Understanding the Veterans Services Landscape in California

Understanding the Veterans Services Landscape in California MAC TAYLOR • L E G I S L A T I V E A N A L Y S T • JANUARY 2017 AN LAO REPORT 2 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT EXECUTIVE SUMMARY Supplemental Report Language Required LAO to Report on Veterans Service Landscape in California. A statement of legislative intent adopted by the Legislature during deliberations on the 2016-17 budget package directed the Legislative Analyst’s Office (LAO) to report on the role of the veterans homes in the 21st century. In light of data constraints, the supplemental report language was revised to require the LAO to report on the current veterans service landscape in California— including services in the state’s veterans homes and services outside the veterans homes (“in the community”). Specifically, the LAO was directed to review federally and state-funded services related to four service areas of legislative interest: long-term care, mental and behavioral health, transitional housing, and employment assistance. Federal and State Governments Provide a Wide Array of Veterans Services Within the Veterans Homes and in the Community. Qualified veterans have a variety of federally and state-funded options for long-term care, mental and behavioral health, transitional housing, and employment assistance. The state’s veterans homes provide independent living and long-term care services to about 2,500 California veterans. Veterans may also use federal veterans benefits to finance private long-term care. Mental and behavioral health care is available to eligible veterans through the federal Veterans Health Administration, a division of the U.S. Department of Veterans Affairs. Residents of the veterans homes may also access basic mental and behavioral health services at the homes. Both the state and federal governments offer a variety of options for homeless veterans or veterans looking for affordable housing, including the Transitional Housing Program for homeless veterans located at the West Los Angeles veterans home. For veterans looking for employment assistance, the state administers several federal grants targeted at veterans through the Employment Development Department. Legislature Has Opportunity to Improve Service Delivery Within the Veterans Homes. In our review of the services offered by the veterans homes, we found that: (1) the longest wait-lists at the homes are for the highest levels of long-term care and (2) the homes have limited capacity to serve veterans with complex mental and behavioral health needs. If the Legislature is interested in improving service delivery at the veterans homes, it may wish to take action to reduce and prioritize wait-lists, restructure the levels of care offered at each home, ensure staffing ratios are appropriate for residents with complex needs, and address staffing challenges at all levels. www.lao.ca.gov Legislative Analyst’s Office 3 AN LAO REPORT 4 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT INTRODUCTION Supplemental Report Language Required in the veterans homes and outside of the homes (“in LAO to Report on Veterans Service Landscape in the community”) based on four specified service California. A statement of legislative intent (known categories, and (3) possible recommendations to as “supplemental report language”), adopted by improve service delivery to the veteran population the Legislature during deliberations on the 2016-17 in California. The four service categories of budget package, directed the Legislative Analyst’s particular interest are: long-term care, mental Office (LAO) to report on the role of the veterans and behavioral health, transitional housing, and homes in the 21st century by March 15, 2017. As employment assistance. We were directed to focus originally intended, this language would have on state and federally funded veterans services required the LAO to produce a forward-looking and to base our research on a sample of veterans analysis on how the needs of veterans in California homes and the surrounding community. Together will change over time and whether the state’s with legislative staff and the administration, we veterans homes will be able to meet the anticipated selected the veterans homes in Yountville (Napa needs—to the extent such a report was feasible County), West Los Angeles (Los Angeles County), given the availability of data to project veterans’ and Redding (Shasta County) for our sample. future needs. Based on our review of available data We conducted visits at these veterans homes and and discussions with the California Department of interviews with the County Veterans Service Veterans Affairs (CalVet), we concluded that there Offices (CVSOs) of these counties. is currently not sufficient data to reasonably project In this report, we describe the demographics the future needs and preferences of California’s of California’s veterans and provide a high-level veterans, as desired initially by the Legislature. overview of veterans services provided in the Reporting Language Revised in Light of homes and services provided in the community. We Data Constraints. Given the data constraints, then review the federal and state services available we participated in discussions with legislative to veterans for long-term care, transitional housing, staff and the administration to refocus the report mental and behavioral health, and employment requirement. It was agreed that we would report, assistance and provide our findings. Finally, we by the original due date of March 15, 2017, on: highlight issues for legislative consideration and (1) the demographics of California’s veterans, (2) an offer options to improve service delivery within the overview of existing services provided to veterans veterans homes. THE DEMOGRAPHICS OF CALIFORNIA’S VETERANS California’s Veterans Share Many characteristics of California’s veterans are generally Demographic Characteristics With Veterans comparable to the demographic characteristics of Nationwide. Of the estimated 21 million veterans veterans nationwide in terms of gender, age, and in the United States, about 1.8 million veterans live time-period served. As of 2016, it is estimated in California—more than in any other state. As that over 90 percent of California’s veterans are shown in Figure 1 (see next page), the demographic male, more than half of California’s veterans www.lao.ca.gov Legislative Analyst’s Office 5 AN LAO REPORT are over age 60, and veterans who served in the California’s veterans are more racially and Vietnam war make up the largest share of the ethnically diverse than veterans across the United Graphic Sign Off veteran population. Younger veterans—those who States. For example, 17 percent of California Secretary began service after September 11, 2001—make up veterans identify as Hispanic or Latino, compared 15 percent of California’s veteran population. to only 7 percent nationally. CaliforAnniaa ilsy asltso home However, California’s Veterans Differ tAo RroTugWhlOy RonKe- t#h1ir6d0 o4f 4th0e nation’sM APsiAan-American From Veterans Nationally on Race/Ethnicity veterans, who make up 6 percent ofD Ceapliufotrynia’s Template_LAOReport_mid.ait and Income. Deviating from national trends, veteran population (compared to 1 percent of Figure 1 Veterans Characteristicsa,b 2016 Gender Age 80+ 100% 70 to 79 80 60 to 69 60 50 to 59 40 40 to 49 20 30 to 39 Under 20 to 29 Male Female 5 10 15 20 25% Percent of Veteran Population California United States Race/Ethnicity Time-Period Servedc Percent of Veteran Population 35% Other Race or Ethnicity 30 Asian-American 25 20 Black or African-American 15 Hispanic or Latino 10 White, Non-Hispanic 5 10 20 30 40 50 60 70% World Korean Vietnam Gulf Post Peacetime War II Conflict Era War Era 9/11/01 Veterans, (before 9/11/01) all eras a Estimated by the U.S. Department of Veterans Affairs. b United States estimates include California. c Reflects the earliest war in which the veteran served, if any. 6 Legislative Analyst’s Office www.lao.ca.gov Graphic Sign Off Secretary Analyst MPA Deputy ARTWORK #160440 Template_LAOReport_mid.ait AN LAO REPORT the veteran population nationwide). In Figure 2 addition, the median household income Geographic Concentration of for California’s veterans in 2014 was California’s Veteran Population estimated to be about $74,000, about 2016 $12,000 higher than the estimated median household income for Californians overall. Number of Veteransa According to data from 2015, 7.5 percent of 1-9,999 California’s veteran population was below 10,000-49,999 the poverty level, compared to 14.3 percent 50,000-99,999 of Californians overall. (We note that the 100,000-149,999 150,000+ income data reflect the median income of households containing veterans, and therefore do not necessarily reflect the median income of veterans themselves. In addition, the income data are estimated from the American Community Survey, in which veterans must choose to identify themselves as veterans—this may lead to underreporting of veterans.) Largest Share of California’s Veterans Live in Southern California. California’s veterans live throughout the state, but concentrate in a few key areas. As shown a Estimated by the U.S. Department of Veterans Affairs. in Figure 2, the largest share of veterans live in Southern California counties. Los has the most veterans of any Northern California Angeles County is home to the most veterans county (approximately 90,000), followed by Santa (approximately 330,000) and San Diego County has Clara, Alameda, and Contra Costa Counties, with the second-most veterans of any California county about 60,000 veterans living in each county. (approximately 230,000). Sacramento County OVERVIEW OF SERVICES AVAILABLE TO VETERANS In this section, we provide a high-level compensation. In a subsequent section, we provide overview of key federally and state-funded a more in-depth analysis focusing on the four services provided to veterans within the veterans service areas of legislative interest. homes and in the community. This section does S v H erviceS in eteranS omeS not provide an exhaustive list of federally and state-funded services, but rather highlights several The state of California runs eight veterans major benefits, including long-term care through homes for eligible veterans to receive residential the veterans homes, health care, and disability or long-term care. (Refer to Figure 3 on the next www.lao.ca.gov Legislative Analyst’s Office 7 AN LAO REPORT page to see the location of veterans homes and the State Law and Administrative Regulations Set years residents were first admitted at each home.) Eligibility Requirements, Admissions Priorities The veterans homes are designed to serve older for Veterans Homes. State law provides broad or disabled veterans, whose needs range from guidelines for who is eligible to live in a veterans independent living with minimum supervision to home—generally, residents of California who are advanced medical care for residents with significant aged or disabled, anGd driascphharigce dS firgomn aOctfifve duty disabilities. The homes provide medical care, under honorable conditions (that is, without a Secretary meals, personal care services, therapeutic activities, dishonorable discharge). CalVet has adopted further Analyst recreational events, and some transportation rules and regulations to guide who is eligible to MPA for residents. In a later section, we provide a live in a veterans home. These administrative rules Deputy detailed discussioAn RofT tWhe OloRngK-t e#r1m6 c0a4re4, 0mental generally restrict admission to veterans who are 55 and behavioral health, transitional housing, and or older—or, at any age, veterans who are homeless Template_LAOReport_mid.ait employment services available at the homes. or have a disability. (We note that non-veteran spouses may also be admitted to the veterans home if they meet certain criteria, Figure 3 per state law.) Regulations California’s Veterans Homes also state that the veterans homes have the right to deny Year Residents First Admitted admission to veterans with behavioral concerns who would threaten the safety and security of other residents, or Redding (2014) veterans requiring specialized care beyond what is provided at the homes. Once deemed eligible, veterans are admitted to the Yountville (1884) homes on a first-come, first- served basis. If there is not a bed available, veterans may Fresno (2014) be placed on a wait-list in the order in which they applied. State law and regulations, however, prioritize certain veterans for admissions, as Lancaster (2010) Barstow (1996) follows: Ventura (2010) • State Law Prioritizes West Los Angeles (2010) Distinguished, Wartime Veterans for Admission. Chula Vista (2000) Medal of Honor recipients and former prisoners of war 8 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT are prioritized over all other veterans for to be offset by “member fees” charged to the admission to the homes. Wartime veterans veterans home residents. Member fees for veterans are prioritized over veterans who served home residents are calculated as a percentage solely during peacetime. of the resident’s annual income—ranging from 47.5 percent for independent living to 70 percent • Regulations Prioritize Veterans With for skilled nursing care. Residents with very low or Various Hardships for Admission. no income do not pay member fees. (At the time of Regulations state that the homes may take this report, CalVet was in the process of revising into account veterans’ social and economic regulations that limit the amount of fees the home hardship, age, and disability needs, and may collect based on the resident’s income.) In prioritize them for admission accordingly. addition, residents who have a significant disability These factors generally allow homeless incurred or aggravated during service (that is, a veterans to be placed for high-priority or service-connected disability rating of 70 percent or urgent admission. higher, which we describe later in this report) do Veterans Homes Serve Mostly Older Veterans. not pay a share of cost because the veterans homes Like most long-term care services, the veterans receive an enhanced federal reimbursement rate homes primarily serve older veterans. In July for their care. In September 2016, veterans home 2016, about 80 percent of veterans home residents residents across all homes paid—on average—about were over the age of 65 and 34 percent were over $1,000 in monthly member fees. Eight percent of age 85. Most veterans home residents (77 percent) residents across all homes were exempt from paying served in World War II, Korea, or Vietnam, with member fees that month because they had low or Vietnam-era veterans making up the largest share no income or were associated with the enhanced (32 percent). The racial and ethnic makeup of the federal reimbursement rate. veterans homes is less diverse than California’s S c erviceS in tHe ommunity overall veteran population, with 85 percent of veterans identifying as white (compared to A wide range of veterans services are provided 77 percent of all California veterans). in the community, largely funded by the federal Veterans Homes Funded by State and Federal Sources, Figure 4 Some Veteran Out-of-Pocket Veterans Homes Funding and Reimbursements Costs. The veterans homes (Dollars in Millions) received $315 million General 2016-17 Fund in 2016-17 to fund the General Fund $315 homes’ daily operations and Offsetting Reimbursementsa, b care for residents. As shown in USDVA (federal funds) -71 Figure 4, about $90 million of this Medi-Cal (federal funds) -11 amount is estimated to be offset Medicare (federal funds) -9 Member fees -25 by reimbursements from the U.S. Net Total, General Fundc $199 Department of Veterans Affairs a Projected by the California Department of Veterans Affairs. b (USDVA), Medi-Cal, and Medicare, Reimbursements are returned to the General Fund and shown as negative amounts. c General Fund appropriation minus projected reimbursements. and about $25 million is estimated USDVA = United States Department of Veterans Affairs. www.lao.ca.gov Legislative Analyst’s Office 9 AN LAO REPORT government. (We broadly