U.S. Customs and Border Protection: Progress and Challenges in Recruiting, Hiring, and Retaining Law Enforcement Personnel

CBP is responsible for securing U.S. borders and employs nearly 45,000 law enforcement officers across its three operational components at and between U.S. ports of entry, in the air and maritime environment, and at certain overseas locations. In recent years, CBP has not attained target staffing levels for its law enforcement positions, citing high attrition rates in some locations, a protracted hiring process, and competition from other law enforcement agencies.

This statement addresses CBP's efforts to (1) recruit and more efficiently hire law enforcement applicants, and (2) retain law enforcement officers. This statement is based on a GAO report issued in June 2018 on CBP's recruiting, hiring, and retention efforts along with updates as of February 2019 on actions CBP has taken to address GAO's prior recommendation. For the previous report, GAO analyzed CBP data on recruitment efforts, hiring process steps, and retention rates; examined strategies related to these activities; and interviewed CBP officials and union groups. GAO also reviewed information on CBP actions to implement GAO's prior recommendation.

In June 2018, GAO reported that U.S. Customs and Border Protection (CBP) increased its emphasis on recruitment by establishing a central recruitment office in 2016 and increasing its participation in recruitment events, among other things. As a result, the number of applications it received for law enforcement positions across its operational components—the Office of Field Operations, U.S. Border Patrol, and Air and Marine Operations—more than tripled from fiscal years (FY) 2013 through 2017. Also, in November 2017, CBP hired a contractor to more effectively target potential applicants and better utilize data to enhance CBP's recruitment and hiring efforts. However, at the time of GAO's June 2018 report, it was too early to gauge whether the contractor would be effective in helping CBP to achieve its goal to recruit and hire more law enforcement officers.

CBP improved its hiring process as demonstrated by two key metrics—reducing its time-to-hire and increasing the percentage of applicants that are hired. As shown in the table, CBP's time-to-hire decreased from FY 2015 through 2017. CBP officials stated that these improvements, paired with increases in applications, have resulted in more hires. However, the hiring process remains lengthy. For example, in FY 2017, CBP officer applications took more than 300 days, on average, to process. Certain factors contributed to the lengthy time-to-hire, including process steps that can be challenging and time-consuming for applicants to complete—such as the polygraph exam—as well as CBP's reliance on applicants to promptly complete certain aspects of the process—such as submitting their background investigation form.

CBP enhanced its efforts to address retention challenges. However, staffing levels for law enforcement positions consistently remained below target levels. For example, CBP ended FY 2017 more than 1,100 CBP officers below its target staffing level. CBP officials cited employees' inability to relocate to more desirable locations as the primary retention challenge. CBP offered some relocation opportunities to law enforcement personnel and has pursued the use of financial incentives and other payments to supplement salaries, especially for those staffed to remote or hard-to-fill locations. However, retaining law enforcement officers in hard-to-fill locations continues to be challenging for CBP. GAO reported that CBP could be better positioned to understand its retention challenges and take appropriate action to address them by implementing a formal process for capturing information on all departing employees. In response, CBP officials reported taking steps to implement a CBP-wide exit survey and plan to analyze the results of the survey quarterly, beginning April 2019.

GAO recommended in its June 2018 report that CBP systematically collect and analyze data on departing law enforcement officers and use this information to inform retention efforts. DHS concurred, and CBP has actions planned or underway to address this recommendation.

I am pleased to be here today to discuss our work on U.S. Customs and  Border Protection’s (CBP) efforts to recruit, hire, and retain law  enforcement personnel. CBP is responsible for, among other things,  securing U.S. borders to prevent acts of terrorism and stopping the  unlawful movement of people, illegal drugs, and other contraband across  U.S. borders. To carry out these objectives, CBP employs nearly 45,000  law enforcement personnel across its three operational components—the  Office of Field Operations (OFO), U.S. Border Patrol ((Border Patrol), and  Air and Marine Operations (AMO)—at and between U.S. ports of entry, in  the U.S. air and maritime environment, and at certain overseas locations.  However, in recent years, CBP has not been able to attain its statutorily- established minimum staffing levels for its Border Patrol agent positions  or its staffing goals for other law enforcement officer positions, citing high  attrition rates in some locations, a protracted hiring process, and  competition from other federal, state, and local law enforcement  agencies. Additionally, Executive Order 13767, issued in January 2017,  called for CBP to hire 5,000 additional Border Patrol agents, subject to  available appropriations. Consistent with this directive, Border Patrol is  aiming to attain a staffing level of 26,370 Border Patrol agents (5,000  agents above the fiscal year 2016 statutorily-established level). As of  early February 2019, Border Patrol had 19,443 agents onboard, which is  6,927 agents below the target level, according to CBP.

In June 2018, we reported on the extent to which CBP has developed and  implemented an approach to recruit qualified law enforcement officers,  revised its hiring process and made efforts to more efficiently hire law  enforcement applicants, and developed and implemented an approach to  retain law enforcement officers. This statement summarizes information  from that report, as well as actions CBP has taken, as of February 2019,  to address our recommendation from the report that CBP systematically  collect and analyze data on departing law enforcement officers and use  this information to inform retention efforts. To conduct the work for our  June 2018 report, we analyzed CBP data on recruitment efforts, hiring  process steps, and retention rates and retention incentives; reviewed  documentation on CBP recruitment, hiring, and retention strategies; and  interviewed officials from CBP and each of the three operational  components. We also interviewed officials from the National Border Patrol  Council union and National Treasury Employees Union—which represent  CBP officers. For this statement, we also reviewed the November 2017  contract CBP awarded to Accenture Federal Services, LLC, to help meet  the staffing requirements outlined in Executive Order 13767 and  interviewed CBP officials responsible for managing the contract. More  detailed information on our objectives, scope, and methodology is  contained in our June 2018 report. We also reviewed information on CBP  actions to implement our prior recommendation. The work upon which  this statement is based was conducted in accordance with generally  accepted government auditing standards. Those standards require that  we plan and perform the audit to obtain sufficient, appropriate evidence to  provide a reasonable basis for our findings and conclusions based on our  audit objectives. We believe that the evidence obtained provides a  reasonable basis for our findings and conclusions based on our audit  objectives.

CBP Has Taken Steps to Improve Its Recruting and Hiring Process, but the Process Remains Lengthy

CBP Has Enhanced Its Recruitment Efforts and Applications for Law Enforcement Officer Positions Have Increased

We reported in June 2018 that CBP increased its emphasis on  recruitment by establishing a central recruitment office and increasing its  participation in recruitment events. Specifically, CBP’s recruitment budget  allocated by the centralized recruting office almost doubled, from  approximately $6.4 million in fiscal year 2015 to more than $12.7 million  in fiscal year 2017. CBP also more than tripled the total number of  recruitment events it participated in, from 905 events in fiscal year 2015 to  roughly 3,000 in both fiscal years 2016 and 2017. In addition, we reported  that CBP had increased its use of recruitment incentives for OFO  specifically from fiscal years 2015 through 2017 to help staff hard-to-fill  locations. A recruitment incentive may be paid to a newly-appointed  employee if an agency determines that a position is likely to be difficult to  fill in the absence of such an incentive. From fiscal years 2015 through  2017, OFO increased the number of recruitment incentives it paid to CBP  officers from nine incentives in two locations at a total cost of about  $77,600 to 446 incentives across 18 locations at a cost of approximately  $4.3 million. AMO and Border Patrol did not use recruitment incentives  from fiscal years 2015 through 2017.

As a result of its efforts, CBP also experienced an increase in the number  of applications it received for law enforcement officer positions across all  three operational components from fiscal years 2013 through 2017. For  example, with the exception of fiscal year 2014, applications for Border  Patrol agent positions increased every year, from roughly 27,000  applications in fiscal year 2013 to more than 91,000 applications in fiscal  year 2017. Further, during the same period, applications for CBP officer  positions increased from approximately 22,500 to more than 85,000, and  applications for AMO’s law enforcement officer positions increased from  about 2,000 to more than 5,800.

CBP’s Hiring Process Has Improved, but the Process Remains Lengthy

As we reported in June 2018, CBP’s law enforcement applicants undergo  a lengthy and rigorous hiring process that includes nearly a dozen steps,  including a background investigation, medical examination, physical  fitness test, and polygraph examination. Several of these steps can be  done concurrently—for example, CBP can begin the background  investigation while the candidate completes the physical fitness test and  medical examination process steps. Figure 1 depicts the hiring process  for Border Patrol agent and CBP officer positions.

