Existing law provides for the establishment and operation of veterans homes at various sites, and provides for an administrator of each home, as specified. Existing law establishes the duties of the Department of Veterans Affairs with regard to the establishment and regulation of veterans homes.

This bill would require the Department of Veterans Affairs to conduct a survey to assess the ability of veterans homes to assist veterans with complex mental and behavioral health needs, and develop a plan to accommodate that population, as prescribed. The bill would require the department to submit the plan and any recommendations for future legislation necessary to achieve its objectives to specified committees of the Legislature by January 1, 2020. 2020, and to begin adopting the recommendations by appropriate means, by July 1, 2020.

Existing law establishes the Department of Veterans Affairs within state government and sets forth its powers and duties, including, but not limited to, the administration of various programs providing benefits to veterans.

This bill would make a technical, nonsubstantive change to a related provision.

Date of Hearing: August 8, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

SBPCA Bill Id:SB 1314

Author:(Nguyen) – As Amended Ver:April 3, 2018

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the California Department of Veterans Affairs (CalVet) to develop and adopt a plan, as specified, for the state veterans’ homes to assist veterans with complex mental and behavioral health needs. Specifically, this bill requires CalVet to:

1. Conduct a survey to assess the ability of veterans’ homes to assist veterans with complex mental and behavioral health needs.
2. Develop a plan to accommodate that population based on survey results and submit the plan, with any recommendations for future legislation necessary to achieve its objectives, to specified committees of the Legislature by January 1, 2020.
3. Begin adopting the recommendations by July 1, 2020.

FISCAL EFFECT:

1. One-time costs to CalVet of approximately $200,000 to $300,000 (GF) to develop and conduct a survey, develop a plan, and report any recommendations to the Legislature.
2. Unknown costs, likely ranging from the hundreds of thousands to millions of dollars (GF), to adopt and implement any recommendations developed in the plan.

COMMENTS:

1. Purpose. The author intends this bill to better assist veterans with complex mental and behavioral health needs at the state’s veterans’ homes.
2. Background. CalVet operates eight veterans homes throughout the state. These homes provide rehabilitative, residential, and medical care and services to the state's aged or disabled veterans (and eligible veteran spouses). The homes range in size from 60 residents on a 20-acre site to over 1,000 residents on 500 acres. At full capacity, the homes can house and care for approximately 3,000 veterans. As of April 2017, approximately 2,200 members reside in the homes.

The eight veterans’ homes campuses offer different combinations of levels of care, ranging from independent living/domiciliary care to skilled nursing care and memory care. Residents pay a members fee that is calculated based on their annual income and service-related disability status.

The LAO reports that veterans returning from deployment are more likely to have a mental or behavioral health diagnosis than the general public. The veterans homes are equipped to provide basic mental health services, but do not have the capacity to fulfill the demand for complex mental and behavioral health services. Certain staffing and specialized care ratios are required for these residents. According to the LAO, limited staffing resources for residents with significant mental and behavioral health challenges can and does result in veterans being denied admission to or discharged from a veterans’ home.

The Budget Act of 2017 (AB 97, Ting, Chapter 14, Statutes of 2017) instructs CalVet to prepare a master plan, assessing the operation of the veterans’ homes, to be developed no later than July 1, 2019. AB 97 also specifies that the assessment must include a discussion of how veterans with complex mental and behavioral health needs will be accommodated in the plan.

This bill both duplicates and conflicts with the provisions of AB 97.

1. Prior Legislation.

AB 2325 (Irwin, Chapter 128, Statutes of 2018) prohibits eligible California veterans from being denied county mental or behavioral health services while waiting for a determination of eligibility for, and availability of, services provided by the U.S. Department of Veterans Affairs.

SB 409 (Nguyen), of this legislative session, similar to this bill, would have required CalVet to conduct a survey and to develop a plan to help veterans' homes meet the needs of veterans with complex mental and behavioral health needs. That bill was held on the Suspense File in this Committee.

