How Does A Veterans Service Improve Life In A Community
Understanding the Veterans Services Landscape in California
- Introduction
- The Demographics of California's Veterans
- Overview of Services Bachelor to Veterans
- Provision of Specified Services to Veterans
- Bug for Legislative Consideration and Opportunities to Improve Service Delivery
Executive Summary
Supplemental Written report Linguistic communication Required LAO to Written report on Veterans Service Landscape in California. A statement of legislative intent adopted by the Legislature during deliberations on the 2016–17 budget package directed the Legislative Analyst's Office (LAO) to report on the office of the veterans homes in the 21st century. In light of data constraints, the supplemental report language was revised to require the LAO to report on the electric current veterans service landscape in California—including services in the state's veterans homes and services outside the veterans homes ("in the community"). Specifically, the LAO was directed to review federally and state–funded services related to four service areas of legislative interest: long–term intendance, mental and behavioral health, transitional housing, and employment aid.
Federal and State Governments Provide a Wide Array of Veterans Services Within the Veterans Homes and in the Customs. Qualified veterans have a variety of federally and country–funded options for long–term care, mental and behavioral health, transitional housing, and employment aid. The state's veterans homes provide contained living and long–term intendance services to well-nigh 2,500 California veterans. Veterans may as well use federal veterans benefits to finance individual long–term care. Mental and behavioral health intendance is bachelor to eligible veterans through the federal Veterans Health Administration, a division of the U.Southward. Section of Veterans Affairs. Residents of the veterans homes may also access basic mental and behavioral wellness services at the homes. Both the state and federal governments offer a diversity of options for homeless veterans or veterans looking for affordable housing, including the Transitional Housing Program for homeless veterans located at the Westward Los Angeles veterans home. For veterans looking for employment assistance, the state administers several federal grants targeted at veterans through the Employment Development Section.
Legislature Has Opportunity to Improve Service Commitment Inside the Veterans Homes. In our review of the services offered by the veterans homes, we establish that: (i) the longest expect–lists at the homes are for the highest levels of long–term care and (2) the homes have limited capacity to serve veterans with complex mental and behavioral health needs. If the Legislature is interested in improving service delivery at the veterans homes, it may wish to take activity to reduce and prioritize wait–lists, restructure the levels of care offered at each dwelling, ensure staffing ratios are appropriate for residents with complex needs, and address staffing challenges at all levels.
Introduction
Supplemental Report Linguistic communication Required LAO to Report on Veterans Service Landscape in California. A statement of legislative intent (known as "supplemental report language"), adopted by the Legislature during deliberations on the 2016–17 upkeep package, directed the Legislative Analyst'south Role (LAO) to written report on the role of the veterans homes in the 21st century by March xv, 2017. As originally intended, this linguistic communication would have required the LAO to produce a forrad–looking analysis on how the needs of veterans in California volition change over time and whether the state'south veterans homes will be able to meet the predictable needs—to the extent such a written report was feasible given the availability of data to project veterans' future needs. Based on our review of bachelor information and discussions with the California Department of Veterans Affairs (CalVet), we concluded that there is currently not sufficient data to reasonably project the future needs and preferences of California's veterans, as desired initially by the Legislature.
Reporting Language Revised in Low-cal of Data Constraints. Given the data constraints, we participated in discussions with legislative staff and the administration to refocus the report requirement. Information technology was agreed that we would study, by the original due date of March xv, 2017, on: (ane) the demographics of California's veterans, (2) an overview of existing services provided to veterans in the veterans homes and exterior of the homes ("in the community") based on four specified service categories, and (iii) possible recommendations to improve service delivery to the veteran population in California. The four service categories of particular interest are: long–term care, mental and behavioral wellness, transitional housing, and employment assistance. We were directed to focus on state and federally funded veterans services and to base of operations our research on a sample of veterans homes and the surrounding community. Together with legislative staff and the assistants, we selected the veterans homes in Yountville (Napa County), West Los Angeles (Los Angeles County), and Redding (Shasta County) for our sample. We conducted visits at these veterans homes and interviews with the County Veterans Service Offices (CVSOs) of these counties.
In this report, nosotros describe the demographics of California's veterans and provide a high–level overview of veterans services provided in the homes and services provided in the community. We then review the federal and state services available to veterans for long–term care, transitional housing, mental and behavioral wellness, and employment assist and provide our findings. Finally, nosotros highlight issues for legislative consideration and offer options to ameliorate service delivery within the veterans homes.
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The Demographics of California'due south Veterans
California's Veterans Share Many Demographic Characteristics With Veterans Nationwide. Of the estimated 21 1000000 veterans in the Usa, about 1.8 million veterans alive in California—more than than in any other state. As shown in Figure 1, the demographic characteristics of California's veterans are more often than not comparable to the demographic characteristics of veterans nationwide in terms of gender, age, and time–period served. As of 2016, information technology is estimated that over xc percent of California's veterans are male, more than than half of California'south veterans are over historic period sixty, and veterans who served in the Vietnam war make upward the largest share of the veteran population. Younger veterans—those who began service after September 11, 2001—make upwards 15 percentage of California'south veteran population.
However, California's Veterans Differ From Veterans Nationally on Race/Ethnicity and Income. Deviating from national trends, California'south veterans are more racially and ethnically various than veterans across the United States. For case, 17 per centum of California veterans identify equally Hispanic or Latino, compared to simply seven percent nationally. California is too home to roughly i–third of the nation'due south Asian–American veterans, who make up half dozen percent of California's veteran population (compared to 1 percent of the veteran population nationwide). In addition, the median household income for California'due south veterans in 2014 was estimated to be about $74,000, nearly $12,000 higher than the estimated median household income for Californians overall. According to information from 2015, vii.v per centum of California'southward veteran population was below the poverty level, compared to fourteen.3 percent of Californians overall. (Nosotros annotation that the income information reverberate the median income of households containing veterans, and therefore practice not necessarily reflect the median income of veterans themselves. In addition, the income data are estimated from the American Customs Survey, in which veterans must cull to identify themselves as veterans—this may atomic number 82 to underreporting of veterans.)