From fiscal years 2015 through 2017, CBP generally improved its  performance in two key metrics to assess the efficiency and effectiveness  of its hiring process for law enforcement officer positions. Specifically,  CBP reduced its time-to-hire (the average number of days that elapsed  between the closing date of a job announcement and an applicant’s entry- on-duty date) and increased the percentage of applicants that are hired.  With regard to the time-to-hire metric, as shown in table 1, CBP’s time-to- hire decreased from fiscal years 2015 through 2017.

With regard to the percentage of applicants that are hired, CBP’s overall  applicant pass rate metric calculates the estimated percentage of  applicants who successfully complete the hiring process and enter on  duty. CBP data indicate that overall applicant pass rates more than  doubled for CBP officer and Border Patrol agent positions from fiscal  years 2016 through 2017. CBP officials told us that higher overall  applicant pass rates paired with recent increases in the number of  applications received by the agency are starting to result in an increase in  the number of law enforcement officers hired, as applicants complete  CBP’s hiring process and officially enter on duty. As we reported in June  2018, CBP data indicated that more law enforcement officers entered on  duty in the first half of fiscal year 2018 than entered on duty in the first  half of fiscal year 2017. Specifically, the total number of CBP officers and  Border Patrol agents that entered on duty in the first half of fiscal year  2018 increased by roughly 50 percent and 83 percent, respectively, when  compared to the same period of the prior fiscal year. Further, the total  number of AMO law enforcement officers that entered on duty in the first  half of fiscal year 2018 more than doubled from the same period of fiscal  year 2017.

As we reported in June 2018, CBP has made efforts to improve its hiring  process by revising certain aspects of the process, among other things.  According to agency officials, these efforts to streamline and improve  CBP’s overall hiring process have collectively resulted in the decreased  time-to-hire and increased overall applicant pass rates discussed above.  For example, in March 2017, CBP was granted the authority to waive the  polygraph examination for veterans who meet certain criteria, including  those who hold a current, active Top-Secret/Sensitive-Compartmented- Information clearance. Also, in April 2017, CBP received approval from  the Office of Personnel Management to use direct-hire authority for law  enforcement positions, which allows CBP to expedite the typical hiring  process by eliminating competitive rating and ranking procedures and  veterans’ preference. As of March 31, 2018, 77 CBP officers and 107  Border Patrol agents had entered on duty through this authority.

CBP has also made revisions to specific steps in its hiring process,  including the application, entrance examination, and polygraph  examination, among others. For example, in fiscal year 2016, CBP  reordered its hiring process to place the entrance examination as the first  step directly after an applicant submitted an application. Prior to this  change, CBP conducted qualification reviews on applicants to ensure  they met position requirements before inviting them to take the entrance  exam. According to CBP officials, this updated process provided  applicants with the opportunity to obtain a realistic preview of the job they  were applying for earlier in the hiring process. These officials explained  that this helps to ensure that only those applicants who are committed to  completing the hiring process and entering on duty at CBP continue  through the hiring pipeline, which may help to address high applicant  discontinue rates (e.g., roughly half of all eligible applicants in fiscal year  2015 did not take the exam). According to CBP officials, this revision also  created efficiencies as the agency no longer has to spend time and resources on completing qualification reviews for applicants who either  did not show up to take the exam or failed the exam itself.

CBP has also made several changes to its polygraph examination  process step, which has consistently had the lowest pass rate of any step  in its hiring process. For example, among other things, CBP has  increased the number of polygraph examiners available to administer the  test, according to agency officials, and was piloting a new type of  polygraph exam. According to CBP officials, the new examination focuses  on identifying serious crimes and is sufficiently rigorous to ensure that  only qualified applicants are able to pass. Preliminary data from CBP’s  pilot show that this new exam has demonstrated higher pass rates when  compared with CBP’s traditional polygraph exam while also taking less  time, on average, per test to complete. At the time of our review, it was  too early to tell if these efforts will result in improvements to the polygraph  examination step. Available CBP data indicate mixed results. Specifically,  while the average duration to complete this step decreased for all law  enforcement officer positions from fiscal years 2015 through 2017, pass  rates also declined slightly over this same period. For example, for Border  Patrol agents, the pass rate declined from 28 to 26 percent, while for CBP  officers, it declined from 32 to 25 percent.

While CBP had reduced its time-to-hire and made efforts to improve its  hiring process for law enforcement officers, CBP officials noted that the  hiring process remained lengthy, which directly affected the agency’s  ability to recruit and hire for law enforcement positions. CBP officials also  stated that their ability to further improve CBP’s time-to-hire and increase  law enforcement hires was affected by hiring process steps that can be  challenging and time-consuming for applicants to complete, as well as  CBP’s reliance on applicants to promptly complete certain aspects of the  process. In fiscal year 2017, it took an average of 274 days for Border  Patrol agent applicants and 318 days for CBP officer applicants to  complete all hiring steps and enter on duty. According to a leading  practice in hiring we identified for such positions, agencies should ensure  that the hiring process is not protracted or onerous for applicants.  According to CBP officials, the agency’s multi-step hiring process for its  law enforcement officer positions was intentionally rigorous and involves  extensive applicant screening to ensure that only qualified candidates  meet the technical, physical, and suitability requirements for employment  at CBP. Even so, CBP officials across several components told us that  the agency’s time-to-hire was too long and directly affected the  component’s ability to recruit and hire for law enforcement positions. For  example, OFO officials told us that the longer the hiring process takes to  complete, the more likely it was that an applicant will drop out. Further,  qualified applicants may also decide to apply for employment at a  competing law enforcement agency that may have a less rigorous  process than CBP’s, according to CBP officials.

One factor that affects CBP’s ability to efficiently process and onboard  law enforcement officers are specific hiring process steps that are time- consuming and challenging for candidates to complete. For example,  CBP officials cited the polygraph examination as a significant bottleneck  within CBP’s hiring process. In addition to having the lowest pass rate of  any step in CBP’s process, the polygraph examination also took CBP  officer and Border Patrol agent applicants, on average, the longest  amount of time to complete in fiscal year 2017—74 days and 94 days,  respectively. Further, CBP officials told us that these already lengthy time  frames may increase further because of the growing number of applicants  for CBP’s law enforcement positions. In addition, on average, it took CBP  law enforcement officer applicants across all three components 55 days  or more to complete the medical examination and more than 60 days to  complete the background investigation.

CBP’s Accenture Contract Is Intended to Further Enhance CBP’s Recruitment and Hiring Efforts

In November 2017, CBP hired a contractor—Accenture Federal Services,  LLC—to help the agency recruit and hire the 5,000 Border Patrol agents  called for in Executive Order 13767, as well as an additional 2,000 CBP  officers and 500 AMO personnel. Specifically, at the time of our June  2018 report, the contract had a total potential period of 5 years at a not- to-exceed value of $297 million. The contract included a base year and  four 1-year option periods, which CBP may exercise at its discretion for a  total potential period of 5 years. Under this performance-based contract,  Accenture is responsible for enhancing CBP’s recruitment efforts and  managing the hiring process for those applicants it recruits.

We reported that the Accenture contract is intended to enhance CBP’s  recruitment efforts by improving its marketing strategy and utilizing new  ways to capture and analyze data to better inform recruitment efforts,  according to CBP officials. To meet target staffing levels, CBP expected  that the contractor would augment CBP’s current hiring infrastructure  while pursuing new and innovative hiring initiatives. Specifically, the  contractor is responsible for implementing the same hiring process steps  and ensuring that all applicants recruited by Accenture meet CBP’s  standards. CBP officials also told us that Accenture has the flexibility to  pursue novel hiring tactics and pilot initiatives that CBP may not have  considered or been able to undertake. For example, Accenture plans to  pilot innovative ways to reduce the time-to-hire, including by streamlining  steps in the hiring process, which could help to improve CBP’s overall  process and generate increased hires for law enforcement positions. At  the time of our June 2018 report, some key issues were still being  negotiated between CBP and the contractor. For example, while CBP  officials told us that the main metric used to assess Accenture’s  effectiveness will be the total number of hires the contractor produces,  they were still working to finalize other key metrics for evaluating the  contractor’s effectiveness as well as an oversight plan to ensure the  contractor operates according to agency requirements. As a result, we  reported that it was too early to determine whether these initiatives would  help increase the number and quality of applicants for CBP’s law  enforcement officer positions. We also reported that it was too early to  evaluate whether the contractor would be able to efficiently and effectively  provide the surge hiring capacity CBP needs to achieve its staffing goals.

