions, including diabetes, cardiovascular disease, and dementia. However, compared to their civilian counterparts, veterans have higher rates of depression, other mental health conditions, and substance use disorders, as well as higher rates of homelessness and suicide (Kaye et al., 2015). Thus, ensuring that older veterans receive the highest quality of care requires coordinated, interdisciplinary care, as well as a health-care system that has both the infrastructure and leadership commitment to promote continued innovation and quality improvement.

Veterans Affairs’ Geriatric and Extended Care Services for Older Veterans

As part of a broader continuum of services available to older veterans, the VA’s Office of Geriatrics and Extended Care administers institutional and non-institutional long-term service and support programs, with the aim of “honoring veterans’ preferences for health, independence, and well-being in the face of aging, disability, or illness” (U.S. Department of Veterans Affairs, 2016). The VA has developed numerous interdisciplinary, evidence-based programs, such as home-based primary care (now expanded in the community through Medicare as “Independence at Home”; Edes et al., 2014; Kinosian, Taler, Boling, Gilden, & Independence at Home Learning Collaborative Writing Group, 2016) and the Coordinated Transitional Care program (Kind et al., 2016). Other innovative approaches include the VA’s Medical Foster Homes program, which integrates clinical care, social services, and housing support (Levy et al., 2016), and the VA’s hospice model, which allows veterans to receive hospice and disease-modifying care simultaneously (Miller et al., 2017). Recently, the VA has expanded caregiver supports, such as through the VA Caregiver Support Line (Wright, Malcolm, Hicken, & Rupper, 2015). It has also adopted best practices from the community, including the Veteran-Directed Home and Community-Based Service Program, modeled after Medicaid’s Cash and Counseling program (Garrido et al., 2017).

Challenges Facing the Veterans Affairs’ Health-Care System

Despite its large portfolio of innovative programs, the VA has several recognized challenges, including providing timely access to care (Farmer, Hosek, & Adamson, 2016); providing a consistent quality of care across VA sites and programs (Anhang Price, Sloss, Cefalu, Farmer, & Hussey, 2018); a lack of transparency (U.S. Senate Committee on Veterans Affairs, 2019); difficulty meeting the needs of rural veterans, many of whom are older (Ohl et al., 2018); and having confusing eligibility guidelines for some VA programs. For example, coverage for nursing home care can vary based on a veterans’ location and duration of service, service-related disability, and income level. Additionally, because the VA is a discretionary government program with periodic leadership changes, priorities within the VA may shift with election cycles, potentially affecting veterans’ programs and, subsequently, affecting veterans’ health outcomes and quality of care. Despite these challenges, numerous studies have provided evidence that the quality and timeliness of services within the VA rival or exceed those of private sector providers (Farmer, Hosek, & Adamson, 2016).

Recent Efforts to Provide Veterans With Timely Access to Care

The Veterans Access, Choice, and Accountability Act of 2014 was enacted in response to an “access crisis” involving delays in care (Shulkin, 2017). Although the VA has always purchased services for older veterans (e.g., homemaker/home health, contract nursing home services) through the Act, eligible veterans who had to wait >30 days for a specific health-care service, lived >40 miles from any VA clinic, or experienced hardship in accessing VA care had expanded access to a network of community care (CC) providers (U.S. Congress House of Representatives, 2014). With the enactment of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018, eligibility criteria were further expanded, likely increasing veterans’ use of VA-purchased care (Rosen et al., 2018).

Remaining Challenges Balancing Veterans Affairs and Community Care

Veterans who receive care through both the VA and CC may experience more transitions in care, heightening the risk of care fragmentation and poor coordination of care (including duplication of services), which could lead to adverse outcomes, such as hospitalizations (Greenstone et al., 2019). The VA has numerous advantages that facilitate high-quality geriatrics care, as compared to care available in the community. Care in the VA is provided by professionals trained to understand and address the complex issues veterans face, particularly older veterans and those with mental health needs. The VA has well-established interdisciplinary models of care that effectively integrate medical, mental-health, and social-support services, and that are difficult to sustain in private-sector settings. For example, differing financial models within the VA, compared to the private sector, can translate into providers having more time and flexibility to spend in patient visits. Finally, workforce shortages and other factors contribute to limited service availability in many parts of the country. Sometimes, the VA is not only the best option for veterans who need care, but the only one (Ohl et al., 2018).

Advancing Care for Older Veterans in the Future

Looking forward into the 21^st century, several opportunities can ensure that older veterans have access to high-quality and timely care, consistent with the preferences of the veterans being served. More funding could be given to the VA to expand its services for older veterans, such as through non-institutional care services (home-based primary care, adult day services, medical foster homes, and respite) and improving care access through telehealth (i.e., geriatric consultations through VA Video Connect). Resources could be devoted to areas where expansions are needed (e.g., care-giving support) and could further develop and refine care coordination strategies to ensure well-coordinated care between the VA and community providers. Ultimately, more work is needed to understand how to effectively balance VA and non-VA services to best meet older veterans’ needs. Any approach should involve leveraging the strengths of both the VA and community-based providers, to ensure veterans receive care that is timely, patient-centered, and evidence-based. Creating such a system will help older veterans that saw combat in World War II, Korea, and/or Vietnam, but will also need to be flexible enough to adapt to the needs of younger veterans as they approach retirement age.