AB 1361 (E. Garcia), of this legislative session, would have required CalVet to conduct a survey to assess the ability of veterans' homes to assist veterans with complex mental and behavioral health needs, develop a plan to accommodate that population, and submit that plan and any recommendations for future legislation necessary to achieve its objectives to the Legislature. That bill was amended to contain an unrelated issue.

Analysis Prepared by: Jennifer Swenson / APPR. / (916) 319-2081

Date of Hearing: June 26, 2018

ASSEMBLY COMMITTEE ON VETERANS AFFAIRS

Jacqui Irwin, Chair

SBPCA Bill Id:SB 1314

Author:(Nguyen) – As Amended Ver:April 3, 2018

SENATE VOTE: 39-0

SUBJECT: Veterans’ homes: services: complex mental and behavioral health needs

SUMMARY: Requires the California Department of Veterans Affairs (CalVet) to develop and adopt a plan, as specified, for the state veterans’ homes to assist veterans with complex mental and behavioral health needs. Specifically, this bill:

1. Requires CalVet to conduct a survey to assess the ability of veterans’ homes to assist veterans with complex mental and behavioral health needs.
2. Requires CalVet to develop a plan to accommodate that population based on survey results and submit the plan, with any recommendations for future legislation necessary to achieve its objectives, to specified committees of the Legislature by January 1, 2020
3. Requires CalVet to adopt the recommendations by July 1, 2020.

EXISTING LAW:

1. Provides for the establishment and operation of veterans’ homes at various sites, and provides for an administrator of each home, as specified.
2. Establishes the duties of the Department of Veterans Affairs with regard to the establishment and regulation of veterans’ homes.

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. One-time costs to CalVet in the hundreds of thousands of dollars to develop and conduct a survey, develop a plan, and report any recommendations to the Legislature. (Veterans Home Fund)
2. Unknown costs, likely ranging from the hundreds of thousands to millions of dollars, to adopt and implement any recommendations developed in the plan. (Veterans Home Fund)

COMMENTS: California statute stipulates the establishment of Veterans’ Homes in the cities of Yountville, Barstow, Chula Vista, West Los Angeles, Lancaster, Ventura, Fresno, and Redding. These homes provide eligible veterans with long-term care, assisted living, adult day health, independent living, or other health care services. Generally, these homes serve older or disabled veterans who are residents of California and discharged from active duty under honorable conditions. The state’s eight veterans’ homes serve nearly 2,500 California veterans.

In January of 2017, the LAO released a report entitled, Understanding the Veterans Services Landscape in California, which reviewed the federal and state-funded veterans’ services in three of the homes. A portion of the report assesses mental and behavioral health service demand, the services already provided by veterans’ homes, and some conclusions. Ultimately, the report found that veterans’ homes have limited staff resources for residents with mental and behavioral health needs, which in some cases has resulted in a veteran being denied admission into a home or discharged from one.

According to the author:

“SB 1314 requires CalVet to develop a plan to accommodate more residents suffering from complex mental and behavioral health needs in California’s veterans’ homes. The plan should include a strategy for where and how many residents with complex mental and behavioral health needs could best be accommodated, in light of staffing and other budgeting limitations. Additionally, the plan shall also include improvements in the security of each home to ensure the safety of all residents, staff and visitors of the veterans’ homes.”

Is this bill redundant with the Master Plan?

The Budget Act of 2017, chaptered on June 27, 2017, included provisions that instructed CalVet to prepare a master plan, assessing the operation of the veterans’ homes; this plan would need to be developed no later than July 1, 2019. AB 97 also specifies that the assessment must include a discussion of how veterans with complex mental and behavioral health needs will be accommodated in the plan. The committee should consider whether the development and implementation of a plan for state veterans’ homes to assist veterans with complex mental and behavioral health needs has already been addressed in AB 97.