CBP Has Enhanced Its Retention Efforts, but Does Not Systematically Collect and Analyze Data on Departing Law Enforcement Personnel

Retaining Law Enforcement Officers in Hard-to-Fill Locations Has Been Challenging for CBP

In June 2018, we reported that CBP’s annual rates of attrition were  relatively low, but CBP faced challenges retaining law enforcement  officers in hard-to-fill locations. From fiscal years 2013 through 2017,  OFO’s annual attrition rates for the CBP officer position were consistent  at about 3 percent, while rates for Border Patrol agent and AMO’s Marine  Interdiction Agent positions were below 5 percent in 4 out of the 5 fiscal  years we reviewed. When we compared CBP’s annual attrition rates for  these positions to those of other selected law enforcement agencies, we  found that CBP’s attrition rates were similar to U.S. Immigration and  Customs Enforcement’s (ICE) annual attrition rates for its law  enforcement positions and generally lower than those of the Secret  Service and the Federal Bureau of Prisons. Annual attrition rates for  AMO’s aviation positions were higher, ranging from 5.0 percent to 9.2  percent for the Air Interdiction Agent position and 7.8 percent to 11.1  percent for the Aviation Enforcement Agent position. Even so, fiscal years  2015 through 2017, attrition rates for these positions have generally  remained lower than those of the Secret Service and the Bureau of  Prisons.

In addition, from fiscal years 2013 through 2017, CBP’s ability to hire  more law enforcement officers than it lost varied across positions.  Specifically, CBP consistently hired more CBP officers and Aviation  Enforcement Agents than it lost. Further, while CBP generally maintained  its staffing levels for Marine Interdiction Agents, the agency consistently  lost more Border Patrol agents and Air Interdiction Agents than it hired.  Even so, onboard staffing levels for all five of CBP’s law enforcement  officer positions have consistently remained below authorized staffing  levels.

CBP has acknowledged that improving its retention of qualified law  enforcement personnel is critical in addressing staffing shortfalls, but CBP  officials identified difficulties in retaining key law enforcement staff as a  result of geographically-remote and hard-to-fill duty locations. CBP  officials across all three operational components cited location—and  specifically employees’ inability to relocate to posts in more desirable  locations—as a primary challenge facing the agency in retaining qualified  personnel.

Border Patrol officials explained that duty stations in certain remote  locations present retention challenges due to quality-of-life factors. For  example, the officials told us that agents may not want to live with their  families in an area without a hospital, with low-performing schools, or with  relatively long commutes from their homes to their duty station. Border  Patrol’s difficulty in retaining law enforcement staff in such locations is  exacerbated by competition with other federal, state, and local law  enforcement organizations for qualified personnel. According to Border  Patrol officials, other agencies are often able to offer more desirable duty  locations—such as major cities—and, in some cases, higher  compensation.

CBP data indicate that Border Patrol agents consistently leave the  component for employment with other law enforcement agencies,  including OFO as well as other DHS components such as ICE. For  example, while retirements accounted for more than half of annual CBP  officer losses from fiscal years 2013 through 2017, they accounted for  less than a quarter of annual Border Patrol agent losses, indicating that  the majority of these agents are not retiring but are generally leaving to  pursue other employment. Further, according to CBP data, the number of  Border Patrol agents departing for employment at other federal agencies  increased steadily, from 75 agents in fiscal year 2013 to 348 agents in  fiscal year 2017—or nearly 40 percent of all Border Patrol agent losses in  that fiscal year. Border Patrol officials told us, for example, that working a  standard day shift at ICE in a controlled indoor environment located in a  major metropolitan area for similar or even lower salaries presents an  attractive career alternative for Border Patrol agents who often work night  shifts in extreme weather in geographically remote locations. The  President of the National Border Patrol Council also cited this challenge,  stating that unless Border Patrol agents have a strong incentive to remain  in remote, undesirable locations—such as higher compensation when  compared with other law enforcement agencies—they are likely to leave  the agency for similar positions located in more desirable locations.

While OFO officials told us the component did not face an across-the- board challenge in retaining CBP officers, they have had difficulty  retaining officers in certain hard-to-fill locations that may be  geographically remote or unattractive for families, such as Nogales,  Arizona, and San Ysidro, California. As a result, CBP officer staffing  levels in these locations have consistently remained below authorized  targets.

AMO has also had difficulty retaining its law enforcement personnel—and  particularly its Air Interdiction Agent staff—in hard-to-fill locations, such as  Aguadilla, Puerto Rico, and Laredo, Texas. However, given the unique  qualifications and competencies required for the Air Interdiction Agent  position, AMO does not compete with other law enforcement  organizations. Instead, AMO officials told us they compete with the  commercial airline industry for qualified pilots. Specifically, they stated  that this competition is exacerbated by a nationwide shortage of pilots. In  addition, AMO officials explained that there is a perception among  applicants that commercial airlines are able to offer pilots more desirable  locations and higher compensation. However, they told us that AMO  generally provided pilots with higher starting salaries than many regional  airlines as well as most career options available to helicopter pilots.

CBP Has Taken Steps to Address Retention Challenges

All three CBP operational components have taken steps to retain qualified  law enforcement personnel by offering opportunities for employees to  relocate to more desirable locations and pursuing the use of financial  incentives, special salary rates, and other payments and allowances.

Relocation opportunities. Border Patrol, OFO, and AMO have formal  programs that provide law enforcement officers with opportunities to  relocate. For example, in fiscal year 2017, Border Patrol implemented its  Operational Mobility Program and received initial funding to relocate  about 500 Border Patrol agents to new locations based on the  component’s staffing needs. According to Border Patrol officials, retaining  current employees is a top focus for leadership at the component and this  program provides Border Patrol agents with opportunities for a paid  relocation to a more desirable location at a lower cost to CBP than an  official permanent change of station transfer. As of April 2018, Border  Patrol officials told us that 322 Border Patrol agents had accepted  reassignment opportunities through the program and the component  hoped to continue receiving funding to provide these opportunities.

Financial Incentives and Other Payments and Allowances. CBP’s  three operational components have also taken steps to supplement  employees’ salaries through the use of human capital flexibilities—such  as retention and relocation incentives and special salary rates—as well as  other payments and allowances. CBP’s goal in pursuing these human  capital flexibilities is to retain current employees—especially in remote or  hard-to-fill locations—who are likely to internally relocate within CBP to  more desirable duty locations or depart the agency for similar positions at  other law enforcement organizations or commercial airlines.

However, we found that from fiscal years 2013 through 2017, CBP’s use  of such financial incentives and other payments was limited, as the  agency paid a total of four retention incentives and 13 relocation  incentives, and implemented one special salary rate for all positions  during this 5-year period. From fiscal years 2013 through 2017, Border  Patrol did not offer retention incentives to agents and paid two relocation  incentives to transfer Border Patrol agents to Artesia, New Mexico, and  Washington, D.C., at a cost of roughly $78,000. However, in fiscal year  2018, Border Patrol increased its use of relocation incentives to facilitate  the transfer of agents to duty stations along the southwest border that are  less desirable due to the remoteness of the location and lack of basic  amenities and infrastructure. Specifically, as of April 2018, 67 Border  Patrol agents had received such incentives to relocate to duty stations in  Ajo, Arizona; Calexico, California; and Big Bend, Texas; among others.

While Border Patrol did not offer retention incentives during our review  period, it submitted a formal request to CBP leadership in February 2018  for a 10 percent across-the-board retention incentive for all Border Patrol  agents at the GS-13 level and below, which represents the majority of the  component’s frontline workforce. According to Border Patrol  documentation, these incentives, if implemented, could help reduce  Border Patrol’s attrition rate—which has consistently outpaced its hiring  rate—by helping retain agents who may have otherwise left Border Patrol  for similar positions in OFO, ICE, or other law enforcement agencies.  According to CBP officials, as of April 2018, CBP leadership was  evaluating Border Patrol’s group retention incentive request, including the  costs associated with implementing this 10 percent across-the-board  incentive. In addition, as the incentive would benefit Border Patrol agents  in all of the component’s duty locations, the extent to which this effort  would be effective in targeting agent attrition in the remote locations that  represent CBP’s largest staffing challenges remains to be seen. Border  Patrol approved the 10 percent retention incentive and is awaiting funding  for implementation, according to officials.