Largest Share of California'due south Veterans Live in Southern California. California'due south veterans live throughout the state, but concentrate in a few key areas. As shown in Figure two, the largest share of veterans live in Southern California counties. Los Angeles County is dwelling to the most veterans (approximately 330,000) and San Diego County has the 2nd–well-nigh veterans of any California county (approximately 230,000). Sacramento County has the virtually veterans of any Northern California county (approximately ninety,000), followed by Santa Clara, Alameda, and Contra Costa Counties, with about 60,000 veterans living in each county.
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Overview of Services Available to Veterans
In this section, we provide a loftier–level overview of central federally and state–funded services provided to veterans within the veterans homes and in the community. This section does not provide an exhaustive list of federally and state–funded services, just rather highlights several major benefits, including long–term care through the veterans homes, wellness care, and disability compensation. In a subsequent section, we provide a more in–depth analysis focusing on the four service areas of legislative involvement.
Services in Veterans Homes
The land of California runs viii veterans homes for eligible veterans to receive residential or long–term care. (Refer to Effigy 3 to encounter the location of veterans homes and the years residents were outset admitted at each home.) The veterans homes are designed to serve older or disabled veterans, whose needs range from independent living with minimum supervision to advanced medical care for residents with significant disabilities. The homes provide medical care, meals, personal care services, therapeutic activities, recreational events, and some transportation for residents. In a afterward department, we provide a detailed discussion of the long–term care, mental and behavioral health, transitional housing, and employment services available at the homes.
State Police force and Administrative Regulations Set Eligibility Requirements, Admissions Priorities for Veterans Homes. State law provides wide guidelines for who is eligible to live in a veterans dwelling—generally, residents of California who are aged or disabled, and discharged from active duty nether honorable conditions (that is, without a dishonorable discharge). CalVet has adopted further rules and regulations to guide who is eligible to alive in a veterans habitation. These administrative rules generally restrict admission to veterans who are 55 or older—or, at any historic period, veterans who are homeless or have a disability. (We notation that non–veteran spouses may likewise exist admitted to the veterans domicile if they meet sure criteria, per state law.) Regulations also state that the veterans homes have the correct to deny admission to veterans with behavioral concerns who would threaten the safety and security of other residents, or veterans requiring specialized care across what is provided at the homes.
Once deemed eligible, veterans are admitted to the homes on a first–come, first–served basis. If there is not a bed available, veterans may exist placed on a expect–list in the gild in which they applied. State police force and regulations, nonetheless, prioritize certain veterans for admissions, as follows:
- State Law Prioritizes Distinguished, Wartime Veterans for Access. Medal of Honor recipients and former prisoners of war are prioritized over all other veterans for admission to the homes. Wartime veterans are prioritized over veterans who served solely during peacetime.
- Regulations Prioritize Veterans With Diverse Hardships for Admission. Regulations state that the homes may accept into business relationship veterans' social and economic hardship, historic period, and disability needs, and prioritize them for admission accordingly. These factors by and large allow homeless veterans to be placed for high–priority or urgent access.
Veterans Homes Serve Generally Older Veterans. Like well-nigh long–term care services, the veterans homes primarily serve older veterans. In July 2016, well-nigh 80 percent of veterans home residents were over the age of 65 and 34 percent were over historic period 85. Nearly veterans home residents (77 per centum) served in World War Ii, Korea, or Vietnam, with Vietnam–era veterans making up the largest share (32 percentage). The racial and ethnic makeup of the veterans homes is less diverse than California'southward overall veteran population, with 85 percentage of veterans identifying as white (compared to 77 percent of all California veterans).
Veterans Homes Funded by State and Federal Sources, Some Veteran Out–of–Pocket Costs. The veterans homes received $315 meg Full general Fund in 2016–17 to fund the homes' daily operations and care for residents. Equally shown in Figure 4, about $90 million of this amount is estimated to be offset by reimbursements from the U.Due south. Department of Veterans Affairs (USDVA), Medi–Cal, and Medicare, and about $25 million is estimated to be kickoff by "member fees" charged to the veterans home residents. Member fees for veterans dwelling house residents are calculated as a per centum of the resident'southward annual income—ranging from 47.v percent for independent living to 70 percent for skilled nursing care. Residents with very depression or no income do not pay member fees. (At the time of this study, CalVet was in the process of revising regulations that limit the corporeality of fees the home may collect based on the resident'south income.) In addition, residents who have a pregnant disability incurred or aggravated during service (that is, a service–connected disability rating of 70 percent or higher, which we describe later in this written report) do non pay a share of price because the veterans homes receive an enhanced federal reimbursement rate for their intendance. In September 2016, veterans home residents across all homes paid—on average—about $1,000 in monthly member fees. Viii percent of residents across all homes were exempt from paying member fees that month because they had low or no income or were associated with the enhanced federal reimbursement rate.
Effigy 4
Veterans Homes Funding and Reimbursements
( Dollars in Millions)
| 2016–17 | |
| General Fund | $315 |
| Offsetting Reimbursementsa, b | |
| USDVA (federal funds) | –71 |
| Medi–Cal (federal funds) | –xi |
| Medicare (federal funds) | –9 |
| Member fees | –25 |
| Net Total, General Fund c | $199 |
| aProjected by the California Department of Veterans Affairs. bReimbursements are returned to the Full general Fund and shown as negative amounts. cGeneral Fund appropriation minus projected reimbursements. USDVA = Usa Section of Veterans Affairs. | |
Services in the Customs
A wide range of veterans services are provided in the community, largely funded by the federal government. (We broadly define community services in this study equally those provided outside of the veterans homes.) These federal services are administered through USDVA. (In improver to federal services designed specifically for veterans, veterans may access a number of veterans–focused services provided past customs–based organizations or local governments, which vary regionally. Veterans may also access state and federal services non specifically designed for veterans, such every bit Medi–Cal for health care. These groups of services are beyond the scope of this report.) Below, we provide an overview of fundamental federal veterans benefits and eligibility, and discuss how the state connects veterans to these federal services in the customs. (While there are state services targeted to veterans that are provided in the community, these are much less extensive than the federal benefits and services. We discuss these state services in a subsequent section focused on the four service areas of interest.)