According to the author’s office, this bill is necessary because it requires CalVet to adopt the recommendations that would result from the survey required by the bill, rather than continue discussion.

The Master Plan under development, however, is a plan for how to operate the homes, not merely to generate recommendations. Additionally, this bill requires a survey to assess “the ability of veterans’ homes to assist veterans with complex mental and behavioral health needs,” but both the LAO report and a report by the Little Hoover Commission have already assessed that capability and found it lacking. It’s also not clear that a survey of the homes is the right tool for generating a plan to improve these services.

Related Legislation:

SB 409 (Nguyen, 2017) would have required CalVet to conduct a survey and to develop a plan to help veterans' homes meet the needs of veterans with complex mental and behavioral health needs. This bill was held in the Assembly Appropriations Committee.

AB 1361 (E. Garcia, 2017) would have required CalVet to conduct a survey to assess the ability of veterans' homes to assist veterans with complex mental and behavioral health needs, develop a plan to accommodate that population, and submit that plan and any recommendations for future legislation necessary to achieve its objectives to the Legislature. This bill was gutted and amended to an unrelated issue.

REGISTERED SUPPORT / OPPOSITION:

Support

American GI Forum of California
American Legion – Department of California

AMVETS – Department of California

California Association of County Veterans Service Officers

California State Commanders Veterans Council

Military Officers Association of America, California Council of Chapters

Vietnam Veterans of America- California State Council

Opposition

None on File.

Analysis Prepared by: Lucia Saldivar / Christian Burkin / V.A. / (916) 319-3550

 THIRD READING  

Bill No: SB 1314

Author:

:

Vote:

SENATE VETERANS AFFAIRS COMMITTEE: 7-0, 4/24/18

AYES: Newman, Nielsen, Dodd, Hueso, Nguyen, Roth, Wilk

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/25/18

AYES: Lara, Bates, Beall, Bradford, Hill, Nielsen, Wiener

SUBJECT:

SOURCE: Author

DIGEST:

This bill requires the California Department of Veterans Affairs (CalVet) to develop and begin implementing a plan, as specified, for the state veterans’ homes to assist veterans with complex mental and behavioral health needs.

ANALYSIS:

Existing law:

1. Provides for the Veterans Home of California (VHC), an eight-campus system of state veterans homes managed by CalVet’s Veterans Homes Division.
2. Provides eligibility criteria and prioritization for membership at a VHC home.
3. Provides a legal framework authorizing CalVet to deliver varying levels of health and medical care for member veterans residing in VHC homes.

This bill requires CalVet to:

1. Conduct a survey to assess the ability of veterans’ homes to assist veterans with complex mental and behavioral health needs.
2. Develop a plan that addresses factors including, but not limited to:
3. The need for increased staff, including specialized staff, to provide appropriate care, services, and physical security to ensure the safety of the veterans with complex mental and behavioral health needs, all other residents of the homes, staff, and visitors.
4. An evaluation of the required staffing ratios at each level of care.
5. An evaluation of the security profile and needs of each home and recommendations to meet those needs.
6. The ability of each veterans’ home to accommodate veterans with complex mental and behavioral health needs, considering staffing and other budgeting resources, and the objective of minimizing disruption to the existing structure and operation of the veterans’ home system. CalVet may elect to dedicate specific beds or units in one or more veterans’ homes for the complex mental and behavioral health needs population.
7. An evaluation of the plan recommendations to determine which of those recommendations may be adopted through internal guidelines, and which require adoption under the rulemaking provisions of the Administrative Procedure Act or further statutory authorization.
8. Submit the plan and recommendations for future legislation to specified committees of the Legislature by January 1, 2020, and to begin adopting the recommendations by appropriate means, by July 1, 2020.

