Department of Veterans Service: requested information on the availability of other funds

Special Examination Report No. 15-12

December 2015

Why we did this review
This special examination of the Georgia Department of Veterans Service Availability of Other Funds was conducted at the request of the House Appropriations Committee.
The Committee requested that we review the outcomes and expenditures for GDVS' programs. They also asked that we examine whether the department is maximizing access to federal, other state department, and third party funds.
About GDVS
The Georgia Department of Veterans Service (GDVS) is responsible for informing Georgia veterans and their families about available state and federal benefits and assisting and advising them in obtaining benefits to which they are entitled. There were approximately 753,000 veterans residing in Georgia as of September 2014.
GDVS currently operates 49 field offices, 25 satellite locations and an Appeals office to assist veterans throughout the state with benefit claims. As the designated State Approving Agency, GDVS approves and supervises all institutions and establishments in Georgia offering education and training under the Veterans Educational Assistance Program. GDVS also operates two nursing homes that provide medical and nursing services and two state cemeteries for eligible veterans, their spouses and eligible dependents.

Department of Veterans Service
Requested information on the availability
of other funds
What we found In fiscal year 2015, the Georgia Department of Veterans Service (GDVS) received approximately $41.4 million to inform veterans of and assist them in obtaining benefits, and to support operations of veterans nursing homes and cemeteries. GDVS' budget is made up of state, federal and third party funding. Of the $41.4 million in funding, approximately $19.6 million was state funds, $18.3 million was federal funds, and $3.5 was from third-party sources. Approximately 76% ($31.4 of $41.4 million) of all funds were used to support the veterans nursing homes.
Additional funding could be available to GDVS to assist veterans in accessing benefits and support operations of nursing homes and cemeteries. We identified other states that have developed funding sources for providing direct financial assistance to veterans through voluntary contributions and directed revenues. Whether these opportunities are viable for GDVS will depend on the state's policy preferences and the model under which it operates, as well as its roles and responsibilities.
Obtaining additional funds assumes GDVS is effectively and efficiently utilizing the funds it is currently receiving. However, GDVS does not currently collect data that can be used to assess its effectiveness at assisting veterans in obtaining compensation and pension benefits. We found that GDVS' performance measures for providing benefits assistance to veterans are not specific to the services it provides. Rather it relies on data from the U.S. Department of Veterans Affairs (VA) that reflects all Georgia veterans, and all VA compensation received by them, regardless of whether GDVS provided assistance. To determine whether GDVS' current model of using state-funded field offices to provide services to veterans is effective, GDVS would need to establish specific goals for its operations and collect data necessary to measure its progress towards meeting these goals.

270 Washington Street, SW, Suite 1-156

Atlanta, Georgia 30334

Phone: (404)656-2180

www.audits.ga.gov

Below are the areas in which additional funds or opportunities for partnerships may be available. As noted, some changes would require lawmakers to make policy and/or statutory changes, and there may be costs associated with implementation.
Medicare and/or Medicaid funding for nursing homes Originally, Georgia established the veterans nursing homes as a no-cost option for veterans. According to GDVS staff, Georgia selected this approach instead of providing a pension or other financial benefit to veterans. Currently, the state pays approximately 39% of the daily rate. The remaining 61% is covered by VA and through a daily patient fee ($23.53). In fiscal year 2015, VA also paid the full cost of care for approximately 45 patients because of the severity of their service-related disability. Other funding through Medicare and Medicaid may be available. If Georgia were to move to providing more short-term rehabilitation services, Medicare funding may be an option. Other states are using Medicaid funding. Medicaid patients must spend down personal resources in order to become Medicaid eligible and are subject to the Estate Recovery Program. Because Medicaid eligibility is determined outside of GDVS, and because there is a cost associated with certifying the homes, it is difficult to calculate an accurate estimate of cost saving.
Fees for interment of veteran spouses and dependents Georgia covers the full burial cost for spouses and dependents of veterans at state veterans cemeteries. According to GDVS, the Attorney General's office verbally indicated that charging for these services would require a statutory change. In fiscal year 2015, spousal and dependent burials represented 21% (87 of 414) of the total burials. If the state charged a fee commensurate with what other states are charging, approximately $500 per burial, it would generate $43,500 in additional revenue.
Collection of voluntary contributions Some states have established trust funds or other mechanisms to collect voluntary contributions, either through direct donations or state transactions (e.g., income tax check off). These funds are used to administer services and programs, provide direct financial assistance, and award grants to organizations and other entities. To collect such funds in Georgia may require statutory changes and there may be additional costs associated with managing a new funding stream. For example, if Georgia began collecting donations to fund emergency assistance to veterans, there would be a cost to collect, distribute and monitor the funds. In other states we reviewed, these programs generated between $200,000 and $2 million.
Sharing costs related to serving veterans There is no universally accepted model for providing outreach and services to veterans. Of the 14 states we reviewed, 2 operated a fully state-funded model similar to Georgia's. The remaining states either partnered with county and local veteran service organizations or the counties funded and administered claims assistance. Changes to Georgia's model would require cooperation from the county or veteran service organizations and could require statutory changes.
Partnerships to reduce veterans' reliance on Medicaid Establishing a formal partnership with the Department of Community Health (DCH) to use its PARIS system could allow GDVS to identify and reach veterans who may be eligible for compensation and pension benefits from VA, thereby eliminating the need for state-funded Medicaid services. Other states we reviewed have recognized state savings as a result of such partnerships.
What we recommend This report is intended to provide answers to questions posed by the House Appropriations Committee. We hope that this report provides pertinent information to help inform policy decisions.

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Table of Contents

Purpose of the Special Examination

1

Background

1

Georgia Department of Veterans Service

1

U.S. Department of Veterans Affairs (VA)

3

Other Entities Serving Veterans

4

Requested Information

6

What are the outcomes of programs implemented by GDVS?

6

What are GDVS' expenditures by program?