define community disability rating will lead to more generous federal services in this report as those provided outside benefits for that veteran. of the veterans homes.) These federal services are Eligible Veterans Receive Health Care From administered through USDVA. (In addition to Federal Veterans Health Administration federal services designed specifically for veterans, veterans may access a number of veterans- Federal Health Care Centers for Veterans focused services provided by community-based Located Across the State. The federal government organizations or local governments, which vary provides health care to eligible veterans (eligibility regionally. Veterans may also access state and is discussed below) through the Veterans Health federal services not specifically designed for Administration (VHA), a division of the USDVA. veterans, such as Medi-Cal for health care. These The VHA runs medical centers with in-patient groups of services are beyond the scope of this care capacity, community-based outpatient clinics report.) Below, we provide an overview of key (CBOCs), and service centers that help veterans federal veterans benefits and eligibility, and discuss and their families transition to civilian life (“Vet how the state connects veterans to these federal Centers”). These services are typically organized services in the community. (While there are state at the regional level as a “VA health care system.” services targeted to veterans that are provided in Figure 5 displays the locations of VHA medical the community, these are much less extensive than centers, which are generally the hub of regional the federal benefits and services. We discuss these VA health care systems, and the locations of the state services in a subsequent section focused on CBOCs and Vet Centers. Of California’s 1.8 million the four service areas of interest.) veterans, about 750,000 are enrolled in VHA, and approximately 470,000 received care from a VHA A Veteran’s Disability Rating facility in 2015. Veterans not served by the VHA Affects Federal Benefits may access health care through other systems and Many federal veterans benefits depend on a insurers, such as an employer-sponsored health veteran’s “service-connected disability” rating. plan, health insurance purchased through Covered A service-connected disability is defined by the California, or Medi-Cal. USDVA as a physical or mental disability that was Federal Government Prioritizes Health Care incurred or aggravated while in training or active for Certain Veterans. To be eligible for VHA duty. Examples of such conditions include chronic health care, a veteran generally must have served back pain, amputations, traumatic brain injury, on active duty—full-time military service—for depression, and post-traumatic stress disorder. In two continuous years (or the full period of service addition, some veterans are presumed to have been for which they were called to duty) and have a exposed to harm during active duty (for example, service-connected disability. Veterans with a low former prisoners of war or veterans exposed to service-connected disability rating may qualify certain herbicides in Vietnam) and are presumed for VHA health care if their income falls below to have a service-connected disability. Once a a certain threshold. Health care provided by the service-connected disability has been established, VHA—other than the counseling services provided the federal government rates the veteran’s disability by Vet Centers—is not available to veterans from zero percent to 100 percent in increments of dishonorably discharged from the military. Once 10 percentage points. A higher service-connected deemed eligible, the VHA places veterans in one of 10 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT eight priority groups generally based on the severity several hundred dollars monthly. In all of these of the veteran’s service-connected disability, receipt cases, to be eligible for the federal benefit, veterans of other federal benefits, and special veteran status must not have been discharged under dishonorable (for example, Purple Heart medal recipient). conditions. The VHA fully funds the health care of some Graphic Sign Off State Helps Connect Veterans to veterans—typically those in the higher priority Services in the Community groups—while others have required co-pays. Secretary State Partially Funds CVSOs to Help Veterans Analyst Federal Government Provides Disability Apply for Federal Benefits. To apply for health MPA Compensation, Pension to Eligible Veterans care, disability compensation, pension, or other Deputy ARTWORK #160440 Federal monetary benefits—in the form of federal benefits, a veteran must complete a detailed disability compensation and pension—are tTheem plate_LaApOplRiceaptioonrt (_“mclaidim.a”i)t with evidence of his or her second-most utilized federal veteran benefit service-connected disability and proof of income. in California, after health care. In 2015, about This is a lengthy process, and some veterans need 355,000 veterans in California Figure 5 received federal disability Federal Veterans Health Care Across California compensation and over 28,000 California veterans received a pension, with an average disability compensation and/ VHA Medical Centers or pension benefit of about CBOCs Vet Centers $17,000 (including annual and one-time retroactive payments). a To qualify for disability compensation, a veteran must demonstrate he or she has a service-connected disability. To qualify for pension, a veteran must meet some active duty service requirements and be over 65 with limited income or a significant disability. Veterans who are eligible for disability compensation or pension and require assistance with certain activities of daily living (ADLs)—such as bathing, feeding, or dressing—may also receive an additional monetary payment referred to as “aid a A VHA Medical Center in Reno, Nevada serves nearby veterans in California. and attendance” of potentially VHA = Veterans Health Administration and CBOCs = Community-Based Outpatient Clinics. www.lao.ca.gov Legislative Analyst’s Office 11 AN LAO REPORT assistance to gather evidence of their service- as part of the 2016-17 budget package, will connected disability and complete the application. educate veterans and their families about benefits Sometimes, the federal government will reject available to them. Unlike CVSOs, which do the claim and the veteran will appeal the decision some outreach but primarily help veterans apply and, for example, add more medical evidence to for benefits, the main mission of Cal-TAP is his or her claim. The state provides $7.5 million outreach and education. Cal-TAP—currently ($5.6 million General Fund) each year to CVSOs, a in the implementation phase—will offer online joint state- and county-funded program to counsel and in-person presentations from state, federal, veterans on available benefits, help them develop and community-based partner organizations to claims for benefits, provide case management inform and connect veterans to available benefits. services throughout the claim process, and refer Outreach through Cal-TAP will focus on younger veterans to other nonfederal resources. Each veterans as they leave military service, but county has at least one CVSO and larger counties presentations will also be available for veterans at may have several. As shown in Figure 6, in 2015-16, all stages of life. over 400,000 veterans and their family members reached out to CVSOs for Figure 6 assistance, resulting in County Veteran Service Offices (CVSOs) about 109,000 monetary Utilization and Compensationa and health care claims and 2015-16 $487 million in new or increased federal benefits Utilization Veterans or family members who contacted CVSOs 402,472 to veterans. Monetary claims filed 103,475 California Transition Health care claims filed 5,838 Assistance Program Compensationb (Cal-TAP) Aims to Average benefit amount per claimaintc $16,698 Value of new or increased benefit paymentsd $487.2 million Educate Veterans About a Data from the California Department of Veterans Affairs. Available