A Veteran'due south Disability Rating Affects Federal Benefits
Many federal veterans benefits depend on a veteran's "service–continued inability" rating. A service–connected disability is defined past the USDVA as a physical or mental inability that was incurred or aggravated while in grooming or active duty. Examples of such conditions include chronic back pain, amputations, traumatic encephalon injury, depression, and post–traumatic stress disorder. In addition, some veterans are presumed to have been exposed to harm during active duty (for instance, former prisoners of state of war or veterans exposed to certain herbicides in Vietnam) and are presumed to have a service–connected disability. Once a service–connected disability has been established, the federal government rates the veteran'due south inability from nada percent to 100 percent in increments of x percentage points. A higher service–continued inability rating will lead to more generous federal benefits for that veteran.
Eligible Veterans Receive Health Care From Federal Veterans Health Administration
Federal Wellness Care Centers for Veterans Located Across the State. The federal government provides wellness care to eligible veterans (eligibility is discussed below) through the Veterans Health Administration (VHA), a division of the USDVA. The VHA runs medical centers with in–patient care capacity, community–based outpatient clinics (CBOCs), and service centers that help veterans and their families transition to civilian life ("Vet Centers"). These services are typically organized at the regional level as a "VA health care system." Figure v displays the locations of VHA medical centers, which are by and large the hub of regional VA health care systems, and the locations of the CBOCs and Vet Centers. Of California's one.8 million veterans, virtually 750,000 are enrolled in VHA, and approximately 470,000 received intendance from a VHA facility in 2015. Veterans not served by the VHA may access health care through other systems and insurers, such as an employer–sponsored wellness plan, wellness insurance purchased through Covered California, or Medi–Cal.
Federal Government Prioritizes Health Care for Certain Veterans. To exist eligible for VHA wellness care, a veteran generally must accept served on active duty—full–time military service—for 2 continuous years (or the full catamenia of service for which they were called to duty) and have a service–connected disability. Veterans with a low service–continued disability rating may qualify for VHA health care if their income falls below a certain threshold. Health care provided by the VHA—other than the counseling services provided past Vet Centers—is not bachelor to veterans dishonorably discharged from the military. Once accounted eligible, the VHA places veterans in ane of eight priority groups generally based on the severity of the veteran's service–connected disability, receipt of other federal benefits, and special veteran status (for example, Purple Heart medal recipient). The VHA fully funds the wellness care of some veterans—typically those in the higher priority groups—while others take required co–pays.
Federal Government Provides Disability Compensation, Pension to Eligible Veterans
Federal monetary benefits—in the form of disability compensation and pension—are the second–about utilized federal veteran benefit in California, after health intendance. In 2015, virtually 355,000 veterans in California received federal disability compensation and over 28,000 California veterans received a pension, with an boilerplate disability compensation and/or alimony do good of about $17,000 (including almanac and 1–time retroactive payments). To qualify for disability compensation, a veteran must demonstrate he or she has a service–connected disability. To qualify for pension, a veteran must encounter some active duty service requirements and be over 65 with express income or a meaning disability. Veterans who are eligible for disability compensation or pension and require assist with sure activities of daily living (ADLs)—such as bathing, feeding, or dressing—may also receive an additional monetary payment referred to as "assist and omnipresence" of potentially several hundred dollars monthly. In all of these cases, to be eligible for the federal benefit, veterans must not have been discharged under dishonorable atmospheric condition.
Country Helps Connect Veterans to Services in the Community
State Partially Funds CVSOs to Assistance Veterans Apply for Federal Benefits. To utilize for health intendance, disability bounty, pension, or other federal benefits, a veteran must complete a detailed application ("merits") with show of his or her service–continued disability and proof of income. This is a lengthy process, and some veterans need assistance to get together evidence of their service–connected disability and complete the application. Sometimes, the federal government will reject the merits and the veteran will appeal the decision and, for example, add more medical evidence to his or her claim. The state provides $7.5 million ($5.6 million Full general Fund) each year to CVSOs, a joint state– and county–funded program to counsel veterans on available benefits, help them develop claims for benefits, provide case management services throughout the claim process, and refer veterans to other nonfederal resources. Each county has at least ane CVSO and larger counties may have several. As shown in Figure 6, in 2015–16, over 400,000 veterans and their family members reached out to CVSOs for assistance, resulting in about 109,000 monetary and health care claims and $487 million in new or increased federal benefits to veterans.
Figure half dozen
County Veteran Service Offices (CVSOs) Utilization and Compensation a
ii 015–sixteen
| Utilization | |
| Veterans or family unit members who contacted CVSOs | 402,472 |
| Monetary claims filed | 103,475 |
| Health care claims filed | 5,838 |
| Compensation b | |
| Average benefit corporeality per claimaintc | $16,698 |
| Value of new or increased benefit paymentsd | $487.2 million |
| aData from the California Department of Veterans Affairs. bIncludes inability compensation, alimony, and other monetary payments. cIncludes almanac award and i–time retroactive payments. dAnnualized amount of benefits awarded in 2015–16. | |
California Transition Help Program (Cal–TAP) Aims to Educate Veterans Nearly Available Benefits. Cal–TAP—administered by CalVet—adopted as part of the 2016–17 upkeep package, will brainwash veterans and their families about benefits available to them. Unlike CVSOs, which exercise some outreach merely primarily help veterans utilise for benefits, the chief mission of Cal–TAP is outreach and education. Cal–TAP—currently in the implementation phase—will offer online and in–person presentations from country, federal, and customs–based partner organizations to inform and connect veterans to available benefits. Outreach through Cal–TAP volition focus on younger veterans every bit they exit armed forces service, simply presentations will likewise be available for veterans at all stages of life.