Background

State Veterans Homes. The Veterans Homes Division provides rehabilitative, residential medical care and services in a homelike environment for aged and disabled veterans (and eligible veteran spouses) residing in the State's eight veterans homes, which are located in Barstow, Chula Vista, Fresno, Lancaster. Redding, Ventura, West Los Angeles, and Yountville. As of mid-March 2017, more than 2,200 members in total resided in the homes.

Many homes were built in the last 10 years and the state’s laws and regulations governing the homes are not standardized. Some policies and procedures are outdated and need updating to reflect levels of care provided at the homes.

Levels of Care. The eight campuses offer different combinations of the following levels of care that generate increasing levels of cost:

1. Independent living/domiciliary care: Barstow, Chula Vista, Yountville.
2. Residential care/assisted living: All homes except Barstow.
3. Intermediate care: Barstow, Yountville.
4. Skilled nursing care: Barstow, Chula Vista, Fresno*, Redding*, West LA*, Yountville*. (Homes designated with an asterisk* also provide memory care.)
5. Outpatient clinic: In addition to the above levels of care, each home provides an outpatient clinic to serve its members with comprehensive multidisciplinary assessments as well as ongoing primary care and veteran's routine care needs.

The Legislative Analyst’s Office (LAO) recently reported research indicating a high prevalence of mental health diagnoses among members of the veterans community and also that California’s veterans homes have limited capacity to serve veterans with complex mental and behavioral health needs. The LAO stated:

Research shows that although most veterans return from deployment without mental or behavioral health conditions, veterans are relatively more likely to have a mental or behavioral health diagnosis than the general population. Mental and behavioral health conditions among veterans are often—but not exclusively—linked to PTSD. Some veterans may have a hard time maintaining relationships, housing, and/or employment due to mental and behavioral health conditions. The prevalence of PTSD among veterans has been studied by several research groups. A 2008 survey by the RAND Corporation estimates that about 14 percent of post–September 11, 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 percent for men and 27 percent for women. These estimated rates among veterans are substantially higher than the estimate of the lifetime prevalence among the total national population, which is roughly 7 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 make up about 7 percent of the U.S. population but about 18 percent of suicides nationwide. The USDVA estimated that in 2014, veterans were 21 percent more likely to die from suicide than their civilian adult peer groups. 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 make up about 7 percent of the U.S. population but about 18 percent of suicides nationwide. The USDVA estimated that in 2014, veterans were 21 percent more likely to die from suicide than their civilian adult peer groups. (LAO Report, “Understanding the Veterans Services Landscape in California,” January 17, 2017, pp. 16-17.)

The LAO also stated:

While basic mental health services are available through the homes, they do not currently have the capacity to take 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 conditions require more staffing resources—ranging from time spent with nursing assistants to social workers and psychiatrists—than residents without such conditions. Limited staffing resources for residents with significant mental and behavioral health challenges can result in veterans being denied admission to or discharged from a veterans home. 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.

On March 21, 2017, before a joint hearing of the Senate and Assembly Committees on Veterans Affairs, CalVet Secretary Vito Imbasciani affirmed that the near-future demographics of state veterans homes is likely to start reflecting a growing population of newer residents, who are younger veterans challenged by the mental and behavioral health complications, including early-onset dementia, resulting from post-traumatic stress injuries and traumatic brain injuries, the two signature wounds of the contemporary conflicts in Iraq and Afghanistan.

Related/Prior Legislation

AB 2325 (Irwin, 2018) prevents a county from denying an eligible veteran county mental or behavioral health services while the veteran is waiting for a determination of eligibility for, and availability of, mental or behavioral health services provided by the United States Department of Veterans Affairs. (Pending in Senate Health Committee)

SB 409 (Nguyen, 2017) requires CalVet to assess the needs of veterans with complex mental and behavioral health needs and develop a plan to meet those needs. (Pending in Assembly Appropriations Committee)