Benefits. b Includes disability compensation, pension, and other monetary payments. c Cal-TAP—administered Includes annual award and one-time retroactive payments. d Annualized amount of benefits awarded in 2015-16. by CalVet—adopted PROVISION OF SPECIFIED SERVICES TO VETERANS In the following sections, we identify the L ong -t erm c are potential service demand, the services provided Long-term care, broadly defined, is assistance in the veterans homes and in the community, and provided to individuals who have ongoing findings from our research for each of the four difficulties performing ADLs, such as bathing, service areas of particular legislative interest— dressing, eating, and toileting. Generally, people long-term care, mental and behavioral health, who need long-term care are older and/or have a transitional housing, and employment assistance. disability that prevents them from being able to 12 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT do such activities without assistance. Individuals Services Provided may receive long-term care in their home from a State Veterans Homes Provide Array of personal care services provider or in a residential Independent Living and Long-Term Care Services facility with on-site health care providers. In for Eligible Veterans. As discussed earlier in addition to the array of long-term care available to this report, the state of California runs eight the general population, veterans have other options veterans homes. These homes provide an array of for long-term care. Eligible veterans may apply to independent living and long-term care services to live at one of the state’s eight veterans homes, or a total of about 2,500 veterans. The services range may use their federal veterans benefits or personal from independent living-style “domiciliary” care income to pay out-of-pocket for private long-term to intensive skilled nursing services for residents care. with dementia or mental impairment (“memory care”). We describe each level of care in Figure 7 Potential Service Demand and show the capacity for each level of care across California’s Veteran Population Is Aging. More all homes in Figure 8 (see next page). Figure 9 than half of California’s 1.8 million veterans are (see next page) displays the distribution of each over the age of 60, and more than 260,000 veterans level of care for each home. Residents receive their (15 percent) are age 80 or older. While not all aging primary health care from each home, in addition to veterans will need long-term care, it is likely that dental, pharmacy, and rehabilitation services. The as individuals age, they will develop difficulties homes also provide residents meals and offer daily with ADLs and require some level of assistance. activities, outings, and transportation to medical In addition, roughly 20 percent of veterans in appointments for specialty care. California receive disability compensation, an Some Veterans Homes Provide Specialized indication that they may need some form of Long-Term Care Services for Residents With long-term care, regardless of age, now or in the Memory Impairment. The veterans homes future. currently offer 219 beds across four veterans homes (refer to Figures 8 and 9 on the next page) for residents with memory impairment, such as Figure 7 Levels of Care Offered at California’s Veterans Homes Level of Care Description Domiciliary (Independent Living) Residents are able to perform ADLs with minimal assistance. Units supervised by non-nursing staff. Residential Care Facility for the Residents require some assistance with ADLs and supervision. Some Elderly (RCFE) (Assisted Living) care provided by nursing staff. Intermediate Care Facility Mid-range skilled nursing care and supervision for residents who require more assistance than an RCFE can provide, but less assistance than a SNF would provide. Skilled Nursing Facility (SNF) Highest level of skilled nursing care and supervision for residents who need assistance with most ADLs. Memory Care Designated SNF care for residents with memory impairment. ADLs = activities of daily living. www.lao.ca.gov Legislative Analyst’s Office 13 Graphic Sign Off Secretary Analyst AN LAO REPORT MPA Deputy Alzheimer’s disease. These memory care units activities for residents with memory impairment. are licensed as skilled nursing units and provide For example, the Redding veterans home offers additional supervision and targeted therapeutic a specialized “music and memory” program for residents with dementia, funded through a research Figure 8 grant. This program uses Veterans Homes' Capacity, customized playlists for each By Level of Care Across All Homesa veteran as a therapeutic and Number of Beds quality-of-life enhancement 1,000 tool. Memory care units have 900 the second-longest wait-list 800 among the levels of care 700 offered by the veterans homes. 600 Veterans May Access 500 Graphic Sign Off Long-Term Care Options in 400 300 Stehcer Ceotamrmyunity. Veterans who 200 Aanrae loyns tthe wait-list for veterans 100 MhPoAmes or would prefer other Domiciliary Residential Intermediate Skilled Nursing Memory Care Dleonpgu-ttyerm care services, have Care Facility Care Facility Facility for the Elderly a range of options to choose Levels of Care from outside of the veterans a Estimated by the California Department of Veterans Affairs for 2016-17. homes. Veterans may use some combination of VHA benefits, disability compensation, Figure 9 ARTWORK #160440 pension, aid and attendance, Veterans Homes' Capacity, for Each Home and by Level of Carea private insurance, or personal Template_LAOReport_mid.ait Number of Beds funds to pay for private 1,200 long-term care. The VHA will Memory Care help fund some long-term 1,000 Skilled Nursing Facility care for veterans including Intermediate Care Facility home- and community-based Residential Care Facility for the Elderly 800 Domiciliary services, as well as residential care and nursing facilities 600 that contract with the VHA. Veterans who are eligible for 400 Medi-Cal and not receiving VHA health care may use 200 their Medi-Cal benefits, which pay for some forms Lancaster Ventura Redding Barstow Fresno Chula Vista West Yountville Los Angeles of long-term care including a Estimated by the California Department of Veterans Affairs for 2016-17. skilled nursing facilities. 14 Legislative Analyst’s Office www.lao.ca.gov ARTWORK #160440 Template_LAOReport_mid.ait AN LAO REPORT LAO Findings veterans tend to stay in the community for as long as possible and move into the veterans homes once To assess the demand for each level of care they need a higher level of care. This trend has across the veterans homes, we reviewed CalVet wait placed pressure on skilled nursing and memory and vacancy data as of October 11, 2016. Figure 10 care capacity. This observation is reflected in the compares the wait-list of each level of care to the long wait-lists for skilled nursing and memory care, capacity across all homes. We summarize our and the short wait-lists for domiciliary and other findings below. lower levels of care. High Unmet Demand for Skilled Nursing As Residents’ Needs Become More Acute, and Memory Care Beds. As shown in Figure 10, Demand for Skilled Nursing Beds Will Rise. As the longest wait-lists across all veterans homes shown in Figure 10, wait-lists for the lower levels are for the highest levels of care: skilled nursing of care are not as high as those for skilled nursing (283 veterans) and memory care (257 veterans). Graphic Sign Off care. As residents age, however, they may develop There are more skilled nursing beds than memory care beds. The wait-list for skilled nursing is at more acute care needs and eventually need skilled Secretary 46 percent of the total capacity for skilled nursing nursing or memory care. For veterans who are Analyst already residents of a veterans home and develop across the veterans homes, while the wait-list for MPA a need for a higher level of care, it is the practice memory care is above the memory care capacity Deputy for the veterans home to place that resident in the across the homes—meaning that the homes first available unit of the higher level of care. In our could theoretically fill twice the number of interviews with veterans homes administrators, memory care beds they currently offer. Demand for skilled nursing beds is highest at the Yountville Figure 10 home where 108 veterans Veterans Homes' Wait-Lists are on the wait-list, followed Compared to Capacity, by Level of Carea by the Redding home where Number of Beds 68 veterans are on the wait-list. The Redding home has the 1,000 Capacity highest demand for memory 900 Wait-List care (110 veterans), followed 800 by the Yountville home 700 600 (90 veterans). 