13

How much funding does GDVS currently get from federal sources and what additional funds could GDVS access through partnerships with federal entities? 17

How much funding does GDVS currently get from other state departments and what

additional funds could GDVS access through partnerships with other state

departments?

23

How much funding does GDVS currently get from third parties and what additional

funds could GDVS access through partnerships with third party entities?

26

Appendicies

30

Appendix A: Objectives, Scope, and Methodology

30

Appendix B: Funding by Source and Program

33

Department of Veterans Service Requested Information on Availability of Other Funds

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Department of Veterans Service Requested Information on Availability of Other Funds

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Purpose of the Special Examination
This review of the Georgia Department of Veterans Service (GDVS) Availability of Other Funds was conducted at the request of the House Appropriations Committee. This report will answer the following questions:
1. What are the outcomes of programs implemented by GDVS?
2. What are GDVS' expenditures by program?
3. How much funding does GDVS currently get from federal sources and what additional funds could GDVS access through partnerships with federal entities?
4. How much funding does GDVS currently get from other state departments and what additional funds could GDVS access through partnerships with other state departments?
5. How much funding does GDVS currently get from third parties and what additional funds could GDVS access through partnerships with third party entities?
A description of the objectives, scope, and methodology used in this review is included in Appendix A. A draft of the report was provided to GDVS staff for review, and pertinent responses were incorporated into the report.
Background
Georgia Department of Veterans Service According to statute, the Georgia Department of Veterans Service (GDVS) is responsible for informing Georgia veterans and their families about available state and federal benefits and directly assisting and advising them in securing the benefits to which they are entitled. As of September 2014, there were approximately 753,000 veterans in Georgia.
GDVS accomplishes its mission to serve veterans through four roles.
Veterans Assistance
o Information and Outreach The Public Information division collects, evaluates and disseminates information to veterans regarding benefits and proper procedures for filing claims with the U.S. Department of Veterans Affairs (VA). The division provides news releases to newspapers, radio and television stations throughout the state and publishes print materials. The division maintains a website, Facebook page, and Twitter account to inform veterans about available benefits, changes pertaining to veterans affairs, and provides information on the status of legislation that may affect veterans. The division also informs GDVS field office staff of changes in law and policy interpretations that impact veterans, and

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supports staff in their efforts to promote the department and services it provides.

Field office staff help veterans and their
families, including their spouses, dependents and beneficiaries, identify and access benefits to which they are entitled.

o Claims and Appeals GDVS provides direct assistance to veterans and their families through its field offices and Appeals division. According to GDVS, it currently has 49 field offices and 25 satellite locations open on a part-time basis to assist veterans. Veterans who affiliate with one of eight designated veteran service organizations can also receive assistance from and file claims through GDVS.1 Field office staff counsel veterans about state benefits such as discounts and fee exemptions. They also inform veterans about federal benefits they may be eligible to receive.
In addition to providing counsel, staff also help veterans file claims for VA compensation and pension benefits. Veterans who suffered or aggravated an injury, during their military service may apply for compensation from VA. The veteran must provide documentation proving the injury is connected to his/her period of service. If VA determines the injury is related to the veteran's service, it assigns the veteran a disability rating (0-100%) based on the severity of the disability and the strength of the evidence linking the disability to the period of service. The veteran's monthly compensation payment is directly related to the rating; the higher the rating, the higher the monthly compensation. Veterans may also receive a retroactive payment if VA determines it to be appropriate based on the evidence. Once the veteran is assigned a disability rating, he/she can receive free treatment for that disability at any VA medical facility.

Veterans age 65 or older may apply for and receive a monthly pension. VA has established eligibility requirements, including income and asset calculations that include, among other things, Social Security payments and owned property.

GDVS staff help veterans file claims by helping them identify and gather documentation necessary to support these claims. In the event that VA's disposition of the claim is not satisfactory to the veteran, either because it is denied, or because the rating or the amount of the benefit is lower than the veteran anticipated, GDVS has an office in Decatur to help with appeals. Appeals officers advise and represent veterans at hearings before the local VA hearing officer or before the Board of Veterans Appeals.

Veterans Education and Training VA requires each state designate a State Approving Agency responsible for approving and supervising entities that offer education and training under its VA Veterans Educational Assistance Program. GDVS' Veterans Education and Training division serves this role. The division conducts inspections annually to ensure that approved institutions and establishments meet and maintain acceptable standards as

1 GDVS is accredited by eight veteran service organizations (American Ex-prisoners of War, Inc., American Legion, American Red Cross, Fleet Reserve Association, Jewish War Veterans of the U.S., Noncommissioned Officers Association, The Retired Enlisted Association, and Veterans of Foreign Wars) to represent their veterans through the claims process. This allows the veteran to designate the veteran service organization as their power of attorney and still have GDVS file the claim.

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set by VA. It also ensures corrective action is taken as necessary. Any public school, private school or other entity offering apprenticeships and on-the-job training is required to meet these standards in order for eligible attendees to receive educational assistance from VA.
War Veterans Nursing Homes2 GDVS operates two nursing home facilities that provide medical and nursing services to Georgia's aged and infirmed veterans. The nursing home in Augusta is a 192-bed skilled nursing care facility operated under an interagency agreement between GDVS and Augusta University (formerly Georgia Regents University). The facility also serves as a teaching facility for medical, pharmacy and allied health students. As of June 2015, the nursing home had 161 patients under its care.
The nursing home in Milledgeville is a 375-bed facility composed of four buildings. One building houses the Alzheimer's Care unit and three buildings are designed for regular skilled nursing home care. One of these buildings is currently not being used; according to GDVS this is because of a low patient census and a need for renovations. The nursing home is operated under a contractual agreement with the United Veteran Services of Georgia, Inc. As of June 2015, the nursing home had 242 patients under its care.
Veterans Memorial Cemeteries GDVS operates two veterans cemeteries. These cemeteries contain sites for casketed burials, columbarium inurnments, in-ground inurnments and memorial markers. The cemetery in Glennville was established in 2007 and is located on 42.6 acres. The cemetery will be the final resting place for more than 21,000 eligible veterans, their spouses and dependents. There were 830 veterans, spouses and family members interred as of June 2015.
The cemetery in Milledgeville was established in 2001 and is located on 142 acres. The cemetery will be the final resting place for more than 100,000 eligible veterans, their spouses and dependents. As of June 2015, the cemetery had 2,505 veterans, spouses, and dependents interred.