From fiscal years 2013 through 2017, OFO paid a total of four retention  incentives at a cost of $149,000 to retain CBP officers in Tucson, Arizona;  Detroit, Michigan; Carbury, North Dakota; and Laredo, Texas. Further,  OFO paid seven relocation incentives at a cost of approximately  $160,000 to relocate personnel to the hard-to-fill ports of Alcan and  Nome, Alaska; Coburn Grove, Maine; and Detroit, Michigan. One OFO  official told us OFO did not regularly use these incentives because its  relatively low annual attrition rates make it difficult to propose a  persuasive business case to CBP leadership that such incentives are  necessary. Further, another OFO official explained that OFO’s strategy is  focused on using recruitment incentives to staff hard-to-fill locations with  new employees.

From fiscal years 2013 through 2017, AMO did not offer retention  incentives to law enforcement personnel and paid a total of four relocation  incentives to transfer three Air Interdiction Agents and one Marine  Interdiction Agent to Puerto Rico at a cost of approximately $84,000.  However, AMO has taken steps to pursue additional human capital  flexibilities to address its difficulty in retaining Air Interdiction Agents,  including a group retention incentive and a special salary rate.

CBP Does Not Have a Systematic Process to Capture and Analyze Data on Departing Law Enforcement Officers

In June 2018, we reported that CBP does not have a systematic process  for capturing and analyzing information on law enforcement officers who  are leaving, such as an exit interview or survey. As a result, the agency  does not have important information it could use to help inform future  retention efforts. Standards for Internal Control in the Federal  Government states that management should obtain relevant data from  reliable sources and process these data into quality information to make  informed decisions in achieving key objectives.  Taking steps to ensure  that the agency’s operational components are systematically collecting  and analyzing complete and accurate information on all departing law  enforcement officers—including the factors that influenced their decision  to separate—would better position CBP to understand its retention  challenges and take appropriate action to address them. We  recommended that CBP should ensure that its operational components  systematically collect and analyze data on departing law enforcement  officers and use this information to inform retention efforts. CBP agreed  with the recommendation. CBP officials reported in February 2019 that  they developed and implemented a CBP-wide exit survey in August 2018  and have taken steps to promote the survey and encourage exiting CBP  employees to fill it out. The officials also noted that they plan to analyze  the survey results on a quarterly basis starting in April 2019. These  actions, if fully implemented, should address the intent of our  recommendation.

Chairwoman Torres Small, Ranking Member Crenshaw, and Members of  the Subcommittee, this completes my prepared statement. I would be  happy to respond to any questions you or the members of the committee  may have.

If you or your staff have any questions about this statement, please  contact Rebecca Gambler at (202) 512-8777 or gamblerr@gao.gov.  Contact points for our Offices of Congressional Relations and Public  Affairs may be found on the last page of this statement.

GAO staff who made key contributions to this testimony are Adam  Hoffman (Assistant Director), Bryan Bourgault, Sasan J. “Jon” Najmi, and  Michelle Serfass.

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U.S. Customs and Border Protection employs about 45,000 law enforcement personnel. Its duties include stopping the unlawful movement of people and drugs across U.S. borders.

CBP has not been able to hire and retain its required number of Border Patrol agents or meet its goals for other law enforcement jobs.

This testimony addresses its recruitment, hiring, and retention efforts, including our earlier recommendation to gather better data on why agents left.

Increased recruitment. Agent applications more than tripled from 2013 to 2017

Faced challenges retaining officers in hard-to-fill locations


VA Health Care: Veterans' Use of Long-Term Care Is Increasing, and VA Faces Challenges in Meeting the Demand

Veterans rely on long-term care to address a broad spectrum of needs, from providing occasional help around the house to daily assistance with eating or bathing to round-the-clock clinical care. Veterans' eligibility for this care is primarily based on their service-connected disability status, among other factors. Congress included a provision in statute for GAO to review VA's long-term care programs. This report (1) describes the use of and spending for VA long-term care and (2) discusses the challenges VA faces in meeting veterans' demand for long-term care and examines VA's plans to address those challenges. GAO reviewed VA documents, such as strategic planning documents for long-term care programs and analyzed VA utilization and expenditure data for fiscal years 2014 through 2018 (the latest available at the time of the review) and projected data through 2037. GAO also interviewed officials from VA, including officials from VA's GEC, which is responsible for overseeing long-term care programs; and from Veterans Service Organizations.

The Department of Veterans Affairs (VA) provides or purchases long-term care for eligible veterans through 14 long-term care programs in institutional settings like nursing homes and noninstitutional settings like veterans' homes. From fiscal years 2014 through 2018, VA data show that the number of veterans receiving long-term care in these programs increased 14 percent (from 464,071 to 530,327 veterans), and obligations for the programs increased 33 percent (from $6.8 to $9.1 billion). VA projects demand for long-term care will continue to increase, driven in part by growing numbers of aging veterans and veterans with service-connected disabilities. Expenditures for long-term care are projected to double by 2037, as shown below. According to VA officials, VA plans to expand veterans' access to noninstitutional programs, when appropriate, to prevent or delay nursing home care and to reduce costs.

VA currently faces three key challenges meeting the growing demand for long-term care: workforce shortages, geographic alignment of care (particularly for veterans in rural areas), and difficulty meeting veterans' needs for specialty care. VA's Geriatrics and Extended Care office (GEC) recognizes these challenges and has developed some plans to address them. However, GEC has not established measurable goals for these efforts, such as specific staffing targets for programs with waitlists or specific targets for providing telehealth to veterans in rural areas. Without measurable goals, VA is limited in its ability to address the challenges it faces meeting veterans' long-term care needs.

GAO is making three recommendations, including that VA develop measurable goals for its efforts to address key challenges in meeting the demand for long-term care. VA concurred with GAO's recommendations and identified actions it will take to implement them.

Veterans—like millions of other Americans—rely on long-term care to  help meet their health or personal care needs for either discrete or  sustained periods of time. Long-term care can address a broad spectrum  of needs, from providing occasional help around the house to daily  assistance with eating or bathing to extensive, round-the-clock clinical  care. In fiscal year 2018, the Department of Veterans Affairs (VA)  provided or paid for long-term care for over 500,000 veterans through 14  long-term care programs. Most veterans receive long-term care through  noninstitutional programs in their homes or communities, while others  receive more extensive care in institutional programs such as nursing  homes. Veterans’ needs for long-term care vary, and VA Medical Centers  (VAMC) help veterans and their families decide which programs may best  meet an individual veteran’s needs.

As one of the largest health care systems in the United States, VA faces  challenges similar to other health care providers when seeking to meet  the growing need for long-term care as the U.S. population ages. For  example, we have previously reported on workforce shortages in key  positions—such as nationwide shortages of nursing assistants and home  health aides—that are critical for supporting long-term care programs.  VA recognizes it faces challenges meeting the demand for long-term care  and has taken some steps to address these challenges in its strategic  planning process. For example, according to 2019 strategic planning  documents, VA has pursued funding to expand some of the long-term  care services accessible to veterans through telehealth.

The John S. McCain National Defense Authorization Act for Fiscal Year  2019 included a provision that we review the availability of VA’s long-term  care programs for veterans, including future demand for, and VA’s  capacity to provide, this care. This report (1) describes the use of and  spending for VA long-term care, and (2) discusses the challenges VA  faces to meet veterans’ demand for long-term care and examines VA’s  plans to address those challenges.

To describe the use of and spending for VA long-term care, we obtained  and analyzed VA data and documents on the long-term care programs  that are overseen by VA’s Geriatrics and Extended Care office (GEC),  and we interviewed VA officials about these programs. Specifically, we  reviewed VA data on the utilization of and obligations for long-term care  programs for fiscal years 2014 through 2018 (the latest complete fiscal  year data available at the time of our review) and projections of utilization  and expenditures developed by VA’s Enrollee Health Care Projection  Model (EHCPM) for fiscal years 2017 through 2037. For both time  periods, VA’s utilization data describe the workload units associated with  providing long-term care. (These workload units may differ by program,  such as the average daily census of veterans receiving care in  institutional programs, or the number of community care visits provided by  organizations that VA pays to provide care to veterans in noninstitutional  programs.) We also obtained and analyzed VA data on the number of  veterans who received care in VA’s long-term care programs for fiscal  years 2014 through 2018—including data on the number of unique  veterans who received long-term care and specific characteristics such as  the number of veterans who served after September 11, 2001 who  utilized these VA programs.