500 Most Homes Have Vacant 400 Domiciliary Beds. In our 300 interviews with veterans 200 homes administrators, 100 they noted that historically, Domiciliary Residential Intermediate Skilled Nursing Memory Care veterans have entered the Care Facility Care Facility Facility for the Elderly homes at the domiciliary level Levels of Care of care, and moved to higher a Wait-list and vacancies across all homes as of October 11, 2016 provided by the California Department of Veterans Affairs. levels of care as their needs grew. More recently, however, ARTWORK #160440 wTewmwp.llaaote.c_aL.AgOovR e pLeogrits_lamtiivde. aAitnalyst’s Office 15 AN LAO REPORT they expressed concern at having some facilities for women. These estimated rates of PTSD among with more residential care facility for the elderly veterans are substantially higher than the estimate (RCFE) beds than skilled nursing beds, because, of the lifetime prevalence of PTSD among the total under the current configuration of beds, they could national population, which is roughly 7 percent. not transition all RCFE residents to skilled nursing The prevalence of mental and behavioral health care should they need it. conditions among veterans is also demonstrated by the comparatively high veteran suicide rate. m B H entaL and eHavioraL eaLtH National-level data show that veterans make up Mental and behavioral health conditions about 7 percent of the U.S. population but about include depression, anxiety, bipolar disorder, 18 percent of suicides nationwide. The USDVA schizophrenia, substance use disorder, and estimated that in 2014, veterans were 21 percent post-traumatic stress disorder (PTSD). Sometimes, more likely to die from suicide than their civilian these conditions are “co-occurring,” meaning some adult peer groups. veterans may experience more than one condition Services Provided simultaneously. Mental and behavioral health conditions are generally treatable and typically Mental and Behavioral Health Services involve some combination of psychotherapy and Available to Veterans Through VHA. The federal medication. VHA runs an array of services for mental and behavioral health treatment for enrolled veterans. Potential Service Demand Figure 11 describes the types of mental and High Prevalence of Mental and Behavioral behavioral health services available at each facility. Health Diagnoses Among Veterans in the General mental and behavioral health services, Community. Research shows that although most such as basic assessments and some prescription veterans return from deployment without mental or medications, are accessible to veterans through behavioral health conditions, veterans are relatively their primary care provider. Specialized mental more likely to have a mental or behavioral health and behavioral health services—including intensive diagnosis than the general population. Mental outpatient, emergency, and inpatient care—are and behavioral health conditions among veterans accessible at most VHA medical centers. Veterans are often—but not exclusively—linked to PTSD. may also access specialized therapy and treatment Some veterans may have a hard time maintaining services, but not emergency or inpatient treatment, relationships, housing, and/or employment due at CBOCs. Veterans may choose to access CBOC to mental and behavioral health conditions. The services via telemedicine instead of in-person clinic prevalence of PTSD among veterans has been visits. The VHA also runs several Vet Centers studied by several research groups. A 2008 survey throughout the state that provide counseling to by the RAND Corporation estimates that about veterans who may not otherwise be eligible for 14 percent of post-September 11, 2001 veterans VHA services. Unlike VHA medical centers and who had returned from Iraq or Afghanistan had CBOCs, services provided by Vet Centers are PTSD at the time of the survey. The National free-of-charge. Vietnam Veterans Readjustment Study estimates Some Veterans Homes Able to Provide the lifetime prevalence of PTSD of Vietnam-era Specialized Mental and Behavioral Health veterans to be 31 percent for men and 27 percent Services for Veterans Within Existing Resources. 16 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT Data from CalVet show that 76 percent of residents provide counseling to this resident and work with at the Barstow and Chula Vista homes have a the resident to develop a plan to avoid harmful mental or behavioral health diagnosis. (Data are behaviors. Transitions Program residents spend not available for the other homes.) Residents of about six months on average with the program, the veterans homes may access some basic mental with the goal of readying the residents to live and behavioral health treatment on site through successfully at the home (outside of the Transitions the homes’ staff of social workers, physicians, Program) or in the community. We note that the psychologists, and psychiatrists. scope of this program is limited, and not currently In addition to these basic services, some homes available at other homes. are able to provide more intensive treatment LAO Findings to veterans. The veterans home in Yountville has developed the Transitions Program within Veterans Homes Have Limited Capacity the home’s existing resources for veterans who to Serve Veterans With Complex Mental and either are: (1) prospective residents with mental Behavioral Health Needs. While basic mental or behavioral health needs beyond what the health services are available through the homes, home is typically able to admit, or (2) current they do not currently have the capacity to take residents in jeopardy of being discharged from in many residents with complex mental and the home due to mental or behavioral health behavioral health needs. State and federal laws problems. The Yountville home offers between and regulations require the homes to maintain 6 and 15 domiciliary-level beds for these certain staffing and specialized care ratios. These residents, depending on need and the availability requirements prevent the veterans homes from of resources. Staff who volunteer to work with admitting or retaining residents who need more Transitions Program residents work beyond their services and support than staff can provide. basic duties to provide individualized therapy, Our interviews with the homes’ administrators supervision, structured activities, and other and staff indicated that residents with mental and treatment for residents. For example, a Transitions behavioral health conditions require more staffing Program resident may need staff to periodically resources—ranging from time spent with nursing check that the resident is not engaging in behavior assistants to social workers and psychiatrists—than that would endanger her or himself and the other residents without such conditions. Limited staffing residents. The Transitions Program staff could resources for residents with significant mental and Figure 11 Mental and Behavioral Health Services Offered at VHA Facilities Facility Type Services Availablea Medical Centers General and specialized outpatient programs. Immediate onsite emergency care. Some inpatient programs available. Medications available onsite. Community-Based Outpatient General and specialized outpatient programs and medications available Clinics (CBOCs) onsite and via telemedicine. Vet Centers Free readjustment counseling for veterans and their families. Does not require VHA health care eligibility. a Reflects services generally available at each