A veteran is "a person who U.S. Department of Veterans Affairs (VA)

served in the active military, VA is the primary federal agency responsible for serving veterans.

naval, or air service, and Through its various programs, VA distributes benefits, medical services

who was discharged or

and other assistance directly to veterans. VA provides grants to various

released therefrom under entities that serve veterans, including state government agencies.

conditions other than

Within VA, the Veterans Benefits Administration (VBA) administers

dishonorable."

benefits and services that provide financial and other assistance to

Source: Code of Federal Regulations

service members, veterans and their families. VBA oversees the delivery of disability compensation and provides supplemental income through pensions. VBA also implements programs that offer education and

training benefits, guaranteed home loans, and vocational rehabilitation services.

Within VA, the Veterans Health Administration (VHA) operates an integrated health care system of medical centers, community based out-patient clinics, community

2 War veterans are veterans who were discharged under other than dishonorable conditions and who served on active duty in the armed forces of the U.S. or on active duty in a reserve component of the armed forces of the U.S., including the National Guard, during wartime or between January 31, 1955 and May 7, 1975.

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living centers and other facilities to provide comprehensive care to veterans nationwide. VHA distributes federal funds to construct, expand, or remodel facilities for providing domiciliary or nursing home care in state veteran homes. VHA also pays at least a portion of the cost of providing nursing home care for eligible veterans.
VA's National Cemetery Administration provides oversight and benefits for veteran burials and distributes funds to establish, expand or improve veterans cemeteries owned and operated by state and other federally recognized governments.

Other Entities Serving Veterans
Additional federal and state government agencies serve Georgia veterans by providing financial assistance, programs and services. Examples of these entities and programs are discussed below.
Federal agencies The Department of Labor offers assistance through employment and training programs and the Department of Housing and Urban Development administers housing programs designed to reduce homelessness among veterans. These same federal agencies also provide funds to assist veterans through direct payments and various grants. Information about available federal programs, projects and services providing assistance or benefits to the public, including veterans, are maintained in the Catalog of Federal Domestic Assistance (CFDA). The programs included in this online database are available to state and local governments, public and private profit and nonprofit organizations and institutions, specialized groups and individuals.
State agencies Some state agencies, in addition to GDVS, offer services and programs specifically for veterans and their families. For example, the University System of Georgia offers fee and tuition waivers. The Workforce Division of the Department of Economic Development, in partnership with the Georgia Department of Labor, provides an online portal that serves as a one-stop shop for veteran resources and employment services. According to GDVS, many of the University System of Georgia and Technical College System of Georgia institutions also have veteran resource centers. For example, Gwinnett Technical College has an office of veterans affairs that guides veterans, their spouses and dependents through admissions, financial aid and other academic services. Middle Georgia State College and Central Georgia Technical College will jointly operate the Military Academic Training Center expected to open in 2016 in Warner Robins. Some agencies also provide programs and services for all residents, including veterans.
Other entities Various organizations advocate and provide assistance to support veterans and their families. Veteran service organizations, such as the Disabled American Veterans and American Veterans (AMVETS), primarily serve veterans and operate chapters and/or posts throughout the state to provide assistance with benefit claims, emergency financial assistance, scholarships, and other services.3 Other organizations, such as the United Way and American Red Cross, provide resources and assistance for military

3 Veteran service organizations that have accredited GDVS do not file claims for veterans, instead GDVS performs this function.

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families in addition to the services they provide other families and local communities. In addition, foundations and philanthropic organizations distribute funding to local and community nonprofit organizations that provide services to veterans, including housing, employment and mental health services.

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Requested Information

What are the outcomes of programs implemented by GDVS?
GDVS tracks and reports activity data for the Veterans Benefits program, the Veterans Memorial Cemeteries, and the War Veterans Nursing Homes. This information is published in the Governor's Budget Report, the Office of Planning and Budget's Performance Measures Report, and GDVS' Annual Report. As discussed in the sections below, the data is largely focused on inputs and outputs. To report on program outcomes and demonstrate its effectiveness, GDVS would need to collect additional information specifically related to the services it provides.
Outcomes Related to Veterans Assistance: Benefits
Our review of outcomes related to the veterans benefits function revealed a need to establish more comprehensive performance measures as well as collect complete data related to specific activities to enable GDVS to assess its effectiveness. GDVS assists veterans and their families in filing claims for compensation and pension benefits. Field service officers help identify and collect the documentation needed to support a veteran's claim for compensation or pension benefits and send the claim to VA for processing. VA determines whether claims are complete, and if so, whether to approve or deny them. If approved, the VA also assigns the veteran's disability rating, compensation amount, and pension amount, as appropriate. While VA collects a significant amount of data on the amount of claims and pension benefits awarded as well as other demographic data related to the veteran, we found that this information is not easily acquired or used to measure outcomes specific to GDVS' performance. Therefore, GDVS would need to collect the information and analyze it internally. GDVS' current data collection systems have limitations that would need to be addressed before this type of analysis could be conducted. Finally, we noted that GDVS' model of using over 50 field service and satellite offices to provide assistance to veterans may also influence the effectiveness of its service delivery. These areas are discussed in more detail in the following sections.
Outcome Measures GDVS has established six measures related to veterans benefits that it reports to the Office of Planning and Budget (OPB). Three of these measures are published in OPB's Performance Measure Report and the Governor's Budget Report. However, for several measures the information is not isolated to GDVS' activities. For example, information on the total compensation and pension dollars coming into Georgia reflects all dollars received by all Georgia veterans regardless of whether GDVS provided assistance. As a result, it is not a measure of GDVS' effectiveness. To more accurately measure its own effectiveness, GDVS would need to establish specific goals and objectives for what it wants to impact and then design measures and data collection techniques to assess its progress. The measures and results for fiscal years 2014 and 2015 are shown in Exhibit 1.

