A New Approach to California's Veterans Homes

A New Approach to California’s Veterans Homes REPORT #237, MARCH 2017 LITTLE HOOVER COMMISSION DEDICATED TO PROMOTING ECONOMY AND EFFICIENCY IN CALIFORNIA STATE GOVERNMENT Little Hoover Commission To Promote Economy and Efficiency Pedro Nava Chairman The Little Hoover Commission, formally known as the Milton Jack Flanigan Vice Chairman Marks “Little Hoover” Commission on California State Government Organization and Economy, is an independent state oversight agency. Scott Barnett David Beier By statute, the Commission is a bipartisan board composed of five public members appointed by the governor, four public members Anthony Cannella Senator appointed by the Legislature, two senators and two assemblymembers. Chad Mayes In creating the Commission in 1962, the Legislature declared its purpose: Assemblymember Don Perata ...to secure assistance for the Governor and itself in promoting economy, efficiency and improved services in the transaction of the public Sebastian Ridley-Thomas Assemblymember business in the various departments, agencies and instrumentalities of the executive branch of the state government, and in making the Richard Roth Senator operation of all state departments, agencies and instrumentalities, and all expenditures of public funds, more directly responsive to the Jonathan Shapiro wishes of the people as expressed by their elected representatives... Janna Sidley The Commission fulfills this charge by listening to the public, Helen Iris Torres consulting with the experts and conferring with the wise. In the Sean Varner course of its investigations, the Commission typically empanels advisory committees, conducts public hearings and visits government Former Commissioners Who operations in action. Served During The Study Loren Kaye Its conclusions are submitted to the Governor and the Legislature for their consideration. Recommendations often take the form of David A. Schwarz legislation, which the Commission supports through the legislative Commission Staff process. Carole D’Elia Executive Director Contacting the Commission Jim Wasserman Deputy Executive Director All correspondence should be addressed to the Commission Office: Tamar Lazarus Little Hoover Commission Project Manager 925 L Street, Suite 805, Ciana Gallardo Sacramento, CA 95814 Research Analyst (916) 445-2125 littlehoover@lhc.ca.gov Matthew Gagnon Research Analyst This report is available from the Commission’s website at www.lhc.ca.gov. Aleksander Klimek Intern Letter from the Chair Letter from the Chair March 1, 2017 The Honorable Kevin de León The Honorable Jean Fuller President pro Tempore of the Senate Senate Minority Leader and members of the Senate The Honorable Anthony Rendon The Honorable Chad Mayes Speaker of the Assembly Assembly Minority Leader and members of the Assembly Dear Governor and Members of the Legislature: California opened its first veterans home in the heart of the Napa Valley in 1884 – the same year the cornerstone for the Statue of Liberty was laid in the New York Harbor and the Washington Monument was completed on the National Mall in our nation’s capital. Like these icons of our nation’s strength and values, California’s veterans homes have endured as a representation of the state’s unwavering commitment to service members who have given of themselves to protect those values. But California’s veterans homes are more than just monuments. For those few who land a spot within one, they become homes in the truest sense. They provide shelter, nourishment, community and support for those who are aging and frail, as well as those whose injuries – both visible and those that go unseen – leave them incapable of caring for their own health. This care, however, comes at a cost. Veterans homes in other states have demonstrated that, through fiscal policies and limits on the level of care and services provided, it is possible to operate with little to no state funding. In contrast, California’s eight veterans homes will cost the state General Fund approximately $185 million in fiscal year 2017-18, after collecting all revenue due from the federal government and other sources. With a budget to fill 2,610 beds, this will amount to a cost of approximately $71,000 per bed for the year. Given that the great majority of California’s 1.7 million veterans are likely to never step foot within the walls of one of the veterans homes or directly benefit from such a subsidy, the Commission asks policymakers to consider: Should California revise its veterans homes program to make it more self- sufficient, while identifying additional strategies to use the savings to support more veterans in need? The Commission’s answer is an emphatic yes. California must take steps to ensure that the debt society owes to veterans is paid in full across the spectrum, not just to a particular few. The Commission is not advocating reneging the promises already Little Hoover Commission | 1 A New Approach to California’s Veterans Homes made to current residents or those veterans waiting to get into a home. The Commission is advocating that state leaders question assumptions and past decisions about what kind of care veterans want and need and how it is best delivered. Times and circumstances change and California must incorporate the best new vision for veterans care. And it specifically means considering why we continue to maintain our veterans homes program as is, without ensuring it offers the best model of care for our neediest veterans. California veterans leaders and policymakers need more information about the state’s veterans – who they are, where they live, their health status and needs – and the services available to them. The California Department of Veterans Affairs (CalVet) should take the lead in collecting this information and use answers to guide decisions about the veterans homes program and other veterans services. CalVet leaders, too, should regularly evaluate the services offered among the homes and ensure that they are appropriate for current and future veterans. Given the changing needs and demographics of the veterans population – which is at the same time shrinking, aging, and becoming more diverse – viable options should include modifying the types of services provided in the homes, repurposing aging homes or redirecting investment towards other home and community-based care options. Likely, the need for the veterans homes will remain for some time. However, California should ensure that the most vulnerable veterans are among the first to be offered care. The homes also should reduce care options by intelligently revising the domiciliary program for veterans who can still care for themselves and taking steps to increase availability of beds for the growing number of veterans in need of skilled nursing and memory care. To shore up funding for the homes, policymakers must reexamine fiscal policies and introduce reforms that allow the homes to maximize revenue collection and function more self-sufficiently. Finally, the 615-acre campus at Yountville, unique among California’s veterans homes, offers opportunity to reimagine the types of programs and services available to veterans. The Commission heard testimony about specific infrastructure challenges afflicting this historic home and also met in Yountville with CalVet officials, infrastructure financing experts, community advocates and Yountville home residents to consider the future of this campus. Because its challenges are so complex, the Commission will continue to consider opportunities for the state to make the best use of this campus with a public hearing in Sacramento in June 2017. As the Commission launched its review of the state’s veterans home program in October 2015, in response to a request from Assemblymember Jacqui Irwin, chair of the Assembly Committee on Veterans Affairs, Commissioners and others had concerns with inconsistent leadership at the top reaches of CalVet. Since the appointment of the current Secretary, Dr. Vito Imbasciani, a practicing physician and military veteran, much has changed to offer hope. In short, the Commission has been encouraged by his calls for bold reform. To that end, the Commission respectfully offers its findings and recommendations in the hope of advancing reform and helping ensure California does its best to care for those who have served and sacrificed for us, and stands prepared to assist. Pedro Nava Chair, Little Hoover Commission 2 | www.lhc.ca.gov Contents Contents 5 Executive Summary 10 Introduction The Commission’s Study Process ........................................................................................... 12 13 Background California’s Rapidy Changing Veteran Population .................................................................. 13 The Formation and Growth of California’s Veterans Homes .................................................. 16 Oversight of the Veterans Homes of California: California Department of Veterans Affairs History and Responsibilities ................................................................................................... 20 23 Redefining The Role of California’s Veterans Homes in the 21st Century Right-Sizing California’s Veterans Homes ............................................................................... 23 Reasserting California’s Commitment to Veterans ................................................................. 29 Conclusion .............................................................................................................................. 36 Recommendation 1: The Legislature should amend the Military and Veterans Code to clarify the homes admissions policies and ensure access for the neediest veterans ..... 36 Recommendation 2: The Legislature should amend the Military and Veterans Code to eliminate domiciliary care from the state’s veterans home program ............................... 37 Recommendation 3: To determine whether Calvet should repurpose or shutter one or any of the veterans homes, CalVet should establish a process to systematically evaluate and review each veterans home as it approaches its 20-year mark, and periodically thereafter, and make recommendations to policymakers regarding the future of the home ......................................................................................................... 37 Recommendation 4: CalVet should conduct an assessment to consider the needs of California’s overall veteran population ........................................................................... 37 Recommendation 5: As CalVet repurposes its veterans homes program savings should be redirected to home- and community-based veterans services ..................... 37 Little Hoover Commission | 3 A New Approach to California’s Veterans Homes Contents 38 Simplify, Stabilize Funding for the Veterans Homes A Complicated Budget Process Obscures Costs, Revenue Sources ........................................ 38 Other States Operate Veterans Homes with Little Cost to State Taxpayers ............................ 41 Conclusion .............................................................................................................................. 44 Recommendation 6: To streamline and modernize the state’s veterans home program, the Governor and Legislature should amend the Military and Veterans Code ............................................................................................................................... 45 Recommendation 7: CalVet should amend regulations to specify consequences for residents who do not maintain adequate insurance coverage or otherwise pay their share of their costs ......................................................................................................... 45 Recommendation 8: To enhance fiscal transparency, CalVet should make available, online in an accessible format, its financial reports to the Legislature .......................... 45 46 Appendices Appendix A: Public Hearing Witnesses .................................................................................. 46 Appendix B: Advisory Committee Meeting Participants ........................................................ 47 Appendix C: Little Hoover Commission December 8, 2015 Letter to Governor and Legislature .. 49 Appendix D: Additional Charts ............................................................................................... 51 55 Notes 4 | www.lhc.ca.gov Executive Summary Executive Summary F or more than a century, California, like many states already have more challenging health needs than their across the nation, has proudly maintained homes predecessors and this trend is likely to continue. In the for veterans and their spouses. Indeed, the state’s coming decades, California’s population of veterans also commitment to giving back to those who have served us will both shrink and become more diverse in terms of all is so strong that in the late 2000s, as many among the gender, race and ethnicity. Researchers anticipate that Greatest Generation began to age, Californians approved compared to their younger comrades, those serving in spending to nearly double the capacity of its veterans the Gulf War and the most recent conflicts in Iraq and homes system from 1,984 beds in three homes to nearly Afghanistan, may need support earlier in life and for 3,000 beds in eight homes. The California Department more years due to the severity of their service-connected of Veterans Affairs (CalVet) broke ground on its new disabilities. homes in June 2007 and for the next six years undertook unprecedented construction which culminated in October The Cost of the Veterans Homes 2013 with the opening of the two newest homes in Fresno and Redding. As a result of this building spree, California today boasts the largest system of veterans California’s veterans home beds come at a cost, both homes in the nation. Within these walls, veterans are in terms of the high price tag of health care, as well as offered a range of services including independent living, the opportunity cost of not investing elsewhere. The assisted living or residential care, intermediate care and state’s eight veterans homes are expensive to operate skilled nursing for veterans who are age 55 or older or are and consume the lion’s share of General Funds allocated disabled or homeless and in need of long-term care. to CalVet each year. In fiscal year 2017-18, California budgeted $306 million for the homes to fill approximately 2,610 beds.1 This translates to a staggering $117,241 California’s Veterans per bed. Yet the Commission found the math is more nuanced and complicated, as described in detail later Most of the veterans currently living in the state’s in this report. In large part, the figure is not accurate homes served during World War II and the Korean War. because it does not account for revenue the state collects Generally, veterans from these conflicts arrived later in from individual residents, insurers and federal programs life in good health and with sufficient resources to care such as the U.S. Department of Veterans Affairs and the for themselves. However, an increasing number of home Centers for Medicaid and Medicare to offset the cost of residents served during the Vietnam War and come to the veterans homes. In 2017-18, revenue collections the homes in poorer health than those serving in earlier are likely to cover 39 percent of the total cost, leaving cohorts. Many have complex physical and mental health California taxpayers to pay approximately $71,000 a year needs, some of which the homes are not yet capable of per bed.2 The Commission also found that policy choices addressing. significantly drive the costs. But, residents of these eight homes – approximately Trends in long-term care show that in California and across 2,700 individuals in 2015-16 – represent just a fraction of the nation, investments are increasingly being made the more than 1.71 million veterans who currently live in in community-based rather than institutional settings. California. Of them, approximately 1.11 million, or about Community-based services and supports generally cost 65 percent, are over the age of 55. An alarming number less than institutional care, and also allow families to avoid of California’s homeless are veterans, many of whom also potential hardships stemming from separation that is are aging. Research suggests California’s aging veterans unavoidable in institutional care settings. Little Hoover Commission | 5 A New Approach to California’s Veterans Homes With this review, the Commission urges veterans, veteran care offered among the state’s veterans homes. leaders and policymakers to ask hard questions about why California continues to invest in veterans homes, Current policies provide admission for residents of and to consider when and where other options might the state who are aged or disabled and who were allow California to help more service members with honorably discharged from active duty, as well as certain a similar level of investment. California should not non-veteran spouses. Though residents are generally maintain the status quo simply because we have always admitted on a first-come, first-served basis, priority cared for aging and disabled veterans in distinct veterans may be granted for homeless veterans, Medal of Honor homes. California’s rapidly changing veteran population recipients, ex-prisoners of war and wartime veterans. will undoubtedly redefine what types of services are Eligibility does not include a means test or consider a needed, and soon. California should prepare now to veteran’s level of disability. However, if enacted, changes thoughtfully consider how to meet the demands of proposed in January 2017 as part of the budget would tomorrow’s veterans in the most fair and equitable way introduce these reforms. possible, while keeping promises to those who already depend on the veterans homes for their care. To start, Role of the Veterans Homes. California’s veterans the Commission challenges state leaders to redefine homes serve a wide range of residents – from those in the role of the veterans homes in the 21st century and need of little more than a roof over their head to those simultaneously examine the funding mechanisms to in need of around-the-clock nursing care. However, support the veterans homes. health care needs of California’s veterans home residents, and potential residents indicate a growing need for Redefining the Role of California’s Veterans skilled nursing beds, while demand for domiciliary Homes in the 21st Century beds – those offered to veterans generally capable of caring for themselves – is in decline. Demographic indicators suggest that this trend will only increase as State policymakers and veterans leaders have the more Vietnam-era veterans age. More recent veterans – opportunity to boldly reconsider and renew California’s including some of those recently returned from conflicts commitment to its veterans and redefine how the state’s in Iraq and Afghanistan – are returning with serious veterans homes meet the needs of current and future service-connected disabilities and may need long-term veterans. Care must be taken, however, to account services and supports. At the same time, there is an for the uniqueness of the various cohorts of veterans increasing need for housing options for veterans who are and ensure that what is done now to help the growing homeless or at risk of becoming homeless. As currently number of aging Vietnam veterans also can be useful in structured, the veterans homes generally offer long-term helping veterans who are now in their 30s and 40s. But housing and are not set up to provide temporary housing the state’s review must not focus solely on the population for veterans who may need short-term assistance and currently and potentially served within the veterans health care. homes. Policymakers must look for opportunities to build a system of care for all California’s veterans, of which the homes are one component. To begin, California’s veteran Redefining California’s Veterans Strategy. While leaders must conduct a needs assessment of the state’s policymakers are taking steps to right-size the veterans overall veterans population, as well as determine what homes, they also should feel emboldened to consider services currently are available and where, and what else strategies to more equably distribute the state’s limited is needed. resources to facilitate care for more of the state’s veterans. To ensure that care is provided where it is most needed, the Commission recommends streamlining Admission. With limited beds available to potentially the state’s veterans homes program, potentially freeing thousands of veterans who could benefit, policymakers resources that could be diverted to fill service gaps for must begin by considering how benefits from the homes more veterans in need. Some options: are distributed among the state’s veterans and whether the homes offer the right kind of care. The Commission recommends policymakers more explicitly define the • Modify level of services provided in the homes admissions priorities and reconsider the scope of veterans homes. Veterans homes in many other 6 | www.lhc.ca.gov Executive Summary states limit care offerings to veterans in need Recommendations of intensive skilled nursing. California, too, should gradually eliminate its domiciliary beds Recommendation 1: The Legislature should amend and, where possible, increase offerings of more the Military and Veterans Code to clarify the homes intensive nursing care. admissions policies and ensure access for the neediest veterans. Policymakers should consider prioritizing • Repurpose the veterans homes. Federal rules admission based on financial status, disability rating or require states to maintain operations of veterans other factors. homes built with federal funds for 20 years or face a penalty. But, penalties are not incurred Recommendation 2: The Legislature should amend the after this period should state leaders decide to Military and Veterans Code to eliminate domiciliary close or repurpose a facility. Veterans leaders care from the state’s veterans home program. Instead, should regularly evaluate the effectiveness of the homes should focus on providing care for veterans in each veterans home in meeting the needs of need of high-level medical care, such as skilled nursing California’s veterans. If there is little demand care. Existing domiciliary residents should be allowed for a particular home, policymakers should to remain in the state’s veterans homes program as the reconsider how that facility might be better put state gradually moves away from domiciliary care. to use to help veterans regionally. Recommendation 3: To determine whether Calvet • Stop building homes. In the past, policymakers should repurpose or shutter one or any of the have opted to build more veterans homes in veterans homes, CalVet should establish a process to order to expand services to California’s veterans. systematically evaluate and review each veterans home However, trends in long-term care suggest that as it approaches its 20-year mark, and periodically these “bricks and mortar” models of care have thereafter, and make recommendations to policymakers lost favor. Instead, older adults prefer care regarding the future of the home. Such a review should options that allow them to remain at home include consideration of the needs of the regional veteran and in their communities, and communities population, projections about the changing composition throughout the state and country are responding. of the veteran population, as well as an assessment of resources available to serve them. Veteran residents, • Redirect investment toward home and as well as community members and other stakeholders community-based care. With the bulk of CalVet’s should have a participatory role in the process. funding invested in the state’s eight veterans homes, California lacks less-intensive options to Recommendation 4: CalVet should conduct an assist older or disabled veterans who need some assessment to consider the needs of California’s overall assistance, but would prefer to remain at home veteran population. As part of this assessment, the or in their communities. Yet, examples abound department should project, to the extent possible, the of programs that help individuals before they