facility type, though specific services may vary by location. VHA = Veterans Health Administration. www.lao.ca.gov Legislative Analyst’s Office 17 AN LAO REPORT behavioral health challenges can result in veterans total number of homeless veterans. Despite data being denied admission to or discharged from limitations, the estimated proportion of veterans a veterans home. Data from the Yountville and who are homeless is higher than the estimated Redding homes show that in 2015-16, 30 applicants proportion of all individuals in California who are were denied admission and 32 residents were homeless, which was about 0.3 percent. discharged (10 involuntarily) due to behavioral Services Provided health-related concerns about staffing and care disruption. Veterans Homes Administratively Prioritize Homeless Veterans on Wait-list. As discussed t H o ranSitionaL ouSing and tHer previously in this report, state regulations allow the o H v ptionS for omeLeSS eteranS veterans homes to prioritize veterans with social Transitional housing is one approach to help and economic hardship for admission into the homeless individuals and families take a step veterans homes, which generally allows homeless toward permanent housing. Transitional housing veterans to be considered for high-priority or programs typically provide shelter for a fixed urgent admission. Figure 12 shows the proportion period of time (for example, one year) to allow the of veterans at each home who self-identified as participant to receive services, such as counseling homeless immediately prior to admission (whom and employment assistance, while he or she secures we refer to as “previously homeless veterans”). stable income and housing. We note that there While the proportion of previously homeless are local governments and community-based veterans varies across the homes, on average, about organizations that provide transitional housing one-quarter of veterans identify as previously and services for homeless veterans (some using homeless. federal grants). Consistent with the scope of this West Los Angeles Veterans Home Partners report, however, we limit our discussion to veterans With Federal Government to Provide Transitional services directly administered by the federal Housing Program (THP). The large proportion government and state programs for homeless of previously homeless veterans at the West Los veterans. In this section, we describe the state and Angeles veterans home (as shown in Figure 12) is federal transitional housing options for veterans, in part due to the THP located at this home. The as well as other state and federal services targeting West Los Angeles veterans home is one of three homeless veterans or veterans in need of affordable organizations that partners with the USDVA housing. location in West Los Angeles (which owns the campus where the West Los Angeles home is Potential Service Demand located) to provide veterans with temporary Homelessness Disproportionately Affects housing while they look for stable housing Veterans. Point-in-time data from an annual, and income. Candidates for THP are chosen federally sponsored homelessness count estimates after graduating from a USDVA substance use that about 11,000 California veterans (0.7 percent rehabilitation program on the West Los Angeles of the estimated California veteran population) campus. The THP residents live at the West Los were homeless on January 30, 2015. As this count Angeles veterans home while they prepare to captures only homeless individuals who identify transition to life in the community by looking themselves as veterans, it likely underestimates the for housing, employment, and/or educational 18 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT opportunities. Participants may access federal VHA health care, and participate in case services on the West Los Angeles USDVA campus, management services and recommended including general VHA health care services, treatment (for example, mental health specialized mental and behavioral health care, treatment) provided by the program. vocational rehabilitation, and other employment Nationally, there are a fixed amount assistance services. of vouchers. Since 2008, the federal Variety of Federal and State Housing government has provided approximately Programs Aim to Make Affordable Housing 16,500 vouchers to California veterans. Of Available to Veterans in the Community. The the 8,000 vouchers allocated nationally in federal and state governments administer a number 2016, California received 1,390. of programs that aim to help veterans transition • California Veterans Housing and into permanent housing, or to make permanent Homelessness Prevention Program. housing more affordable. Below, we describe three Proposition 41—approved by voters in key federal and state programs. June 2014—provides $600 million to Graphic Sign Off • Federal Housing Vouchers for Veterans. the California Department of Housing Together with the U.S. Department of and Community Development, the Secretary Housing and Urban Development (HUD), California Housing Finance Agency, and Analyst the USDVA administers the Veterans CalVet to develop affordable housing for MPA Affairs Supportive Housing (HUD-VASH) veterans and their families. (The funds Deputy program. This program allows local for Proposition 41 were redirected from housing authorities with high prevalence previously approved general obligation of veterans homelessness to apply for an bonds for the CalVet Home Loan program, allocation of federally funded “housing choice” vouchers for veterans (colloquially Figure 12 known as “Section Proportion of Previously 8” vouchers among Homeless Veterans by Veterans Homea the non-veteran 2015-16, Percent of Residents population). These 50% vouchers generally 45 allow veterans to 40 find permanent 35 30 housing in the 25 community and 20 apply the value of 15 the voucher toward 10 their rent payment. 5 To be eligible for Fresno Redding Lancaster Ventura Yountville Chula West Barstow Vista Los HUD-VASH, a Angeles veteran must be a Data provided by the California Department of Veterans Affairs. homeless, eligible for www.lao.ca.gov Legislative Analyst’s Office 19 ARTWORK #160440 Template_LAOReport_mid.ait AN LAO REPORT which we discuss below.) By law, all is managing about 5,500 home loans Proposition 41 funds must be used to (valued at about $1 billion) for veterans and serve veterans and their families, and at their families. The program is self-funded least 50 percent of the funds must serve through bond funds and loan repayments. veterans with extremely low incomes (which HUD defines each year by region). LAO Findings As of June 2016, the state had awarded With High Prevalence of Mental and approximately $180 million of the funds to Behavioral Health Diagnoses, Admitting More develop about 1,500 housing units through Previously Homeless Veterans Could Place a competitive grant process. About 900 of Staffing Pressures on Veterans Homes. The USDVA the 1,500 units are set aside specifically for estimates about 80 percent of homeless veterans homeless veterans. As shown in Figure 13, nationwide have mental and behavioral health or the planned units are located throughout substance use disorders. In our interviews at the the state, with the most units in the Los veterans homes, staff indicated that previously Angeles area. homeless residents sometimes have a difficult time readjusting to living near other people, and often • California Home Loan Program for need mental or behavioral health treatment to help Veterans. The CalVet Home Loan program them transition to life at the veterans home. As provides various types of home loans to we discussed previously, the veterans homes have eligible veterans. These loans are primarily limited capacity to care for veterans with significant backed by a USDVA guarantee. The CalVet mental and behavioral health challenges. If the Home Loan program provides veteran- homes begin to admit more previously homeless specific loan services and targets veterans veterans who also have mental or behavioral who may not otherwise qualify for a home health diagnoses, then staff may face challenges loan, which may make it easier for certain balancing the care of veterans with acute mental veterans to obtain affordable housing. and behavioral health needs and maintaining the Currently, the CalVet Home Loan program staffing requirements for the rest of the veterans at Figure 13 the home. Veterans Housing and Homelessness Prevention Program: Grants Awarded by Locationa e mpLoyment (Dollars in Millions) a SSiStance Total Number of Location Awarded Housing Unitsb When veterans leave military service, they may Bay Area $29 207 Los Angeles 84 686 have difficulty translating Inland/Orange 22 205 the skills they acquired to San Diego 17 188 non-military jobs. Several Other 27 263 services at the state and Totals $179 1,549 a Data from the California Department of Housing and Community Development for grant award Rounds 1 federal levels aim to help and 2, as of June 2016. b veterans transition back Projected. into the labor force. 