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Provision of Specified Services to Veterans
In the post-obit sections, we identify the potential service demand, the services provided in the veterans homes and in the customs, and findings from our inquiry for each of the 4 service areas of particular legislative interest—long–term intendance, mental and behavioral health, transitional housing, and employment aid.
Long–Term Care
Long–term care, broadly divers, is assistance provided to individuals who take ongoing difficulties performing ADLs, such equally bathing, dressing, eating, and toileting. Generally, people who need long–term intendance are older and/or accept a disability that prevents them from being able to do such activities without aid. Individuals may receive long–term care in their home from a personal intendance services provider or in a residential facility with on–site health care providers. In addition to the array of long–term care available to the general population, veterans have other options for long–term care. Eligible veterans may apply to live at one of the state's eight veterans homes, or may use their federal veterans benefits or personal income to pay out–of–pocket for private long–term care.
Potential Service Demand
California's Veteran Population Is Aging. More than than half of California's one.8 million veterans are over the age of threescore, and more than than 260,000 veterans (15 percent) are age lxxx or older. While non all aging veterans will need long–term care, information technology is likely that every bit individuals age, they volition develop difficulties with ADLs and require some level of assistance. In add-on, roughly 20 percent of veterans in California receive disability bounty, an indication that they may need some form of long–term care, regardless of historic period, now or in the future.
Services Provided
State Veterans Homes Provide Array of Independent Living and Long–Term Care Services for Eligible Veterans. As discussed earlier in this report, the state of California runs 8 veterans homes. These homes provide an array of independent living and long–term care services to a total of nigh ii,500 veterans. The services range from contained living–style "domiciliary" care to intensive skilled nursing services for residents with dementia or mental impairment ("retentiveness care"). We depict each level of care in Figure 7 and show the capacity for each level of intendance across all homes in Figure 8. Figure 9 displays the distribution of each level of intendance for each abode. Residents receive their primary health care from each domicile, in addition to dental, chemist's shop, and rehabilitation services. The homes as well provide residents meals and offer daily activities, outings, and transportation to medical appointments for specialty care.
Figure vii
Levels of Care Offered at California'southward Veterans Homes
| Level of Intendance | Description |
| Domiciliary (Contained Living) | Residents are able to perform ADLs with minimal assistance. Units supervised past not–nursing staff. |
| Residential Care Facility for the Elderly (RCFE) (Assisted Living) | Residents crave some assistance with ADLs and supervision. Some care provided by nursing staff. |
| Intermediate Intendance Facility | Mid–range skilled nursing intendance and supervision for residents who crave more than assist than an RCFE can provide, but less assistance than a SNF would provide. |
| Skilled Nursing Facility (SNF) | Highest level of skilled nursing intendance and supervision for residents who need assistance with near ADLs. |
| Memory Care | Designated SNF intendance for residents with memory impairment. |
| ADLs = activities of daily living. | |
Some Veterans Homes Provide Specialized Long–Term Care Services for Residents With Memory Harm. The veterans homes currently offer 219 beds across four veterans homes (refer to Figures 8 and 9) for residents with retention impairment, such equally Alzheimer'south affliction. These memory care units are licensed as skilled nursing units and provide additional supervision and targeted therapeutic activities for residents with memory damage. For case, the Redding veterans home offers a specialized "music and retentivity" programme for residents with dementia, funded through a enquiry grant. This program uses customized playlists for each veteran as a therapeutic and quality–of–life enhancement tool. Memory care units take the 2d–longest expect–listing amongst the levels of care offered by the veterans homes.
Veterans May Admission Long–Term Care Options in the Customs. Veterans who are on the wait–list for veterans homes or would prefer other long–term care services, have a range of options to cull from exterior of the veterans homes. Veterans may use some combination of VHA benefits, disability compensation, pension, assistance and attendance, private insurance, or personal funds to pay for individual long–term intendance. The VHA will aid fund some long–term care for veterans including dwelling house– and community–based services, every bit well as residential care and nursing facilities that contract with the VHA. Veterans who are eligible for Medi–Cal and not receiving VHA wellness care may utilise their Medi–Cal benefits, which pay for some forms of long–term intendance including skilled nursing facilities.
LAO Findings
To assess the demand for each level of care across the veterans homes, we reviewed CalVet wait and vacancy data equally of October xi, 2016. Figure 10 compares the look–list of each level of care to the chapters across all homes. We summarize our findings below.
High Unmet Need for Skilled Nursing and Memory Intendance Beds. As shown in Figure 10, the longest await–lists across all veterans homes are for the highest levels of care: skilled nursing (283 veterans) and retention care (257 veterans). There are more skilled nursing beds than memory intendance beds. The look–list for skilled nursing is at 46 percent of the full capacity for skilled nursing across the veterans homes, while the wait–list for retentivity care is in a higher place the retention intendance chapters across the homes—meaning that the homes could theoretically fill twice the number of memory care beds they currently offer. Demand for skilled nursing beds is highest at the Yountville home where 108 veterans are on the wait–list, followed by the Redding domicile where 68 veterans are on the wait–list. The Redding home has the highest demand for retentivity care (110 veterans), followed by the Yountville dwelling (90 veterans).
Most Homes Have Vacant Domiciliary Beds. In our interviews with veterans homes administrators, they noted that historically, veterans have entered the homes at the domiciliary level of care, and moved to higher levels of care as their needs grew. More recently, nonetheless, veterans tend to stay in the customs for as long as possible and motion into the veterans homes once they need a college level of intendance. This trend has placed pressure on skilled nursing and retentiveness care capacity. This observation is reflected in the long wait–lists for skilled nursing and memory care, and the curt wait–lists for domiciliary and other lower levels of intendance.
As Residents' Needs Become More Acute, Need for Skilled Nursing Beds Will Rise. As shown in Figure 10, look–lists for the lower levels of intendance are not equally loftier as those for skilled nursing care. Equally residents age, nevertheless, they may develop more than acute care needs and eventually need skilled nursing or retentiveness care. For veterans who are already residents of a veterans home and develop a demand for a higher level of care, it is the practice for the veterans home to place that resident in the first bachelor unit of the higher level of care. In our interviews with veterans homes administrators, they expressed concern at having some facilities with more residential care facility for the elderly (RCFE) beds than skilled nursing beds, because, under the current configuration of beds, they could non transition all RCFE residents to skilled nursing intendance should they need it.