needs of each cohort of veterans over the next several need more advanced medical and nursing care. decades. In addition, the department should assess and Policymakers should look for opportunities to catalog the array of services currently available for aged facilitate partnerships among care providers and, and disabled veterans, making this information available if available, redirect savings from a streamlined online in a user-friendly, searchable format, and identify veterans home program toward amplifying home any critical gaps in services given conclusions from the and community-based services and supports for department’s needs assessment. veterans. Recommendation 5: As CalVet repurposes its veterans homes program savings should be redirected to home- and community-based veterans services. Little Hoover Commission | 7 A New Approach to California’s Veterans Homes Simplify, Stabilize Funding for the Veterans defined in Section 1012.3 of the Military and Veterans Homes Code. Specifically, CalVet may charge 47.5 percent of a resident’s annual income for domiciliary care, 55 percent In fiscal year 2017-18, California’s eight veterans for residential care for the elderly or assisted living, 65 homes received state funds totaling more than $306 percent for intermediate care and 70 percent for skilled million. After accounting for expected reimbursements nursing. Often, this fee covers just a portion of the costs, which CalVet collects from the federal government, and after accounting for other forms of reimbursement, resident fees and other revenue sources, ongoing leaves the state footing the remainder of the bill. annual operational costs are likely to run California taxpayers upwards of $185 million. This amounts to a In other states, the cost of care is established upfront budget of approximately $71,000 a year per bed after and veterans are responsible for their share, using a reimbursements. Still, the average total cost per bed combination of supports from the VA and other federal – approximately $117,000 – is a figure experts in long- and state entitlement programs, private insurance term care say is more than enough to pay for exceptional and private pay. If this is insufficient, a resident may private nursing home care in a high-cost state like be required to spend down their assets until they are California.3 Other states have demonstrated that state- exhausted, and then enroll in the state’s Medicaid operated veterans homes can provide long-term nursing program where the federal government contributes care with little impact to General Fund coffers. So too to the cost of their care. Policymakers should revisit should California. the Military and Veterans Code to clarify that residents should be charged fees based on the cost of their care. The process to determine how much it costs taxpayers to Doing so might provide greater incentive for residents provide care in its veterans homes is overly burdensome, to maintain private insurance or enroll in other public lengthy and opaque. CalVet is almost required to work assistance programs to help cover the cost of care. backwards – to focus energy hunting down various revenue sources to make up for what was issued up front. Enrollment in health insurance programs. Collecting To paint a complete picture of the homes’ budget, CalVet additional reimbursements from health insurance officials must track revenue collection, sometimes for programs can significantly offset the cost the state incurs years. These practices – and the resultant high costs to to provide care to veterans home residents, but California the General Fund – stem from past policy decisions, many does not statutorily require veterans home residents to of which are codified in the state’s Military and Veterans maintain annual coverage. Currently, state regulations Code and in administrative regulations. It is time for an only require potential veterans home residents to update. demonstrate that they have health insurance before they are admitted to a home. Veterans home administrators Policymakers have a significant opportunity to re- say that under the current policy, they do not have think how California cares for its veterans and create sufficient authority to enforce or require residents to a more efficient and effective system of care to help maintain coverage and can only encourage residents to more of those who have served. Throughout its maintain insurance. However, without consequences, review, the Commission heard from veterans leaders, they say this is not enough. Senior CalVet officials, home administrators and others who suggested that including the Secretary, have stated a desire to require by reforming several key financial policies, California’s that residents maintain insurance in order to help defray veterans homes could operate more efficiently. the cost of care.4 Legislative changes that govern how the homes collect revenue from several key sources – resident fees, health It is important to note that even for some veterans home insurance programs and federal reimbursement programs residents who have health insurance, coverage may be – offer opportunities for savings: insufficient to pay the costs of their care. Millions of Californians gained health insurance coverage through the Resident fees. Instead of charging veteran home Affordable Care Act, including an estimated 1.18 million residents a fee based on the cost of their care, the who enrolled in Medi-Cal, California’s Medicaid program. residents in California pay an amount based on a formula Because of their age, many veterans home residents 8 | www.lhc.ca.gov Executive Summary qualify for and receive Medicare benefits. However, these Recommendations benefits may not cover all health care costs. Per diem. Veterans homes in some other states limit Recommendation 6: To streamline and modernize the admission to veterans who have high levels of disability, state’s veterans home program, the Governor and incurred during, or as a result of their military service. Legislature should amend the Military and Veterans The U.S. Department of Veterans Affairs reimburses Code to: states for the full cost of caring for eligible “service- connected” veterans. Federal reimbursement for other ▪ Define the scope of benefits included for veterans contributes to the cost of their care, but is veterans home residents. insufficient to cover it completely. ▪ Empower CalVet to establish daily costs of care California’s veterans homes offer priority admission per resident, for each level of care. for certain veterans, such as prisoners of war, Medal of Honor recipients and homeless veterans, but do not grant ▪ Clarify that veterans home residents are priority based on a veteran’s disability rating. While some charged fees based on the cost of care and believe service-connected veterans are most deserving of may pay for those fees from various sources, assistance because of the level of their disability, others including the U.S. Department of Veterans caution that prioritizing admissions for this subset of Affairs per diem and other reimbursements, veterans could be viewed as discriminatory. California’s health insurance or private income. policymakers should revisit the veterans homes admission policies, including whether priority admission should ▪ Require veterans home residents to maintain be granted based on a veterans disability rating. At a adequate health insurance throughout their minimum, CalVet should develop strategies to assist more residence in a veterans home. veterans that qualify for the benefits which they are due. By taking action to stabilize funding for the veterans homes, California has the opportunity to create a more efficient veterans home system and reduce the homes’ Recommendation 7: CalVet should amend regulations to reliance on General Fund support. Adjusting the veterans specify consequences for residents who do not maintain homes policies to reduce their dependence on state adequate insurance coverage or otherwise pay their funding is not out of line with California’s tradition, share of their costs. particularly if pared with other changes that might allow the state to reinvest savings in other programs to Recommendation 8: To enhance fiscal transparency, serve more veterans. The Commission advocates that CalVet should make available, online in an accessible savings be redirected toward supporting programs – and format, its financial reports to the Legislature, which potentially different kinds of programs than are currently should be augmented to include: offered through the veterans homes – so that more than just a fraction of the state’s veterans may benefit. ▪ The amount of state funds budgeted to each home and the amount of revenue collected, and if necessary, the remaining amount of expected revenue, over a period of several years. ▪ The costs of care per resident, by level of care for each veterans home. ▪ The costs of facility maintenance, as well as projections for future maintenance costs, for each veterans home. Little Hoover Commission | 9 A New Approach to California’s Veterans Homes Introduction The Commission began its review of the California the Commission as critical to progress and the continued Department of Veteran Affairs (CalVet) and its lack of a systematic approach.” The department was operation of the California veterans homes program struggling, she wrote, “to treat the home locations with a hearing in October 2015. In part, this study as a networked system and to have its regulatory and allowed the Commission to follow up on previous leadership structure keep pace with the growth.” recommendations issued in its 2013 report, An Agenda Assemblymember Irwin said the department must view for Veterans: The State’s Turn to Serve. In that report, the homes as a unified system and plan accordingly which focused primarily on the quality and availability for the shifting demographics of the state’s veteran of veterans services for the nearly two million veterans population.5 residing in California, the Commission called on policymakers to improve veteran outreach and assist With this review, the Commission did not explore, in the federal government in reducing what was then depth, issues surrounding the governance or leadership an unconscionable backlog of claims processing for of the homes. Though the historic turbulence at the compensation and benefits for California veterans. top of the organization and an absence of leaders with The Commission purposely chose not to focus on the medical training and experience running health care veterans homes in 2013, even though the veterans organizations has been cause for concern, the qualities of homes division was, and remains, a significant portion of the current leadership exemplify the type of leader who the CalVet budget. Given CalVet’s then-growing homes should sit atop CalVet. Because the department, in many division and its new leadership after years of turnover, ways, functions as a long-term care organization that the Commission opted to give CalVet more time to also offers services to the community, the Commission implement a strategy for the homes and offer time for its believes its leadership should have a skillset that includes leadership to gel. a thorough understanding of the management and operations of health care organizations. The Commission Unfortunately, the Commission’s optimism proved applauds the appointment of the current Secretary premature. In the two years between the Commission’s who, unlike recent predecessors, brings both a strong August 2013 CalVet report and the September 2015 medical background and a track record of reform-minded appointment of CalVet Secretary, Dr. Vito Imbasciani, leadership in the military and private sector. the department’s top management continued to experience high turnover rates. Indeed, before Secretary In requesting the Commission’s review, Assemblymember Imbasciani’s appointment, the department had seen four Irwin noted concerns about the functionality and secretaries in as many years – the longest serving just shy relevancy of the CalVet Farm and Home Loan program. of two years. The same held true for the top leadership At its October 2015 hearing, the Commission learned at most of the state’s veterans homes. that the once-beleaguered home loan program had overcome various challenges and is now providing In July 2015, Assemblymember Jacqui Irwin, chair of needed and valuable lending services to a growing the Assembly Committee on Veterans Affairs, asked the number of veterans. Commissioners found it to be a Commission to take a new look at CalVet – this time self-sufficient program, though noted it would likely need specifically to focus on the veterans homes and the home voter approval for additional bond funding to continue to loan program. In a letter to the Commission, the veterans provide affordable home loans to California’s veterans. committee chair stated, “CalVet has continued to be challenged in many areas, including an extremely high The hearing, however, raised concerns for Commissioners degree of turnover in the very leadership team noted by about the quality and level of care provided in the 10 | www.lhc.ca.gov Introduction state’s eight veterans homes, the stability and design of more about the administration’s plans for the campus the system’s funding structure, and finally, the future and to consider further opportunities for its future of the state’s unique Yountville campus. In the pages use. Following the hearing, the Commission will issue a that follow, the Commission first examines the mission subsequent report to specifically address the future of and scope of care provided among the state’s veterans the Yountville veterans home campus. homes given the changing nature and needs of the state’s veteran population. The Commission considers who is served by the homes and, just as important, who is not? With an eye toward improving access to long-term Recommendations from Little services and supports for a greater portion of the state’s Hoover Commission’s 2013 Report, veterans than can be helped through the eight veterans An Agenda for Veterans homes, the Commission reflects on the effectiveness of the institutional model of care for aging and disabled Recommendation 1: Now that the Legislature veterans compared to other options for long-term has allocated one-time money to fund the services and supports that are gaining prevalence across the country. Several alternative community-based California Department of Veterans Affairs’ plan options to help veterans receive the care they need at to help alleviate the backlog of claims in U.S. home, or closer to home, are described. In making its Veterans Administration offices in California, the recommendations, the Commission also reviews CalVet’s Legislature should monitor the department’s plans to address needs of the next generation of veterans results to determine whether additional funding is and considers available services to help veterans beyond warranted. those provided in the veterans homes. Recommendation 2: California’s state and federal Finally, the Commission reviews the current process and representatives should continue to work with mechanisms for funding the veterans homes, which alone and press federal agencies to obtain up-to- require significant annual General Fund contributions. date information from veterans and relay it to The Commission explores several strategies for improving appropriate state agencies through electronic revenue collection, thus offsetting the amount state means, enabling state agencies to reach veterans taxpayers directly contribute to the homes. Drawing on sooner after their departure from the military. strategies employed by other states, the Commission considers how California, too, might amend policies, Recommendation 3: To improve outreach to specifically updating outdated statutory code and veterans and to increase the amount of veteran administrative regulations – to create more efficient and benefits entering California, the state should self-sufficient veterans homes. This potentially would allow greater funding flexibility for the California allow the state to expand other types of long-term Department of Veterans Affairs, including the services and supports for veterans who do not live in the redirection of savings from operational efficiencies veterans homes. for demonstrated strategies that help veterans file Throughout its review, the Commission heard significant benefit claims and pursue referrals for services. testimony about both the challenges plaguing the historic Recommendation 4: State lawmakers should review 615-acre Yountville veterans home campus and also, at an advisory meeting in Yountville, considered some of and update the Military and Veterans Code. the opportunities that could allow the expansive campus to flourish. Unique not only in its age, but also its size, the Yountville veterans home affords policymakers, veterans leaders and advocates the opportunity to think boldly and creatively about how to use this site to serve California’s veterans. However, because the issues are so complex, the Commission has committed to holding an additional hearing in June 2017 in Sacramento to learn Little Hoover Commission | 11 A New Approach to California’s Veterans Homes The Commission’s Study Process State Veterans Home Board discussed the governance and funding of Tennessee’s successful and cost-effective The Commission began this study with an October veterans homes program and shared some of its best 2015 hearing to learn about the California Department practices. of Veteran Affairs’ progress in implementing recommendations from its 2013 report, An Agenda In June 2016, the Commission visited the West Los for Veterans: The State’s Turn to Serve. Responding Angeles Veterans Home and held an advisory meeting to the request of Assemblymember Jacqui Irwin, the to consider the future of the state’s veterans home Commission also used the hearing to begin a new review program. Participants included a diverse group of experts of the department’s veterans homes and home loan including researchers specializing in long-term care and programs. The Commission heard from a panel of CalVet veterans’ health, representatives from veterans service staff, including the deputy secretaries from the Veterans organizations and representatives from CalVet and the Services Division, the Farm and Home Loans Division and U.S. Department of Veterans Affairs. Commissioners the Veterans Homes Division. Additionally, the director asked participants to consider how the state’s veterans of veterans services in Solano County discussed how home program could be structured to best meet the new funding for county veterans services officers has needs of current and future generations of California successfully stimulated greater outreach to veterans. A veterans and how partnerships might enhance the state’s graduate student researcher also shared the results of ability to serve aging and disabled veterans. her investigation of the veterans home program and her recommendations for further research. Next, in November 2016, the Commission again visited the Yountville Veterans Home and held an advisory At the October hearing and again during a November meeting to consider the future of the Yountville campus. 2015 visit to the Yountville Veterans Home, the It heard lessons from other successful renovations Commission learned that deferred maintenance and of public facilities and innovative financing options infrastructure neglect at Yountville has created an unsafe and discussed opportunities to expand on-campus and undignified living environment for veterans. The partnerships. Participants included representatives from Commission in December 2015 wrote the Governor and non-profit organizations serving veterans, public-private legislative leaders, alerting them to serious deficiencies at partnership experts, locally-elected leaders, legislative the Yountville campus and calling for urgent maintenance staff members, Yountville Allied Council members, and and repairs. In the letter, included as Appendix C, the representatives from CalVet and the U.S. Department of Commission also acknowledged significant progress by Veterans Affairs. The meeting also was well attended by CalVet since 2013 to reduce the backlog of claims and Yountville home members and several provided public expand outreach to veterans. The letter reiterated the comments to the Commission. Commission’s intent to continue reviewing the veterans homes program. Public hearing witnesses and advisory committee meeting participants are listed in Appendices A and B. The Commission used its second hearing, in March 2016, to learn more about the organization, cost and quality of During this study, Commission staff received valuable California’s veterans homes program. Newly appointed input through interviews, meetings and discussions with CalVet Secretary, Dr. Vito Imbasciani, shared his vision countless other researchers, veteran service organizations for the department and specifically the homes program, and advocates and members of the state’s veterans while administrators of three state veterans homes homes. Though the Commission greatly benefited from described their experiences and challenges in overseeing the contributions of all who shared their expertise, the the facilities. The chair of the California Veterans Board findings and recommendations in this report are the described the role of the board in relation to the veterans Commission’s own. homes. Finally, the executive director of the Tennessee 12 | www.lhc.ca.gov Background Background California’s Rapidly Changing Veteran But projections estimate that both the number of Population veterans, and the number of senior veterans, will decline sharply over the next several decades. The number of California’s veteran population is large and diverse. Of all U.S. veterans age 55 and above is projected to drop the 21 million veterans living in the U.S. in 2017, more about 33 percent between 2015 and 2040, driving the veterans call California home than any other state in the decline in the nation’s overall veteran population. In nation. The U.S. Department of Veterans Affairs estimates California, over the same period, the decline will be that among the 1.71 million veterans currently living in more pronounced. By 2040, California’s overall veteran California, approximately 1.11 million, or about 65 percent, population will shrink by more than 42 percent to just are over the age of 55. In addition, approximately 162,000, 1.03 million. (Tables comparing California’s veteran or about nine percent of all veterans in California, are population in 2017, 2030 and 2040 are included in women veterans – more than any other state but Texas. Appendix D). The number of veterans age 55 and older California’s veterans population also reflects the racial will decline by more than 55 percent to 541,000.9 and ethnic diversity of the state. More Native Americans and Asian American veterans live in California than any Nonetheless, for the foreseeable future, veterans aged other state, and California’s population of Latino veterans 55 and older will continue to make up a majority of the is second only to Texas.6 About 5 percent of California’s veteran population nationally. The same holds true veterans are gay, lesbian or bisexual.7 And among all, in California. However, these veterans will comprise a more homeless veterans seek shelter in California than smaller portion of the state’s veteran population – just 52 elsewhere in the nation.8 percent in 2040, compared to 65 percent in 2015.10 Little Hoover Commission | 13 A New Approach to California’s Veterans Homes Source: U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Table 6L: Vetpop2014 Living Veterans by State, Age Group, Gender, 2013-2043. And, Table 8L: Vetpop2014 Living Veterans by State, Race and Ethnicity, 2013-2043. Accessed December 8, 2016 at https://www.va.gov/vetdata/veteran_population.asp. Researchers are still learning about the unique health found that “veterans of these two time periods needs of each cohort of veterans. But they point out that generally arrived at later life in good health with the effects of service vary by era and by conflict, so much sufficient economic resources and strong social so that findings about the needs of aging veterans