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Inpatient VA Hospice Care: Clinically Needed, Promoted by VERA

American Academy of Hospice and Palliative Care Medicine
Atlanta, GA
June, 2000

Scott T. Schreve, DO
Veterans Affairs Medical Center
Inpatient VA Hospice Care: Clinically Needed, Promoted by VERA

Inpatient VA hospice care is needed to compliment the largely outpatient, Medicare driven community hospice services available. The Veterans Equitable Resource Allocation System (VERA) provides reimbursement for this inpatient workload and can prove beneficial to facilities operating inpatient hospice units. Through specialization of designated nursing home care staff and units, inpatient VA Hospice units can be established to provide end-of-life care while improving VERA reimbursement for the facility's network.

Quite often, the "right time and right place" for end-of-life care is inpatient VA hospice care. The VA has become a leader in providing end-of-life care. Initiatives such as the Palliative Care Index, Pain as a 5th Vital Sign and the VA Faculty Scholars Program have added to an established infrastructure to address the full continuum of care for veterans. This continuum of care includes strong academic and educational affiliations to support the VA's mission in training future physicians and health care providers. VA has significant expertise in geriatrics and palliative care as the demographics of the largely aging veteran population mandate. 32% of veterans are over age 65, and the cohort of veterans over the age of 85 will continue to grow beyond the year 2010 (1). Complimenting this commitment to quality end-of-life care, the VA has extensive research capabilities to substantiate the innovative care systems being modeled. The VA end-of-life care systems are likely to be emulated in the community.

The non-VA community hospice care programs do not meet the needs of many veterans. Non-VA or community hospice care is largely outpatient as this is one of the requirements for receiving Medicare certification (2). Because non-VA Hospice is mostly outpatient, a caregiver in the home is typically required. The availability of a capable caregiver is limited in the frail elderly veteran population. Additionally, numerous barriers to community hospice referral exist such as the prognostic uncertainty of designating a patient as terminal (less than 6 months to live). This is an obstacle for many referring physicians and often leads to late referrals. Other barriers to hospice care include cultural, ethnic and socioeconomic issues. The Medicare hospice program is largely end-of-life care for white middle-class cancer patients. The veteran population and their needs for care at end-of-life differ from the non-VA community population.

Veterans receiving hospice care have a greater need for inpatient care. Hospice care in the VA Health System serves approximately 11,300 veterans per year with about 35% of this care provided in an inpatient setting (3). This percentage of VA hospice care provided in the inpatient setting is greater than in the non-VA hospice setting for variety of reasons. 22% of veterans that received hospice care lived alone. Living alone precludes the likelihood of a capable caregiver for round the clock end-of-life care as is typically needed in community hospice care. In addition to lack of a caregiver, only 61% of veterans receiving hospice care had Medicare coverage to even be eligible to receive Medicare hospice services. While not a common or substantial private insurance benefit, hospice care may be included in some private health insurance policies but 32% of veterans receiving hospice care had no insurance versus 4% of hospice patients in the community. The provision of VA hospice care, outpatient and inpatient, is needed to provide adequate end-of-life care, which would not otherwise be available to many veterans.

In addition to the clinical needs, facilities with inpatient hospice units can benefit from the VERA methodology. VERA was developed to reimburse Veterans Integrated Service Networks (VISN's) based on workload. Some of the goals of VERA include:

  • Treating the greatest number of veterans having the highest priority
  • Aligning resource allocation policies to the best practices in healthcare
  • Complying with congressional mandate

Dying veterans are a high priority and hospice care is a mandated veterans benefit. Under VERA, veterans can receive the appropriate inpatient hospice care while the facility may benefit from enhanced VERA reimbursement. Many hospice admissions will be classified as "clinically complex". Under the VERA guidelines, a patient's stay of "more than 30 (combined) days of care during a year in the long term care setting of VA nursing home" qualifies for reimbursement of $42,153. If a facility's inpatient hospice unit such as ours has significant turnover (our average length of stay is 30-40 days), the total complex care reimbursement under VERA can be substantially greater than a traditional nursing home. The following table compares our facility's hospice unit to a typical nursing home care unit:

Table 1.


Inpatient Hospice

Traditional NHCU




Average Length of Stay

35 days

180 days


133 (actual FY99)


% of patients meeting complex care VERA criteria (estimated)





# of patients meeting complex care VERA criteria





VERA Reimbursement for complex care only





Our facility's experience with inpatient hospice care has shown clinical and financial advantages. Our unit has developed a referral network that depends largely on community hospice agencies. Almost 2/3's of our inpatient hospice referrals come from community agencies that believe many veterans are best served in an inpatient setting. Noteworthy is that these community agencies are sacrificing their Medicare funding in making the referral to provide appropriate patient care.

Under the Veterans Equitable Resource allocation method, our inpatient hospice unit yields greater reimbursement for our VISN than a typical nursing home care unit. Inpatient hospice care is needed by veterans and is not readily available in the community. VA is setting the standard of care for excellent end-of-life care. This model of coordinating end-of-life inpatient VA hospice care with community hospice agencies meets the needs of dying veterans and offers financial rewards for the facility.


  1. VA Long-Term Care at the Crossroads. Report of the Federal Advisory Committee on the Future of VA Long-Term Care. June, 1998.
  2. Medicare Hospice Benefit. U.S. Department of Health & Human Services Health Care Financing Administration, 1995.
  3. The Veterans Hospice Care Study: An Evaluation of VA Hospice Programs. Center for Health Quality, Outcomes & Economic Research. HSR&D Field Program. February, 1998.
  4. Veterans Equitable Resource Allocation System Handbook for 2000.

Other Resources By

Scott T. Schreve, DO

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