In terms of spending, VA reports information on its obligations, which  refer to a definite commitment that creates a legal liability of the  government to make a payment immediately or in the future; these  obligations are incurred, for example, when the agency signs a contract,  awards a grant, or purchases services. The EHCPM projects future  expenditures, which refer to the actual spending of money to liquidate a  federal obligation. Therefore, we report obligations for long-term care for  fiscal years 2014 through 2018 and we report VA’s EHCPM projections of  expenditures for long-term care for fiscal years 2017 through 2037. We  interviewed VA officials about all the data we reviewed, including officials  from GEC and from VA’s Office of Enrollment and Forecasting, and  reviewed related documents about VA’s long-term care programs. Based  on our review of the data and documents, interviews with knowledgeable  officials, and comparisons to other published reports, we determined the  VA data were sufficiently reliable for our purposes of describing trends in  the utilization of and spending for VA long-term care.

To discuss the challenges VA faces to meet veterans’ demand for long- term care and examine VA’s plans to address those challenges, we  reviewed relevant VA documents and interviewed VA officials about VA’s  capacity to provide long-term care, including those from GEC and those  from the Office of Policy and Planning responsible for strategic planning.  Relevant documents we reviewed included VA policies, a 2018-2024  strategic planning document from VA, a 2018-2019 strategic planning  document from the Veterans Health Administration (VHA), a 2019  strategic planning document from GEC, and internal reports. For  example, we reviewed how VA and VHA’s strategic goals related to long- term care were represented in GEC’s strategic planning documents, and  we reviewed a June 2019 report from VA’s Healthcare Analysis and  Information Group, a research group within VA, summarizing the results  of its survey of VAMCs on long-term care issues. We also reviewed  relevant articles and reports on long-term care challenges outside of VA  to put VA’s challenges in context. Further, we interviewed officials from  four Veterans Service Organizations to gather their perspectives on VA’s  long-term care programs. We examined VA’s plans to address challenges  to meet veterans’ demand for long-term care against relevant criteria from  GAO’s body of work on effectively managing performance under the  Government Performance and Results Act of 1993 (GPRA), as enhanced  by the GPRA Modernization Act of 2010, VA performance goals, and in  the context of federal standards for internal controls related to the  remediation of deficiencies and the timeframes for correcting  deficiencies.

We conducted this performance audit from April 2019 to December 2019  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

For many veterans, long-term care is provided directly or purchased by  VA. VA provides or pays for long-term care for eligible veterans enrolled  in VA’s health care through a variety of programs, including institutional- based care like nursing homes and noninstitutional programs like home  health care, which provides care to veterans in their own homes.

VA provides or pays for long-term care—ranging from assistance with  dressing and bathing to clinical care for spinal injuries or dementia— through a range of three institutional and 11 noninstitutional programs.  Institutional programs, such as nursing homes, typically provide more  acute skilled nursing care in a residential facility; noninstitutional  programs, such as the Home-Based Primary Care program, provide care  to veterans in their homes or communities. (See fig. 1 for a list of VA’s  institutional and noninstitutional long-term care programs and app. I for  brief descriptions of these programs.)

Institutional Programs. VA provides or pays for eligible veterans to  receive long-term care in three institutional programs that primarily  provide skilled nursing care, such as for rehabilitation after surgery or for  health issues or disabilities that require 24-hour care in a residential  facility. These three programs include: VA Community Living Centers  (VA-owned and -operated), Community Nursing Homes (publicly or  privately owned and under contract with VA), and State Veterans Homes  (state-owned and -operated homes approved and supported by VA).

Noninstitutional Programs. VA provides or pays for eligible veterans to  receive noninstitutional long-term care through 11 home or community- based programs, where most veterans receive long-term care. Several of  VA’s noninstitutional programs provide personal care assistance to help  veterans with activities of daily living—e.g., dressing, eating, bathing— that enable veterans to remain living at home, including the Homemaker  Home Health Aide, Community Adult Day Health Care, and Respite Care  programs. VAMCs evaluate veterans to determine the extent to which  they can perform activities of daily living and to identify the available  programs that would best meet their needs. In addition, VA’s  noninstitutional programs include the Community Residential Care  program where caregivers—in settings such as Medical Foster Homes  where no more than three residents receive care—provide 24 hour care  for veterans who cannot live alone because of medical or mental health  conditions.

Several of VA’s long-term care programs serve veterans with special  needs. For example, some of these programs, such as certain  Community Nursing Homes, Adult Day Health Care, and Hospice and  Respite Care programs, have specially trained staff to serve veterans with  dementia. The Spinal Cord Injury and Disability Home Care program and  certain VA Community Living Centers are equipped to serve veterans  needing ventilator care. In addition, some programs offer specific services  for younger veterans, such as certain Adult Day Health Care programs.

Eligibility for and Placement into VA Long- Term Care Programs

All veterans enrolled in the VA health care system are eligible for VA’s  basic medical benefits package, which includes certain institutional and  noninstitutional long-term care services. A veteran’s eligibility for fully or  partially covered nursing home care is determined by the veteran’s  priority for care, which is generally based on the veteran’s service- connected disability status. Specifically, VA must cover the full cost of  nursing home care for veterans who need this care for a service- connected disability and for veterans with service-connected disabilities  rated at 70 percent or more. To the extent resources allow, VA may  cover this nursing home care for certain other veterans, such as former  prisoners of war and those awarded the Purple Heart. For all other  veterans, VA may generally cover nursing home care to the extent  resources and capacity allow and with the veteran’s agreement to share  certain costs.

Veterans’ placement in any particular institutional or noninstitutional long- term care program may depend on their clinical needs, disability ratings,  preferences, and the availability of VA programs. When funds are limited,  the agency may prioritize program placement based on veterans’ service- connected disability ratings. Decisions about which long-term care  programs may be the best fit are made at the VAMC level between VA  providers, veterans, and their families. VA providers may discuss a range  of factors when making decisions about this care, such as health needs,  the type of care provided in different programs, space availability,  eligibility, and the veteran’s geographic preference. For facility-based  programs, VAMC staff may also encourage veterans to take a tour of the  prospective home. VA’s stated goal is to honor veterans’ preferences for  care, including finding ways for veterans to age in their homes and  communities instead of nursing homes.

Selected Demographics of Veterans in Long-Term Care

A diverse set of veterans receive care in VA’s long-term care programs.  According to VA data for fiscal year 2018, 70 percent (370,821) of the  veterans who received VA long-term care during the fiscal year were  aged 65 or older. (See fig. 2.) In addition, 91 percent (480,299) of those  who received this care had served in the military prior to September 11,  2001. Lastly, according to VA data for fiscal year 2018, 55 percent  (291,197) of veterans receiving long-term care had some level of service- connected disabilities.

VA’s planning for veterans’ long-term care is informed by broader  strategic planning by VA and the VHA and then operationalized by GEC  at the program level. Veterans Integrated Service Networks (VISN) then  implement GEC strategies for their regions and VAMCs implement and  manage the various programs.

VA, through the Assistant Secretary for Enterprise Integration’s office,  sets a strategic plan that identifies agency-wide goals. For example,  VA’s fiscal year 2018 through 2024 strategic plan identifies a goal that  veterans “choose VA for easy access, greater choices, and clear  information to make informed decisions,” and the plan notes that VA  should “understand veterans’ needs throughout their lives to enhance  their choices and improve customer experiences.”  VA develops its  agency-wide strategic plan every four years.

VHA, through its Office of Policy and Planning, identifies strategies  within VA’s health care system to address VA’s agency-wide goals.  For example, VHA’s fiscal year 2018 through 2019 strategy,  operationalizing VA’s goal for veteran choice, is to “honor veterans’  preferences by offering home and community based care to prevent  unwanted nursing home care.” VHA strategic planning occurs every  two years according to VA officials.

VHA’s Office of Enrollment and Forecasting uses the EHCPM to  project the utilization of and cost for care across most of VA’s health  care programs 20 years into the future, including most long-term care  programs.