today ties.”12 might not apply to future generations. Still, research suggests: • Vietnam veterans, however, are more likely to reach their golden years in worse health, • World War II veterans who survived into later in part due to their service. Upon separation life were in better health around age 70 than from service, Vietnam veterans had worse veterans from subsequent wars. However, psychological outcomes and higher mortality older WWII-era veterans experience steeper rates due to accidents, suicide and homicide. age-related health declines and, among those Research highlights service-related physical and with overseas duty or combat exposure, have mental health challenges among these veterans, higher mortality in mid- to late-life, in part due such as Agent Orange exposure and cancer to high rates of smoking. Overall, researchers risk, combat and post-traumatic stress disorder, found “veterans from this era demonstrated suicide and substance use.13 In addition to these considerable resilience over the life course and more serious health issues, these veterans, seem to have fared relatively well as they aged as a group, fared worse than veterans before into later-life.”11 them on many socio-economic indicators: a higher percentage experienced unemployment • The overall impact of service among Korean and were enrolled in the U.S. Department of War and Post-Korean War/Cold War veterans Agriculture’s Supplemental Nutrition Assistance was similar to their WWII peers. Although some Program, fewer owned homes and more were experienced negative health consequences, divorced.14 Many female veterans from this era, overall the group used GI Bill benefits to advance now age 65 and over, already suffer from multiple their upward social mobility. Researchers chronic illnesses. Nearly 70 percent report three 14 | www.lhc.ca.gov Background or more chronic conditions, including arthritis, male comrades.19 Musculoskeletal injuries, post- hypertension, depression, chronic lung disease, traumatic stress disorder, hearing loss, mental osteoporosis, cancer and post-traumatic stress health injuries and traumatic brain injuries are disorder.15 the most common reasons that some among this cohort have already filed for VA disability • Less is known about the long-term health compensation claims.20 These findings may impacts of service on more recent veterans suggest they may need support earlier in life and of the Gulf War and War on Terror. Today’s for longer than previous generations of veterans. veterans experience more days of direct combat than veterans of previous conflicts – from In addition, researchers are still learning how military about 45 days during World War II to now over service affects family members. Findings from a recent 1,000 days, one veterans home administrator study suggest households with a disabled veteran are told Commissioners. He said this exposure has more likely than others to experience home hardship serious impacts on veterans’ brains and health.16 (such as a leaky roof or ceiling, broken windows or Advances in medical treatments and technology plumbing problems), medical hardship (such as the mean that more wounded veterans are able inability to see a doctor or dentist when needed), to survive injuries that in previous wars would bill-paying hardship (such as falling behind on rent or likely have killed them.17 Thus, rates of service- mortgage, missing utility payments or otherwise not connected disability among Iraq and Afghanistan meeting essential expenses) and food insufficiency (such veterans are about double that of previous as sometimes not eating enough).21 Given both the aging cohorts, and more return from their service with veteran population and the prevalence of poverty and post-traumatic stress disorder, traumatic brain material hardship among disabled older adults, research injuries and amputations.18 Female veterans suggests policymakers may also need to consider the who served in the Gulf War already have rates broader impact of service on families and caregivers. of service-connected disability higher than their Source: U.S. Department of Veterans Affairs. Little Hoover Commission | 15 A New Approach to California’s Veterans Homes The Population Within California’s Veteran Homes. The Formation and Growth of California’s The demographic composition of veterans living in the Veterans Homes state’s veterans homes is rapidly changing. Today, the largest cohort of veterans home residents served during Following the Civil War, many indigent and disabled World War II and the Korean War. But most of these soldiers incapable of earning livelihoods found themselves veterans are in their 80s and 90s and this population is without places to live. In response, citizens and fraternal dwindling within the veterans homes. At the same time, veterans organizations, such as the Grand Army of the Vietnam-era veterans, many of whom are now at least Republic, raised funds to form “Old Soldiers Homes” for in their 60s, are becoming a larger presence, making up the nation’s wounded soldiers. States, too, began to one third of the residents in California’s veterans homes, establish homes to meet the needs of these veterans. and bringing with them new challenges and demands. Connecticut, in 1864, became the first state to establish a Also, 33 Gulf War veterans reside in one of the state’s home for its aged and disabled veterans. California was veterans homes. Veterans of recent conflicts in Iraq among the first, opening its “Old Soldiers Home” in 1884 and Afghanistan, who are more diverse in terms of their in Yountville. The home was originally established in 1882 gender and race than previous cohorts, have yet to enter by Mexican War veterans and members of the Grand Army the homes en masse – currently only one resides in the of the Republic and funded and operated by the Veterans’ Yountville home. But, this cohort represents the next Home Association in San Francisco.23 wave of service members who may need services from the state. More than 120 veteran spouses also reside in In 1888, the federal government began helping states the homes. Currently, the majority of residents are white lighten costs of operating veterans homes, beginning an men, though in the future this population may become enduring partnership with states to care for the nation’s more diverse, reflecting the diversity among California’s veterans. With this shift in federal policy, the Veterans’ overall veteran population.22 Home Association in San Francisco deeded the Yountville home to the state in 1899, where it has remained in operation since. Built when California had fewer than one million residents, the Yountville home remained the state’s only residential facility for veterans for more than a century, even as the state’s population swelled past 30 million. No longer. Twenty years ago, as World War II veterans began to age, California joined the rest of the nation in a building spree of new veterans homes, with the help of the federal government which pays up to 65 percent of construction costs for new state veterans homes.24 California opened its first new 400-bed home in Barstow in 1996 and a second 400-bed facility in Chula Vista in 2000. In recent years the California Department of Veterans Affairs opened five more homes in Ventura, Lancaster, West Los Angeles, Fresno and Redding. Bonds approved by California voters supplemented federal funding to add these nearly 1,800 new living spaces to the CalVet homes system.25 If filled to capacity, California’s veterans homes could house 2,950 individuals, including veterans and their spouses or widows, and parents whose children died while serving in the Armed Forces. It is important to note, however, that Source: California Department of Veterans Affairs. the department cannot use all of these beds. Some beds are not actively licensed or certified for various reasons. Nor does the department receive funding to fill all beds. 16 | www.lhc.ca.gov Background “This was an unprecedented construction effort,” Imbasciani told Commissioners in March 2016. To Secretary Imbasciani noted in testimony to the that end, the department has formed 20 separate Commission. “Not just to build seven new facilities, but task forces charged with the development of uniform to nearly triple the capacity of our veterans homes from policies and procedures across all aspects of the homes, 1,000 to nearly 3,000 residents.”26 from budgeting and procurement to human resource practices, admission, pharmacy, nursing and human During this most recent construction boom, the safety. Expected outcomes include adoption of electronic department focused on little else, CalVet leaders said. medical records systems, standardized billing processing, As a result, the homes largely operated as independent improved revenue collection and computerized entities. Today, the department is working on improving pharmaceutical tracking and distribution, the Secretary home administration by integrating and standardizing said. The end goal of these efforts: to provide the same care among the eight homes. “If you consider the resident experience, regardless of the home in which a individual homes to be stars, it is my aim to form them veteran resides.27 into a readily recognizable constellation,” Secretary CalVet Task Forces Clinical Non-Clinical Activities and Volunteer Coordinators Administrative Assistance Director of Nursing Patient Benefit Insurance Officers Educational Services Plant Operations Food and Nutrition Services Residential Care Unit Leader Infection Control Triple Check Medicare Part A Medical Records VA Per Diem/Veteran Claim Reps Pharmacy Admissions Physicians Rehabilitation Therapy Social Work Standard Compliance Source: California Department of Veterans Affairs. Little Hoover Commission | 17 A New Approach to California’s Veterans Homes How Many People Live in California Veterans Homes? Capacity & Projected Use in FY 2017-18 Physical Capacity The number of beds approved by the U.S. Department of Veterans Affairs during the 2,950 construction of each veterans home. The Yountville home, built before U.S. DVA involvement, includes the number of rooms that are habitable. Licensed Beds The number of SNF and ICF beds licensed by the California Department of Public Health and the 2,873 number of RCFE beds licensed by the California Department of Social Services. Domiciliary beds are not licensed, but are included in the figure. Also includes beds that are designated as “suspense,” meaning they are licensed, but not being used. The U.S. Department of Veterans Affairs also certifies the maximum number of beds for which it will pay the state a per diem. In FY 2017-18, the number of USDVA- certified beds was 2,997. Active Licensed Beds 2,652 The number of beds that are licensed and currently available for use. Budgeted Census 2,610 The number of beds for which CalVet receives state funding to use. The amount varies each year and is negotiated through the state budget process. Actual Average Daily Census The average daily occupancy of all beds. The 2,464 actual number of veterans home residents is higher, as it accounts for all individuals admitted, as well as those who were discharged and those who died.For example, in fiscal year 2015-16, the actual average daily census was 2,149, but the homes served a total of 2,782 individual residents. Source: California Department of Veterans Affairs. 18 | www.lhc.ca.gov Background California’s Veterans Homes Provide a Wide Range ICF beds, or almost 10 percent of all veterans of Care. California’s system of eight veterans homes homes beds. In fiscal year 2017-18, the offer an array of services to residents capable of living department was budgeted to fill 165 ICF beds. independently and to those needing intensive round- Intermediate care facilities are available in the the-clock skilled nursing care. Though the levels of care Yountville and Barstow homes. offered among California’s veterans homes varies by home, California’s veterans homes, as a statewide system, • Skilled Nursing Facility includes intensely staffed provide four levels of care: 28 24-hour nursing care for chronically ill, terminally ill, or those with severe dementia. Skilled nursing • Domiciliary includes room and board with limited residents have greater access to rehabilitation direct supervision for self-sufficient residents. therapies, nursing care, pharmacy management, Residents have access to all of the home’s structured activities and clinical dietary services. services, activities and medical care, and can CalVet has capacity for 943 skilled nursing beds, transfer to higher levels of care as needed, and as or approximately 31 percent of all active beds. space is available. CalVet has capacity for 1,049 In fiscal year 2017-18, the department was domiciliary beds, or approximately 35 percent of budgeted to fill 859 skilled nursing beds. Skilled all beds in the state’s veterans homes. However, nursing care is available in all of the state’s in fiscal year 2017-18, the department was only veterans homes, except the homes in Ventura budgeted for 933 domiciliary beds. Domiciliary and Lancaster.29 The homes in Barstow, Fresno, care is available at the homes in Yountville, Redding and Yountville currently designate 219 Barstow, Chula Vista and West Los Angeles. The skilled nursing beds for memory care. Residents West Los Angeles veterans homes currently uses in skilled nursing facility memory units live in its 84 domiciliary beds to operate a transitional safe, supervised environments and may suffer housing program for the U.S. Department of from confusion, memory loss, difficulty making Veterans Affairs. decisions, solving problems or conversing. • Residential Care Facility for the Elderly (RCFE) • Community-Based Adult Services (CBAS) or adult or assisted living includes room and board for day health care will include a range of services residents who are primarily independent, but such as nursing services, physical, occupational require minimal non-clinical assistance and and speech therapy, mental health care, social supervision with some basic activities of daily services and counseling to older or disabled living, such as hygiene, dressing, eating and veterans who live at home or in the community, walking. Medications are centrally stored and but need help during the day. The department distributed for residents to self-administer. has plans to offer these services at two of its CalVet has capacity for 634 RCFE beds, or nearly newer homes in Lancaster and Ventura, but has a quarter of all beds in California’s veterans delayed activating the program until all of its homes. In fiscal year 2017-18, the department newer homes are filled. Still, in fiscal year 2017- was budgeted to fill 555 RCFE beds. RCFE care 18, the department received funds to provide is available in all of the state’s veterans homes, adult day health care for veterans. except the home in Barstow. • Intermediate Care Facility (ICF) includes minimally staffed 24-hour nursing care for individuals who are disabled, elderly, or non- acutely ill. Residents often require licensed nursing assistance with medications and treatments and unlicensed nursing assistance with several activities of daily living. Residents also have access to all medical services provided by CalVet. The department has capacity for 324 Little Hoover Commission | 19 A New Approach to California’s Veterans Homes California Veterans Homes Census and Level of Care Summary, Fiscal Year 2017-18 Budgeted Census by Level of Care Physical Facility Opened Capacity Skilled Intermediate RCFE Domiciliary Yountville April 1884 1,184 231 105 48 637 Barstow Feb 1996 400 40 60 ― 120 Chula Vista May 2000 400 180 ― 33 92 Ventura Jan 2010 60 ― ― 60 ― Lancaster Feb 2010 60 ― ― 60 ― West LA Oct 2010 396 228 ― 84 84 Fresno Oct 2013 300 120 ― 180 ― Redding Oct 2013 150 60 ― 90 ― Totals 2,950 859 165 555 933 Source: California Department of Veterans Affairs. Oversight of the Veterans Homes of required that the department’s top executive be a veteran.30 Through executive order, Governor Wilson California: California Department of made the department head a Cabinet-level position. Veterans Affairs History and Responsibilities Today, CalVet helps veterans and their families claim Across the nation, states have adopted various models veterans’ benefits and offers its own low-cost loans to to govern their veterans homes. Many place the help veterans buy homes and farms. CalVet also provides homes within their state’s Department of Veterans rehabilitative, residential and medical care and services Affairs or another state agency. Other states outsource to veterans. The department employs more than 3,100 management to private operators. California operates its people with a 2017-18 budget of $447.5 million. The veterans homes through CalVet. state’s General Fund contributes $377 million and the remainder comes from various special funds and in the CalVet is a stand-alone, full-service state agency that form of reimbursements.31 The department is organized serves California’s nearly two million veterans and around three core program areas: Veterans Homes, their families, and administers the Veterans Homes CalVet Home Loans and Veterans Services. of California. For many years, CalVet resided within California’s State and Consumer Services Agency. In CalVet’s veterans homes program is the largest of 1994, to raise the department’s profile, Governor Pete its three program areas and employs most of the Wilson, himself a veteran, signed legislation that moved department’s staff, more than 2,900, in headquarters and the department out of the agency. The legislation also in the homes. The homes program also consumes most 20 | www.lhc.ca.gov Background of the department’s budget, an estimated $365 million in Each veterans home’s senior leadership team is fiscal year 2017-18 as shown below.32 recommended by the Secretary of Veterans Affairs and appointed by the Governor. Home administrators, CalVet’s deputy secretary of veterans homes, appointed responsible for managing and administering the veterans by the Governor, oversees the administration of the homes, are empowered to adopt rules and regulations state’s veterans home program and is responsible for governing the admission of applicants and may prescribe monitoring all aspects of medical care provided to the the conditions upon which they may enter and remain in homes’ residents. Under the Military and Veterans Code, the home. California’s eight home administrators have it is preferred that the deputy secretary be a medical demonstrated experience in long-term care facilities doctor or a “professionally trained hospital administrator or multifaceted health care programs and are licensed with experience in managing a multihospital organization nursing home administrators who have a track record of and training or experience in the care of the elderly.” success in the private sector and/or other states.34 However, this is not a requirement for appointment.33 Additional State and Federal Oversight Organizations Several state and federal organizations have roles in overseeing the quality of care provided within California’s veterans homes: The California Veterans Board advises the department and secretary on policies for operations of the department, but is not involved in its day-to-day operations. The board, which consists of seven veterans appointed by the Governor, also hears appeals by California veterans that pertain to state benefits such as denial of a home loan, student waiver or admission into a veterans home. Board members serve as volunteers and receive $100 per diem to meet every other month in cities statewide. An executive officer staffs the board.35 The board, created in 1921 as the Veterans Welfare Board, initially managed various veterans’ aid programs. Also, until recently, the board was authorized to set policy for CalVet operations. (In reality, however, that was not the actual practice for more than 40 years). State authorities recast the Veterans Welfare Board as the California Veterans Board in 1946 in the wake of World War II. Simultaneously that year, the state established the current CalVet department. The Commission, during its 2013 study of CalVet operations, noted that the role of the California Veterans Board, as defined in the California Military and Veterans Code, should be reviewed and clarified.36 Legislation enacted shortly afterward in October 2013 remade the board into an advisory body instead of a policy-setting body and changed its composition.37 In its new advisory role the seven-member board is reviewing California veterans homes and surveying veterans homes in other Little Hoover Commission | 21 A New Approach to California’s Veterans Homes states. Each board member is assigned to a specific home the recent surveys and inspections have been “stellar” in California and meets twice a year with its Allied Council and expects that the star ratings will be brought back up members and staff. to reflect these more favorable findings. However, he noted that the infrastructure problems at the Yountville California’s Department of Public Health licenses campus, particularly in its 1930s-era skilled nursing all skilled nursing and intermediate care facilities in facility, make it challenging to receive the highest the state, including the state’s veterans homes. The ratings.40 department also issues licenses for nursing home administrators, including administrators of the state’s The California Department of Social Services licenses all veterans homes. Additionally, the public health the state’s residential care facilities, including its veterans department inspects all skilled nursing and intermediate homes. The department is required to visit facilities at care facilities at least once every two years to ensure least once every five years, or as often as necessary, to compliance with state laws. It periodically inspects these ensure quality of care. It rates deficiencies as isolated, facilities on behalf of the federal Centers for Medicare a pattern or widespread. It also ranks them by severity, & Medicaid Services (CMS) as part of the federal ranging from level one, no actual harm with potential recertification process.38 The CMS developed a Five-Star for minimum harm, to level four, immediate jeopardy to Quality Rating System to help consumers, their families resident health or safety.41 and caregivers compare nursing homes. The health inspection ratings are based on onsite inspections, while The U.S. Department of Veterans Affairs certifies other portions of the rating, including staffing and quality and annually inspects the veterans homes to ensure measures, are based on information self-reported by the compliance with federal requirements for various levels facilities. Current star ratings for California’s veterans of care. When the department documents deficiencies homes are displayed below. “The current low ratings are the homes must develop a correction plan and actions due to poor survey results several years ago,” the Deputy to address the findings.42 The Barstow and Redding Secretary for Veterans Homes told Commissioners in homes currently meet all USDVA standards. But the March 2016. He explained that “serious incidents that Chula Vista and Yountville homes are each addressing affect survey outcomes can continue to impact a CMS identified deficiencies in several areas. The remaining rating for 36 months, even after the problems have been newer homes are still undergoing the process of USDVA corrected.”39 Secretary Imbasciani told Commissioners certification.43 CMS Star Rating Performance of California’s Veterans Home as of January 2017 Facility Health Inspection Staffing Quality Measures Barstow Chula Vista Redding Yountville Source: Medicare.Gov, Nursing Home Compare. Accessed February 2, 2017 at https://www.medicare.gov/NursingHomeCompare/search.html. 22 | www.lhc.ca.gov Redefining The Role of California’s Veterans Homes in the 21st Century Redefining The Role of California’s Veterans Homes in the 21st Century Despite the expansion of California’s veterans home “I’ve got a passion for making sure that system in recent years and growing wait lists for we correct the wrong with our Vietnam the most intensive levels of care, some have begun to veterans who went undiagnosed and question this expensive model of long-term care, which untreated and