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Exhibit 1

Veterans Benefits Performance Measures As Reported By GDVS

Fiscal Years 2014 and 2015

Description

FY 2014

FY 2015

Number of Veterans in Georgia (per calendar year)

774,464

752,822

Total Veterans Compensation & Pension Dollars into Georgia (millions per calendar year)

$2,482

$3,004

Veterans Compensation and Pension Dollars per Georgia Veteran (per calendar year)1 Number of Veterans per Veterans Field Service Office2 Number of Appeals Hearings (per calendar year)

$3,205 14,894
2,602

$3,991 14,762
2,716

Number of Veterans Field Service Offices

52

51

1 Equals total compensation divided by number of Georgia veterans ($2,482 million/774,464 = $3,205)

2 Equals number of veterans divided by number of field offices (774,464/52 = 14,894)

Source: GDVS data

Data Collection GDVS currently uses two systems to collect data, an electronic system to collect claims information and a manual system to collect activity data. As discussed below, we identified limitations with these processes that would need to be addressed to allow GDVS to begin collecting comprehensive, complete and accurate information on its activities.
VetraSpec, GDVS' electronic system, captures information on claims. Our review of VetraSpec identified inaccuracies and incomplete information. For example, VetraSpec has fields to collect county of residence, social security number, date of birth, and date claims are filed. While all of these fields would be useful in analyzing performance, we found a significant number of blanks and errors made these fields unreliable. Because of a lack of controls over how information was recorded and entered, it was not possible to verify the accuracy of the data. According to interviews with field office supervisors, they did not verify the data, nor were they reviewing hardcopy files maintained at the field office level to validate the field staff's data entry. Additionally, it was not clear which system field offices should use to report certain information about its activities.
GDVS also manually collects information on activities performed at field offices and compiles it into Weekly Statistical Reports. Offices submit reports weekly and information on the number and types of visits is compiled manually and used to update the Veterans Services Board monthly; it is also published in the annual report. We reviewed a total of 56 reports submitted by field offices and found errors in five (9%); the total number of visits reported was wrong because the current and previous totals were added together incorrectly. In January 2015, GDVS updated its written guidance for field offices on how data should be recorded for the Weekly Statistical Reports.

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Use of VA Data We attempted to measure GDVS' performance by identifying the number of veterans GDVS assisted and the amount of compensation and pension dollars these individuals received from VA. Our intention was to link individual claims to GDVS field offices to make a determination about effectiveness at that level as well. We obtained data from VA that identified the entity that assisted with the claim, the dates of submissions and awards, and amount and type of award.4 However, we were unable to obtain the veteran's county of residence and therefore unable to associate a claim with a GDVS field office. In addition, we found limitations with the data field that identified the entity assisting with the claim. For example, 31% of claims processed had no entity listed and it was unclear whether this was a data entry error. We also found GDVS identified as the assisting entity for 31% of the claims processed in federal fiscal year 2013.5 GDVS estimates that it assisted with approximately 60% of the Georgia claims filed. As a result of these limitations, it is not possible to use VA data to assess GDVS' effectiveness with assisting veterans with claims. Therefore, to measure their effectiveness, GDVS would need to collect this information.
Other States' Performance Measures We found that other states reported results and outcomes for their veterans' assistance activities, which provide information about their effectiveness. For example, Texas reports the number of claims filed for compensation, the number of active compensation and pension cases, and the number of VA decisions appealed. Florida reports on the number of claims processed and the number of veterans served by their department. Oregon and Tennessee focus on goal-oriented outcome measures such as "60% of claims will be fully developed upon submission" and "recovery of new VA benefit dollars for Oregon veterans, their dependents, and survivors with Oregon Department of Veterans' Affairs claims representation." Washington also focuses on the number of fully developed claims submitted.
Service Delivery Model GDVS' ability to effectively serve Georgia's veterans may be impacted by the model in which the agency is operating. Currently, GDVS operates a solely state-funded system of 49 field service offices and 25 satellite offices to manage claims. There is no one accepted service delivery model; however, of the 14 states we reviewed, only Maryland and Virginia had solely state funded and managed systems similar to Georgia's. Ten states use a collaborative model in which claim support services are managed and supported by a county government or contracted out to a Veteran Service Organization.6 The remaining two states, Florida and Ohio, were solely county operated.
According to GDVS staff, 49 of the field offices have been in their current locations for over 30 years; however, there has been no comprehensive evaluation of placement or staffing. Staff indicated that second offices were

4 GDVS and other accredited Veteran Service Organizations are required to provide their services free of charge. These entities are identified as having "power of attorney" for purposes of filing the claim and this information is captured by VA.
5 Claims processed during federal fiscal year 2013 include claims submitted during prior fiscal years.
6 Alabama, Louisiana, Mississippi, North Carolina, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, and Washington.