Mental and Behavioral Health
Mental and behavioral health weather include depression, anxiety, bipolar disorder, schizophrenia, substance utilize disorder, and post–traumatic stress disorder (PTSD). Sometimes, these conditions are "co–occurring," pregnant some veterans may feel more than than ane condition simultaneously. Mental and behavioral wellness conditions are more often than not treatable and typically involve some combination of psychotherapy and medication.
Potential Service Demand
Loftier Prevalence of Mental and Behavioral Health Diagnoses Amid Veterans in the Community. Inquiry shows that although most veterans return from deployment without mental or behavioral health weather condition, veterans are relatively more probable to have a mental or behavioral health diagnosis than the general population. Mental and behavioral health conditions among veterans are often—merely non exclusively—linked to PTSD. Some veterans may have a hard time maintaining relationships, housing, and/or employment due to mental and behavioral health atmospheric condition. The prevalence of PTSD among veterans has been studied by several research groups. A 2008 survey by the RAND Corporation estimates that almost xiv percent of post–September xi, 2001 veterans who had returned from Iraq or Afghanistan had PTSD at the time of the survey. The National Vietnam Veterans Readjustment Study estimates the lifetime prevalence of PTSD of Vietnam–era veterans to be 31 per centum for men and 27 pct for women. These estimated rates of PTSD amid veterans are substantially higher than the estimate of the lifetime prevalence of PTSD among the full national population, which is roughly seven percent.
The prevalence of mental and behavioral health conditions among veterans is also demonstrated by the comparatively high veteran suicide rate. National–level data show that veterans brand up nearly vii percent of the U.S. population but about xviii percentage of suicides nationwide. The USDVA estimated that in 2014, veterans were 21 percent more than likely to dice from suicide than their civilian developed peer groups.
Services Provided
Mental and Behavioral Health Services Bachelor to Veterans Through VHA. The federal VHA runs an array of services for mental and behavioral health treatment for enrolled veterans. Figure 11 describes the types of mental and behavioral wellness services available at each facility. General mental and behavioral health services, such as basic assessments and some prescription medications, are accessible to veterans through their primary intendance provider. Specialized mental and behavioral health services—including intensive outpatient, emergency, and inpatient care—are accessible at most VHA medical centers. Veterans may also access specialized therapy and treatment services, merely non emergency or inpatient handling, at CBOCs. Veterans may choose to access CBOC services via telemedicine instead of in–person clinic visits. The VHA too runs several Vet Centers throughout the state that provide counseling to veterans who may non otherwise be eligible for VHA services. Dissimilar VHA medical centers and CBOCs, services provided by Vet Centers are free–of–charge.
Figure 11
Mental and Behavioral Wellness Services Offered at VHA Facilities
| Facility Type | Services Available a |
| Medical Centers | General and specialized outpatient programs. Immediate onsite emergency care. Some inpatient programs bachelor. Medications available onsite. |
| Community–Based Outpatient Clinics (CBOCs) | General and specialized outpatient programs and medications available onsite and via telemedicine. |
| Vet Centers | Complimentary readjustment counseling for veterans and their families. Does non crave VHA health care eligibility. |
| aReflects services by and large bachelor at each facility type, though specific services may vary by location. VHA = Veterans Health Administration. | |
Some Veterans Homes Able to Provide Specialized Mental and Behavioral Health Services for Veterans Within Existing Resources. Information from CalVet evidence that 76 percent of residents at the Barstow and Chula Vista homes accept a mental or behavioral health diagnosis. (Data are not available for the other homes.) Residents of the veterans homes may admission some basic mental and behavioral wellness handling on site through the homes' staff of social workers, physicians, psychologists, and psychiatrists.
In addition to these basic services, some homes are able to provide more intensive treatment to veterans. The veterans home in Yountville has adult the Transitions Programme inside the dwelling house's existing resources for veterans who either are: (ane) prospective residents with mental or behavioral wellness needs across what the abode is typically able to admit, or (2) current residents in jeopardy of being discharged from the domicile due to mental or behavioral health problems. The Yountville home offers between 6 and xv domiciliary–level beds for these residents, depending on need and the availability of resources. Staff who volunteer to work with Transitions Program residents work across their bones duties to provide individualized therapy, supervision, structured activities, and other handling for residents. For example, a Transitions Plan resident may need staff to periodically cheque that the resident is non engaging in behavior that would endanger her or himself and the other residents. The Transitions Program staff could provide counseling to this resident and work with the resident to develop a plan to avert harmful behaviors. Transitions Programme residents spend about half-dozen months on average with the program, with the goal of readying the residents to live successfully at the home (outside of the Transitions Program) or in the community. We note that the telescopic of this program is limited, and not currently bachelor at other homes.
LAO Findings
Veterans Homes Have Limited Chapters to Serve Veterans With Complex Mental and Behavioral Health Needs. While bones mental health services are available through the homes, they do not currently accept the chapters to have in many residents with complex mental and behavioral health needs. State and federal laws and regulations require the homes to maintain certain staffing and specialized care ratios. These requirements prevent the veterans homes from admitting or retaining residents who need more services and support than staff can provide.
Our interviews with the homes' administrators and staff indicated that residents with mental and behavioral health weather crave more than staffing resource—ranging from time spent with nursing assistants to social workers and psychiatrists—than residents without such conditions. Limited staffing resource for residents with significant mental and behavioral health challenges tin result in veterans being denied admission to or discharged from a veterans dwelling house. Data from the Yountville and Redding homes show that in 2015–16, 30 applicants were denied admission and 32 residents were discharged (10 involuntarily) due to behavioral health–related concerns about staffing and care disruption.