unfortunately, most chose provides housing and services for only a fraction of the self-treatment in the form of drugs state’s veterans. Across the state and the country, various and alcohol. We have an obligation community-based models of care are demonstrating that to not dispose of another generation similar types of long-term care services and supports of veterans. We are losing our current can be provided from the family home or in licensed warriors to suicide at the rate of almost health facilities in communities. With budget shortfalls one an hour in this country. That’s ever on the horizon, California must prioritize and think unacceptable to me. [And,] that begs strategically about how it invests its limited resources so the question, why do we have veterans it can best care for today’s veterans while also preparing homes? I’d like to say we have them to care for the next generation of veterans. because we take care of people that nobody else wants, and we’re better at it because we understand their needs better Right-Sizing California’s Veterans Homes than anyone else. We as a society have an obligation to reach out to them and Under a best case scenario, where California’s veterans meet their needs where they are.”44 homes are licensed and funded to operate at capacity, they still could serve less than 1 percent of veterans in Yet others question the sageness of continuing the the state. Weighing the needs of the other 99 percent program without reform. “If the homes didn’t exist, we of veterans, the Commission respectfully asks: At what likely wouldn’t create them today,” one senior RAND point do we consider why we have and maintain this analyst observed to Commission staff. Noting that the program in light of all the other pressing needs for the state veterans homes provide extreme care for a few vast majority of veterans who will never see the inside of veterans at life’s end, while recent veterans are coming one of the state’s eight veterans homes? At what point home with different kinds of physical and mental injuries do other priorities demand that we modify or slowly that require immediate attention, another researcher cycle out of the veterans home program or look at other commented, “It’s a philosophical question: At which point options of care? in the lifecycle of a veteran is it most effective to put resources?”45 While recognizing the limitations of the current veterans homes program, some passionately defend its continued The Commission encourages policymakers and state existence as a means to fulfill a societal obligation veterans leaders to consider these important questions to veterans. For example, in an impassioned speech in earnest. Besides maintaining the status quo, several at the Commission’s March 2016 public hearing, the options exist to streamline the state’s veterans homes administrator from the Yountville home explained his program and also to consider alternate means to expand motivation for modernizing the state’s veterans homes services for some of the state’s most vulnerable veterans. program: Little Hoover Commission | 23 A New Approach to California’s Veterans Homes A Home for All Veterans? In the absence of sufficient government assistance following the Civil War, California’s “I’m very sensitive to the fact that so large first veterans home was created by a fraternal veterans a part of my effort – personnel, dollars and organization to provide aid to indigent and disabled everything else – goes to the homes where veterans having difficulty earning a livelihood. From we’re treating .001 percent of our California this humble beginning, the system has expanded its [veteran] population.” mission beyond serving the state’s poorest veterans to Dr. Vito Imbasciani, Secretary, California Department more broadly serving honorably discharged “aged and of Veterans Affairs. March 3, 2016. Little Hoover disabled” veterans. Commission hearing, Sacramento, CA. Today, admission to the homes is guided by the state’s Military and Veterans Code and administrative regulations. Potential veterans home residents must be Some believe the veterans homes’ broad admission residents of the state who are aged or disabled and who policies promote equity, admitting residents on a first- were honorably discharged from active duty. Certain come, first-served basis. Others, including a member of the California Veterans Board, believe the homes’ non-veteran spouses also may apply. But CalVet’s admission policies need refinement. She reflected, “Not policies also restrict admission to veterans who are age all veterans are equal. When we have limited resources 55 and above, though the age requirement is waived and can’t give every veteran something, we need to look for disabled or homeless veterans in need of long-term at who gets priority.”52 With limited resources to serve care.46 Veterans homes admit on a first-come, first- one of the largest veteran populations in the nation, the served basis but offer priority admissions for homeless Commission questions whether California’s one-size-fits- veterans, Medal of Honor recipients, ex-prisoners of war all approach to the state’s veterans homes continues to and wartime veterans. Admission preference is not given make sense. based on a veteran’s level of disability.47 Reforms proposed in January 2017 as part of the budget Without means-tested eligibility requirements for its process would, if enacted, allow the CalVet Secretary to residents like other state support programs such as Medi- prioritize admission for certain veterans who qualify for Cal, “the sense is that the homes are for all vets,” CalVet’s benefits from the U.S. Department of Veterans Affairs chief financial officer said.48 based on their level of disability. The CalVet secretary also could establish needs-based criteria for admission to the homes, and allow any veteran who met that criteria System-wide, California’s eight veterans homes could to be granted priority admission.53 house just 2,950 residents, if filled to capacity. However, the homes are neither licensed, certified nor budgeted This would, in part, begin to address concerns raised to operate at capacity. The department estimates that in throughout the Commission’s review by various experts 2017-18, the homes will fill, on average, approximately who called for a need to better define the mission of the 2,500 beds.49 But accounting for turnover when residents California veterans homes and clarify who exactly they relocate from the homes or pass away, CalVet will serve are intended to serve.54 Is it the poor or disabled veteran, more. For example, in fiscal year 2015-16, the average homeless veteran, the elderly in need of skilled nursing daily occupancy of all beds was 2,149, but during the same facilities or some combination of these? Determining period 2,782 individuals actually resided in the homes.50 exactly how to refine the homes admissions priorities will These individuals are but a fraction of the estimated require further consideration of the state’s veterans, their needs and the existing resources available to help them – 1.7 million veterans in California in 2017, of whom as discussed below. Additionally, consideration should be approximately 65 percent are 55 years old or more.51 given to the financial implications of prioritizing certain veterans, such as those with high levels of disability, as discussed in the next chapter. 24 | www.lhc.ca.gov Redefining The Role of California’s Veterans Homes in the 21st Century The Right Kind of Care? Nationally, the level and range population over the next several years, and further of care offered within state-operated veterans homes when veterans of the conflicts of Iraq and Afghanistan varies by state. Over the course of its review, the need care. The Legislative Analyst’s Office, in a January Commission learned that veterans homes in some other 2017 report cautioned that should the homes begin to states limit veterans home admissions to residents in admit more veterans with complex mental or behavioral need of around-the-clock skilled nursing or specialized health diagnoses, they may face staffing challenges from care for individuals with Alzheimer’s or other forms of “balancing the care of veterans with acute mental and dementia. Veterans homes in both Texas and Tennessee, behavioral health needs [while] maintaining the staffing for example, only provide long-term nursing care.55 Other requirements for the rest of the veterans at the home.”58 states, like Florida, provide domiciliary care in a separate facility from its nursing home care programs.56 Few, if Modify Level of Services Provided in the Veterans any, offer such a broad range of care options as does California. And despite the wide array of services offered Homes. California’s veterans homes offer far more among the state’s eight veterans homes, it is not clear domiciliary beds than any other state.59 Indeed, the that the homes are providing the right mix of care for majority of beds within California’s veterans homes, California’s veteran population. some 59 percent, are earmarked for veterans who are self-sufficient or who can function with little assistance in CalVet leaders told the Commission that the homes either the homes’ domiciliary or assisted living programs. are scrambling to respond to and prepare for vastly Fewer are designed for veterans who need at least some different health care needs among the current and future level of nursing assistance.60 veteran cohorts. Among current residents, the rates of Alzheimer’s disease and other forms of dementia are on the rise, as is the need for skilled nursing care and memory care, CalVet Deputy Secretary Coby Petersen told Commissioners in March 2016.57 In addition, CalVet leadership explained, Vietnam-era veterans are applying to the homes later in life, but with a higher number of medical diagnoses and prescriptions than what the homes long-term care facilities used to see. Many come with long-undiagnosed and untreated physical and psychological challenges, exacerbated by self-treatment in the form of drugs and alcohol. Despite recent efforts to create behavioral and mental health programs for the veterans homes, California’s homes remain unprepared to care for large populations of veterans with complex mental and behavioral health challenges. “The needs of the Vietnam-era and younger veterans are not being met by our current structure,” the Yountville home administrator told Commissioners in March 2016. “Behavioral health, addiction issues, post-traumatic stress disorder, traumatic brain injuries, women’s health issues and homelessness are diagnoses/ Source: California Department of Veterans Affairs. issues which we have little training, staffing or programs to support.” Domiciliary care is less expensive per resident, per CalVet leaders recognize that without changes in day, than other forms of care offered within the state’s the kinds of services offered in the veterans homes, veterans homes. Though the cost of care varies by home, this challenge will only compound as Vietnam-era in fiscal year 2015-16, the average cost of domiciliary veterans age and comprise a larger portion of the home care across all veterans homes was $214.68 per resident, Little Hoover Commission | 25 A New Approach to California’s Veterans Homes per day. Of this, however, CalVet recouped $77.79 in “The nation, both the private and the federal systems, is reimbursements, leaving about $136 per resident, per certainly moving away from domiciliary care,” Secretary day for California’s taxpayers. In comparison, after Imbasciani told Commissioners in testimony at the March reimbursements, daily care costs for skilled nursing care 2016 hearing. “So that would be the first question to was approximately $347, $190 for intermediate care ask: Why do we still support the housing of veterans that and $221 for residential care for the elderly.61 (More may not require anything except a place to go to sleep at information about the daily cost of patient care, by level, night – and maybe not even that – and concentrate on by home is included in Appendix D.) the veteran population that requires skilled nursing care or memory care?” However, in recent years, the U.S. Department of Veterans Affairs has begun to de-emphasize the Some veterans home officials and other veterans policy domiciliary program. The federal VA no longer funds experts suggested with a limited bed space and a growing construction of domiciliary beds for independent living, need for long-term care, California should do away with CalVet officials said in November 2015. Veterans homes its domiciliary care program and instead ramp up the with existing domiciliary beds are grandfathered in, number of beds dedicated to skilled nursing care and however.62 In light of this policy, some states do not offer memory care. Opportunities abound: The Yountville domiciliary care within their veterans homes. veterans home currently receives funding to support more than 630 domiciliary beds, and the homes in Despite the ample supply of beds for veterans capable Barstow and Chula Vista receive funding to provide an of living independently, there is a growing demand for additional 200 domiciliary beds. More than 550 assisted a spot in one of the state’s 859 skilled nursing beds. living beds, in the veterans homes Residential Care for As of January 2017, 766 individuals had completed an the Elderly program, also could be modified, along with application to one of the eight veterans homes and were necessary staffing and equipment, to provide enhanced waiting for admission. Of these, 606, nearly 80 percent, levels of care. Should policymakers decide to amend the are waiting for a skilled nursing facility bed.63 “We turn Military and Veterans Code to eliminate the veterans away 1,000 veterans a year who need skilled nursing homes’ domiciliary program, care should be given to care,” the administrator of the Yountville veterans home ensure that current residents are not displaced through told Commissioners in March 2016. He lamented that such a transition. Their residency in the homes should be the homes lack capacity to meet their needs, even while grandfathered in. demand for domiciliary care is shrinking.64 26 | www.lhc.ca.gov Redefining The Role of California’s Veterans Homes in the 21st Century Residential Care for Intermediate Care Skilled Nursing Domiciliary the Elderly Facility Facility Facility Capacity Wait List Capacity Wait List Capacity Wait List Capacity Wait List Barstow 120 0 ― ― 60 0 40 15 Chula Vista 92 17 33 3 ― ― 180 34 Fresno ― ― 180 12 ― ― 120 76 Lancaster ― ― 60 1 ― ― ― 0 Redding ― ― 90 20 ― ― 60 174 Ventura ― ― 60 4 ― ― ― 0 West LA 84 0 84 25 ― ― 228 66 Yountville 637 69 48 2 105 7 231 241 Totals 933 86 555 67 165 7 859 606 Sources: Thomas Martin, Assistant Deputy Secretary of Veterans Homes, California Department of Veterans Affairs. February 3, 2017. Personal communication with Commission staff. Also, California Department of Veterans Affairs. Budget Estimate Package. Budget Year 2017-18. Submitted January 10, 2017. Little Hoover Commission | 27 A New Approach to California’s Veterans Homes Opportunities to repurpose any veterans home Improving the Application Process necessarily will be limited by space. The veterans homes for Veterans and Their Families in Ventura and Lancaster, for example, were built to house just 60 veterans, while the veterans home in in At any given time, there may be hundreds of West Los Angeles, Barstow and Chula Vista are larger Californians waiting for a spot in one of the state’s facilities, designed with beds for approximately 400 eight veterans homes. Indeed, in January 2017, veterans. Uniquely, the Yountville home was constructed more than 750 veterans were waiting their turn. to house more than 1,100 veterans in multiple buildings Currently, veterans may apply to one home at a across an expansive 615-acre campus. time, rather than to the system overall. This means a resident may wait months for a bed at a certain Given the federal limitation, the five newest homes level of care in one home. If rejected, a candidate could not be repurposed without penalty to the state must reapply for either a different level of care or until sometime after 2030. However, the veterans to a different home, resetting the process and his or home in Barstow, which opened in February 1996, could her space on the wait list if no bed is immediately potentially be repurposed this year, and the home in available. Without an automated system to track Chula Vista, which opened in May 2000, could be up for wait lists across the homes, or a centralized place consideration in May of 2020. One prominent veterans to contact when questions arise, potential residents advocate suggested the state immediately consider and their families may be left with a great deal closing or repurposing the veterans home in Barstow of uncertainty regarding their future. To help, because it has challenges maintaining full capacity and CalVet should regularly notify potential residents has failed to serve a revitalizing role to the community, of their status on the wait list and offer a contact as promised when built. Repurposed as a low-level should questions arise. Ideally, this communication correctional facility for veterans, he said, the state could could be done through a secure site online where likely house a portion of the correctional population more potential residents and their families can track all efficiently and possibly provide more targeted programs steps of the application process. and services to help veterans succeed upon release.66 Build More Veterans Homes? In the past, state Repurpose the Veterans Homes. Some experts policymakers have opted to build more veterans homes question whether it makes sense for the state to as a way to expand veterans services throughout the continue operating some of its existing veterans homes state. Most recently, lawmakers passed a series of bills in and suggest the veterans homes should not continue 2002 authorizing the construction of new veterans homes to operate in perpetuity. Instead, they said the state in the Central Valley and Los Angeles, and renovating should regularly evaluate their effectiveness in meeting the state’s then three existing homes in Yountville, the needs of California’s veterans, whether they offer Barstow and Chula Vista.67 This effort stemmed from appropriate levels of care or if they should be repurposed recommendations from a Blue Ribbon Task Force created to meet different needs. by Governor Gray Davis in 1999 to review and make recommendations on ways to improve the quality of Federal regulations require state veterans homes built health care provided at California’s veterans homes. The 10-member task force, comprised of noted veterans and with federal construction funds, as seven of California’s healthcare experts, issued a report in September 2000, eight veterans homes were, to operate for at least 20 recommending the construction of new veterans homes years. If states use the facility for another purpose within near to VA medical centers and in locations with sufficient 20 years after construction, a portion of the construction nursing staff.68 Looking forward, however, many experts grant must be repaid to the federal government.65 caution against simply building more veterans homes to However, after 20 years, states do not face a monetary meet future demand. Some have stated simply that the penalty for repurposing veterans homes. state should not build more veterans homes. 28 | www.lhc.ca.gov Redefining The Role of California’s Veterans Homes in the 21st Century Much has changed in the years since the task force issued Reasserting California’s Commitment to its recommendations. Professor Fernando Torres-Gil, Veterans director of UCLA’s Center for Policy Research on Aging and a former member of the Blue Ribbon Task Force, Before right-sizing the veterans homes program or said that in the early 2000s, the policy conversation was repurposing homes, the state must address broader all about institutions: where to build institutional care questions about the mission of the homes division and facilities and how to make them more efficient. Now, the needs of current and next generation of veterans. he and other long-term care experts suggest that the In modernizing its veterans home program, state “bricks and mortar” model of building institutions is too policymakers and veterans leaders have the opportunity inflexible and costly compared to other models of care. to boldly reconsider and renew California’s commitment Some say the veterans homes are excessively costly to to its veterans. For more than 130 years, the bulk of the operate and maintain, particularly given they can only state’s investment in its veterans went toward creating serve a small number of veterans at a time. As is, so few safe, caring communities for service members to live out veterans are able to access this benefit that some liken it their lives. And though the state’s eight veterans homes to winning the lottery. offer great benefit to its residents, the Commission urges policymakers to consider whether what worked for While recognizing the benefits of living in one of the veterans more than 130 years ago remains the best option state’s veterans homes, some suggest the option can for serving California’s veterans today and in the future. create undue hardships for veterans and their families. For example, room availability and a veteran’s unique Though there is a dearth of easily accessible information health care needs can limit the number of homes to about California’s veteran population, evidence suggests that which he or she might receive care. To get into a home, just as the nature of conflicts has radically evolved, so, too, a service member may need to move far away from have the needs of California’s service members. California family, friends and other community supports. The wife must have a long-term strategy to care for its veterans. of one such service member said the decision to send her Armed with more information about where the veteran husband to the home in West Los Angeles – 500 miles population will likely grow or decline and what services from their home in the Bay Area – was “horrible,” but exist for them, CalVet and state policymakers will be better necessary because they had few other options for him to equipped to develop a comprehensive plan to reinstate the receive quality, affordable care. state’s commitment to veterans in the 21st century. Professor Torres-Gil said the policy conversation has Begin With A Needs Assessment. First, state policymakers now shifted to emphasize ways to keep people in their and veterans leaders must ask: What are the health care homes and in their communities. “We can’t just rely needs of veterans currently living in California and how do on institutional care,” he told Commission staff. He these needs vary by a veteran’s period of service? And, will explained that aging Vietnam veterans think differently changes in the demographic characteristics of California’s and want different things than WWII veterans, and are veterans population over the next several decades prompt more open to an assortment of home and community- changes in health care needs? based services. But, he noted, many Vietnam veterans are isolated, without a home, a family or a strong support To answer these questions, CalVet must better system. Others may have families who are interested in understand the demographics of California’s entire their care, but geographically unable to assist. Still others veteran population. Beyond a simple count of veterans may have strong family support. He and other long- over a certain age, a thorough needs assessment should term care experts recommend that the state think about consider veterans’ physical, functional and cognitive providing an array of long-term services and supports healthcare needs prevalent among veterans today, as for veterans, including some in the most independent well as how those needs might change in the future. An settings, including in private homes, to others in the most assessment also should consider the socio-economic supportive setting, like nursing homes.69 conditions that can drive veterans’ needs for long-term services and supports. Little Hoover Commission | 29 A New Approach to California’s Veterans Homes Since the Commission launched its review in October California’s veterans, wherever they live, should have 2015, CalVet has hired two experts in the field access to a full spectrum of healthcare services to meet of behavioral care and demographics to help the the growing complexity of their needs as they age. And department assess the needs of future veterans home many resources, beyond those offered in the eight residents. These staffers have been asked to study veterans homes, exist. A map on the next page depicts whether the department is satisfying the needs of some of the key state and federally-funded health care current veterans home residents and, looking forward, facilities for veterans, as well as the veteran population how the changing demographic composition of veterans by county. Yet, despite efforts to catalogue services in the state will change the needs of those living in the for veterans across the state, the Commission heard state’s veterans homes. “We know what’s coming at us throughout its review that, too often, veterans are not next, and they may not require the kind of housing and aware of all resources available to them, including the licensed beds that we have been concentrating on…since state’s veterans homes. 