Testimony of Colette V. Browne
Professor, University of Hawai'i
School of Social Work

January 9, 2006

Mr. Chairman and Members of the Senate Committee on Veterans Affairs:

Thank you for the opportunity to participate in this hearing on long term care in Hawai'i, and the role of the Department of Veterans Affairs in providing this care.

Mr. Chairman, we at the School of Social Work join in welcoming you to Hawai'i.  We appreciate your leadership and your commitment to working in a bipartisan manner to better understand how to ensure that the needs of older adults, specifically veterans, are met with accessible and affordable quality of care.  I am professor and Chair of the School of Social Work's gerontology program.  For more than fifteen years, I have served as a gubernatorial appointment to the State's Policy Advisory Board for Elderly Affairs.  In this capacity, I learned a great deal from the older adults in our great State.  I also speak to you today as the proud daughter of a World War II veteran. I will speak specifically about the availability of long-term care services in Hawai'i.

Long-term care refers to a range of support services provided in a variety of home, community, and institutional settings, and coordinated to meet the needs of people of all ages with disabilities or serious or chronic illnesses.  Examples of these services range from personal assistance, transportation, home health, meals, nursing care, case management, and adult day care.  Although these services are age-irrelevant, research informs us that the primary consumers are older adults.  Nationally, nearly 45 million Americans, or one in every six, are 60 years of age and over. Most older Americans are healthy, contributory members of society.  Others, especially those over the age of 85 who compose the fastest growing cohort within the aging population, have become frail and are dependent on others for care. This dramatic shift in our nation's population has clear implications for long-term care, in part because older adults have more chronic ailments than do younger adults.  Older citizens account for almost one-quarter of hospital days in 2001, have a higher physician and hospital utilization rate, use 69 percent of home health services, and represent 83 percent of nursing home residents.

Mr. Chairman, Hawai'i has one of the nation's fastest growing aging populations.  Today, there are 120,000 citizens who are 60 and over, or 17 percent of our state's population. To put this in perspective, between 1970 and 2000, the older adult population increased by 207 percent while the total population increased by 57 percent.  Our life expectancy is greater than any other state--an average of 80 years compared to the nation as a whole at 77 years.  By 2020, an estimated 400,000 residents will be over the age of 60, composing 25% of the State's population. 

To determine what the State's needs are and may be for long-term care, researchers estimate that 15 percent of citizens have limitations or disabilities that require some form of long term care.  In Hawai'i, this is estimated to be 31,000 people. It is important to note that of this population, 82 percent have annual incomes of less than $20,000. These are individuals most at-risk of needing public support for long-term care.

Similar to her sister states, Hawai'i provides for its disabled and elderly citizens with a wide array of health and supportive care services provided in institutions, health care and social service sites, community based programs and in the home. Over the past twenty years, numerous reports and studies conducted by public and private entities have examined this issue of long term care for Hawai'i.  A review of these reports finds a great deal of agreement that the long term care system in general is:  complex and fragmented, institutionally-biased, lacking in its capacity for critical services, limited in its efforts to maximize federal funding for programs for special needs, supports and services; limited in its agency awareness; and experiencing a shortage of adequately trained professional and direct support workers, especially in rural areas of the state. 

Long-term care is not only nursing home beds, although the very frail can be found needing this level of care. According to the Health Care Association of Hawai'i, in 2003 Hawai'i had fewer than half the national average of long term care beds per 1,000 population aged 65 and over even though we have the fastest growing population in the 85 and over group.  The State's nursing facility median occupancy was 93.7 percent. This same report found that Hawai'i has the most dependent nursing facility residents as measured by higher acuity in areas such as activities of daily living, mobility and medical support requirements.  This results in the need for more resources to be utilized in these patients' care. Because of this higher acuity level of Hawaii's nursing facility resident, the average total nursing hours per patient day in Hawai'i is 4.57 compared to 3.24 hours per day on the mainland.

To finance existing services, Hawai'i relies on a mix of public and private funders and agencies, together with private and family resources.   This is similar to the rest of the nation. Projecting into the future, the Hawai'i Health Information Corporation's recent report on forecasting long-term care bed days in Hawai'i found that Hawai'i's aging population is and will continue to be a challenge for long term care service delivery as baby boomers age.  This is because older adults are much more likely to require acute care hospitalization, long-term care, home care and hospice, placing heavy demands on the Medicare and Medicaid programs. This same report found that in both rural and urban settings in Hawai'i, the increases in health care utilization are for age related disorders, such as heart disease, diabetes, cancer and stroke. In short, Hawai'i 's citizens have the greatest longevity, one of the nation's most rapidly aging populations, the most ethnically-diverse population, and, looking at Hawai'i's most frail--the oldest, sickest and most dependent nursing home population in the United States.