GEC’s strategic planning operationalizes VA and VHA goals and  strategies for long-term care at the program level. For example, to  achieve VA’s goal of veteran choice and VHA’s strategy of honoring  veteran preferences, GEC developed a model to identify veterans at  the highest risk of needing nursing home care. According to GEC  officials, the GEC strategic planning process generally occurs  annually.

VISNs are responsible for managing and overseeing VAMCs within  their regions where long-term care is delivered, with a GEC point of  contact at each VISN who can address GEC issues as they arise,  according to VA officials.

VAMCs within each VISN are, according to VA officials, responsible  for the management of individual long-term care programs, including  oversight of long-term care programs’ quality of care. As previously  noted, VAMCs also have a role in guiding decisions about individual  veterans’ long-term care placement.

Other health care systems nationwide are also planning to meet the  growing demand for long-term care and have developed strategies to  address future long-term care challenges. For example, some state  agencies, which provide long-term care through Medicaid, have  developed strategies to help aging citizens live in their communities by  enhancing community-based services and developing the workforce to  provide care. VA has a federal Geriatrics and Gerontology Advisory  Group to share knowledge with other long-term care providers and to  advise the Secretary and Under Secretary for Health on all matters  related to geriatrics and gerontology for the care of veterans.

Utilization of and Spending for VA Long-Term Care Have Increased in Recent Years and Are Projected to Increase

Utilization of VA Long- Term Care Increased from Fiscal Years 2014 through 2018

Our analysis of VA data shows that the number of veterans receiving care  in one or more of the VA long-term care programs increased 14 percent  from fiscal years 2014 through 2018, from 464,071 to 530,327 veterans.  The data also show that utilization increased more for noninstitutional  programs than for institutional programs. Specifically by program type, VA  data show that the number of veterans receiving institutional long-term  care increased 8 percent during these years, from 97,124 to 105,151,  while the number receiving noninstitutional care increased 16 percent,  from 395,736 to 459,783. VA officials told us that the agency is  continuing to expand veterans’ access to noninstitutional care programs  because institutional care is more costly than home- or community-based  care, and because veterans prefer to delay or reduce the amount of  nursing home care they receive.

Our analysis showed that utilization of long-term care—in terms of various  VA workload units—also generally increased from fiscal years 2014  through 2018.

The average daily census increased for two of VA’s three institutional  programs—Community Nursing Homes increased by 26 percent from  7,771 to 9,808 and State Veterans Homes increased by 1 percent  from 23,176 to 23,423.

Five of the 11 noninstitutional programs experienced increases in their  workload over this period, ranging from 8 percent to 48 percent. For  example, the number of VA clinic stops (one type of VA workload unit)  in the Homemaker Home Health Aid program—which served  approximately 23 percent of the veterans receiving noninstitutional  long-term care in fiscal year 2018—increased 48 percent from 8.3  million to 12.3 million clinic stops. (See app. II for more information on  veterans’ utilization of institutional and noninstitutional long-term care  by program.)

According to VA, veterans’ use of VA long-term care programs increased  during fiscal years 2014 through 2018 for several reasons, including that  a large number of Vietnam veterans are aging and that more veterans are  receiving higher service-connected disability ratings. We found the  number of veterans who served on or after 9/11 and received VA long- term care to have increased at a faster rate than the overall number of  veterans who received this care, from fiscal year 2014 through 2018.

VA Spending for Long- Term Care Increased 33 Percent from Fiscal Years 2014 through 2018

Our analysis of VA data shows that VA’s spending for long-term care— which VA reports as obligations—increased 33 percent, from $6.8 billion  in fiscal year 2014 to $9.1 billion in fiscal year 2018. Furthermore, over  this time period institutional program obligations declined as a proportion  of total obligations, from 74 percent to 67 percent, while the proportion of  noninstitutional program obligations rose from 26 percent to 33 percent.  (See fig. 3.)

Looking at VA’s three institutional programs, our analysis shows VA’s  obligations for these programs increased 21 percent from fiscal years  2014 through 2018, from $5.0 billion to $6.1 billion. The highest share of  obligations for institutional care over this time period was for the VA  Community Living Centers program, which increased 11 percent, from  $3.3 billion to $3.7 billion. This percentage increase was less than the  increases for the Community Nursing Homes program (49 percent) and  the State Veterans Homes program (33 percent); however, costs for  these last two programs are significantly lower than for the other  institutional program.

VA obligations for its 11 noninstitutional long-term care programs  increased 66 percent, from $1.8 to $2.9 billion, between fiscal years 2014  and 2018. Noninstitutional programs with the highest share of  obligations during that period included the Homemaker Home Health  Aide, Home-Based Primary Care, Purchased Skilled Home Care, and  Home Telehealth programs. Noninstitutional programs with the highest  obligation increases included the Homemaker Home Health Aide (109  percent) and Purchased Skilled Home Care (164 percent) programs.  However, two noninstitutional programs saw obligations decline during  these years, including the State Home Adult Day Health Care program  with a 59 percent decrease, and the Community Residential Care  program with a 10 percent decrease. (See app. II for more information  on VA’s obligations for institutional and noninstitutional long-term care by  program.)

VA Projects Utilization of VA Long-term Care to Increase from Fiscal Years 2017 through 2037

VA projects utilization of long-term care will increase for most of the  programs included in VA’s EHCPM from fiscal years 2017 through  2037.

For the two institutional programs included in the EHCPM, VA projects  that utilization based on workload units (average daily census) will  increase by 80 percent for the Community Nursing Homes program  but will decrease by 10 percent for the Community Living Centers  program.

For the 10 noninstitutional programs included in the EHCPM, VA  projects that utilization based on workload units (which differ by  program) will increase for nine of the 10 programs—with increases  ranging from 1 percent to 95 percent. For example, the number of VA  clinic stops for the Homemaker Home Health Aide program is  projected to increase 84 percent. (See app. III for more information on  projected utilization for institutional and noninstitutional long-term care  by program.)

VA reports that these projections are based on expected increases in the  number of veterans who will rely on VA for their long-term care needs  through fiscal year 2037. According to VA officials, these projected  increases are due to a variety of factors, including that VA plans to  continue expanding the availability of home- and community- based care,  and plans to provide care to an increasing number of aging veterans and  veterans rated in the highest service-connected disability groups. For  example, VA data show that the proportion of long-term care provided to  veterans with service-connected disabilities is projected to increase from  60 percent to 78 percent of utilization from fiscal year 2017 to 2037, and  the proportion of this care provided to post-9/11 deployed combat  veterans is projected to increase from 1 percent to 6 percent of all long- term care utilization during these years. Further, VA officials told us that  the agency has planned to expand veterans’ access to noninstitutional  care when appropriate, and they have integrated these assumptions into  the EHCPM.

VA Projects Expenditures for Long-Term Care to Increase from Fiscal Year 2017 through 2037, with Noninstitutional Programs Accounting for an Increased Share of Expenditures

VA projects that increases in overall demand for long-term care for  veterans will result in future expenditure increases for the programs  included in VA’s EHCPM. Specifically, VA’s model projects expenditures  will more than double from fiscal years 2017 through 2037, increasing  from $6.9 billion to $14.3 billion (107 percent). VA projects that its  expenditures for its institutional programs will be higher than for its  noninstitutional programs, reaching $7.5 billion and $6.8 billion,  respectively, by fiscal year 2037. However, VA also projects that the  proportion of expenditures for institutional long-term care will decrease  from 63 percent to 53 percent, as the share for noninstitutional programs  increases. (See fig. 4.)

While VA expenditures are projected to increase for all long-term care  programs included in the EHCPM from fiscal years 2017 through 2037,  the size of these projected increases vary by program. For example, VA  projects its expenditures for institutional programs to increase 71 percent  overall over this time period, with the VA Community Living Centers  program projected to increase 50 percent and the Community Nursing  Homes program to increase 149 percent. VA projects that its  expenditures for noninstitutional programs will increase 168 percent over  this time, with the largest projected increases including the Community  Adult Day Health Care (240 percent), Home Respite Care (231 percent),  and the Homemaker Home Health Aide (212 percent) programs. (See  app. III for more information on projected expenditures for institutional  and noninstitutional long-term care by program.)