SB 485 (Nielsen 2017) requires CalVet to adopt uniform statewide policies and procedures addressing a wide variety of matters, including, but not limited to, admission of applicants, conditions upon which members may enter and remain in the home, resident disciplinary procedures, quality of care standards, an internal quality of care review process, delineating which services will be provided to members by the state, setting staffing standards, and staff training requirements. (Pending in Assembly Veterans Affairs Committee)

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Appropriations Committee:

• One-time costs to CalVet in the hundreds of thousands of dollars to develop and conduct a survey, develop a plan, and report any recommendations to the Legislature. (Veterans Home Fund)
• Unknown costs, likely ranging from the hundreds of thousands to millions of dollars, to adopt and implement any recommendations developed in the plan. (Veterans Home Fund)

SUPPORT: (Verified 5/23/18)

American GI Forum of California

AMVETS-Department of California

American Legion-Department of California

California Association of County Veterans Servicer Officers

California State Commanders Veterans Council

Military Officers Association of America-California Council of Chapters

Vietnam Veterans of America-California State Council

OPPOSITION: (Verified 5/23/18)

None received

Prepared by:

5/26/18 15:26:26

**** END ****

SENATE COMMITTEE ON

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

SB 1314 (Nguyen) - Veterans’ homes: services: complex mental and behavioral health needs

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

SB 1314 would require the California Department of Veterans Affairs (CalVet) to conduct a survey to assess the ability of veterans’ homes to assist veterans with complex mental and behavioral health needs, and to develop and implement a plan to accommodate that population, as specified.

Fiscal Impact:

• One-time costs to CalVet in the hundreds of thousands of dollars to develop and conduct a survey, develop a plan, and report any recommendations to the Legislature. (Veterans Home Fund)
• Unknown costs, likely ranging from the hundreds of thousands to millions of dollars, to adopt and implement any recommendations developed in the plan. (Veterans Home Fund)

Background:

CalVet operates eight veterans homes throughout the State. These homes provide rehabilitative, residential, and medical care and services to the state's aged or disabled veterans (and eligible veteran spouses). The homes range in size from 60 residents on a 20 acre site to over 1,000 residents on 500 acres. At full capacity, the homes can house and care for approximately 3,000 veterans. As of April 2017, approximately 2,200 members reside in the homes.

The eight veterans homes campuses offer different combinations of levels of care, including:

Independent living/domiciliary care (Barstow, Chula Vista, Yountville):

This level of care is for residents able to perform activities of daily living with, at most, minimal assistance. Non-nursing employees provide limited supervision. Residents have access to all of the home's services, activities, and medical care. Individuals can transfer to higher levels of care as needed. Independent living is also referred to as domiciliary by CalVet and the USDVA.

Residential care/assisted living (All homes except Barstow):

Residential Care Facilities for the Elderly (RCFE) is available for residents who require minimal assistance and supervision with some activities of daily living. RCFE services may include care by licensed nurses.

Intermediate care (Barstow, Yountville):

This level is for residents who often require licensed nursing assistance with medications and treatments, and generally require unlicensed nursing assistance with several daily living activities.

Skilled nursing care (Barstow, Chula Vista, Fresno, Redding, West LA, Yountville):

This level provides 24-hour services of licensed nurses and certified nursing assistants, and is more comprehensive than intermediate care. Skilled nursing residents have greater access to rehabilitation therapies, nursing care, pharmacy management, structured activities and clinical dietary services.

Memory care (Fresno, Redding, West LA and Yountville):

Memory care programs within skilled nursing facilities.

Outpatient clinic (All):

In addition to the above levels of care, each home provides an outpatient clinic to serve its members. The clinics provide comprehensive multidisciplinary assessments as well as ongoing primary care. The clinics address the veteran's routine care needs and also will arrange visits with outside medical specialists as necessary.