Here in Hawai'i, the Department of Veterans Affairs (VA) is a key government agency that provides services to veterans on all major islands.  Nationally, the Department of Veterans Affairs is responsible for providing federal benefits to veterans and their families.  The most visible of all VA benefits and services is health care, providing a wide spectrum of medical, surgical, and rehabilitative care.

Similar to all public and private agencies, the VA is challenged to meet the needs of this growing population.  Unlike other states, Hawai'i has two unique characteristics that impact the delivery of care.  First, Hawaii's island geography compounds challenges related to access and utilization of services. As an island state, travel must be by plane or boat. Second, our multicultural population is unlike any other state, with a mix of 22 percent Caucasian, 22.8 percent Hawaiian, 11.7 percent Filipino, 16.4 percent Japanese, 16.3 percent mixed, 3.1 percent Chinese, and the category of ?other" equal to 7.7 percent.  Preferences, cultural values, and practices all influence health status and choice of care.  Furthermore, eighty percent of our population resides on the island of Oahu, where most of our main government programs are provided.  The State is challenged to ensure that all of its citizens receive equal care.  In summary, Hawai'i is one of the most ethnically diverse states, has one of the fastest growing aging populations in the nation, and its unique geography lends itself to specific challenges related to access and quality care issues. 

As the nation grows older, Congress is presented with the needs of those who so well have served our nation.  In turn, the VA works to meet the needs of its constituencies by responding to recent Congressional laws and mandates within its budgeted resources.  This typically results in the prioritization of services.  Inpatient rehabilitation, community care, respite services, palliative care and nursing home care are some of the long-term care services offered to veterans through the VA.  On our neighbor islands, the VA operates community-based outpatient clinics in their attempts to meet needs.  Some services, like homemaker and adult day care, are provided under the Uniform Health benefit to all veterans. Other services, such as nursing home care, are provided under the Millennium Law by contracted community institutions to those with service-connected disabilities.

What we have learned is that veterans and non veterans appear to want the same thing when it comes to long-term care. A recent AARP study found that most adults prefer to receive care in their own home, are not confident about being able to pay for nursing home care; feel it is important for the government to help pay for long term care services, and support being able to decide about the kind of care they want to purchase. It is worth pointing out that it is not only the needs of veterans that must be considered, but those of their families, who have and continue to provide the bulk of long term care.  Services to support families, then, must be part of our mix of long-term care.

A critical need in which we at the University see the VA taking a key leadership role is the education and training of new professionals in geriatrics and gerontology. This is no small task, as the recruitment of new professionals continues to be a challenge.  The Veterans Administration fulfills a critical and valued community need in its training of future geriatricians, geriatric psychiatrists, and geriatric social workers.   

Mr. Chairman, the problems around long-term care are huge, and clearly no one agency can do it alone.  Long-term care requires collaboration. Throughout the nation, aging networks, health care providers and community services are joining together to promote and improve the well-being of older adults.  A recent report, A Strategic Plan: On Achieving Outcomes on Creating a Legacy: Healthy Aging Project (2005-2009), a partnership among the Aging Network, Department of Health, and public and private agencies here in Hawai'i, offered a blueprint for improving health of na kupuna--our elders.  This report recommended that any venture to improve the health of our elders must be community driven, inclusive, community-owned, built upon existing community assets and infrastructure to ensure long term sustainability, and use evidence-based strategies.  Ensuring the adequacy of the state's infrastructure to provide long-term care requires skilled and knowledgeable professionals and paraprofessionals committed to quality care.  From a university perspective, we remain concerned about meeting future long-term care workforce needs.  We therefore respectfully request Congressional support for the training and education of future professionals in medicine, nursing, social work and other related fields.

In closing, a recent Summit on Long-Term Care organized by the Hawai'i Institute for Public Affairs analyzed previous reports and studies, plans and data, and arrived at the following conclusion.  The need exists to build the political will and gain greater community support for the issue of long term care.  This hearing can hopefully be seen as a concrete step toward building both.

The VA provides a number of critically important services for our veterans.  Nonetheless, they face similar challenges that our state and private entities face: a growing aging population with increasing fiscal restraint. We are all here today because we understand the enormous sacrifice that our soldiers and their families make everyday to serve their country.  The question is:  Will the nation be there for our veterans with the necessary long term care services when they need us?  The mission of the VA is clear.  Have we, in turn, provided them with the requisite resources to meet this need?

I thank you for this opportunity to speak with you today, and I am happy to answer any questions.