1888,” Secretary Imbasciani testified to the Commission in March 2016. “We might need whole new structures, Since 2010, CalVet has produced an annual California and I don’t mean organizational structures, but physical Veterans Resource Book that includes information about structures. They may not need campuses,” he said. state and federal benefits for veterans. The 220-page book describes various health care, education, housing, employment and other services available for veterans in California. Though the book also includes a directory of veterans service offices and organizations, it is not “We know what currently exists and how we designed for a veteran to easily search for services currently care for our residents is not where located in his or her community. we’re going to be in five to 10 years from now.” As the state’s top veteran organization, CalVet can, and Coby Petersen, Deputy Secretary, Veterans Homes, should, better coordinate care among state, federal and California Department of Veterans Affairs. other providers to ensure veterans are aware of and March 3, 2016. Little Hoover Commission hearing, access the services to which they are due. CalVet should Sacramento, CA. systematically catalogue, and make available online, in a searchable format, the various resources available to California’s veterans in the veterans homes and in communities throughout the state. By identifying existing The Commission commends this forward-looking services for California’s veterans, whatever their stage investment to help CalVet leaders evaluate the future role of life, CalVet can begin to build a continuum of care of the veterans homes. However, any consideration of so individual veterans, as well as service providers, can the state’s veterans homes program must be taken within more easily find appropriate programs and services, and a larger context. CalVet should conduct, or contract with coordinate their efforts where possible. university researchers to conduct, an assessment of the entire veteran population in order to help policymakers In a 2015 report, A Customer-Centric Upgrade for consider how well the state is repaying the debt it owes California Government, the Commission recommended to veterans across the spectrum, not just those in one state government departments focus on customer needs particular area. to improve Californians interactions with government. The Commission encourages CalVet to consider the recommendations from its 2015 report to take a Identify Available Veterans Resources and Service Gaps. customer-centric approach in cataloguing services and Policymakers and CalVet leaders also should consider: to consult with civic technologists and user experience What services are available to meet the needs of veterans experts on this endeavor. today? Are these services sustainable? And, what needs are going unmet? 30 | www.lhc.ca.gov Redefining The Role of California’s Veterans Homes in the 21st Century Little Hoover Commission | 31 A New Approach to California’s Veterans Homes Consider Veterans’ Changing Preferences. Finally, CalVet Efforts to Identify Veterans Services leaders should regularly and formally engage veterans across the state and in various stages of life to ask: How With the goal of better connecting veterans should the state invest its resources to help veterans and to services, veterans advocacy groups in some where do current programs fall short? communities have begun to develop lists of all regionally available services for veterans. For Historically, the bulk of state funding for veterans has example, the Ventura County Military Collaborative, supported the veterans homes. But California’s veterans comprised of more than 180 government and may have different ideas about how and where the state nonprofit agencies, created a directory of local can and should offer help. According to recent research resources for veterans.70 Mike McManus, Ventura from the AARP, the majority of adults age 65 and older County’s Veteran Service Officer, said the directory – some 87 percent – prefer to age at home and in their helps local veteran service agencies connect communities rather than in institutional settings like veterans to services. “If we’re not the direct service skilled nursing facilities.74 Anecdotal evidence suggests provider we’ll know who is,” he explained.71 veterans’ preferences are no different. One member of California’s veteran board told Commissioners that, In Los Angeles, the Community Veterans from a veteran’s perspective, proximity to family and Engagement Board, sponsored by the U.S. transportation are most important. “If I can stay at home, Department of Veterans Affairs and comprised of VA I will,” he said.75 Another veteran who served during the leaders, veterans advocacy groups and community Iraq and Afghanistan conflicts commented that her peers stakeholders, attempted to do an assessment are not likely to think of retiring in one of the state’s of community-based veterans resources, board veterans homes. “As people get older, I’m not sure if they member and President and Chief Executive Officer would want to go to the remote locations. They’d want of U.S. Vets, Stephen Peck, told Commissioners. to be closer to their families,” she said.76 According to Mr. Peck, the effort successfully identified many community-based service options National spending trends for long-term services and for veterans in Los Angeles, but resulted only in supports indicate a steady and increasing preference a compilation of organization names and phone for community-based care. A 2015 report by Truven numbers. The data was not identified by community, Health Analytics found that in 2013, for the first time, he explained, so veterans could not find out what spending on home and community-based services resources were close to home. He suggested accounted for approximately 51 percent of all state and the state should expand on this effort and make federal Medicaid spending, surpassing investments in information readily available so that wherever a vet institutional care. At the same time, in California, home walks in a door to get help, there is a resource to and community-based services accounted for 62 percent inform them what is available nearby.72 of spending.77 In 2016, CalVet organized a leadership conference Despite these trends, demand for a slot in one of the to convene federal VA officials, County Veteran state’s veterans homes beds will likely remain, particularly Service Officers (CVSOs) and community-based for veterans who cannot afford other long-term care groups to discuss how to share information options. Unlike privately-run nursing care facilities, the and improve coordination to make it easier for veterans homes do not turn away veterans who can’t pay. California’s veterans to access services. Secretary However, recent trends suggest that in the future, the Imbasciani told Commissioners the department veterans homes might not be as desirable for self-sufficient plans to compile information from participants veterans or others who can get the care they need in their and begin to create a list identifying the resources own homes or communities. “Most veterans will likely available to the state’s veteran population.73 prefer to age in place at their own homes,” one long-term care expert told Commission staff. “The state should look for opportunities to help them do that.”78 32 | www.lhc.ca.gov Redefining The Role of California’s Veterans Homes in the 21st Century Redirect Investment Toward Home and Community- to eligible veterans across the country. In 2015, nearly Based Care. With the bulk of CalVet’s funding invested 750,000 veterans, or about 40 percent of all veterans in the state’s eight veterans homes, California lacks living in California, were enrolled in the VA health care less-intensive options to assist older or disabled system and eligible to receive treatment from a VA veterans who need some assistance, but would prefer facility. (However, only 450,000 received treatment to remain at home or in their communities. Experts from a VA facility.)80 Services offered by the VA include told Commissioners the state should invest in more several home and community-based care programs for flexible-care options that can adapt to the changing veterans in need of skilled services, case management needs of the state’s veteran population. Specifically, they and help with activities of daily living, such as bathing, suggested investing in community-based care options dressing, preparing meals or taking medication. “We rather than investing in building more institutional care. have a laundry list of programs for veterans,” Ann Brown, “Community-based care programs are the easiest to size Director of the VA Greater Los Angeles Healthcare up and down,” said Dr. Bruce Chernof, President and System, told Commissioners. “California has the state Chief Executive Officer of the SCAN Foundation.79 homes, but that’s it. What California doesn’t have is options. Not caregiver support, not adult day health Discussion at the Commission’s June 2016 advisory care.”81 Federal community-based programs include:82 meeting focused on exploring community-based models of care to serve a larger portion of California’s older and • Adult Day Health Care allows veterans to receive disabled veterans than the homes currently are able to health services from nurses, therapists and social assist. Much of the discussion focused on opportunities workers, as well as participate in social activities to coordinate care and keep veterans in their and find peer support, companionship and communities for a considerable amount of time before recreation during the day, then return home at they need more advanced medical care, like the kind one night.83 (CalVet received funding in FY 2017-18 might receive in a skilled nursing facility. for adult day health care programs at two of its veterans homes, but does not yet have plans to The U.S. Department of Veterans Affairs Veterans Health offer these services.) Administration offers an array of long-term care services Additional Long-Term Care Programs for California’s Veterans and Others In addition to the state’s veterans home program, California offers a patchwork of programs for long-term care. They include in-home supportive services administered by the Department of Social Services, adult day health care and other programs that serve older adults, caregivers and residents in long-term care facilities administered by the Department of Aging, and Medi-Cal, administered by the Department of Health Care Services. The Commission reviewed these programs and other programs in its 2011 report on California’s long-term care system, A Long-Term Strategy for Long-Term Care. At the time, the Commission found that California’s long- term care programs were dispersed over several different departments and lack a leader to coordinate efforts, streamline enrollment or assess long-term health needs for frail individuals who wish to stay at home rather than enter a nursing home. The Commission urged the Governor and Legislature to improve the state’s assessment, data collection and case management tools and give local governments the flexibility, control and support they need to best meet clients’ needs at the local level. Better coordination could assist California’s most vulnerable populations, including veterans, find needed medical care. Yet the state has made little improvement in this arena in the six years since the Commission’s last review. Little Hoover Commission | 33 A New Approach to California’s Veterans Homes • Home-Based Primary Care provides health available to them. One long-term care expert suggested care services in a veteran’s private residence. A that CalVet should invest in case managers to connect VA physician supervises a health care team of veterans to existing services such as Medi-Cal, Medicaid physicians, nurse practitioners, care managers and other VA programs. “It would be in CalVet’s best and social workers to address veterans needs at interest to more deeply engage at the county, state and home. Services include primary care visits, case federal levels and coordinate better,” she said.88 management, physical, occupational and speech therapy, nutrition counseling and mental health Additionally, several long-term care experts told services.84 Commissioners that, through partnerships, the state could enhance supportive housing options for veterans • Homemaker and Home Health Aide Care allows who do not yet require intensive medical care. For veterans to get assistance with activities of daily example, Mike McManus, Ventura County Veterans living as needed, several times a week or just Service Officer, suggested the state might establish once in a while.85 a voucher program to contract with long-term care providers who set aside rooms for veterans. “It’s nice • Medical Foster Home Care is a new program for communities with a home, but look at the math: We offered to veterans who are enrolled in the have 41,000 veterans in Ventura County and a 60-bed VA’s home-based primary care program as an home,” Mr. McManus told Commission staff. He said the alternative to nursing care, but in a private home numbers don’t add up when the majority of the county’s environment. A trained caregiver provides veterans are older, but the home serves veterans, and services to a few individuals, who may or may not qualified family members, from across the state.89 all be veterans. The VA inspects and approves medical foster homes and pays for and provides Others suggested the state could partner with a participant’s medical care. Veterans pay community-based organizations that offer supportive caregivers out-of-pocket for room and board – housing options for veterans. One participant at the about $1,500 to $3,000 a month depending on Commission’s June 2016 advisory committee meeting the level of care needed.86 Because this is not observed that the capacity of community-based a mandated program, it is not yet available in organizations to provide housing for veterans has ramped all VA medical centers. However, VA staff noted up due to increased federal funding, as well as California’s early success for older veterans requiring nursing Housing and Homelessness Prevention Program, or care, including some with severe dementia, as Proposition 41. He noted, however, that community- well as younger veterans suffering from traumatic based homes for veterans don’t have capacity to offer brain injuries, and some mental health patients the higher levels of nursing home care that is provided by because residents get care from consistent the state’s veterans homes, but suggested with enhanced providers and have consistent schedules and programs “we could hold onto them in the community activities.87 for a time before they need a skilled nursing facility or memory care.” These types of community-based care programs likely could help California’s population of veterans who can function independently without the need for nursing care, but need some additional services and supports. California currently offers several programs that might assist qualified veterans to stay at home longer. However, more could be done to enhance community-based care options for veterans. For example, the state could amplify the availability of programs to assist veterans in modifying their homes with ramps, medical alert systems or other improvements that would allow them to receive in-home care or bolster resources to help veterans navigate the different programs and funding sources 34 | www.lhc.ca.gov Redefining The Role of California’s Veterans Homes in the 21st Century Supportive Housing Options for Homeless Veterans An alarming number of California’s veterans are homeless. On a single night in January 2016, there were more than 9,600 homeless veterans in California, approximately a quarter of all homeless veterans in the nation.90 However, an increasing number of housing opportunities for veterans now exist, in part, as a response to a national campaign launched by the Obama Administration and the U.S. Department of Veterans Affairs in 2010 to end veteran homelessness. Some examples: • Proposition 41, the state’s Veterans Housing and Homelessness Prevention Program approved by voters in June 2014, will create an estimated 4,800 new veterans housing units, including more than 1,200 permanent supportive housing units for chronically homeless veterans.91 • The federal HUD-VASH (U.S. Department of Housing and Urban Development – U.S. Department of Veterans Affairs Supportive Housing) voucher program provides rental assistance as well as case management and clinical services for homeless veterans.92 • Non-profit organizations, such as U.S. Vets, New Directions for Veterans and Swords to Plowshares, among others, operate supportive housing programs at the community level to help veterans successfully address their physical and mental health needs, obtain education, seek employment and otherwise reintegrate into society. The Commission learned, however, that many of the community-based supportive housing programs currently available for California’s homeless veterans, lack the type of skilled nursing care provided in California’s veterans homes and other long-term care facilities. The West Los Angeles veterans home is the only state facility offering a temporary supportive housing option for homeless veterans. CalVet created the program in 2013 by converting 84 skilled nursing beds into domiciliary level beds. These transitional housing beds were authorized while the veterans home completed construction on a kitchen large enough to provide food service to its skilled nursing residents. The kitchen became operational in late 2015. Secretary Imbasciani stated in a May 2016 Assembly Veterans Affairs Committee hearing that he wants to revert those beds to be used for their intended purpose: to provide skilled nursing care to California’s veterans. The department will have to go through the licensing process in order to convert these beds back to skilled nursing level of care.93 Going forward, CalVet should engage the federal VA and other regional partners to consider how to better coordinate resources for homeless veterans and build a continuum of both temporary and long-term care options for California’s veterans. Little Hoover Commission | 35 A New Approach to California’s Veterans Homes Conclusion Additionally, just as California’s veterans population changes and becomes more diverse, so, too, must the California was among the first in the nation to commit to state’s programs for veterans evolve. Going forward, investing in housing for impoverished service members CalVet leaders and state policymakers should not take for at the end of their lives and today boasts the largest granted the need for the state’s veterans homes. Simply system of veterans homes in the nation. For more than a because they have been the state’s go-to approach in century, the veterans homes have helped California fulfill the past to expand veterans services does not make a commitment to take care of its sickest, most vulnerable the homes the only viable care model going forward. veterans. And the eight veterans homes undoubtedly Repurposing or shuttering veterans homes that have provide an important service, particularly for those who outlived their purpose or not lived up to their promise cannot afford nursing care or other medically necessary should be considered viable options when planning for treatments and need a safe, comfortable place to live the future. out their twilight years. However, currently within the veterans homes, the state also houses some service CalVet should continuously evaluate the veterans home members who require little more than a place to sleep program, along with the needs of the state’s overall at night. And the overwhelming majority of California’s veteran population, to ensure that the state invests veterans, particularly those who do not live in the Los in the most needed model of care and that benefits Angeles region or a city close to one of the state’s existing are spread widely among the veteran population. Any homes, will never benefit from this costly program. savings that are achieved from streamlining the veterans home program, and improving the program’s revenue In reality, so few servicemembers benefit from the homes as discussed in a following chapter, should be directed that California does not have the resources to serve all toward expanding services for veterans. Already, veterans in need. But, by weighing both the benefits and veterans and long-term care experts point to community- costs of maintaining the veterans program, CalVet has based care as a means to expand services to a greater the opportunity and responsibility to ensure the debt number of veterans, while also allowing veterans to stay that society owes to veterans is paid in full across the close to their homes and families. spectrum, not just in one particular area. Finally, CalVet should leverage its leadership position to California’s veterans homes program undoubtedly needs build partnerships with the federal government, veterans a reboot. The policies governing the veterans homes are service organizations and other long-term care providers vague. It is not clear whether the mission of the veterans to create a continuum of care options. CalVet cannot go homes is to care for sickest veterans, or whether they are it alone. But through fostering partnerships in California’s intended as a place where all veterans may reside – or at strong and active veterans community, California can least the sparse minority lucky enough to land a spot in make strides in helping veterans know what services are a state veterans home. Current policies potentially allow available to them, whatever their need, wherever they live. individuals with little or low income, but other financial resources, to take up limited bed space that should go to those who could not otherwise survive. Policymakers Recommendations must clarify the mission of the homes is to provide quality nursing and medical care for veterans who otherwise Recommendation 1: The Legislature should amend would have no place to turn. the Military and Veterans Code to clarify the homes admissions policies and ensure access for the neediest CalVet also should right-size its costly veterans home veterans. Policymakers should consider prioritizing program to better meet the needs of today’s veterans. To admission based on financial status, disability rating or start, the state should eliminate its domiciliary program other factors. and instead focus the mission on providing care for veterans most in need – those who are no longer capable of living at home or in their communities and need some level of nursing assistance. 