Funding for the annual operating expenses of the veterans homes comes from the State's General Fund, and any reimbursements CalVet receives are then remitted back to the General Fund. These reimbursements come from five sources:

• Medicare, a federally funded program which pays hospital inpatient and outpatient care, and some skilled nursing care;
• Medi-Cal, funded by the federal and state governments, which pays skilled nursing facility daily rates and various health care costs;
• Member fees paid by residents in accordance with their income and level of care;
• "Aid and Attendance," which are federal payments for veterans who need personal care assistance; and
• The U.S. Department of Veterans Affairs (USDVA), which pays a per diem rate for each veteran in the homes.

Residents pay a members fee that is calculated based on their annual income and service related disability status. In September 2016, veterans homes residents, on average, paid about $1,000 in monthly member fees.

According to the LAO, in July 2016, about 80% of veterans home residents were over the age of 65 and 34% over the age of 85. By comparison, more than half of California’s veteran population is over age 60 and 15% are over age 80. Additionally, about 20% of California’s veterans receive disability compensation, which may suggest a potential need for future long-term care.

The LAO reports that veterans returning from deployment are more likely to have a mental or behavioral health diagnosis than the general public. The veterans homes are equipped to provide basic mental health services, but do not have the capacity to fulfill the demand for complex mental and behavioral health services. Certain staffing and specialized care ratios are required for these residents, and according to the LAO, limited staffing resources for residents with significant mental and behavioral health challenges can result and has resulted in veterans being denied admission to or discharged from a veterans home.

Proposed Law:

This bill would require CalVet to conduct a survey to assess the ability of veterans’ homes to assist veterans with complex mental and behavioral health needs, and develop a plan to accommodate that population. The plan would at the minimum address the need for increased staff to provide appropriate care, services, and physical security; an evaluation of the required staffing ratios at each level of care; an evaluation of the security profile and needs of each home and recommendations to meet those needs; the ability of each veterans’ home to accommodate veterans with complex mental and behavioral health needs; and an evaluation of the plan recommendations to determine which of those recommendations may be adopted through internal guidelines, and which require adoption under the rulemaking provisions. This bill would also require CalVet, on or before January 1, 2020, to submit to the budget and veterans affairs committees of the Legislature the plan developed and any recommendations for future legislation necessary to achieve the plan’s objectives and adopting the plan recommendations by July 1, 2020.

Related Legislation:

AB 2325 (Irwin, 2018) would prevent a county from denying an eligible veteran county mental or behavioral health services while the veteran is waiting for a determination of eligibility for, and availability of, mental or behavioral health services provided by the United States Department of Veterans Affairs. This bill is pending in the Assembly Floor.

SB 409 (Nguyen, 2017), similar to this bill, would require CalVet to conduct an assessment survey and to develop a plan to help veterans' homes meet the needs of veterans with complex mental and behavioral health needs. This bill is pending on the Assembly Appropriations Committee suspense file.

SB 485 (Nielsen 2017) would require CalVet to adopt uniform statewide policies and procedures addressing a wide variety of matters, including, but not limited to, admission of applicants, conditions upon which members may enter and remain in the home, resident disciplinary procedures, quality of care standards, an internal quality of care review process, delineating which services will be provided to members by the state, setting staffing standards, and staff training requirements. This bill is pending in the Assembly Veterans Affairs Committee.

AB 1361 (E. Garcia, 2017), similar to this bill, would have required CalVet to conduct a survey to assess the ability of veterans' homes to assist veterans with complex mental and behavioral health needs, develop a plan to accommodate that population, and submit that plan and any recommendations for future legislation necessary to achieve its objectives to the Legislature. This bill was gutted and amended to an unrelated issue.

AB 1365 (Reyes, Chapter 509, Statutes of 2017) requires CalVet to submit an annual planning and financial report to the Legislature detailing amount of state funds budgeted to and the amount of revenue collected from the homes, the remaining amount of expected revenue, the costs of care per resident, current maintenance costs of the homes, and projected maintenance costs for the homes.