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opened in Fulton and Hall counties when space became available to co-locate with a new VA veterans' clinic. A field office was also opened in Cobb County; staff indicated this location was chosen because of the large veteran population. In August 2015, GDVS submitted a proposal to open eight additional field offices, primarily located in the Metro Atlanta region. The proposal was based on veteran population estimates; it did not include closing any existing offices. As noted earlier, GDVS would have to collect more comprehensive data about its activities and outcomes at a field office level to determine the effectiveness of field offices.
To determine the effectiveness of its model GDVS would need to establish goals for its individual field offices and collect data necessary to measure its progress towards meeting these goals. By doing so, GDVS could identify those field offices that are effectively serving veterans as well as any that are underperforming or underutilized. It may also be useful to conduct a more future facing assessment of veterans needs based on the changing demographics of Georgia's veterans. According to VA, the veteran population is younger and has more females than previously. This change in demographics may impact how individuals look for information or what type of information they are seeking.
GDVS' Response: GDVS cited multiple reasons that make outcome measurement related to veterans assistance difficult, including the timeline for approval of claims, the quality and availability of data from the VA and information system limitations. GDVS acknowledged that it is "at a point where we are able to begin to push harder on our field offices to complete more of the fields in the electronic data processing system." It noted that doing so may make more data points available over time. It also indicated that the VA's Digits to Digits (D2D) portal for accepting electronic claims applications is expected to be fully operational in Georgia by the end of 2015 and that functionality will allow staff to see immediately when a claim is submitted and actually received by the VA.
GDVS also noted that "[t]he concept for establishing and maintaining GDVS field offices around the state is to place these offices close to where veterans are residing to the maximum extent possible based on available funding. Consequently, some of the smaller offices may not be as busy on a field service officer basis as other offices located in more populous areas. The intent is to have the offices available to serve and assist veterans when they come to them with their needs, whatever and whenever they may be. GDVS does not believe utilization of field offices should be the prime criteria for placement of these offices-conversely, availability of service to veterans should be the prime criteria."
Auditor's Response: We acknowledge that setting outcome measures related to veterans assistance is not a simple task. However, absent measures focused on the desired outcomes of the agency's activities, the state cannot know whether the investment it is making each year, and the investment it has made for over 65 years, is having the intended results. Other states have established measures by identifying specific areas of focus and determining the desired impact they are interested in achieving.
Outcomes Related to Information and Outreach GDVS does not report measures related to the effectiveness of its information and outreach efforts. In its annual report, GDVS describes the activities and types of information published and disseminated. Between fiscal years 2009 and 2011, GDVS

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spent between 4-10% of its $20,000 annual outreach budget; in fiscal year 2012, it spent all of its $735 budget. Funds were spent to manage the website and social media pages. However, the number of veterans accessing the website or social media pages has not been collected or used to determine how many of those accessing GDVS through these means applied for benefits. As a result, there is no data to determine whether these outreach efforts are effective.
Of the 10 states reviewed, 7 have focused on outreach as part of their overall strategy. These states focus on multiple methods and delivery channels for pushing information out. For example:
North Carolina's Department of Veterans Affairs launched the "NC4VETS" campaign in 2014, which includes a stand-alone website with social media links, a 24-hour call center, and marketing materials.
Ohio's Department of Veterans Services uses print, radio, television, and electronic media to reach veterans. For example, it published and distributed 60,000 pocket-sized Benefits Resource Guides; it advertises through radio and television; it operates an email listserv distributing a monthly newsletter; and it contracted for development of a veteran's services mobile phone application that includes maps and locations of all county service offices, which 6,500 users have downloaded.
The Department also targeted its efforts by running ads in the Military Times family of newspapers and sponsoring shopping cart ads at 28 of Ohio's highest volume Kroger stores encouraging veterans to apply for benefits.
Oregon's Department of Veterans' Affairs reaches its veterans through print, electronic media, and cooperation with other entities. For example, it created a veterans benefits magazine listing all resources and benefits in plain language. It also operates a blog to make official announcements including publicizing events. Finally, the state is funding a one-time $1 million dollar grant for outreach; county veteran service offices can apply.
GDVS' Response: According to GDVS, "[t]he reason [it] does not report performance measures for its outreach activities is these activities are included in the Administration fiscal program and the performance measures for this program were determined and standardized by the Governor's OPB in conjunction with the House and Senate budget and evaluation offices."
Additionally, GDVS noted in its response that it "will review the ideas mentioned in the report for some of the other states with the view to implement some of them to meet the needs of Georgia's veterans."
Outcomes Related to War Veterans Nursing Homes GDVS has established seven performance measures for each of the war veterans nursing homes. The measures and results for fiscal years 2014 and 2015 are shown in Exhibit 2. This information is provided to OPB.
Other states report on performance measures such as occupancy rate, number of beds available, and patient days (number of days services are provided multiplied by the number of patients receiving those services).

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Exhibit 2 War Veterans Nursing Homes Performance Measures Fiscal Years 2014 and 2015

2014

2015

Description

Augusta Milledgeville Augusta Milledgeville

Average Daily Census

156

221

153

243

Cost Per Veteran Patient Day

$191

$195

$207

$206

Number of Deficiencies During

State Licensure Inspection

0

0

0

0

Number of VA Criteria Met (out of 66)1

66

64

66

64

Percentage of Funded Beds

Filled

92%

97%

82%

99%

Percentage of Patients Receiving Aid and Attendance2

14%

37%

12%

42%

Percentage of Patients who

Rated the Home Good or Excellent3

98.84%

N/A

N/A

N/A

Overall Patient Satisfaction Score (out of 5)3

N/A

4.32

4.68

4.48

1 The reported results are from annual inspections conducted by VA and based on criteria it has established regarding standards of care.

2 Aid and Attendance is an income based federal benefit provided through VA. It is designed to help veterans cover medical expenses, including those associated with nursing home care.

3 In 2014, each veterans nursing home used its own patient satisfaction measure.

Source: GDVS data

GDVS provides additional activity data in its annual reports, including the total days of care provided, the number of admissions, discharges, deaths, and average length of stay for both homes. The Augusta home reports the average age of the patients and types and number of treatments provided (see Exhibit 3). While not included in the annual report, Milledgeville also tracks the average age of its patients and reported it was 79 in fiscal year 2014.

Exhibit 3

War Veterans Nursing Homes Activity Data, Fiscal Year 2014

Description

Augusta

Milledgeville

Total Days of Care Provided Average Age of Patient (years) Admissions Discharges/Deaths Average Length of Stay (days) Number of Physical Therapy Treatments Number of Occupational Therapy Treatments

56,891 83
205 207 238 7,077 4,093

80,520 Not provided
180 72
1,264 Not provided Not provided

Source: GDVS Annual Report 2014

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GDVS' Response: According to GDVS, the contract for the Milledgeville War Veterans Home is up for rebid in 2016. It indicated that it will include a requirement that the contractor provide "an annual report of operations and care, similar to that published by the Georgia War Veterans Nursing Home in Augusta...This will provide comparable data and information for both homes that can be used by the GDVS and other decision makers."