36 | www.lhc.ca.gov Redefining The Role of California’s Veterans Homes in the 21st Century Recommendation 2: The Legislature should amend the Military and Veterans Code to eliminate domiciliary care from the state’s veterans home program. Instead, the homes should focus on providing care for veterans in need of high-level medical care, such as skilled nursing care. Existing domiciliary residents should be allowed to remain in the state’s veterans homes program as the state gradually moves away from domiciliary care. Recommendation 3: To determine whether CalVet should repurpose or shutter one or any of the veterans homes, CalVet should establish a process to systematically evaluate and review each veterans home as it approaches its 20-year mark, and periodically thereafter, and make recommendations to policymakers regarding the future of the home. Such a review should include consideration of the needs of the regional veteran population, projections about the changing composition of the veteran population, as well as an assessment of resources available to serve them. Veteran residents, as well as community members and other stakeholders should have a participatory role in the process. Recommendation 4: CalVet should conduct an assessment to consider the needs of California’s overall veteran population. As part of this assessment, the department should project, to the extent possible, the needs of each cohort of veterans over the next several decades. In addition, the department should assess and catalog the array of services currently available for aged and disabled veterans, making this information available online in a user-friendly, searchable format, and identify any critical gaps in services given conclusions from the department’s needs assessment. Recommendation 5: As CalVet repurposes its veterans homes program savings should be redirected to home- and community-based veterans services. Little Hoover Commission | 37 A New Approach to California’s Veterans Homes Simplify, Stabilize Funding for the Veterans Homes As a symbol of California’s resolute commitment to its policymakers to consider other strategies that might veterans, the state built one of the largest systems enable the state to leverage its investment to extend care of veterans homes in the nation. Though the federal to more veterans. government contributed a significant portion of the funds required to construct these facilities, the state maintains A Complicated Budget Process Obscures responsibility for their operations and upkeep.94 Costs, Revenue Sources In fiscal year 2017-18, the Governor’s Budget allocated approximately $306.7 million to CalVet to operate the The current budget process for the state’s veterans state’s eight veterans homes. After accounting for homes, which requires CalVet to track revenues at reimbursements from the federal government, resident each of the homes to offset up-front General Fund fees and other revenue sources, as described in detail contributions, obscures the homes’ annual impact on the below, ongoing annual operational costs are expected to overall state budget. Yet, without easy access to these run California taxpayers upwards of $185 million.95 figures, it is difficult for policymakers and others to track spending trends and analyze how California’s homes Taking care of veterans in these eight homes, regardless compare to peers in other states. of the level of care, costs approximately $117,000 a year per bed – a figure experts in long-term care say is more Like other California state agencies, CalVet annually than enough to pay for exceptional private nursing home receives an appropriation from the General Fund in the care in a high-cost state like California.96 In comparison, state budget with which it operates the veterans homes. the statewide average annual cost of care in an assisted Unlike many others, however, CalVet collects revenue living facility in 2016 was $48,000. Average annual costs throughout the year in the form of federal payments, of skilled nursing home care in California are $91,250 insurance and other reimbursements which are used for a semi-private room and more than $112,000 for a to offset or pay back a portion of the department’s private room. Estimates suggest these costs will increase General Fund expenditures. Thus, the amount of funding approximately 34 percent by 2026.97 allocated in the budget does not accurately represent the true cost of the veterans homes program for any given Policymakers and others must consider: Is there a better budget year. way to invest state resources in order to care for more of California’s most vulnerable veterans? Up-front Allocation. The homes’ annual General Fund allocation is based on two figures: staffing levels and Over the course of its review, the Commission learned projected census (an estimate of the average daily census that other states have figured out how to operate their or, as described to Commission staff by one CalVet official, veterans homes on a combination of federal funds, fees the number of “heads in beds”). In fiscal year 2017- and financial contributions from residents, largely or 18, CalVet will receive approximately $306 million from entirely without state funds. This is done in a variety of the General Fund to operate the homes, not including ways, through admissions policies, by limiting the kinds the cost to run the systems’ headquarters. This will of care the veterans homes provide and by enacting support approximately 2,900 positions and a projected more cost-sharing measures that hold veteran residents average daily census of 2,528 residents.98 This amounts accountable for the cost of their care. The Commission to approximately 81 percent of CalVet’s total anticipated does not advocate defunding state support for California’s support from the General Fund in fiscal year 2017-18.99 aging and disabled veterans. It is however calling for But, because of the revenue collected and paid back 38 | www.lhc.ca.gov Simplify, Stabilize Funding for the Veterans Homes throughout the year, it is not accurate to say that this is the • Medicare: A federal health insurance annual operating cost of the veterans homes. program for people age 65 and older or certain younger people with disabilities or end-stage renal disease. For those residents Revenue. To offset or reimburse the veterans homes’ enrolled in the program, CalVet may receive General Fund expenditures, CalVet collects revenue reimbursement for medical care provided, from a variety of sources, including the U.S. Department as well as for certain other expenses, such as of Veterans Affairs, federal, state and private health prescription medications.105 insurance plans, and fees charged to resident members. Primary revenue sources for the homes include: • Medi-Cal: A joint federal-state health care program for low-income individuals. The • Federal Per Diem: A daily amount paid by the federal government generally contributes United States Department of Veterans Affairs 50 percent of the costs. For residents to each home for each veteran resident. Rates enrolled in the program, CalVet may receive vary depending on level of care and the veteran’s reimbursement for essential medical care service-connected disability.100 services provided to preserve health, alleviate sickness and mitigate handicapping The standard per diem rate in 2017 is $106.10 conditions.106 per veteran for nursing home care, $45.70 per veteran for domiciliary care and $84.52 per • Private Insurance: CalVet receives payments veteran for adult day healthcare. The per diem from a resident’s private insurance, including is enhanced for veterans with service-connected health maintenance organizations.107 disability of 70 percent or higher – meaning that their disability was incurred or aggravated in the • Member Fees: As defined by the Military line of duty in the active military, naval or air and Veterans Code, CalVet charges a service – or for veterans who need nursing care percentage of a resident’s annual income due to their service-connected condition.101 The as determined by his or her level of care. rates of the enhanced per diem vary each year The percentages, which are set in state law, and are dependent on the actual cost of care in are as follows: 47.5 percent for domiciliary each facility and geographic area. In 2017, the care, 55 percent for residential care for the enhanced per diem is $569.63 at the Yountville elderly or assisted living, 65 percent for veterans home, $544.76 at the Redding home intermediate care and 75 percent for skilled and $495.84 at the veterans homes in Barstow, nursing care.108 Fresno, Chula Vista and West Los Angeles.102 Federal law specifies that veterans homes may • Lease Agreements: Lease income generated not collect member fees for veterans receiving from the state-owned property at the enhanced per diem; this amount is considered veterans homes.109 “payment in full to the state home” for care provided to qualifying veterans.103 CalVet anticipates collecting $121.5 million in revenue for budget year 2017-18. More than two thirds would come • Aid and Attendance: Funding from the from the federal government in the form of per diems, United States Department of Veterans Affairs Aid and Attendance and Medicare.110 When collected, for residents in need of nursing level care to this will offset approximately 39 percent of the cost of provide additional assistance with activities running the homes. of daily living. The current payment rate is $716 per month.104 Little Hoover Commission | 39 A New Approach to California’s Veterans Homes maximize its ability to generate revenue at the veterans homes, department officials formalized a goal to increase revenue in the Yountville, Barstow and Chula Vista Veterans Homes by 7 percent a year, to offset the costs to the General Fund by 70 percent by 2016-17.113 CalVet representatives said they have been making progress, particularly by hiring four additional claims representatives to help veteran residents file claims for Aid and Attendance from the U.S. Department of Veterans Affairs. The claims representative for the Fresno home, for example, had processed 37 claims, generating more than $400,000 in one-time retroactive payments and more than $50,000 in new monthly benefits, Coby Petersen, deputy secretary for the Veterans Homes, told the Commission in October 2015.114 In addition, particularly in its newer homes, CalVet officials have prioritized filling beds to recoup federal per diem and Source: California Department of Veterans Affairs. other reimbursements. CalVet estimates that by filling the beds in the three newest homes the department could increase its revenue by more than $45 million Despite Offsets, Veterans Homes Remain Dependent on annually. The department also has bolstered efforts to General Funds to Operate: Despite revenue collected educate and enroll qualified residents in Medicare plans. to offset state spending, California’s veterans homes rely heavily on the General Fund. Indeed, the majority of Even with these improvements, it typically takes the funding for the homes comes from the General Fund. In department several years to collect all anticipated 2017-18, General Fund support is expected to exceed revenue. For example, as of November 2016, the $185 million even after reimbursements. department had collected approximately $81.9 million out of an anticipated $102.5 million in reimbursements CalVet officials told the Commission that regulations for fiscal year 2015-16. CalVet received approximately governing the fiscal structure of the state’s veterans $285 million in fiscal year 2015-16 to operate the homes ultimately place the burden of paying for care homes, not including funds to support headquarters provided in the homes on California taxpayers. What or to repay lease revenue bonds. When all anticipated is not collected in “revenue” is paid for from the reimbursements are received, this will amount to General Fund. For example, state regulations specify approximately 35 percent of General Fund revenues for that “The Veterans Home of California shall admit all fiscal year 2015-16.115 eligible applicants, provided that care for their needs can be furnished within the available resources of the Veterans Home and subject to the levels of care for which direct admission is permitted.”111 CalVet officials told “Now, the average cost in the homes is about Commission staff the department interprets this, and $320 per day, but we get on average about similar references, to indicate that the department – not $110 per day in fees. Taxpayers are footing home residents – ultimately is responsible for the cost of two-thirds of the cost of care. The goal is to resident care.112 In other words, when insufficient funds reverse this to one-third.” are collected to pay for the cost of resident care, CalVet, Dr. Vito Imbasciani, Secretary, California Department as the payer of last resort, holds that responsibility. of Veterans Affairs. November 30, 2016. California Veterans Board meeting, Sacramento, CA. A Strategic Goal to Increase Revenue: Following a 2013 report from the State Auditor that called on CalVet to 40 | www.lhc.ca.gov Simplify, Stabilize Funding for the Veterans Homes The state’s newest veterans homes in West Los Angeles, as a political subdivision and instrumentality of the state Redding and Fresno have recently received Medicare and allows the homes to operate like a for-profit nursing certification and recognition from the U.S. Department home. The organization is “self-operating, self-sufficient of Veterans Affairs. CalVet now can collect federal per and growing for the future,” Mr. Harries explained.120 diem for eligible residents, which also should improve the homes’ revenue. Previously lacking these certifications, Over the course of its review, the Commission heard CalVet was prevented from collecting federal from CalVet officials and others that the statutes and reimbursements and had to instead rely on revenue from regulations governing the homes’ finances are outdated residents’ fees, which are generally significantly lower and have prevented the homes from operating as than the actual costs of care.116 efficiently as peers in other states. Still, department officials told the Commission in March In part, CalVet officials point to regulations that they say 2016, statutory limitations on the homes’ fee structure require the veterans homes to take ultimate responsibility and other financial components prevent the state’s for incurring the cost of care for their residents. veterans homes from being cost neutral.117 Essentially Additionally, some suggest that by incentivizing revenue these limitations are policy choices that have been made collection from other sources, as is done in other states, over time by the Legislature and Governors. California’s veterans homes could increase revenues and significantly reduce dependence on the General Fund. Legislative changes that govern how the homes collect Other States Operate Veterans Homes with revenue from several key sources – resident fees, health Little Cost to State Taxpayers insurance programs and federal reimbursement programs – offer opportunities for savings: California’s contributions to its veterans homes far exceed what many other states invest in operations. A survey Resident Fees: States have flexibility to determine how of 28 other states conducted by CalVet staff in 2013 on much to charge veterans home residents. While some the cost of care and fees charged to residents found states charge residents fees based on the cost of their that nearly 30 percent of the states participating in the care, California charges residents based on a percentage survey used little to no state funds.118 Veterans homes of their incomes. For low-income residents who rely in several states, including Texas, Colorado, Florida, on Social Security as their primary income source, the Maine, Tennessee and Utah, are entirely self-sufficient, amount paid is significantly less than the actual cost of paid for by a combination of federal funds, fees and their care. This fee structure makes the state pay the financial contributions from residents.119 Though CalVet difference. has prioritized increasing revenue from other funding sources, it remains more dependent on state funds than In Maine, the amount veterans home residents pay its peers. for their care varies based on whether they qualify for Medicare, Medicaid or are paying privately. “If residents Tennessee’s four veterans homes operate on an annual apply for Medicaid and are denied because they are over budget of approximately $50 million, without state funds. the asset limit, we consider them private pay and they The homes rely on funding from government programs are responsible for the charge. We set a rate structure, like Medicare, Medicaid and other programs offered for not based on income, but based on our analysis of our veterans by the U.S. Department of Veterans Affairs that cost structure. There is no directive or statue about how reimburse qualified individuals for health care and related much they pay.”121 expenses, as well as private insurance and fees paid directly by residents. Ed Harries, executive director of the The Tennessee State Veterans’ Homes set fees upfront, Tennessee State Veterans’ Homes Board told Commission before residents are admitted. Potential residents need staff that the system’s revenues exceed operating only review the homes’ website to find out how much it expenses, providing the homes an emergency fund of $17 will cost: $230 per day plus the cost of medications for million. Indeed, state money is sought only to assist with long-term care room and board.122 The homes’ admission the cost to construct new homes. Mr. Harries attributed agreement enumerates the various ways residents can the homes’ financial health to its board, which operates Little Hoover Commission | 41 A New Approach to California’s Veterans Homes pay this fee – with a combination of Medicare, Medicaid, the home to carry the bulk of the cost with no one to private insurance or assistance from U.S. Department bill. (To participate in Medi-Cal, applicants cannot exceed of Veterans Affairs – as well as what happens when $2,000 in personal property, including cash reserves in a resident fails to pay.123 In evaluating applicants to savings or checking accounts.)126 the homes, “income levels aren’t taken into play,” Mr. Harries told Commission staff. He said “a veteran’s socio- “The problem is the fee structure prevents basing what economic status and assets are between the veteran and we charge a resident on the cost of their care,” one Medicaid if that’s the route they are going.” If veterans senior home administrator told Commission staff. “We don’t pay the home’s fees, they are issued a discharge charge based on a percentage of their income, which is a notice and get a call from the home’s general office. “We fraction of what it [the charge] could be.” can put liens on their property,” Mr. Harries explained. “My advantage over for-profit homes is that my arm for Though some argue that maintaining the current fee collections is the Tennessee Attorney General.” structure is a policy choice intended to ensure that care remains affordable for residents, this policy prevents the In Washington, the veterans homes establish a daily state from tapping into other funding sources upon which room rate for residents – $231 for skilled nursing care other states rely. Under the current policy, veterans – which captures the full cost of their care. Residents home residents in California are not required to spend use the same payment sources they would in other down their assets to help pay for the cost of their care. nursing homes or care facilities, namely, Medicare, Theoretically, a veteran could enter one of the state’s Medicaid, private pay and long-term care insurance. veterans homes with a low-income level, but millions of Residents unable to pay the daily room rate must agree dollars worth of assets in an owned home. Because state to apply for Medicaid and any other benefits, insurance law requires resident fees to be set based on income, or entitlements for which they are eligible. They also but does not account for their total assets, the state are required to spend down their assets until they taxpayers cover the difference. For those with fewer are exhausted, and then enroll in the state’s Medicaid resources, this policy also discourages residents from program where the federal government contributes to spending down their assets to the point at which they the cost of their care.124 could qualify for Medi-Cal, the state’s health insurance program for low-income individuals. Some suggest that In California, resident fees are not set upfront based if residents were charged fees based on the actual cost of on the cost of care. Instead they are determined by a their care, they might have greater incentive to maintain resident’s income level. Thus, the amount residents private insurance or enroll in other public assistance pay to live in one of the state’s veterans homes varies programs to help cover the cost of care. based on the level of care they receive and the amount of their annual income. Specifically, statutory code It is important to note that upon death of a resident, specifies that CalVet may charge 47.5 percent of a CalVet may collect from the resident’s estate any resident’s annual income for domiciliary care, 55 percent remaining obligations owed the home. However, CalVet for residential care for the elderly or assisted living, 65 collects approximately 10 percent of unreimbursed costs percent for intermediate care and 70 percent for skilled this way because most residents do not have substantial nursing.125 For example, a resident in one of the home’s assets, such as homes, rental properties, stocks or bonds. skilled nursing programs receiving $1,000 a month in These reimbursements are placed in the state Morale, Supplemental Security Income would pay 70 percent of Welfare and Recreation Fund – which provides for the their income, or $700 per month, for their care. But, general welfare of veterans home residents – not the the Chula Vista administrator noted in testimony to the General Fund.127 Commission, the cost of care for a skilled resident could be $200 to $500 a day, depending on the necessary Enrollment in health insurance programs: treatments, medications, and other services or supplies. Reimbursements from health insurance programs can If this resident also was enrolled in the Medi-Cal program, significantly offset the cost of care provided to veteran the $300 a month in income could, if it went unused, home residents. As described above, some states require eventually add up to an amount sufficient to disqualify residents to pay their share of the cost of care through the resident from reenrolling in Medi-Cal, thus requiring 42 | www.lhc.ca.gov Simplify, Stabilize Funding for the Veterans Homes various means, including maintaining enrollment in a non-VA provider. Still others who are eligible for federal health insurance and other benefit programs for which benefits may not enroll to receive them because the they are eligible. extended travel time to reach a VA health facility is too great a barrier. In California, state regulations require potential residents of the state’s veterans homes to demonstrate that they Senior CalVet officials told Commission staff that while have health insurance before they are admitted to a residents in other states’ veterans homes might be home. Specifically, veterans must be participating in a referred to a debt collection agency or risk eviction for qualified private health service plan, a U.S. Department of failing to maintain insurance coverage or enrollment Veterans Affairs medical program or have an application in other benefits programs, there are no incentives for pending for such coverage. Non-veteran applicants residents in California to complete annual re-enrollment must be participating in a federal, state or private health paperwork. The administrator of the Chula Vista service plan prior to being admitted.128 Veterans Home explained that to remain eligible for Medi-Cal, participants have to recertify their eligibility Current regulations do not, however, require residents annually. However, if a resident or their representative to continue to provide evidence of insurance annually. with power of attorney doesn’t fill out the paperwork, Because CalVet is considered the payer of last resort, the there are no ramifications and nothing in law to require department is left footing the bill when residents fail to them to submit an update. “We’re doing what we can to maintain insurance. In practice, home administrators collect,” he