Transitional Housing and Other Options for Homeless Veterans
Transitional housing is one approach to aid homeless individuals and families take a pace toward permanent housing. Transitional housing programs typically provide shelter for a fixed flow of time (for example, one year) to allow the participant to receive services, such as counseling and employment assistance, while he or she secures stable income and housing. Nosotros note that there are local governments and community–based organizations that provide transitional housing and services for homeless veterans (some using federal grants). Consistent with the scope of this report, nonetheless, we limit our give-and-take to veterans services directly administered past the federal government and state programs for homeless veterans. In this department, we describe the state and federal transitional housing options for veterans, equally well as other state and federal services targeting homeless veterans or veterans in need of affordable housing.
Potential Service Demand
Homelessness Disproportionately Affects Veterans. Signal–in–time data from an annual, federally sponsored homelessness count estimates that nearly 11,000 California veterans (0.vii percent of the estimated California veteran population) were homeless on Jan 30, 2015. Every bit this count captures but homeless individuals who identify themselves as veterans, it likely underestimates the total number of homeless veterans. Despite information limitations, the estimated proportion of veterans who are homeless is higher than the estimated proportion of all individuals in California who are homeless, which was nigh 0.3 percent.
Services Provided
Veterans Homes Administratively Prioritize Homeless Veterans on Wait–listing. As discussed previously in this study, state regulations let the veterans homes to prioritize veterans with social and economic hardship for admission into the veterans homes, which generally allows homeless veterans to be considered for loftier–priority or urgent access. Figure 12 shows the proportion of veterans at each home who cocky–identified as homeless immediately prior to admission (whom nosotros refer to as "previously homeless veterans"). While the proportion of previously homeless veterans varies across the homes, on average, about 1–quarter of veterans identify as previously homeless.
West Los Angeles Veterans Home Partners With Federal Regime to Provide Transitional Housing Program (THP). The large proportion of previously homeless veterans at the West Los Angeles veterans home (as shown in Effigy 12) is in part due to the THP located at this dwelling house. The West Los Angeles veterans dwelling is i of 3 organizations that partners with the USDVA location in West Los Angeles (which owns the campus where the West Los Angeles home is located) to provide veterans with temporary housing while they await for stable housing and income. Candidates for THP are called after graduating from a USDVA substance employ rehabilitation program on the West Los Angeles campus. The THP residents live at the West Los Angeles veterans dwelling while they prepare to transition to life in the community by looking for housing, employment, and/or educational opportunities. Participants may admission federal services on the Due west Los Angeles USDVA campus, including full general VHA wellness care services, specialized mental and behavioral health care, vocational rehabilitation, and other employment aid services.
Variety of Federal and State Housing Programs Aim to Make Affordable Housing Available to Veterans in the Customs. The federal and state governments administrate a number of programs that aim to help veterans transition into permanent housing, or to make permanent housing more affordable. Beneath, we describe three key federal and land programs.
- Federal Housing Vouchers for Veterans. Together with the U.S. Department of Housing and Urban Development (HUD), the USDVA administers the Veterans Diplomacy Supportive Housing (HUD–VASH) program. This program allows local housing authorities with high prevalence of veterans homelessness to employ for an allocation of federally funded "housing choice" vouchers for veterans (colloquially known as "Section eight" vouchers amid the non–veteran population). These vouchers by and large allow veterans to find permanent housing in the community and apply the value of the voucher toward their hire payment. To exist eligible for HUD–VASH, a veteran must be homeless, eligible for VHA health intendance, and participate in case management services and recommended treatment (for example, mental health handling) provided past the plan. Nationally, in that location are a fixed amount of vouchers. Since 2008, the federal government has provided approximately 16,500 vouchers to California veterans. Of the 8,000 vouchers allocated nationally in 2016, California received 1,390.
- California Veterans Housing and Homelessness Prevention Programme. Proposition41—approved by voters in June 2014—provides $600 million to the California Department of Housing and Community Development, the California Housing Finance Agency, and CalVet to develop affordable housing for veterans and their families. (The funds for Proposition 41 were redirected from previously approved general obligation bonds for the CalVet Home Loan programme, which we hash out below.) By law, all Proposition 41 funds must be used to serve veterans and their families, and at least 50 percent of the funds must serve veterans with extremely depression incomes (which HUD defines each year by region). As of June 2016, the country had awarded approximately $180 million of the funds to develop about 1,500 housing units through a competitive grant procedure. About 900 of the 1,500 units are set aside specifically for homeless veterans. As shown in Figure 13, the planned units are located throughout the state, with the almost units in the Los Angeles surface area.
- California Home Loan Program for Veterans. The CalVet Home Loan plan provides various types of home loans to eligible veterans. These loans are primarily backed past a USDVA guarantee. The CalVet Home Loan programme provides veteran–specific loan services and targets veterans who may not otherwise qualify for a home loan, which may get in easier for certain veterans to obtain affordable housing. Currently, the CalVet Dwelling Loan plan is managing about 5,500 home loans (valued at about $one billion) for veterans and their families. The program is cocky–funded through bond funds and loan repayments.
Figure thirteen
Veterans Housing and Homelessness Prevention Program:
Grants Awarded past Location a
( Dollars in Millions)
| Location | Total Awarded | Number of Housing Units b |
| Bay Area | $29 | 207 |
| Los Angeles | 84 | 686 |
| Inland/Orange | 22 | 205 |
| San Diego | 17 | 188 |
| Other | 27 | 263 |
| Totals | $179 | 1,549 |
| aData from the California Department of Housing and Community Development for grant award Rounds 1 and 2, as of June 2016. bProjected. | ||
LAO Findings
With Loftier Prevalence of Mental and Behavioral Health Diagnoses, Admitting More Previously Homeless Veterans Could Identify Staffing Pressures on Veterans Homes. The USDVA estimates about fourscore percent of homeless veterans nationwide accept mental and behavioral health or substance use disorders. In our interviews at the veterans homes, staff indicated that previously homeless residents sometimes have a difficult time readjusting to living about other people, and often need mental or behavioral health handling to help them transition to life at the veterans home. As we discussed previously, the veterans homes have limited capacity to treat veterans with meaning mental and behavioral wellness challenges. If the homes begin to admit more previously homeless veterans who too have mental or behavioral health diagnoses, then staff may face challenges balancing the care of veterans with acute mental and behavioral wellness needs and maintaining the staffing requirements for the rest of the veterans at the habitation.