20 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT Potential Service Demand within full-service AJCCs. Specifically, these federal funds support the Disabled Higher Unemployment Rate Among Veterans Outreach Program (DVOP) California’s Veterans. In 2015, California had one and Local Veterans’ Employment of the nation’s highest veterans unemployment Representatives (LVERs). The DVOP rates at 6.8 percent. The unemployment rate staff provides “career individualized for California veterans was higher than the services,” such as career assessments, California non-veteran unemployment rate planning, intensive job training, vocational (6.0 percent). While the unemployment rate is education, and other employment-related generally high among veterans, certain veterans are services to disabled veterans. Data disproportionally affected by high unemployment. from EDD show that, as of September Veterans with significant service-connected 2015, about 1,100 (76 percent) veterans disabilities (defined as a disability rating of receiving DVOP intensive services entered 60 percent or higher) have a higher unemployment employment after exiting the program. rate than other veterans. Young veterans—those The LVERs work with veterans and who served in active duty after September 11, employers to help facilitate employment 2001—also have a higher unemployment rate than opportunities, training, and job placement other veterans. (We note that the unemployment for veterans. rate, as measured by the federal Bureau of Labor Statistics, excludes individuals who have stopped • Veteran Employment-Related Assistance looking for work or otherwise dropped out of the Program (VEAP). The state allocates about labor force.) $5 million annually from a federal grant for VEAP, which awards grants through Service Provision a competitive process to community- State Employment Development Department based organizations offering employment (EDD) Runs Employment Assistance Programs services targeted to veterans. Currently, for Veterans. The California EDD runs a variety of 21 organizations throughout California employment assistance programs, some of which receive VEAP funding. target veterans. These programs are generally Federal Government Directly Administers funded by federal grants and administered through Some Vocational Rehabilitation and Employment the statewide network of employment centers, Services for Eligible Veterans. The USDVA the America’s Job Centers of California (AJCC). administers a vocational rehabilitation and Pursuant to federal law, veterans are typically employment program for veterans with service- prioritized for services through the AJCC. In connected disabilities, and general employment addition to granting priority to veterans, the state services for other veterans aiming to re-enter leverages two federal funding streams to support the labor force. Veterans with service-connected employment assistance for veterans: disabilities may receive comprehensive career • Jobs for Veterans State Grant (JVSG). assessments, vocational counseling, job training, The JVSG—a federal grant program— case management, and job placement services provided about $19 million in federal through the Veterans Rehabilitation and funds in 2016-17 for additional staffing Employment (VR&E) program. For veterans www.lao.ca.gov Legislative Analyst’s Office 21 AN LAO REPORT without service-connected disabilities, or for Most Residents at Veterans Homes Are of veterans who do not want VR&E services, the Retirement Age, Without Need for Employment federal government offers an online job database Assistance. Approximately 90 percent of (known as the “Veterans Job Bank”) and online residents at the veterans homes are over the age training to aid veterans in their job search. of 65 (typically thought of as retirement age). State and Federal Governments Grant Hiring Accordingly, few veterans at the veterans homes Preference to Veterans. The state and federal need or want employment assistance. One notable governments use ranking systems to identify the exception is the group of veterans participating in highest qualified applicants to fill civil service THP at the West Los Angeles home, as veterans positions. These ranking systems grant preference served in that program are typically working-age to veterans applying for most state and federal jobs. and looking for stable income and housing. As While this preference does not guarantee a veteran part of THP, veterans participate in employment will be hired, veterans with hiring preference are assistance programs through USDVA. generally moved to the top tier of applicants. ISSUES FOR LEGISLATIVE CONSIDERATION AND OPPORTUNITIES TO IMPROVE SERVICE DELIVERY In our review, we identified four key health treatment options a veteran may have in the opportunities for the Legislature to improve service community and prioritize admission for veterans delivery at the veterans homes. These opportunities without reasonable alternatives to the homes. Such could improve service delivery by reducing and a policy goal would likely lead the Legislature to prioritizing the wait-lists, providing the appropriate prioritize in statute the regulations that CalVet level of care for current and prospective residents has established administratively to prioritize of the homes (including those with complex needs), veterans who are homeless, or have economic lowering the vacancy rates, and ensuring the homes hardship that may prevent them from obtaining are properly staffed. alternate care. Alternately, the Legislature could prioritize admitting veterans whose care the federal Prioritizing the Wait-List government reimburses at a higher rate—those While certain limited groups of veterans (such receiving skilled nursing services and those with as Medal of Honor recipients and former prisoners a service-connected disability rated 70 percent of war) are prioritized for admission to the veterans or higher. This would prioritize veterans with homes by state statute, admission priorities have significant care needs, and also lead to increased largely been established administratively through federal reimbursements for the cost of care for such regulations. If the Legislature wishes to ensure veterans. If the Legislature decides to prioritize certain groups of veterans are prioritized for admission for certain groups of veterans, we admission to the veterans homes, it could codify suggest that the Legislature consult with CalVet its own admission priorities in statute. As the regarding any additional staffing needs and other Legislature considers its priorities, it may wish to budget requirements the new admissions rules consider what long-term care, housing, or mental could create. 