said, “But if a resident has all their needs met told Commission staff that this loophole means that the we have no teeth to compel them to re-enroll.”130 homes are missing out on a potential revenue source, while CalVet staff has to spend a lot of time trying to get Secretary Imbasciani told Commissioners that he wants to residents to maintain their health insurance. They can make it a requirement for residents to maintain insurance encourage residents to reapply and they dedicate staff in order to help defray the cost of care.131 to helping residents fill out enrollment forms. But they lack a mechanism to require residents to maintain health Per Diem: The U.S. Department of Veterans Affairs insurance. It’s not the law. reimburses states for providing nursing home care, domiciliary care and adult day healthcare to eligible Even for some veterans home residents who have health veterans. States receive a higher, or enhanced, per insurance, coverage may be insufficient to pay the costs diem rate when caring for veterans who have a service- of their care, participants at the Commission’s June connected disability, meaning they are disabled by an 2016 advisory meeting explained. Since the Affordable injury or illness that was incurred or aggravated during Care Act was enacted in 2010, more than 3.8 million active military service. Veterans who have a service- Californians have gained health insurance coverage, connected disability rated at 70 percent or higher and including an estimated 1.18 million who enrolled in Medi- who need nursing home care are eligible to receive the Cal, California’s Medicaid program which was expanded enhanced per diem.132 under the Act.129 Because of their age, many veterans home residents qualify for and receive Medicare benefits. In order to maximize federal reimbursements, some state However, he noted these benefits do not cover all health veterans homes have prioritized admission of veterans care costs. For example, a resident may be enrolled who are eligible to receive enhanced federal funding based in a basic health insurance program, but elect not to on a medical diagnosis that assesses their level of disability. purchase supplemental coverage to assist with the cost of The administrator of one state veterans home in Florida, prescription medication or long-term care. for example, told Commission staff her facility prioritizes veterans who are service-connected. “We do serve others, Other veteran residents may have health insurance but if they’re on the service-connected disability list, they coverage through the federal VA, but have difficulty go to the top of the wait list,” she said.133 accessing care if there is no VA hospital or clinic near the veterans home. For example, to visit a VA hospital, California’s veterans homes do not give admission residents in the Redding veterans home need to travel preference to veterans based on their service-connected 170 miles to the VA Medical Center in Sacramento or visit Little Hoover Commission | 43 A New Approach to California’s Veterans Homes disability. Many veterans living in the homes may have Governor and Legislature, too, must engage. some service-connected disabilities, but not enough to get at least a 70 percent rating. For example, more than In improving how the state manages its veterans homes, 450 residents, or about 8 percent of all CalVet veteran policymakers have a significant opportunity to reconsider home residents in 2014-15, had some service-connected how California cares for its veterans and create a more disability. But only 157 were rated high enough to efficient and effective system of care to help more of qualify for enhanced per diem funding from the federal those who have served. Department of Veterans Affairs.134 In the past, California’s policies for its veterans homes While some believe service-connected veterans are most have reflected a value of serving all veterans regardless deserving of assistance because of the level of their of their income or assets. Yet, today, some believe disability, others caution that prioritizing admissions for these policies may unintentionally favor a small group this subset of veterans could be viewed as discriminatory. of veterans who are able to reside in the homes while Because a veteran’s service-connected rating must be thousands of others go underserved or unserved in generated by the U.S. Department of Veterans Affairs, communities and on the streets of major cities across the any veteran who has not been evaluated by the VA state. The Commission agrees. To build a system of care health system would essentially be precluded from for the state’s most vulnerable veterans, policymakers living in the homes. California’s policymakers should and thought leaders must question previous assumptions consider whether California should grant priority to ensure they continue to best serve veterans today and admission based on disability. At a minimum, CalVet tomorrow. To begin, California must stabilize its funding should develop strategies to help more veterans become mechanisms for the homes, balancing payer sources evaluated so they may receive the benefits to which among state and federal government entities, as well as they are due. Currently, budget trailer bill language the residents, in order to create a more efficient system. introduced in January 2017 would authorize CalVet to California can no longer afford to simply issue a check prioritize admission to veterans who have a 70 percent or from the General Fund each year and ask the veterans higher service-connected disability rating from the U.S. homes to chase revenue in hopes it will catch up with the Department of Veterans Affairs.135 costs. In return for the care that they receive, California must ask its veterans homes residents to become good stewards of their care, accountable for maintaining Conclusion insurance or enrollment in benefit programs to help cover the cost of their care. Inevitably, some veterans Over the course of its review, the Commission heard will not have sufficient personal resources to pay for their from many stakeholders, as well as the CalVet Secretary, care. The intent is not to limit in any way their access to that the state’s laws and policies governing the homes the homes – just the opposite – but rather to help them are in need of a thorough review. Previous legislation enroll in other supportive programs that could contribute introduced in 2016 attempted to update the Military to the cost of their care. Adjusting the veterans homes and Veterans Code Sections relating to the veterans policies to reduce their dependence on state funding homes and modify some aspects of the fee structure is not out of line with California’s tradition, particularly and admissions policies.136 Though this legislation was if pared with other changes that might allow the state not fruitful, the Commission believes this effort should to reinvest savings in other programs to serve more be revisited and expanded. The reforms proposed in the veterans. January 2017 budget trailer language are a good start. Yet, the state, too, must better understand what drives The Commission commends CalVet leaders for the costs of providing care in its veterans homes. Within undertaking a review of the Military and Veterans Code the homes, policymakers should revisit regulations that and updating current regulations in order to improve are interpreted to require the homes to provide residents standardization and administrative functions across the unlimited access to care and instead define what services veterans homes and reduce the department’s impact and supplements should be included for veterans home on the General Fund.137 Yet, CalVet alone cannot decide residents. The department also should analyze staffing what policies will best serve the state’s veterans. The levels across the homes to determine what drives 44 | www.lhc.ca.gov Simplify, Stabilize Funding for the Veterans Homes costs and to identify opportunities for improvement. Recommendation 8: To enhance fiscal transparency, Opportunities also may exist to better predict and CalVet should make available, online in an accessible account for ongoing facilities costs. For example, format, its financial reports to the Legislature, which CalVet should have a mechanism to monitor, plan for should be augmented to include: and address maintenance issues across the system, but particularly in the oldest homes. The department ▪ The amount of state funds budgeted to each maintains an ongoing list of identified projects that home and the amount of revenue collected, and require attention at each home which it prioritizes annually for funding.138 But, by only focusing on projects if necessary, the remaining amount of expected for the next fiscal year, this system is imperfect for long- revenue, over a period of several years. term planning. Without a thorough and true accounting ▪ The costs of care per resident, by level of care of the costs of operating and maintaining the state’s eight veterans homes, policymakers and others cannot begin for each veterans home. to consider whether other approaches might enable the ▪ The costs of facility maintenance, as well as state to assist more veterans. projections for future maintenance costs, for each veterans home. Recommendations Recommendation 6: To streamline and modernize the state’s veterans home program, the Governor and Legislature should amend the Military and Veterans Code to: ▪ Define the scope of benefits included for veterans home residents. ▪ Empower CalVet to establish daily costs of care per resident, for each level of care. ▪ Clarify that veterans home residents are charged fees based on the cost of care and may pay for those fees from various sources, including the U.S. Department of Veterans Affairs per diem and other reimbursements, health insurance or private income. ▪ Require veterans home residents to maintain adequate health insurance throughout their residence in a veterans home. Recommendation 7: CalVet should amend regulations to specify consequences for residents who do not maintain adequate insurance coverage or otherwise pay their share of their costs. Little Hoover Commission | 45 A New Approach to California’s Veterans Homes Appendices Appendix A Public Hearing Witnesses The lists below reflect the titles and positions of witnesses at the time of the hearings. Public Hearing on CalVet Veterans Homes October 15, 2015 Sacramento, California Keith Boylan, Deputy Secretary, Veterans Services Coby Petersen, Deputy Secretary, Veterans Homes, Division, California Department of Veterans Affairs California Department of Veterans Affairs Marina Fisher, Graduate Student Researcher, Berkeley Ted Puntillo, Director of Veterans Services, Solano Center for Health Technology County Theresa Gunn, Deputy Secretary, Farm and Home Loan Division, California Department of Veterans Affairs Public Hearing on CalVet Veterans Homes March 3, 2016 Sacramento, California Timothy Bouseman, Administrator, Veterans Home of Coby Petersen, Deputy Secretary, Veterans Homes, California, Redding California Department of Veterans Affairs Ed Harries, Executive Director, Tennessee State Charlene Taylor, Chair, California Veterans Board Veterans Home Board Donald Veverka, Administrator, Veterans Home of Lael Hepworth, Administrator, Veterans Home of California, Yountville California, Chula Vista Dr. Vito Imbasciani, Secretary, California Department of Veterans Affairs 46 | www.lhc.ca.gov Appendices Appendix B Advisory Committee Meeting Participants The lists below reflect the titles and positions of witnesses at the time of the hearings. Advisory Committee Meeting on the Future of the Veterans Homes Program June 17, 2016 Veterans Home of California, West Los Angeles Los Angeles, California Monica Banken, Outreach Programs Coordinator, RAND Mike McManus, Veteran Services Officer, County of Ventura Corporation Caroline Morales, Member, California Veterans Board and Inna Berger, President and Chief Executive Officer, Oxnard Lieutenant Colonel, U.S. Army Family Circle ADHC Stephen Peck, President and Chief Executive Officer, U.S. Ann Brown, Director, VA Greater Los Angeles Healthcare Vets System Milo Peinemann, Senior Director of Housing and Public Jessica Brown-Mason, Director, The Salvation Army Haven Policy, New Directions for Veterans Hugh Crooks, Vice Chair, California Veterans Board Dr. Jonathan Sherin, Executive Vice President for Military Communities and Chief Medical Officer, Volunteers of Kathy Gaither, Retired Annuitant, California Department of America Veterans Affairs Pouneh Simpson, Chief Financial Officer of Veterans Homes, Scotte Hartronft, Chief of Staff, VA Greater Los Angeles California Department of Veterans Affairs Healthcare System Paul Sullivan, Deputy Secretary, Communications and Public Ted Howells, Chief Executive Officer, New Directions for Affairs, California Department of Veterans Affairs Veterans Fernando Torres-Gil, Professor of Social Welfare and Public Sarah Hunter, Senior Behavioral Scientist, RAND Corpora- Policy at UCLA and Director of the UCLA Center for Policy tion Research on Aging Dr. Vito Imbasciani, Secretary, California Department of Richard Valdez, Department Legislative Director, Disabled Veterans Affairs American Veterans Department of California Elizabeth Laughton, Associate, Munger, Tolles & Olson LLP Julian Manalo, Administrator, Veterans Home of California, West Los Angeles Little Hoover Commission | 47 A New Approach to California’s Veterans Homes Advisory Committee Meeting on the Future of the Yountville Veterans Home November 17, 2016 Veterans Home of California, Yountville Yountville, California Keith Armstrong, Director, San Francisco Veterans Lourdes Morales, Senior Fiscal & Policy Analyst, Affairs Health Care System Family Therapy Program, Legislative Analyst’s Office U.S. Department of Veterans Affairs John Moreno, Consultant, Office of Assemblymember Lorena Barrera, Field Representative, Office of U.S. Bill Dodd Congressman Mike Thompson Coby Petersen, Deputy Secretary, Veterans Homes of Thomas Bucci, Director of Long-Term Care, California California, California Department of Veterans Affairs Department of Veterans Affairs Neil Remnant, Member, Allied Council Pete Conaty, Lieutenant Colonel, U.S. Army (Retired) Bruce Saito, Director, California Conservation Corps John Dunbar, Mayor of Yountville Pouneh Simpson, Chief Financial Officer of Veterans Callie Freitag, Fiscal & Policy Analyst, Legislative Homes, California Department of Veterans Affairs Analyst’s Office John Spangler, Chief Consultant, Assembly Committee David Gerard, Director, Capitol Development & on Veterans Affairs Construction Division, California Department of Ursula Stuter, Deputy Administrator, Veterans Home Veterans Affairs of California, Yountville Dr. Vito Imbasciani, Secretary, California Department John Swensson, Veterans Advocate, De Anza College of Veterans Affairs J.P. Tremblay, Deputy Secretary, Legislation & Liam Kelly, Principal, KPMG Infrastructure Advisory Government Relations, California Department of Tracy Krumpen, District Director, Office of Senator Lois Veterans Affairs Wolk Donald Veverka, Administrator, Veterans Home of Christine Loeber, Executive Director, The Pathway California, Yountville Home, Inc. Ed Warren, Chair, Yountville Allied Council Julian Manalo, Administrator, Veterans Home of Leon Winston, Chief Operating Officer and Housing California, West Los Angeles Director, Swords to Plowshares Craig Middleton, Former Executive Director, The Presidio Trust 48 | www.lhc.ca.gov State of California LITTLE HO OV ER COMMIS S ION December 8, 2015 Pedro Nava The Honorable Edmund G. Brown Jr. Chairman Governor of California Loren Kaye Vice Chairman The Honorable Kevin de León The Honorable Jean Fuller David Beier President pro Tempore of the Senate Senate Minority Leader Anthony Cannella and members of the Senate Senator Jack Flanigan The Honorable Toni G. Atkins The Honorable Kristin Olsen Chad Mayes Speaker of the Assembly Assembly Minority Leader Assemblymember and members of the Assembly Don Perata Sebastian Ridley-Thomas Dear Governor and Members of the Legislature: Assemblymember Richard Roth With this letter, the Little Hoover Commission is taking an unprecedented step in drawing Senator immediate attention to critical infrastructure issues raised in a current review of the David Schwarz California Department of Veterans Affairs (CalVet) that began with a public hearing in Jonathan Shapiro October 2015, followed by a November site visit to the Yountville Veterans Home. At the Sumi Sousa hearing and on the site visit, the Commission learned that the Yountville Veterans Home, Carole D’Elia through deferred maintenance and neglect, is failing to provide the safe and dignified Executive Director living environment that California veterans deserve. There are critical infrastructure repairs requiring immediate and ongoing attention at this once crown jewel of the state’s veterans home program. On the day of the Commission’s visit, only one of the five elevators in the N.M. Holderman building – a multi-story skilled nursing facility housing 230 veterans – was functional. According to residents, the elevators have been broken for many months. It is unconscionable that these veterans who served our nation and now require wheelchairs, scooters and walkers for mobility, are seemingly trapped indoors waiting for the sole functioning elevator while state bureaucracy fails to move on timely repairs. It is our understanding that the department is now addressing this issue, but the length of time required for action reflects a systemic issue with facility management. The Commission also learned that the antiquated heating system was out in one building at the home for more than a month. Because the state has not invested in new equipment, repairs take longer when parts are hard to find or have to be custom built. It is unacceptable that the men and women who risked their lives for our freedom should have to face additional health and safety hazards while living in a California veterans home. For Yountville to remain a safe, viable home, repairs and infrastructure upgrades are desperately needed. The Commission urges immediate action. The Commission’s review of CalVet stems in part from the Commission’s work two years ago. In its 2013 report, An Agenda for Veterans: The State’s Turn to Serve, the Commission called on policymakers to improve outreach to the state’s nearly two million veterans and assist the federal government in reducing an unreasonably excessive backlog in processing claims. The Commission convened the October 2015 public hearing to assess the progress that CalVet has made implementing the recommendations from its 2013 report. I am pleased to report significant progress has been made in reducing the backlog of claims and expanding outreach to veterans. Testimony provided at the October 2015 hearing indicates the CalVet strike teams’ assistance in claims processing has brought in nearly $87 million in one-time payments to California veterans and additional annual payments of $141 million. Milton Marks Commission on California State Government Organization and Economy  http://www.lhc.ca.gov/ 925 L Street, Suite 805  Sacramento, CA 95814  916-445-2125  fax 916-322-7709  e-mail littlehoover@lhc.ca.gov Additional state funding provided to the County Veterans Service Officers helped hire more than 60 additional county-level staff who assisted in submitting over 13,000 new claims for veterans. This resulted in $32 million in new federal benefits. The Commission commends policymakers for making these investments and recommends the state continue to measure and report the results of these efforts to the Legislature. The October 2015 hearing served another purpose – to respond to a letter from Assemblymember Jacqui Irwin, Chair of the Assembly Committee on Veterans Affairs, asking the Commission to conduct a new assessment and provide “much needed recommendations to guide CalVet toward the standards of excellence our veterans deserve.” She noted “the extremely high degree of turnover in the very leadership team noted by the Commission as critical to progress and the continued lack of a systemic approach” to managing the state’s veterans homes. She specifically asked the Commission to assess the veterans home and home loan programs. Since the Commission’s 2013 report, two secretaries have stepped down, three undersecretaries have left and there has been significant turnover in top administrators at a majority of the state’s eight veterans homes. The Commission welcomes the September appointment of Vito Imbasciani as the new Secretary and commends his willingness to accept the difficult challenge in restoring leadership and confidence in the department, particularly in the veterans homes division. At the October 2015 hearing, the Commission learned that the once-beleaguered home loan program has overcome various challenges, including low utilization during the Great Recession, and is now providing needed and valuable lending services to a growing number of veterans. It is a self-sufficient program that likely will need voter approval for additional bond funding to continue to provide affordable home loans to California veterans. Clearly the state can and must do better with its veterans homes program, which has grown in the past several years from three to eight homes. The program consumes approximately 80 percent of the department’s $426.6 million budget, yet serves less than one percent – approximately 2,500 – of the state’s 1.8 million veterans. Much of the budget for the homes, approximately two-thirds, comes from the state General Fund. More importantly, the Commission learned that the quality of care, as measured by the Centers for Medicaid and Medicare Services, has fallen at all three of the older skilled nursing facilities from four- and five-star ratings – the highest possible – to two- and three-star ratings. On the health inspection rating, the only portion of the rating system that is not self-reported, two facilities scored one star, the lowest possible rating, while the third facility scored a two-star rating. This is not acceptable. The Commission intends to continue its review of the veterans home program with additional research, site visits and another public hearing in the State Capitol in 2016 and will provide recommendations later next year. But the Commission could not stand by as the study proceeds without drawing attention to the urgent maintenance and infrastructure issues at the Yountville home. The Commission looks forward to assisting the Administration and the Legislature as it continues its review of the veterans home program and particularly looks forward to a timely update on the progress on the urgently needed infrastructure repairs at the Yountville home. Sincerely, Pedro Nava Chairman c: Assemblymember Jacqui Irwin Secretary Vito Imbasciani Appendices Appendix D Additional Charts How Much Does It Cost to Provide Care Among California’s Veterans Homes? Costs Per Patient, Per Day, Fiscal Year 2015-16 Little Hoover Commission | 51 A New Approach to California’s Veterans Homes Source: Pouneh Simpson, Chief Financial Officer, Department of Veterans Affairs. February 3, 2017. Personal communication with Commission staff. 52 | www.lhc.ca.gov Appendices California’s Veteran Population Little Hoover Commission | 53 A New Approach to California’s Veterans Homes 54 | www.lhc.ca.gov Notes Notes 8 U.S. Department of Housing and 19 Janet M. Wilmoth and Andrew S. Urban Development. 2016 PIT Estimate London. Refer to endnote 14. 1 California Department of Veterans of Veteran Homelessness in the U.S. Affairs. Budget Estimate Package. Accessed January 5, 2017 at https:// 20 IAVA. 2014 IAVA member Survey. Budget Year 2017-18. Submitted www.hudexchange.info/resources/ VA Disability Compensation Claims. January 7, 2017. Pages B-5 and C-1. documents/2016-PIT-Estimate-of- 21 Janet M. Wilmoth, Andrew S. Homeless-Veterans-by-State.pdf. 2 California Department of Veterans London and Colleen M. Heflin. 2015. Affairs. Refer to endnote 1. Page B-5, 9 U.S. Department of Veterans Affairs, Economic Well-Being Among Older- “General Fund, State Operations for National Center for Veterans Analysis Adult Households: Variation by Veteran 2017-18 Governor’s Budget,” Page C-1, and Statistics. Refer to endnote 6. and Disability Status. Journal of “Budgeted Census 2017-18” and Page Gerontological Social Work, 58:4, 399- D-1, “Total Estimated Revenue, Revenue 10 U.S. Department of Veterans Affairs, 419. Budget Year 2017-18.” National Center for Veterans Analysis and Statistics. Refer to endnote 6. 