-- END --

SENATE COMMITTEE ON

Senator Josh Newman, Chair

2017 - 2018 Regular

Bill No: Hearing Date: 4/24/18

Subject:

DESCRIPTION

Summary:

This bill requires the California Department of Veterans Affairs (CalVet) to develop and begin implementing a plan, as specified, for the state veterans’ homes to assist veterans with complex mental and behavioral health needs.

Existing law:

1. Provides for the Veterans Home of California (VHC), an eight-campus system of regional state veterans homes managed by CalVet’s Veterans Homes Division.
2. Provides eligibility criteria and prioritization for membership at a VHC home.
3. Provides a legal framework authorizing CalVet to deliver varying levels of health and medical care for member veterans residing in VHC homes.

This bill requires CalVet:

1. To conduct a survey to assess the ability of veterans’ homes to assist veterans with complex mental and behavioral health needs.
2. To develop a plan that addresses factors including, but not limited to, the following:
3. The need for increased staff, including specialized staff, to provide appropriate care, services, and physical security to ensure the safety of the veterans with complex mental and behavioral health needs, all other residents of the homes, staff, and visitors.
4. An evaluation of the required staffing ratios at each level of care.
5. An evaluation of the security profile and needs of each home and recommendations to meet those needs.
6. The ability of each veterans’ home to accommodate veterans with complex mental and behavioral health needs, considering staffing and other budgeting resources, and the objective of minimizing disruption to the existing structure and operation of the veterans’ home system. The department may elect to dedicate specific beds or units in one or more veterans’ homes for the complex mental and behavioral health needs population.
7. An evaluation of the plan recommendations to determine which of those recommendations may be adopted through internal guidelines, and which require adoption under the rulemaking provisions of the Administrative Procedure Act or further statutory authorization.
8. To submit the plan and any recommendations for future legislation necessary to achieve its objectives to specified committees of the Legislature by January 1, 2020, and to begin adopting the recommendations by appropriate means, by July 1, 2020.
9. To begin adopting, on or before July 1, 2020, the plan recommendations, by appropriate means.

BACKGROUND

State Veterans Homes. The Veterans Homes Division provides rehabilitative, residential medical care and services in a homelike environment for aged and disabled veterans (and eligible veteran spouses) residing in the State's eight veterans homes, which are located in Barstow, Chula Vista, Fresno, Lancaster. Redding, Ventura, West Los Angeles, and Yountville. As of mid-March 2017, more than 2,200 members in total resided in the homes.

Many of the homes were built in the last 10 years and the state’s laws and regulations governing the homes are not standardized. Also, some policies and procedures are outdated and need to be updated to reflect the level of care provided at the homes.

Levels of Care. The eight campuses offer different combinations of the following levels of care that generate increasing levels of cost:

1. Independent living/domiciliary care (Barstow, Chula Vista, Yountville): This level of care is for residents able to perform activities of daily living with, at most, minimal assistance. Non-nursing employees provide limited supervision. Residents have access to all of the Home's services, activities, and medical care. Individuals can transfer to higher levels of care as needed. Independent living is also referred to as Domiciliary by CalVet and the USDVA.
2. Residential care/assisted living (All homes except Barstow): Residential Care Facilities for the Elderly (RCFE) are available for residents who require minimal assistance and supervision with some activities of daily living. RCFE services may include care by licensed nurses. In the future, memory care programs may be established within the RCFEs.
3. Intermediate care (Barstow, Yountville): This level is for residents who often require licensed nursing assistance with medications and treatments, and generally require unlicensed nursing assistance with several daily living activities.
4. Skilled nursing care (Barstow, Chula Vista, Fresno, Redding, West LA, Yountville) This level of care provides 24-hour services of licensed nurses and certified nursing assistants, and is more comprehensive than intermediate care. Skilled nursing residents have greater access to rehabilitation therapies, nursing care, pharmacy management, structured activities and clinical dietary services.
5. Memory care: The Fresno, Redding, West LA and Yountville homes provide memory care programs within their skilled nursing facilities.
6. Outpatient clinic: In addition to the above levels of care, each home provides an outpatient clinic to serve its members. The clinics provide comprehensive multidisciplinary assessments as well as ongoing primary care. The clinics address the veteran's routine care needs and also will arrange visits with outside medical specialists as necessary.