The projected expenditures for care provided to veterans with service- connected disabilities are projected to represent a growing percent of  VA’s long-term care expenditures, increasing from 64 percent to 79  percent of expenditures for this care from fiscal years 2017 through 2037.  VA projects that its expenditures for care provided to veterans with  service-connected disabilities will increase 156 percent during this period,  from $4.4 billion to $11.3 billion, while expenditures for care provided to  veterans without service-connected disabilities will increase only 19  percent, from $2.5 billion to $3.0 billion. In addition, VA projects that the  proportion of spending for long-term care provided to post-9/11 deployed  combat veterans will rise from 1 percent to 7 percent during these years,  from $89 million to $981 million, as that cohort of veterans ages.

VA Has Identified Several Key Challenges to Meeting the Demand for Long-Term Care, but Lacks Measurable Goals for Addressing Them

As VA works to meet veterans’ growing demand for long-term care, it  faces a number of key challenges: workforce shortages, geographic  alignment of care, and difficulty meeting veterans’ needs for specialty  care. (See table 1.) These challenges, which VA has identified, are similar  to challenges faced by other health care systems. However, while VA’s  GEC—the office that manages VA long-term care programs—is aware of  these challenges, as of November 2019 GEC’s strategic planning has not  identified measurable goals for addressing them.

Addressing workforce shortages. According to VA, the agency  faces challenges hiring the staff needed to meet veterans’ demand for  long-term care, a challenge that is likely to grow as demand for care is  projected to increase in coming years. We have previously reported  on workforce shortages in key positions—such as nursing assistants  and home health aides—that are critical for supporting long-term care  programs and affect health care systems beyond VA. Within VA, the  Healthcare Analysis and Information Group (HAIG) report found that  80 percent of VA community living centers had, at the time of the  report, current vacancies for nursing assistant or health technician  positions. These workforce challenges have led to waitlists for some  long-term care programs. For example, VA officials told us staffing  challenges were the key factor creating a waitlist of 1,780 veterans for  the Home-Based Primary Care program. (The HAIG report found 65  percent of VA facilities cited staffing as a barrier to expanding Home- Based Primary Care.) GEC officials recognize these workforce  challenges and told us they have developed some workforce  strategies such as offering geriatrics training to rural primary care  providers through GEC’s Geriatric Scholars Program.

Aligning care geographically. According to VA, the agency faces  challenges aligning its provided or purchased long-term care with  where veterans live. VA data show that 2.8 million VA-enrolled  veterans lived in rural areas as of 2018, and that veteran populations  have shifted to different geographic regions. Providing long-term care  in rural areas is a challenge experienced by other health care  systems; for example, a report from the Rural Policy Research  Institute identified challenges with providing long-term care in rural  areas, including “more limited access to services and support” and the  “absence of an adequate workforce and infrastructure.” VA officials  also told us that veterans moving from one region to another presents  demand and capacity challenges. For example, officials told us that  veterans have moved away from the Northeast and to the South, and  that VA now has too many long-term care beds in the Northeast and  too few in the South. VA officials acknowledged the challenge of  aligning care with where veterans live and pointed to telehealth,  where veterans can receive care remotely, and to Veteran Directed  Care program, which provides veterans with a budget to manage their  own care, as approaches that could provide care to veterans in rural  areas with limited access to VA provided or purchased care. GEC  officials have also identified potential strategies to address the issue;  for example, GEC’s strategic planning includes a proposal to expand  telehealth geriatrics services to reach more veterans, although  officials told us this effort is currently unfunded. Further, VA officials  from the Office of Policy and Planning said an ongoing market  assessment project will provide information that will help VA align its  provided and purchased care with where veterans live to better meet  veteran needs.

Meeting needs for specialty care. According to VA, the agency  faces challenges meeting some specialty care needs for veterans in  long-term care. Specifically, it can be difficult to find appropriate long- term care settings for veterans with dementia, behavioral issues, and  for veterans requiring a ventilator. Meeting specialty care needs is  also a challenge for other health care systems; for example, a 2017  study from the RAND Corporation found that the U.S. health system  does not have sufficient capacity to care for a growing number of  people with Alzheimer’s disease. Challenges in providing this type of  care are not new for VA. For example, in 2013 we reported that VA  officials told us that while “in certain geographic areas [community  living centers] provide certain services that are not available in the  community, such as dementia care, behavioral health services, and  care for ventilator-dependent residents,” in other areas “these  specialized services might not be available in a [community living  center] and instead might be available at a community nursing  home.” As previously mentioned, VA has developed some programs  to provide specialty care (e.g. VA’s Spinal Cord Injury and Disability  Care program and the agency’s efforts to educate home caregivers on  how to better serve veterans with dementia).

While GEC recognizes and has taken some steps to address the  challenges it faces in meeting the demand for long-term care, our review  of GEC’s most recently approved strategic planning document from  March 2019 shows that GEC has not established measurable goals for its  efforts to address these three key challenges.

GEC has not established measurable goals for its efforts to address  workforce shortages, such as specific staffing targets necessary to  address the waitlist for the Home-Based Primary Care program, or  defining the number of rural providers it expects to train through the  Geriatrics Scholar program.

GEC has not established measurable goals for its efforts to address  the geographic alignment of care, such as specific targets for  providing long-term care within the Home Telehealth and Veteran  Directed Care programs.

GEC has not established measurable goals for its efforts to address  difficulties meeting veterans’ needs for specialty care, such as specific  targets for the number of available ventilators or the number of  caregivers educated to help veterans with dementia.

According to GAO’s body of work on effectively managing performance  under the Government Performance and Results Act of 1993 (GPRA), as  enhanced by the GPRA Modernization Act of 2010, federal agencies  should clarify and clearly define measurable outcomes for each strategic  objective and assess progress towards those goals. VA officials told us  that competing priorities, including implementation of the VA MISSION  Act of 2018, have affected GEC’s ability to effectively address challenges  to meeting veterans’ long-term care needs. Without measurable goals,  however, VA is limited in its ability to better plan for and understand  progress towards addressing the challenges it faces meeting veterans’  long-term care needs. As VA works to address these challenges, it does  so along with other health care systems, and VA has opportunities for  leveraging outside experience through VA’s Geriatrics and Gerontology  Advisory Group. For example, the Advisory Group recently acknowledged  workforce challenges and recommended that VA “devise strategies to  create incentives and identify and remove barriers” for the recruiting and  retaining the health care workforce needed to care for VA’s growing  geriatric veteran population.

In addition to the key challenges that VA and many other health care  systems face, VA has identified, but has not planned to take steps to fully  address, challenges at the VAMC level that affect its ability to meet  veterans’ long-term care needs. Specifically, VA has identified issues with  inconsistency in the management of the 14 long-term care programs at  the VAMC level that could lead to inefficient and inequitable decisions  about long-term care across VA. While VA has identified the steps it can  take to address these issues, it has not implemented these steps.

First, VA identified that VAMCs do not have a consistent approach to  managing VA’s 14 long-term care programs. GEC officials told us that  fragmentation of the long-term care programs within the VAMCs—that  is, where programs could be run by one or more departments within  the VAMC, for example the Nursing department or the Social Work  department at VAMCs where there are not GEC staff—hinders  standardization and the ability to get veterans the right care. Similarly,  the HAIG report found that VAMCs organize their long-term care  programs differently and recommended that to “efficiently, reliably,  and equitably serve veterans” VA align GEC programs “at all VISNs  and eventually VAMCs nationwide.” GEC strategic planning  documents outline a goal of alignment within the VISNs, and officials  said alignment has been established within the VISNs. However, VA  officials told us that, as of October 2019, they had not taken action to  pursue VAMC-level alignment with a GEC point of contact at each  VAMC that could provide consistency across long-term care programs  at the VAMC level.

Second, GEC has developed a tool to improve the consistency with  which VAMCs determine the amount of services needed for veterans  based on their specific health issues. However, as of October 2019,  VA has not required the tool be used in all VAMCs. VA has identified  that VAMCs do not have a consistent approach to determining the  amount of noninstitutional long-term care services veterans need. VA  officials told us that, as of October 2019, VAMCs used different  methods to assess the amount of noninstitutional long-term care  services veterans need—for example, how many hours of in-home  care veterans need. As a result, decisions about the amount of  services veterans receive may vary by VAMC. The HAIG report  recommended that VA use a standardized approach to ensure the  “balance of noninstitutional care programs, program reliability, and  equity of resource distribution.” GEC officials said the tool they  developed is currently being used by some VAMCs, and they expect  VA will require the tool to be used by all VAMCs sometime in the next  year. However, VA has not set time frames for this requirement.