Outcomes Related to Veterans Memorial Cemeteries
GDVS has established five performance measures for the veterans memorial cemeteries. The measures and results for fiscal years 2014 and 2015 are shown in Exhibit 4. This information is published in the Office of Planning and Budget's Performance Measure Report.

Other states report similar information. We did not identify any additional measures that other states were using.

Exhibit 4

Veterans Memorial Cemeteries Performance Measures

Fiscal Years 2014 and 2015

Description

2014

Total Interments

2,921

Total Interments per Year

342

State Cost per Interment

$1,459

State Maintenance Cost per Interment

$2,101

Percentage of Graves Marked in a Timely Manner1

90.9%

1 VA sets this standard at 95% of graves marked in 60 days or fewer.

Source: GDVS data

2015 3,335
414 $1,340 $1,742 100%

Outcomes Related to Veterans Education and Training
GDVS does not have performance measures to assess the effectiveness of its education and training efforts. In its 2014 annual report, GDVS published the number of approved educational institutions (380) and the number of approved training establishments (1,196). GDVS' contract with VA requires the division of education and training to conduct compliance and other visits. However, GDVS' performance measures do not provide specifics on the number of inspections or visits it conducted; rather it states that it conducted "...numerous visits for the purpose of approval, reapproval, inspection, and compliance surveys." In information submitted for the Office of Planning and Budget's Performance Measure Report GDVS reported the "number of schools and training establishments" as 1,654. However, it does not specify whether these are approved entities or total number of entities in the state.
Of the 14 states we reviewed, 8 of the veterans affairs offices did not perform this function as these functions were assigned to other state agencies. In the states in which veterans affairs offices do perform this function, we found examples of performance measures such as average number of veterans participating in education and training programs (Texas), percentage of requests for approval processed in 30 days of receipt (Virginia), and the number of schools inspected (Mississippi).

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GDVS' Response: According to GDVS, it "will breakout the data reported to more clearly specify numbers for visits to institutions by purpose of visit, such as application approval, inspection, etc. The GDVS will also look at other data points, such as reported for other states...to see which may be of value to the GDVS and other readers of the information."
What are GDVS' expenditures by program?
GDVS' expenditures for fiscal year 2015 were approximately $41 million. As shown in Exhibit 5, War Veterans Nursing Homes are the largest expenditure, accounting for 76% of GDVS' total spending in fiscal year 2015. Veterans Memorial Cemeteries is the smallest GDVS program, accounting for slightly less than 2% of total expenditures.
Expenditure data from fiscal year 2011 through fiscal year 2015 shows that GDVS' actual expenditures have fluctuated. Expenditures decreased by $1 million between fiscal year 2011 and fiscal year 2013 and increased by over $5 million between fiscal year 2013 and fiscal year 2015. The War Veterans Nursing Homes program accounted for most of this increase. GDVS' budgeted expenditures for fiscal year 2016 show a reduction of approximately $2 million from the previous year. This reduction is reflected in the War Veterans Nursing Homes program. According to GDVS, the projected patient census for 2016 was lowered which reduced the projection for federal funds by 24%. Staff indicated that actual federal funds received are based on final patient census and will be adjusted as necessary at the end of the fiscal year.

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Exhibit 5 War Veterans Nursing Homes Represent Majority of GDVS' Total Expenditures, Fiscal Years 2011 to 20161
Actual

Budgeted

Description Revenue Federal State Other Total Revenue Expenditures

FY 2011 FY 2012

FY 2013

FY 2014

FY 2015

FY 2016

$15,046,447 20,320,198 1,607,520
$36,974,165

$14,991,882 20,340,315 1,454,938
$36,787,135

$15,119,640 19,833,627 1,392,733
$36,346,000

$17,019,797 20,135,998 3,529,130
$40,684,925

$18,317,032 19,599,341 3,469,645
$41,386,018

$14,855,830 20,812,317 3,131,422
$38,799,569

Administration
Georgia Veterans Memorial Cemetery

$1,247,759 $1,353,108 $1,425,995 $1,564,023 $1,758,811 $1,801,404

Glennville
Milledgeville
Subtotal Georgia War Veterans Nursing Home

$246,620 $373,597 $620,217

$279,093 410,904
$689,998

$312,823 467,722
$780,545

$313,003 339,628
$652,631

$337,600 336,863
$674,462

$342,805 496,285
$839,090

Augusta Milledgeville Subtotal Veterans Benefits Field Operations Claims Education and Training Subtotal
Total Expenditures

$10,281,651 15,127,694
$25,409,344

$10,229,228 14,969,160
$25,198,388

$8,060,856 878,520 662,754
$9,602,131 $36,879,451

$7,587,417 906,188 651,423
$9,145,028 $36,386,522

$10,515,352 16,011,248
$26,526,600
$5,485,550 931,178 690,688
$7,107,415 $35,840,555

$12,415,292 18,260,206
$30,675,498
$5,946,118 955,545 686,289
$7,587,952 $40,480,104

$12,375,740 18,819,232
$31,194,972

$11,149,743 16,483,417
$27,633,160

$5,768,145 923,297 631,696
$7,323,138 $40,951,383

$6,891,636 1,006,839 627,440
$8,525,915 $38,799,569

1 Values may not add due to rounding. Source: PeopleSoft data

Department of Veterans Service Requested Information on Availability of Other Funds

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Use of State Funds GDVS is budgeted to receive $20.8 million in state funds, which represents 54% of its total budget for fiscal year 2016. How these funds are used is discussed in the following bullets and shown in Exhibit 6.
Exhibit 6 State Appropriations by Program, Fiscal Year 2016

Veterans Benefits 31%

War Veterans Nursing Home
57%

Administration 9%
Source: PeopleSoft Data

Veterans Memorial Cemetery 3%

About $6.4 million of the $20.8 million (31%) in state funds is allocated to the Veterans Benefits program. Approximately $5.4 million of these funds support the Field Operations program and $1 million is for the Claims program. As discussed in the first section Georgia has elected to operate a state-funded field office model.
About $1.8 million of the $20.8 million (9%) is allocated to Administration. This program includes the Public Information division which supports outreach efforts.
About $12 million of the $20.8 million (57%) is allocated to the War Veterans Nursing Homes program to pay for medical services provided to veteran patients. Under Georgia's approach skilled nursing care is provided at little cost to the veteran. Generally, state funds cover half of the per diem rate for regular veteran patients with VA funds making up the difference. As discussed in subsequent sections, the state's expense may be offset by a daily patient fee of $23.53. Additionally, the VA pays the full cost of care for certain service connected disabled veterans.