The Legislative Analyst’s Office (LAO) recently reported research indicating a high prevalence of mental and behavioral health diagnoses among members of the veterans community and also that California’s veterans homes have limited capacity to serve veterans with complex mental and behavioral health needs.^[1] The LAO stated:

Research shows that although most veterans return from deployment without mental or behavioral health conditions, veterans are relatively more likely to have a mental or behavioral health diagnosis than the general population. Mental and behavioral health conditions among veterans are often—but not exclusively—linked to PTSD. Some veterans may have a hard time maintaining relationships, housing, and/or employment due to mental and behavioral health conditions. The prevalence of PTSD among veterans has been studied by several research groups. A 2008 survey by the RAND Corporation estimates that about 14 percent of post–September 11, 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 percent for men and 27 percent for women. These estimated rates of PTSD among veterans are substantially higher than the estimate of the lifetime prevalence of PTSD among the total national population, which is roughly 7 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 make up about 7 percent of the U.S. population but about 18 percent of suicides nationwide. The USDVA estimated that in 2014, veterans were 21 percent more likely to die from suicide than their civilian adult peer groups. 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 make up about 7 percent of the U.S. population but about 18 percent of suicides nationwide. The USDVA estimated that in 2014, veterans were 21 percent more likely to die from suicide than their civilian adult peer groups.

The LAO also stated:

While basic mental health services are available through the homes, they do not currently have the capacity to take 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 conditions require more staffing resources—ranging from time spent with nursing assistants to social workers and psychiatrists—than residents without such conditions. Limited staffing resources for residents with significant mental and behavioral health challenges can result in veterans being denied admission to or discharged from a veterans home. 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.

On March 21, 2017, before a joint hearing of the Senate and Assembly Committees on Veterans Affairs, CalVet Secretary Vito Imbasciani affirmed that the near-future demographics of state veterans homes is likely to start reflecting a growing population of newer residents, who are younger veterans challenged by the mental and behavioral health complications, including early-onset dementia, resulting from post-traumatic stress injuries and traumatic brain injuries, the two signature wounds of the contemporary conflicts in Iraq and Afghanistan.

COMMENT

Prior/Related Legislation

1. SB 409 (Nguyen, 2017) requires CalVet to conduct an assessment survey and to develop a plan to help veterans' homes meet the needs of veterans with complex mental and behavioral health needs. (Pending, suspense file, Assembly Appropriations Committee)
2. AB 2325 (Irwin, 2018) prevents a county from denying an eligible veteran county mental or behavioral health services while the veteran is waiting for a determination of eligibility for, and availability of, mental or behavioral health services provided by the United States Department of Veterans Affairs. (Pending, Assembly Health Committee)
3. SB 485 (Nielsen 2017) requires CalVet to adopt uniform statewide policies and procedures addressing a wide variety of matters, including, but not limited to, admission of applicants, conditions upon which members may enter and remain in the home, resident disciplinary procedures, quality of care standards, an internal quality of care review process, delineating which services will be provided to members by the state, setting staffing standards, and staff training requirements. (Pending, Assembly Veterans Affairs Committee)

POSITIONS

Sponsor: Author

Support:

American GI Forum of California

AMVETS-Department of California

American Legion-Department of California

California Association of County Veterans Servicer Officers

California State Commanders Veterans Council

Military Officers Association of America-California Council of Chapters

Vietnam Veterans of America-California State Council

Oppose: None received

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1. LAO Report, “Understanding the Veterans Services Landscape in California,” January 17, 2017, pp. 16-17. ↑