One of VA’s performance goals is to provide highly reliable and integrated  care and support and excellent customer service. Furthermore, federal  internal controls dictate that federal agencies should exercise oversight  responsibility, for example by overseeing the remediation of deficiencies  as appropriate and providing direction to management on appropriate  time frames for correcting these deficiencies. Although VA has identified  steps it can take to improve consistency in long-term care programs,  according to officials, it has not prioritized their implementation. Without a  reliably consistent approach to administering long-term care programs  across its VAMCs, VA may not consistently and equitably meet veteran  preferences and needs.

VA currently faces difficult challenges meeting the demand for long-term  care. These challenges—such as addressing workforce shortages,  aligning care geographically, and meeting specialty care needs—are  likely to intensify as veterans’ demand for long-term care grows.  However, a lack of measurable goals in the strategic planning efforts of  VA’s GEC, which has the lead responsibility for managing VA’s 14 long- term care programs, affects VA’s ability to appropriately plan for and  understand its progress towards addressing long-term care challenges. In  addition to these key challenges, VA has identified, but not yet fully  addressed, inconsistencies in the management of the 14 long-term care  programs at the VAMC level. These inconsistencies in determining both  the best program for veterans and the amount of noninstitutional care  veterans need can lead to inefficient and inequitable experiences with  VA’s long-term care programs.

We are making the following three recommendations to VA:  The Secretary of VA should direct GEC leadership to develop measurable  goals for its efforts to address key long-term care challenges: workforce  shortages, geographic alignment of care, and difficulty meeting veterans’  needs for specialty care. (Recommendation 1)

The Secretary of VA should direct GEC leadership to set time frames for  and implement a consistent GEC structure at the VAMC level.  (Recommendation 2)

The Secretary of VA should direct GEC leadership to set time frames for  and implement a VAMC-wide standardization of the tool for assessing the  noninstitutional program needs of veterans. (Recommendation 3)

We provided a draft of this report to VA for review and comment. In its  comments, reproduced in appendix IV, VA concurred with our three  recommendations and identified actions it is taking to implement them.  Specifically, VA said that it will: (1) take steps to incorporate measurable  goals and defined timelines into its strategies to meet the long-term care  challenges; (2) work to establish a time frame for the execution of a  uniform GEC structure at the VAMC level; and (3) work to establish a time  frame for the execution of a VAMC-wide standardized tool for evaluating  non-institutional care needs for veterans. VA also provided technical  comments that we incorporated as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of the Department of Veterans Affairs, and  other interested parties. In addition, the report will be available at no  charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at silass@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix V.

Appendix I: Department of Veterans Affairs’ (VA) Institutional and Noninstitutional Long- Term Care Program Descriptions

VA provides or pays for long-term services and supports, or long-term  care, for eligible veterans through a range of three institutional and 11  noninstitutional programs. VA covers the full or partial cost of nursing  home care for eligible veterans who require skilled nursing home care in  an institutional program. Specifically, VA covers the full cost of nursing  home care for veterans who need this care for a service-connected  disability—which is an injury or disease that was incurred or aggravated  while on active duty—and for veterans with service-connected disabilities  rated at 70 percent or more. To the extent resources allow, VA may  cover this care for certain other veterans, such as former prisoners of war  and those awarded the Purple Heart. For all other veterans, VA may  cover nursing home care to the extent resources and capacity allow and  with the veteran’s agreement to share certain costs. (See table 2 for  more information about these programs.)

In addition, all veterans enrolled in the health care system are eligible for  VA’s basic medical benefits package, which covers, among other things,  a comprehensive array of medically necessary home- and community-  based health services. While a veteran’s priority for care generally  determines whether these services are provided at full or partial cost, the  VA may not charge a copay for home hospice care and may waive  copays for home telehealth services. (See table 3 for more information  about these programs.) A veteran’s placement in a particular program  may depend on their clinical needs, preferences, and the availability of  VA funding and programs.

Appendix II: Utilization and Obligations for Department of Veterans Affairs’ (VA) Long- Term Care Programs, Fiscal Years 2014 to 2018

Subtotal institutional programs Noninstitutional programs (workload units in thousands) Homemaker Home Health Aide 9,999 8,328 11,136 Home-Based Primary Care 1,671 1,755 1,599 Purchased Skilled Home Care Home Telehealth

payment for a Home Hospice Care program visit from a community provider. The units for each  program may differ. VA officials told us that these data do not include non-veterans and may differ  from data included in VA’s congressional budget justification for a variety of reasons, including the  timing of when they looked at the data, the inclusion of additional data, and that VA used a standard  definition of services for all years. In addition to these programs, VA may provide stipends or other  services to caregivers for veterans who were seriously injured in the line of duty through the  Caregiver Support program. Disabled veterans may also be eligible for increased compensation  benefits from the Veterans Benefits Administration.

Program Institutional programs VA Community Living Centers Community Nursing Homes

Appendix III: Projected Utilization and Expenditures for Department of Veterans Affairs’ (VA) Long-Term Care Programs, Fiscal Years 2017 through 2037

Appendix III: Projected Utilization and  Expenditures for Department of Veterans  Affairs’ (VA) Long-Term Care Programs, Fiscal  Years 2017 through 2037 these data do not include non-veterans and may differ from data included in VA’s budget request for  a variety of reasons, including the timing of when they looked at the data, the inclusion of additional  data, and that VA used a standard definition of services for all years.

Program Institutional programs VA Community Living Centers

Appendix IV: Comments from the Department of Veterans Affairs

Appendix V: GAO Contact and Staff Acknowledgments

Sharon M. Silas, (202) 512-7114 or silass@gao.gov  In addition to the contact named above, Karin Wallestad (Assistant  Director), Luke Baron (Analyst-In-Charge), Kye Briesath and Corinne  Quinones made key contributions to this report. Also contributing were  Laurie Pachter, Vikki Porter, Jennifer Rudisill, and Selah Myers.

Veterans Affairs: Sustained Leadership Attention Needed to Address  Long-Standing Workforce Problems, GAO-19-720T (Washington, D.C.:  Sept. 18, 2019).

Veterans Health Care: VA Needs to Improve Its Allocation and Monitoring  of Funding, GAO-19-670 (Washington, D.C.: Sept. 23, 2019).

VA Health Care: Actions Needed to Improve Family Caregiver Program,  GAO-19-618 (Washington, D.C.: Sept. 16, 2019).

Veterans Health Care: Opportunities Remain to Improve Appointment  Scheduling within VA and through Community Care, GAO-19-687T  (Washington, D.C.: July 24, 2019).

VA Health Care: Estimating Resources Needed to Provide Community  Care, GAO-19-478 (Washington, D.C.: June 12, 2019).

VA Real Property: Improvements in Facility Planning Needed to Ensure  VA Meets Changes in Veterans’ Needs and Expectations, GAO-19-440  (Washington, D.C.: June 13, 2019).

VA Nursing Home Care: VA Has Opportunities to Enhance Its Oversight  and Provide More Comprehensive Information on Its Website,   GAO-19-428 (Washington, D.C.: July 3, 2019).

Long-Term Care Workforce: Better Information Needed on Nursing  Assistants, Home Health Aides, and Other Direct Care Workers,   GAO-16-718 (Washington, D.C.: Aug. 16, 2016).

VA Mental Health: Clearer Guidance on Access Policies and Wait-Time  Data Needed, GAO-16-24 (Washington, D.C.: Oct. 28, 2015).

VA Nursing Homes: Reporting More Complete Data on Workload and  Expenditures Could Enhance Oversight, GAO-14-89 (Washington, D.C.:  Dec. 20, 2013).

Older Americans: Continuing Care Retirement Communities Can Provide  Benefits, but Not Without Some Risk, GAO-10-611 (Washington, D.C.:  June 21, 2010).

VA Health Care: Long-term Care Strategic Planning and Budgeting Need  Improvement, GAO-09-145 (Washington, D.C.: Jan. 23, 2009).

Veterans rely on long-term care from the VA for everything from occasional help around the house to round-the-clock care. Eligibility is primarily based on the extent of a service-connected disability.

Demand for long-term care increased 14% and VA’s expected spending went up 33% from FY 2014-2018. VA projects demand will continue to increase and spending will double by 2037.

VA faces 3 key challenges to meeting long-term care needs: finding enough workers, providing care where geographically needed, and providing specialty care.

We made 3 recommendations, including that VA develop measurable goals in these areas.