22 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT Serving Veterans With Complex Mental and CalVet may choose to dedicate specific units or a Behavioral Health Needs in Veterans Homes set of beds in one or several veterans homes for residents with complex mental and behavioral As discussed previously, all veterans homes health needs. provide some basic level of mental and behavioral health support, but have limited capacity to assist Adapting to Changing Demand for veterans with complex mental and behavioral Levels of Care health needs. Veterans home residents with such Within the veterans homes, the long wait-lists needs require increased staff contact to ensure their for the highest levels of care (skilled nursing own safety and well-being, as well as the safety and and memory care) and high vacancy rates for well-being of other residents. In addition, licensing lower levels of care (domiciliary) raise questions requirements for veterans homes require certain about what flexibility the homes have to adapt to staffing ratios at each level of care. Admitting more changing demand across the levels of care. Due to residents with mental and behavioral health needs stricter licensing requirements for the highest levels without increasing staffing resources could place of care, converting any existing units to higher pressure on staff and jeopardize level-of-care and levels of care would require legislative action to safety requirements at each home. authorize unit renovations and approve budget If the Legislature determines that serving adjustments associated with such renovations. veterans with complex mental and behavioral If the Legislature is interested in addressing the health needs is a priority, then it may wish to direct changing demand for levels of care within veterans CalVet to develop new staffing standards for units homes, it could consider several options—each that have a significant proportion of residents with trade-offs. The Legislature may wish to reduce with mental and behavioral health needs. The wait-lists for the skilled nursing and/or memory new staffing standards would likely require an care level of care by renovating existing units increased staffing ratio and additional specialized licensed for lower levels of care to accommodate mental and behavioral health staff—along with higher levels of care. If the Legislature wishes to a corresponding budget adjustment—to ensure pursue this option, then it may want to consider its the homes would be able to appropriately care for goals when selecting which units to renovate. For residents with complex needs without jeopardizing example, the Legislature may wish to minimize the the safety and well-being of all residents of the cost associated with the renovations. In this case, homes. the Legislature could prioritize converting existing In addition to adjusting staffing standards, the RCFE units into skilled nursing facility units, Legislature may wish to direct CalVet to develop which would likely require minor changes to meet a plan for how they would accommodate more licensing standards. One drawback to this approach residents with complex mental and behavioral is that most RCFE units also have waiting lists, and health needs. The plan should include a strategy converting RCFE units to skilled nursing facility for where, how, and how many residents with units would likely increase wait-lists for RCFE beds. complex mental and behavioral health needs could Alternately, the Legislature may wish to prioritize best be accommodated, in light of staffing and renovating empty or semi-vacant domiciliary other budgeting resources and the objective of units at the Yountville home. Converting units minimizing disruption to the current makeup of at Yountville would be costly and require major the veterans homes as practicable. For example, www.lao.ca.gov Legislative Analyst’s Office 23 AN LAO REPORT physical changes to the buildings. As another employees, the homes are somewhat constrained option, the Legislature could prioritize converting in their ability to adjust wages to make them more units at homes where the demand for skilled competitive. In more rural areas like Redding, staff nursing and memory care are highest (Yountville report that it is difficult to attract qualified staff and Redding). amidst a regional scarcity of such staff. If the Legislature is interested in pursuing Challenges Recruiting and Retaining any of these options, then, as a first step, it could Specialized Staff May Reduce Ability to Draw direct CalVet to provide an assessment of which Down Federal Funds. Staffing challenges at the homes and how many beds they could reasonably veterans homes are not limited to entry-level jobs. convert given the current occupancy and wait-lists Several homes report being unable to recruit or at each home. This assessment should include cost retain specialized health care providers, such as estimates for the anticipated renovations associated psychiatrists and rehabilitation staff (physical with meeting a higher licensing standard. For therapists, occupational therapists, and speech proposals that could potentially displace current therapists). Administrators at the homes point to veterans homes residents, the assessment should two primary reasons for this challenge: salary and also include estimates of how many residents location. In some cases, the salaries for specialized at which levels of care would be displaced, and staff are not competitive with private-sector salaries a proposal for how to move the veterans into for a comparable job. In other cases, the location of appropriate accommodations with minimal care the home may not be desirable to specialized staff. disruption, with the goal that each resident remain Sometimes, both salary and location are barriers within their respective veterans home, if so desired. to retaining staff. Homes that are unable to provide rehabilitation services are consequently unable Addressing Staffing Challenges to draw down federal Medicare reimbursements At the Veterans Homes for rehabilitation, which can be a lucrative Homes Report Difficulty Recruiting and reimbursement source for the homes. Retaining Entry-Level Staff. In our interviews Review CalHR Classifications to Improve at the veterans homes, administrators and staff Recruitment and Retention. There are a number consistently noted challenges in recruiting and of initial steps the Legislature could take to retaining entry-level nursing and food service staff. address staffing challenges at the veterans homes. In areas with a high cost of living (for example, The Legislature could direct CalVet to survey Yountville or West Los Angeles), low-wage staff the homes to identify hardest-to-hire positions. may need to commute from farther away because With this information, the Legislature could they cannot afford to live near the veterans home, direct the California Department of Human likely reducing the pool of interested potential Resources (CalHR) to remove any burdensome or employees. In areas where competition is high for unnecessary requirements that create barriers to entry-level staff, individuals may opt for other, hiring and retaining qualified individuals in the higher-paying jobs. For example, the West Los relevant state classifications. (The Legislature could Angeles home reports that several hospitals in direct the administration to incorporate this review the area pay higher wages for Certified Nursing as part of its ongoing Civil Service Improvement Assistants than the veterans home. Since the Project—an effort led by the Government veterans homes are staffed by public (state) Operations Agency and CalHR to review and 24 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT improve state civil service rules and procedures.) some homes remain hard to recruit and retain, the Following an initial survey, CalVet could regularly Legislature could consider providing homes with submit to the Legislature recruitment and retention targeted recruitment and retention funding for data so that the Legislature can consider the issue hardest-to-hire positions. as part of the annual budget process. If positions at www.lao.ca.gov Legislative Analyst’s Office 25 AN LAO REPORT 26 Legislative Analyst’s Office www.lao.ca.gov AN LAO REPORT www.lao.ca.gov Legislative Analyst’s Office 27 AN LAO REPORT LAO Publications This report was prepared by Callie Freitag and reviewed by Lourdes Morales. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. 28 Legislative Analyst’s Office www.lao.ca.gov