Employment Aid
When veterans leave military service, they may have difficulty translating the skills they acquired to non–military jobs. Several services at the state and federal levels aim to help veterans transition dorsum into the labor force.
Potential Service Need
Higher Unemployment Rate Amongst California'due south Veterans. In 2015, California had one of the nation's highest veterans unemployment rates at 6.8 percent. The unemployment rate for California veterans was higher than the California not–veteran unemployment rate (six.0 percentage). While the unemployment charge per unit is by and large high among veterans, certain veterans are disproportionally affected past loftier unemployment. Veterans with pregnant service–connected disabilities (defined as a disability rating of 60 per centum or college) have a higher unemployment rate than other veterans. Immature veterans—those who served in active duty after September 11, 2001—also accept a higher unemployment rate than other veterans. (We notation that the unemployment charge per unit, equally measured past the federal Bureau of Labor Statistics, excludes individuals who have stopped looking for piece of work or otherwise dropped out of the labor force.)
Service Provision
Land Employment Evolution Department (EDD) Runs Employment Assistance Programs for Veterans. The California EDD runs a multifariousness of employment assistance programs, some of which target veterans. These programs are generally funded by federal grants and administered through the statewide network of employment centers, the America's Job Centers of California (AJCC). Pursuant to federal constabulary, veterans are typically prioritized for services through the AJCC. In addition to granting priority to veterans, the country leverages two federal funding streams to back up employment assist for veterans:
- Jobs for Veterans State Grant (JVSG). The JVSG—a federal grant program—provided about $19 meg in federal funds in 2016–17 for additional staffing within total–service AJCCs. Specifically, these federal funds back up the Disabled Veterans Outreach Program (DVOP) and Local Veterans' Employment Representatives (LVERs). The DVOP staff provides "career individualized services," such as career assessments, planning, intensive chore training, vocational instruction, and other employment–related services to disabled veterans. Data from EDD show that, as of September 2015, near one,100 (76 percent) veterans receiving DVOP intensive services entered employment after exiting the plan. The LVERs work with veterans and employers to help facilitate employment opportunities, preparation, and job placement for veterans.
- Veteran Employment–Related Assistance Program (VEAP). The state allocates about $5 meg annually from a federal grant for VEAP, which awards grants through a competitive procedure to community–based organizations offering employment services targeted to veterans. Currently, 21 organizations throughout California receive VEAP funding.
Federal Authorities Direct Administers Some Vocational Rehabilitation and Employment Services for Eligible Veterans. The USDVA administers a vocational rehabilitation and employment program for veterans with service–connected disabilities, and general employment services for other veterans aiming to re–enter the labor force. Veterans with service–continued disabilities may receive comprehensive career assessments, vocational counseling, chore training, case management, and job placement services through the Veterans Rehabilitation and Employment (VR&E) plan. For veterans without service–connected disabilities, or for veterans who practice not want VR&E services, the federal regime offers an online job database (known as the "Veterans Job Depository financial institution") and online preparation to help veterans in their job search.
Land and Federal Governments Grant Hiring Preference to Veterans. The state and federal governments utilise ranking systems to identify the highest qualified applicants to fill civil service positions. These ranking systems grant preference to veterans applying for well-nigh country and federal jobs. While this preference does not guarantee a veteran will be hired, veterans with hiring preference are generally moved to the top tier of applicants.
Almost Residents at Veterans Homes Are of Retirement Age, Without Need for Employment Help. Approximately 90 pct of residents at the veterans homes are over the age of 65 (typically thought of equally retirement age). Accordingly, few veterans at the veterans homes demand or want employment assistance. One notable exception is the group of veterans participating in THP at the West Los Angeles home, every bit veterans served in that program are typically working–age and looking for stable income and housing. As office of THP, veterans participate in employment assistance programs through USDVA.
Back to the Superlative
Issues for Legislative Consideration and Opportunities to Improve Service Delivery
In our review, we identified four key opportunities for the Legislature to improve service commitment at the veterans homes. These opportunities could improve service delivery by reducing and prioritizing the expect–lists, providing the advisable level of care for current and prospective residents of the homes (including those with complex needs), lowering the vacancy rates, and ensuring the homes are properly staffed.
Prioritizing the Await–List
While certain limited groups of veterans (such equally Medal of Honour recipients and former prisoners of war) are prioritized for admission to the veterans homes by state statute, admission priorities have largely been established administratively through regulations. If the Legislature wishes to ensure certain groups of veterans are prioritized for admission to the veterans homes, it could codify its own admission priorities in statute. Equally the Legislature considers its priorities, it may wish to consider what long–term care, housing, or mental wellness treatment options a veteran may have in the community and prioritize admission for veterans without reasonable alternatives to the homes. Such a policy goal would likely lead the Legislature to prioritize in statute the regulations that CalVet has established administratively to prioritize veterans who are homeless, or have economical hardship that may prevent them from obtaining alternate care. Alternately, the Legislature could prioritize admitting veterans whose care the federal government reimburses at a higher rate—those receiving skilled nursing services and those with a service–continued disability rated seventy percent or higher. This would prioritize veterans with pregnant intendance needs, and likewise lead to increased federal reimbursements for the cost of care for such veterans. If the Legislature decides to prioritize admission for sure groups of veterans, we suggest that the Legislature consult with CalVet regarding any additional staffing needs and other budget requirements the new admissions rules could create.
Serving Veterans With Complex Mental and Behavioral Health Needs in Veterans Homes
As discussed previously, all veterans homes provide some bones level of mental and behavioral health support, just take limited capacity to assist veterans with complex mental and behavioral wellness needs. Veterans home residents with such needs require increased staff contact to ensure their own safety and well–being, as well as the prophylactic and well–being of other residents. In addition, licensing requirements for veterans homes require certain staffing ratios at each level of care. Admitting more residents with mental and behavioral health needs without increasing staffing resources could place force per unit area on staff and jeopardize level–of–care and rubber requirements at each abode.