22 Pouneh Simpson, Chief Financial 3 California Department of Veterans Officer, California Department of Affairs. Refer to endnote 1. Pages B-5, 11 Janet M. Wilmoth and Andrew Veterans Affairs. February 3, 2017. C-1 and D-1. Also, Bruce Chernof, S. London. 2016. “Chapter 11 The Personal communication with CEO, SCAN Foundation. June 3, Influence of Military Service on Aging.” Commission staff. 2016. Personal communication with Included in the Handbook of Aging Commission staff. and the Social Sciences, eight edition. 23 California Department of Veterans Edited by L.K. George and K.F. Ferraro. Affairs. December 10, 2012. Veterans 4 Dr. Vito Imbasciani, Secretary, Home of California Yountville Facilities California Department of Veterans 12 Janet M. Wilmoth and Andrew S. Master Plan Evaluation. Page 322. Affairs. November 30, 2016. California London. Refer to endnote 11. 24 Code of Federal Regulations, Title 38, Veterans Board Meeting, Sacramento, 13 Janet M. Wilmoth and Andrew S. Chapter 1, Part 59.80. Accessed December CA. Also, Lael Hepworth, Administrator, London. Refer to endnote 11. 28, 2016 at http://www.ecfr.gov/cgi-bin/ Veterans Home of California, Chula retrieveECFR?gp=&SID=2906ba6338568 Vista. March 3, 2016. Written 14 Janet M. Wilmoth and Andrew cd5db53606cb2ede6f9&mc=true&n=pt testimony to the Commission. Also, S. London. 2017. “Characteristics of 38.2.59&r=PART&ty=HTML#se38.2.59_ Timothy Bouseman, Administrator, Veterans and Non-Veterans within 180. Veterans Home of California, Redding. Twentieth-Century Cohorts in the March 3, 2016. Written testimony to United States.” Pp. 11-35 in Louis 25 Veterans’ Homes Bond Act of the Commission. Hicks, Eugenia L. Weiss, and Jose R. 2000. http://vig.cdn.sos.ca.gov/2000/ Coll (Editors), The Civilian Lives of U.S. primary/pdf/16.pdf. Note: The 5 California Assemblymember Veterans: Issues and Identities. Santa Veterans’ Homes Bond Act of 2000 Jacqui Irwin. July 13, 2015. Letter to Barbara, CA: Praeger. provided $50 million to CalVet Pedro Nava, Chairman, Little Hoover to design and construct veterans Commission. 15 Gerontologist, 2016, Vol. 56, No. homes in California and complete 6 U.S. Department of Veterans Affairs, S1, S10-S13. a comprehensive renovation of the National Center for Veterans Analysis veterans home at Yountville. 16 Donald Veverka, Administrator, and Statistics. Veteran Population Veterans Home of California, Yountville. 26 Dr. Vito Imbasciani, Secretary, Tables by State, Age/Gender and Race/ March 3, 2016. Testimony to the California Department of Veterans Ethnicity. Accessed December 8, Commission. Affairs. March 3, 2016. Testimony to 2016 at https://www.va.gov/vetdata/ the Commission. veteran_population.asp. 17 Janet M. Wilmoth and Andrew S. London. Refer to endnote 11. 27 Pouneh Simpson, Chief Financial 7 California Health Interview Survey. Officer, California Department of 2015. Topic: self-reported sexual 18 U.S. Department of Veterans Affairs, Veterans Affairs. January 31, 2017. orientation, limited to population who National Center on Homelessness Among Personal communication with served on active duty in the U.S. Armed Veterans. August 2016. “Research Brief. Commission staff. Forces. Accessed January 23, 2017 at Emerging Populations: Female, OEF/OIF/ http://ask.chis.ucla.edu. OND and Older Veterans.” Little Hoover Commission | 55 A New Approach to California’s Veterans Homes 28 Coby Petersen, Deputy Secretary id=201320140AB717. 48 Pouneh Simpson, Chief Financial for Veterans Homes, California Officer, California Department of Department of Veterans Affairs. 38 California State Auditor. Report Veterans Affairs. December 14, October 22, 2015. Written testimony 2012-119. Pages 11-12. May 9, 2013. 2015. Personal communication with to the Commission. Also California California Department of Veterans Commission staff. Also, California Department of Veterans Affairs. Budget Affairs: It Has Initiated Plans to Serve Military and Veterans Code. Refer to Estimate Package. Refer to endnote 1. Veterans Better and More Cost- endnote 34. Section 1012. Page C-1. Efficiently, but Further Improvements Are Needed. Accessed on December 49 California Department of Veterans 29 California Department of Veterans 12, 2016 at http://www.auditor.ca.gov/ Affairs. Refer to endnote 1. Page C-1. Affairs. Veteran Homes Briefing for pdfs/reports/2012-119.pdf. Little Hoover Commission. November 50 Pouneh Simpson. Refer to endnote 22. 30, 2015. Page 24. Also, California 39 Coby Petersen, Deputy Secretary Department of Veterans Affairs. Budget for Veterans Homes, California 51 U.S. Department of Veterans Affairs, Estimate Package. Refer to endnote 1. Department of Veterans Affairs. National Center for Veterans Analysis and Page C-1. March 3, 2016. Written testimony to Statistics. Refer to endnote 6. the Commission. 52 Caroline Morales, Member, 30 AB 2597 (Statham). Chapter 238, Statutes of 1994. 40 Dr. Vito Imbasciani. Refer to California Veterans Board. June 3, endnote 26. Also, Dr. Vito Imbasciani. 2016. Personal communication with 31 California Department of November 17, 2016. Little Hoover Commission staff. Finance. Governor’s Budget 2017- Commission Advisory Meeting. 53 Department of Finance. January 18. “Department of Veterans Affairs.” Yountville, CA. 27, 2017. Trailer Bill Language: 206: Accessed on January 24, 2017. 41 California State Auditor. Refer Updates to Military and Veterans Code. 32 California Department of Finance. to endnote 38. Also, California Accessed February 2, 2017 at http:// Refer to endnote 31. Department of Public Health. “Long www.dof.ca.gov/Budget/Trailer_Bill_ Term Care Facility FAQs.” Accessed Langauage/documents/206Updateesto 33 California Military and Veterans December 8, 2017 at http://hfcis.cdph. MilitaryandVeteransCode.pdf. Code. Division 1. Administration of ca.gov/faq/longtermcare.aspx#matrix. Military and Veterans Affairs [50-89]. 54 Senior researchers, RAND. Refer Chapter 2. Department of Veterans 42 California State Auditor. Refer to to endnote 45. Affairs. Sections 74 and 79.2. endnote 38. 55 Texas Veterans Land Board. 34 California Military and Veterans 43 LHC staff review of USDVA Survey “Veterans Homes.” Accessed December Code. Division 5. Veterans’ Institutions Results. 27, 2016 at http://www.glo.texas. [1010-11210]. Chapter 1. Veterans’ gov/vlb/vethomes/index.html. Also, Home of California. Sections 1011, 44 Donald Veverka. Refer to endnote 16. Tennessee State Veterans’ Homes. “Our 1023 and 1044. Facilities.” Accessed December 27, 2016 45 Senior RAND researchers. May 19, at http://www.tsvh.org/ourfacilities. 35 California Military and Veterans 2016. Personal communication with html. Code. Refer to endnote 33. Sections Commission staff. 66, 68 and 72. 56 Kay Maley, Administrator, Clyde E. 46 California Department of Veterans Lassen State Veterans Nursing Home, 36 Little Hoover Commission. August Affairs. CalVet Veteran Homes. Florida. December 1, 2015. Personal 2013. An Agenda For Veterans: The Accessed December 27, 2016 at https:// communication with Commission staff. State’s Turn To Serve. http://www.lhc. www.calvet.ca.gov/calvet-programs/ ca.gov/studies/217/Report217.pdf. veteran-homes. 57 Coby Petersen. Refer to endnote 39. 37 AB 717, Chávez. Veterans. 47 California Military and Veterans 58 Legislative Analyst’s Office. California Legislature. October 10, Code. Refer to endnote 34. Section January 2017. “Understanding the 2013. 2013-2014 Regular Session. 1012. Also, 12 CCR § 501. Veterans Veterans Services Landscape in Accessed on December 12, 2016 Home Admission and § 502. Priorities California.” at http://leginfo.legislature.ca.gov/ for Admissions. 59 U.S. Department of Veterans faces/billTextClient.xhtml?bill_ Affairs, Veterans Health Administration, 56 | www.lhc.ca.gov Notes Chief Business Office Purchased Care. http://californiahealthline.org/morning- Commission staff. July 2014. “VA Medical Centers of breakout/veterans-homes-davis- Jurisdiction for State Home Programs.” appoints-task-force-to-review-quality/. 77 Truven Health Analytics. June Accessed on March 8, 2016 at http:// Also, Bill Analysis AB 34 (Runner). 30, 2015. “Medicaid Expenditures for www.va.gov/PURCHASEDCARE/docs/ ftp://www.leginfo.ca.gov/pub/01-02/ Long-Term Services and Supports (LTSS) programs/nvc/Map-SH-VAMC.pdf. bill/asm/ab_0001-0050/ab_34_ in FY 2013: Home and Community- cfa_20010416_152335_asm_comm.html Based Services were a Majority of LTSS Spending.” 60 California Department of Veterans 69 Fernando Torres-Gil, Director, Affairs. Refer to endnote 1. Page C-1. Center for Policy Research on Aging. 78 Lisa Shugarman. Refer to endnote 69. UCLA. May 27, 2016. Personal 61 Pouneh Simpson. Refer to endnote 22. communication with Commission staff. 79 Dr. Bruce Chernof. Refer to endnote 3. Also, Lisa Shugarman, long-term care 62 Pouneh Simpson, Chief Financial consultant. May 19, 2016. Personal Officer, California Department of 80 U.S. Department of Veterans communication with Commission Veterans Affairs. November 30, Affairs. State Summary: California. staff. Also, Dr. Bruce Chernof. Refer to 2015. Personal communication with Accessed January 25, 2017 at endnote 3. Commission staff. https://www.va.gov/vetdata/docs/ SpecialReports/State_Summaries_ 70 Ventura County Military 63 Thomas Martin, Assistant California.pdf. Collaborative. Resources & Agencies: Deputy Secretary of Veterans Homes, VCMILC Directory. Accessed January California Department of Veterans 81 Ann Brown, Director, VA Greater 5, 2017 at http://www.vcmilc.org/ Affairs. February 3, 2017. Personal Los Angeles Healthcare System. June collaborative.html. communication with Commission staff. 17, 2016. Little Hoover Commission Advisory Meeting. West Los Angeles, 71 Mike McManus, Ventura County 64 Donald Veverka. Refer to endnote 16. CA. Veterans Service Officer. May 27, 2016. Personal communication with 65 Code of Federal Regulations, Title 82 Dr. Debra Saliba, Anna and Harry Commission staff. 38, Chapter 1, Part 59.110. Accessed Borun Endowed Chair in Geriatrics December 28, 2016 at http://www.ecfr. and Gerontology, UCLA, VA GLAHS 72 Stephen Peck, President and CEO, gov/cgi-bin/text-idx?SID=03875516870d Physician and Senior Natural Scientist, U.S. Vets. June 17, 2016. Little Hoover b2b43b25debd498ad15a&mc=true&no RAND Health. June 6, 2016. Personal Commission Advisory Meeting, West de=se38.2.59_1110&rgn=div8. communication with Commission staff. Los Angeles. 66 Pete Conaty, Lieutenant Colonel, 83 U.S. Department of Veterans 73 Dr. Vito Imbasciani, Secretary, United States Army (retired). June 13, Affairs. Geriatrics and Extended Care: California Department of Veterans 2016. Personal communication with Adult Day Health Care. Accessed Affairs. June 17, 2016. Little Hoover Commission staff. January 13, 2017 at https://www. Commission Advisory Meeting, West va.gov/geriatrics/guide/longtermcare/ Los Angeles. 67 AB 2559 (Wesson), Chapter 216, Adult_Day_Health_Care.asp#. Statutes of 2002. SB 1773 (Chesbro), 74 AARP PPI. April 2014. “What Chapter 219, Statutes of 2002. SB 1234 84 U.S. Department of Veterans is Livable? Community Preferences (Johannessen), Chapter 217, Statutes of Affairs. Geriatrics and Extended Care: of Older Adults.” Accessed January 2002. AB 2953 (Wiggins), Chapter 218, Home Based Primary Care. Accessed 4, 2017 at http://www.aarp.org/ Statutes of 2002. January 13, 2017 at https://www. livable-communities/info-2014/livable- va.gov/geriatrics/guide/longtermcare/ communities-facts-and-figures.html. 68 Department of Finance. Fiscal Home_Based_Primary_Care.asp#. Year 2000-01 Budget. Accessed 75 Hugh Crooks, Jr., member, January 5, 2017 at http://www.dof. 85 U.S. Department of Veterans California Veterans Board. June 17, ca.gov/budget/historical_budget_ Affairs. Geriatrics and Extended Care: 2016. Little Hoover Commission Publications/2000-01/gov_bud_sum/ Homemaker and Home Health Aide Advisory Meeting, West Los Angeles. Veterans-N.pdf. California Healthline. Care. Accessed January 13, 2017 at December 2, 1999. “Veterans’ Homes: 76 Tracey Cooper-Harris, Los Angeles https://www.va.gov/geriatrics/guide/ Davis Appoints Task Force to Review Field Coordinator, IAVA. February 18, longtermcare/Homemaker_and_Home_ Quality.” Accessed January 5, 2017 at 2016. Personal communication with Health_Aide_Care.asp#. Little Hoover Commission | 57 A New Approach to California’s Veterans Homes 86 U.S. Department of Veterans 95 California Department of Veterans 105 California State Auditor. Refer to Affairs. Geriatrics and Extended Care: Affairs. Refer to endnote 1. Pages B-5 endnote 38. Page 13. Medical Foster Home Care. Accessed and D-1. January 13, 2017 at https://www. 106 California State Auditor. Refer to va.gov/geriatrics/guide/longtermcare/ 96 California Department of Veterans endnote 38. Page 13. Medical_Foster_Homes.asp#. Also, Affairs. Refer to endnote 1. Also, Page Gerontologist, 2016, Vol. 56, No. 1, B-5, “General Fund, State Operations for 107 California State Auditor. Refer to 62-71. 2017-18 Governor’s Budget,” Page C-1, endnote 38. Page 13. “Budgeted Census 2017-18” and Page 108 California Military and Veterans 87 Dayna Cooper, Director, Home and D-1, “Total Estimated Revenue, Revenue Code. Refer to endnote 34. Community Care, U.S. Department of Budget Year 2017-18.” Also, Bruce Veterans Affairs. June 9, 2016. Personal Chernof. Refer to endnote 3. 109 California State Auditor. Refer to communication with Commission staff. endnote 38. Page 13. 97 Genworth 2016 Cost of Care Study, 88 Lisa Shugarman. Refer to endnote 69. conducted by CareScout.® April 2016. 110 California Department of Veterans Annual Costs: California – State Median Affairs. Refer to endnote 1. Page D-1. 89 Mike McManus. Refer to endnote 71. (2016). Accessed December 8, 2016 at https://www.genworth.com/about-us/ 111 12 CCR § 501. Veterans Home 90 U.S. Department of Housing and industry-expertise/cost-of-care.html. Admission. Urban Development. Refer to endnote 8. 98 California Department of Veterans 112 Pouneh Simpson, Chief Financial 91 California Department of Housing Affairs. Refer to endnote 1. Page C-1. Officer, California Department of Veter- and Community Development. ans Affairs. January 12, 2016. Personal Veterans Housing and Homelessness 99 California Department of Finance. communication with Commission staff. Prevention Program. Accessed January Refer to endnote 31. 12, 2017 at http://www.hcd.ca.gov/ 113 California State Auditor. Refer financial-assistance/veterans-housing- 100 California State Auditor. Refer to endnote 38. Also, California and-homelessness-prevention-program/ to endnote 38. Page 13. Also, Department of Veterans Affairs. docs/vhhp-program-goals.pdf. Pouneh Simpson, Chief Financial Strategic Plan, Fiscal Year 2013-14 – Officer, Department of Veterans 2015-16. Page 9. Accessed on February 92 U.S. Department of Housing Affairs. December 16, 2015. Personal 27, 2017 at https://www.calvet.ca.gov/ and Urban Development. HUD-VASH communication with Commission staff. Documents/StrategicPlan.pdf. Vouchers. Accessed January 12, 2017 at https://portal.hud.gov/hudportal/ 101 Pouneh Simpson. Refer to 114 Coby Petersen. Refer to endnote 28. HUD?src=/program_offices/public_ endnote 100. indian_housing/programs/hcv/vash. 115 California Department of 102 Christina Goebel, Budget and Veterans Affairs. Refer to endnote 1. 93 California Department of Veterans Financial Analyst, Office of Community Pages B-5 and D-1. Affairs. Budget Change Proposal. Fiscal Care, U.S. Department of Veterans Year 2013-14. “Proposal: Conversion Affairs. December 12, 2016. Personal 116 Coby Petersen. Refer to endnotes of Skilled Nursing Facility to Domiciliary communication to Commission staff. 28 and 39. Neighborhoods at West Los Angeles Veterans Home.” 103 Office of the Federal Register. 117 Coby Petersen. Refer to endnote 39. Vol. 78, No. 81. April 29, 2009. 94 Code of Federal Regulations. Section 51.41(c). Per diem for 118 Lynn Scott, Assistant Hospital Refer to endnote 65. Note: The U.S. certain veterans based on service- Administrator, Veterans Home of Department of Veterans Affairs requires connected disabilities. http://www. California, Yountville. December 8, states that receive construction grants va.gov/orpm/docs/20090429_AM97_ 2015. Personal communication with for state veterans homes to operate PerDiemforNursingHomeCare.pdf. Also, Commission staff. the facilities as veterans homes for 20 California Military and Veterans Code. years, but does include provisions for Refer to endnote 34. 119 Marina Fisher, Graduate Student repayment if states choose to repurpose Researcher, Berkeley Center for Health the facilities earlier than 20 years. 104 California Department of Technology, University of California, Veterans Affairs. Refer to endnote 1. Berkeley. Spring 2015. “Improving Service Page D-11. to Those Who Served: Recommendations 58 | www.lhc.ca.gov Notes for Delivering High-Quality Care in 129 U.S. Department of Health and California’s Veterans’ Homes.” Human Services. December 13, 2016. “Impact of the Affordable Care Act 120 Ed Harries, Executive Director, in California.” Accessed December Tennessee State Veterans’ Homes 22, 2016 at https://www.hhs.gov/ Board. March 3, 2016. Written healthcare/facts-and-features/state-by- testimony to the Commission. Also, Ed state/how-aca-is-working-for-california/ Harries. December 17, 2015. Personal index.html. communication with Commission staff. 130 Lael Hepworth, Administrator, 121 Deb Fournier, Chief Operations Veterans Home of California, Chula Officer, Maine Veterans’ Homes. Vista. December 14, 2015. Personal December 14, 2015. Personal communication with Commission staff. communication with Commission staff. 131 Dr. Vito Imbasciani. Refer to 122 Tennessee State Veterans’ endnote 40. Homes. Costs. Accessed December 19, 2016 at http://www.tsvh.org/costs. 132 U.S. Department of Veterans html. Affairs, Office of Public Affairs. “Federal Benefits for Veterans, Dependents 123 Danielle Brown, Finance Director, and Survivors – Chapter 2: Service- Tennessee State Veterans Homes connected Disabilities.” Accessed Board. “Admission Agreement. Revised December 9, 2016 at https://www. October 2015.” December 17, 2015. va.gov/opa/publications/benefits_book/ Personal communication to Commission benefits_chap02.asp. Also, Office of the staff. Federal Register. Refer to endnote 103. Section 51.41 (a)(1-2). 124 Washington Department of Veterans Affairs. Application for 133 Kay Maley. Refer to endnote 56. Admission: WDVA Veterans Homes. Accessed December 19, 2016 at http:// 134 Little Hoover Commission staff www.dva.wa.gov/sites/default/files/ calculation, based on figures received Admission%20Application%20Packet. from Pouneh Simpson, Chief Financial pdf. Also, Washington State Veterans Officer, California Department of Homes. FAQ. Accessed December 19, Veterans Affairs. 2016 at http://www.dva.wa.gov/sites/ default/files/Homes%20FAQ%202.pdf. 135 Department of Finance. Refer to endnote 53. 125 California Military and Veterans Code. Refer to endnote 34. 136 SB 980 (Nielsen), California Legislature – 2015-2016 Regular 126 Lael Hepworth. Refer to endnote Session. 4. Also, Department of Health Care Services. Medi-Cal Q and A. Accessed 137 Coby Petersen. Refer to endnote 39. January 11, 2017 at http://www.dhcs. 138 Coby Petersen. Refer to endnote 39. ca.gov/services/ltc/Documents/Medi_ CalQandA.pdf. 127 California Military and Veterans Code. Refer to endnote 34. Also, Pouneh Simpson. Refer to endnote 27. 128 12 CCR § 501(e). Veterans Home Admission. Little Hoover Commission | 59 A New Approach to California’s Veterans Homes 60 | www.lhc.ca.gov Little Hoover Commission Members Chairman Pedro Nava (D-Santa Barbara) Appointed to the Commission by former Speaker of the Assembly John Pérez in April 2013. Government relations consultant. Former state Assemblymember from 2004 to 2010. Former civil litigator, deputy district attorney and member of the state Coastal Commission. Elected chair of the Commission in March 2014. Vice Chairman Jack Flanigan (R-Granite Bay) Appointed to the Commission by Governor Edmund G. Brown Jr. in April 2012. A member of the Flanigan Law Firm. Co-founded California Strategies, a public affairs consulting firm, in 1997. Scott Barnett (R-San Diego) Appointed to the Commission by former Speaker of the Assembly Toni Atkins in February 2016. Founder of Scott Barnett LLC, a public advocacy company, whose clients include local non- profits, public charter schools, organized labor and local businesses. Former member of Del Mar City Council and San Diego Unified School District Board of Trustees. David Beier (D-San Francisco) Appointed to the Commission by Governor Edmund G. Brown Jr. in June 2014. Managing director of Bay City Capital. Former senior officer of Genentech and Amgen. Former counsel to the U.S. House of Representatives Committee on the Judiciary. Serves on the board of directors for the Constitution Project. Senator Anthony Cannella (R-Ceres) Appointed to the Commission by the Senate Rules Committee in January 2014. Elected in November 2010 and re-elected in 2014 to represent the 12th Senate District. Represents Merced and San Benito counties and a portion of Fresno, Madera, Monterey and Stanislaus counties. Assemblymember Chad Mayes (R-Yucca Valley) Appointed to the Commission by former Speaker of the Assembly Toni Atkins in September 2015. Elected in November 2014 to represent the 42nd Assembly District. Represents Beaumont, Hemet, La Quinta, Palm Desert, Palm Springs, San Jacinto, Twentynine Palms, Yucaipa, Yucca Valley and surrounding areas. Don Perata (D-Orinda) Appointed to the Commission in February 2014 and reappointed in January 2015 by the Senate Rules Committee. Political consultant. Former president pro tempore of the state Senate, from 2004 to 2008. Former Assemblymember, Alameda County supervisor and high school teacher. Assemblymember Sebastian Ridley-Thomas (D-Los Angeles) Appointed to the Commission by former Speaker of the Assembly Toni Atkins in January 2015. Elected in December 2013 and re-elected in 2014 to represent the 54th Assembly District. Represents Century City, Culver City, Westwood, Mar Vista, Palms, Baldwin Hills, Windsor Hills, Ladera Heights, View Park, Crenshaw, Leimert Park, Mid City, and West Los Angeles. Senator Richard Roth (D-Riverside) Appointed to the Commission by the Senate Rules Committee in February 2013. Elected in November 2012 to represent the 31st Senate District. Represents Corona, Coronita, Eastvale, El Cerrito, Highgrove, Home Gardens, Jurupa Valley, March Air Reserve Base, Mead Valley, Moreno Valley, Norco, Perris and Riverside. Jonathan Shapiro (D-Beverly Hills) Appointed to the Commission in April 2010 and reappointed in January 2014 by the Senate Rules Committee. Writer and producer for Amazon Studios, FX, HBO and Warner Brothers. Former counsel to Kirkland & Ellis LLP, chief of staff to Lt. Governor Cruz Bustamante, counsel for the law firm of O’Melveny & Myers LLP, federal prosecutor for the U.S. Department of Justice Criminal Division in Washington, D.C., and the Central District of California. Janna Sidley (D-Los Angeles) Appointed to the Little Hoover Commission by Governor Edmund Brown Jr. in April 2016. General counsel at the Port of Los Angeles since 2013. Former deputy city attorney at the Los Angeles City Attorney’s Office from 2003 to 2013. Helen Torres (NPP-San Bernardino) Appointed to the Little Hoover Commission by Governor Edmund Brown Jr. in April 2016. Executive director of Hispanas Organized for Political Equality (HOPE), a women’s leadership and advocacy organization. Sean Varner (R-Riverside) Appointed to the Little Hoover Commission by Governor Edmund Brown Jr. in April 2016. Managing partner at Varner & Brandt LLP where he practices as a transactional attorney focusing on mergers and acquisitions, finance, real estate and general counsel work. Full biographies available on the Commission’s website at www.lhc.ca.gov. “Democracy itself is a process of change, and satisfaction and complacency are enemies of good government.” Governor Edmund G. “Pat” Brown, addressing the inaugural meeting of the Little Hoover Commission, April 24, 1962, Sacramento, California