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Veterans affairs offices in 8 of the 10 states we reviewed perform this function.7 In all eight states, veterans are responsible for a portion of the cost of care. In addition to VA funding, private pay, private insurance, Medicare and Medicaid were used as funding sources. Some of the states that utilize Medicaid funding provide additional monetary benefits to their state's veterans in the form of tax exemptions or compensation. For example, Pennsylvania and Ohio provide monthly pensions to qualifying veterans. Pennsylvania, Ohio, North Carolina, Maryland, and Alabama provide an income tax exemption specifically related to military income; the specific exemptions vary from state to state.

About $661,000 of the $20.8 million (3%) is allocated to the Veterans Memorial Cemetery program. These funds pay for cemetery operations, including personnel costs. State funds pay the full cost for the burial of spouses and dependents of eligible veterans in veteran cemeteries. The state receives a burial allowance from VA for veteran burial expenses.
Of the 10 states we reviewed, veterans affairs offices in 6 states operate a veterans cemetery program similar to Georgia. However, each of these states charges a fee for the burial of spouses and dependents.

7 Tennessee and Texas operate veterans nursing homes, however these responsibilities have been assigned to other agencies.

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How much funding does GDVS currently get from federal sources and what additional funds could GDVS access through partnerships with federal entities?

Current federal funds All of GDVS' federal funding comes from the U.S. Department of Veterans Affairs (VA). As shown in Exhibit 7, federal funds have represented between 38% and 44% of GDVS' total budget between fiscal years 2011 and 2016. (Appendix B provides funding by source and program for fiscal years 2011 through 2016).
Exhibit 7 Federal Funds Represented Between 38% and 44% of GDVS' Total Budget, Fiscal Years 2011 to 20161

$45,000,000 $40,000,000 $35,000,000 $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000
$5,000,000 $0

4% 41%
55%
2011

4% 41%
55%
2012

4% 42%
55%
2013

9% 42%
49%
2014

8% 44%
47%
2015

8% 38%
54%
2016

State Funds
1 Values may not add due to rounding. Source: PeopleSoft data

Federal Funds

Other Funds

GDVS is budgeted to receive $14.9 million in federal funds, which represents 38% of its total budget for fiscal year 2016 (see Exhibit 8). As discussed below, these funds are budgeted to support veterans nursing homes, cemeteries and education and training functions.

About 90% ($13.3 million of $14.9 million) of these funds are specified for the War Veterans Nursing Homes. VA pays the full cost of care for a select number of patients who meet the criteria. 8 As of June 30, 2015, 45 of the 403 (11%) patients have this designation. VA pays half of the per diem rate for all other veteran patients.

8 Full cost of care is paid for patients who are in the veterans nursing home because of a disability related to their war time service or patients who received a VA disability rating of 70% or higher. In fiscal year 2015 these patients represented 11% of Georgia's veterans nursing home population.

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Fiscal year 2016 federal funds represent a $4.2 million reduction from the prior year. According to GDVS, the projected patient census for 2016 was lowered which reduced the projection for federal funds by 24%. Staff indicated that actual federal funds received are based on final patient census and will be adjusted as necessary at the end of the fiscal year.

About 9% ($1.4 million of $14.9 million) is allocated to the Veterans Benefits program. Approximately $627,000 funds a contract between VA and GDVS for GDVS to serve as the State Approving Agency responsible for approving and overseeing education and training programs for veterans in Georgia. These responsibilities are managed by the Veterans Education and Training division.

About $750,000 of this federal funding is for capital expenditures at the veterans cemeteries. These funds require a 100% state match, which is provided as bond funding by the Georgia State Financing and Investment Commission.

About 1% ($178,000 of $14.9 million) is a burial allowance for the Veterans Memorial Cemetery program. VA pays an interment allowance for each eligible veteran interred at Georgia's veterans cemeteries. For veterans who died after September 30, 2014, the allowance is $745. No federal burial allowance is provided for spouses and dependents. This allowance is paid as a reimbursement based on the actual number of veterans interred.

Exhibit 8

Funding by Source and Program, Fiscal Year 2016

Program

State

Federal

Other

Total

Administration Georgia Veterans Memorial Cemetery Georgia War Veterans Nursing Home Veterans Benefits
FY 2016 Total