If the Legislature determines that serving veterans with complex mental and behavioral health needs is a priority, then information technology may wish to straight CalVet to develop new staffing standards for units that have a meaning proportion of residents with mental and behavioral health needs. The new staffing standards would probable require an increased staffing ratio and additional specialized mental and behavioral wellness staff—along with a corresponding budget adjustment—to ensure the homes would exist able to accordingly intendance for residents with complex needs without jeopardizing the prophylactic and well–beingness of all residents of the homes.
In addition to adjusting staffing standards, the Legislature may wish to directly CalVet to develop a plan for how they would accommodate more residents with circuitous mental and behavioral wellness needs. The plan should include a strategy for where, how, and how many residents with circuitous mental and behavioral wellness needs could best be accommodated, in calorie-free of staffing and other budgeting resource and the objective of minimizing disruption to the current makeup of the veterans homes equally practicable. For case, CalVet may choose to dedicate specific units or a set of beds in one or several veterans homes for residents with complex mental and behavioral health needs.
Adapting to Irresolute Demand for Levels of Care
Within the veterans homes, the long expect–lists for the highest levels of care (skilled nursing and memory care) and high vacancy rates for lower levels of care (domiciliary) raise questions about what flexibility the homes take to arrange to changing need across the levels of care. Due to stricter licensing requirements for the highest levels of intendance, converting any existing units to higher levels of care would crave legislative activity to authorize unit of measurement renovations and approve budget adjustments associated with such renovations.
If the Legislature is interested in addressing the changing demand for levels of care inside veterans homes, it could consider several options—each with merchandise–offs. The Legislature may wish to reduce wait–lists for the skilled nursing and/or memory intendance level of care past renovating existing units licensed for lower levels of care to accommodate higher levels of care. If the Legislature wishes to pursue this pick, so information technology may want to consider its goals when selecting which units to renovate. For instance, the Legislature may wish to minimize the toll associated with the renovations. In this case, the Legislature could prioritize converting existing RCFE units into skilled nursing facility units, which would likely crave small-scale changes to run into licensing standards. Ane drawback to this approach is that near RCFE units also have waiting lists, and converting RCFE units to skilled nursing facility units would probable increase look–lists for RCFE beds. Alternately, the Legislature may wish to prioritize renovating empty or semi–vacant domiciliary units at the Yountville home. Converting units at Yountville would be plush and require major concrete changes to the buildings. Every bit some other option, the Legislature could prioritize converting units at homes where the demand for skilled nursing and retentivity care are highest (Yountville and Redding).
If the Legislature is interested in pursuing any of these options, then, as a get-go step, it could direct CalVet to provide an assessment of which homes and how many beds they could reasonably convert given the electric current occupancy and wait–lists at each dwelling house. This cess should include cost estimates for the anticipated renovations associated with meeting a college licensing standard. For proposals that could potentially displace electric current veterans homes residents, the cess should also include estimates of how many residents at which levels of intendance would be displaced, and a proposal for how to move the veterans into appropriate accommodations with minimal intendance disruption, with the goal that each resident remain within their respective veterans habitation, if so desired.
Addressing Staffing Challenges At the Veterans Homes
Homes Report Difficulty Recruiting and Retaining Entry–Level Staff. In our interviews at the veterans homes, administrators and staff consistently noted challenges in recruiting and retaining entry–level nursing and food service staff. In areas with a high cost of living (for example, Yountville or West Los Angeles), low–wage staff may need to commute from further abroad considering they cannot afford to live near the veterans habitation, likely reducing the pool of interested potential employees. In areas where contest is loftier for entry–level staff, individuals may opt for other, higher–paying jobs. For instance, the W Los Angeles home reports that several hospitals in the area pay higher wages for Certified Nursing Assistants than the veterans home. Since the veterans homes are staffed by public (country) employees, the homes are somewhat constrained in their ability to accommodate wages to brand them more than competitive. In more rural areas like Redding, staff written report that information technology is difficult to attract qualified staff amidst a regional scarcity of such staff.
Challenges Recruiting and Retaining Specialized Staff May Reduce Ability to Draw Down Federal Funds. Staffing challenges at the veterans homes are not express to entry–level jobs. Several homes report being unable to recruit or retain specialized wellness intendance providers, such as psychiatrists and rehabilitation staff (physical therapists, occupational therapists, and speech therapists). Administrators at the homes point to 2 main reasons for this challenge: bacon and location. In some cases, the salaries for specialized staff are not competitive with private–sector salaries for a comparable job. In other cases, the location of the home may non be desirable to specialized staff. Sometimes, both salary and location are barriers to retaining staff. Homes that are unable to provide rehabilitation services are consequently unable to describe down federal Medicare reimbursements for rehabilitation, which tin be a lucrative reimbursement source for the homes.
Review CalHR Classifications to Improve Recruitment and Retention. There are a number of initial steps the Legislature could have to address staffing challenges at the veterans homes. The Legislature could direct CalVet to survey the homes to place hardest–to–hire positions. With this information, the Legislature could direct the California Section of Human Resource (CalHR) to remove any burdensome or unnecessary requirements that create barriers to hiring and retaining qualified individuals in the relevant land classifications. (The Legislature could direct the administration to contain this review as part of its ongoing Ceremonious Service Improvement Project—an attempt led by the Authorities Operations Bureau and CalHR to review and improve land civil service rules and procedures.) Following an initial survey, CalVet could regularly submit to the Legislature recruitment and retention data and so that the Legislature can consider the issue as part of the annual budget process. If positions at some homes remain hard to recruit and retain, the Legislature could consider providing homes with targeted recruitment and memory funding for hardest–to–hire positions.
How Does A Veterans Service Improve Life In A Community,
Source: https://lao.ca.gov/Publications/Report/3525
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