$1,801,404 661,086
11,951,352 6,398,475
$20,812,317

$0

$0

178,004

0

13,300,386 2,381,422

1,377,440 750,000

$14,855,830 $3,131,422

$1,801,404 839,090
27,633,160 8,525,915
$38,799,569

Percent

54%

38%

8%

100%

Source: PeopleSoft data

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Obtaining Additional Federal Funding
Use of Medicare and Medicaid Reimbursements
The primary option for obtaining additional federal funding would be to access Medicare and Medicaid funds for the War Veterans Nursing Homes program. Certifying the veterans nursing homes for Medicare and Medicaid reimbursement could provide additional federal funds to pay for medical care for veteran patients at the homes deemed eligible. See Exhibit 9 for a description of the two programs.
Medicare and Medicaid funding would offset costs currently covered by state appropriations. In fiscal year 2016, the state portion of the appropriation for veterans nursing homes was approximately $12 million. It should be noted that the VA currently covers the full cost of care for patients who are in the veterans nursing home because of a disability related to their war time service or patients who received a VA disability rating of 70% or higher.
Currently, GDVS does not obtain Medicare and Medicaid reimbursements for veterans nursing home patients. GDVS examined the impact of certifying the veterans nursing homes for Medicare and Medicaid reimbursements, and reported its findings to the General Assembly in January 2011. It did not recommend using Medicare and Medicaid citing additional administrative oversight, audits, inspections, billing and other requirements as burdens. GDVS also cited concerns about the quality of care in nursing homes whose revenues are solely derived from Medicare and Medicaid reimbursement. As an alternative, GDVS recommended a daily patient fee to obtain additional funds for its veterans nursing homes.
From 1955 to 2012, Georgia was the only state that did not charge veterans for skilled nursing care at state veterans nursing homes. The cost of care was funded through VA and state appropriations. In 2012, the General Assembly authorized patient fees for veterans nursing home patients. The daily patient fee charged to veterans is currently $23.53. Veterans may request a waiver based on income guidelines; the waiver must be obtained annually.
Our research found that other states utilize Medicare and Medicaid reimbursements to fund medical care for patients in state veterans nursing homes. These reimbursements offset a portion of the state's nursing home costs. Florida, North Carolina, Pennsylvania, Tennessee, Texas, Virginia and Washington obtained Medicare and/or Medicaid reimbursements to pay for care for patients in state veterans nursing homes. These states note that state veterans nursing homes are not a free benefit and the veteran is responsible for a portion of the cost of care. For example, Tennessee identifies Medicare, Medicaid, private insurance and private pay as current payment sources; it also includes the cost of a long term care bed and the cost of medication when estimating the potential cost for a veteran. Texas also cites, "the homes affordability comes from the establishing legislation which allows veteran residents to combine private, federal and/or Medicare or Medicaid to cover daily costs".

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Exhibit 9 Medicare and Medicaid Programs
Medicare
Health insurance program for people 65 or older, certain younger individuals with disabilities and people with End-Stage Renal Disease.
Funded by the federal government and administered by Centers for Medicare and Medicaid Services (CMS).
Medicare Part A covers inpatient hospital stays, care in skilled nursing facilities and certain home health care.
Uses a prospective payment system to pay per diem rates that cover all routine services, ancillary services and capital-related costs for patients.
Medicare Part D helps cover the cost of prescription drugs.

Medicaid
Health insurance program for certain categories of low-income individuals such as pregnant women, aged and disabled individuals.
Administered and funded jointly by federal and state governments.
Federal government requires state matching funds for Medicaid expenditures. For federal fiscal year 2016, the split was 67% federal and 33%state.
CMS and federal regulations provide oversight and guidelines for state Medicaid programs.
Services provided under Medicaid include inand out-patient hospital services, prenatal care, physician services and laboratory and xray services.
Pays full cost of room and board in a nursing facility plus any therapies that are part of the nursing home's regular resident care.

Source: Centers for Medicare and Medicaid Services

Medicare
Medicare provides reimbursement for skilled nursing care for a maximum of 100 days. As GDVS noted in its report to the 2011 General Assembly, there are certification requirements and patient assessments that the facilities do not currently have in place. Staff from Pennsylvania's veterans affairs office indicated they have opted not to obtain Medicare funding. Like Georgia, Pennsylvania's veterans nursing home is focused on long-term care, not short-term rehabilitation, so they did not see a financial benefit to pursuing Medicare funding. However, they have their own pharmacy and have chosen to use Medicare Part D, which is the prescription drug benefit.
GDVS reported that most skilled nursing days of care range from 30-50 days. The Milledgeville veterans nursing home is operated under contract with a private vendor that operates other nursing homes that receive Medicare and Medicaid reimbursements, as a result they have experience with the process.
Medicaid
Obtaining Medicaid reimbursements would offset state funds for veterans nursing home care, but the state would still be required to pay its portion of Medicaid matching funds, which is currently 33%. Veterans would have to be certified as Medicaid eligible which would include spending down their resources to meet income threshold requirements, essentially becoming indigent. As such, these patients would be subject to the Estate Recovery Program, which is a component of the Medicaid program that seeks to recover funds from the patient's estate for services provided.

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The extent to which use of Medicaid funds would benefit the state is unclear. Georgia currently spends approximately $12 million on the veterans nursing homes through its appropriation to GDVS, which represents 43% of the total funding for the homes. Under the current Medicaid rates, the state's portion would be 33%. However, in order to determine if it is cost-effective to become Medicaid certified, the state would need to identify: the cost of certification and claims filing; the number of eligible patients; and the daily rate Medicaid will pay. According to the Georgia Department of Community Health (DCH) staff, a determination would have to be made as to whether the state's Medicaid plan would have to be revised and, if so, how. DCH staff also noted that VA funds would be applied before Medicaid funds were used.
Exhibit 10 The State Pays Approximately $80 Per Day for Veterans Homes Patients

$23.53 Patient Fee

$80.08 State Funds

$103.61 U.S. Department of Veterans Affairs
Source: GDVS data
Nursing home census data from GDVS shows that there were 358 regular patients at veterans nursing homes as of June 2015. Currently, the veterans nursing homes' daily rate per patient is $207.22. See Exhibit 10. The state pays approximately 39% ($80.08) of the daily rate.9 VA covers $103.61. As noted earlier, in addition to covering 50% of the cost for regular patients, VA also covers 100% of the cost for those veterans who have a disability rating of 70% or higher or who are in the nursing home because of a service-related injury. As of June 30, 2015, VA was covering the full cost for 11% (45 of 403) of the patients.
Given the financial restrictions imposed on Medicaid recipients, whether to implement the use of Medicaid reimbursements at veterans nursing homes represents a change in philosophy regarding the state's obligation to veterans.
9 The state's portion of the daily rate per patient is calculated assuming patients pay the $23.53 daily fee.

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GDVS' Response: GDVS restated its position that estimated costs outweigh benefits when considering having the nursing homes use Medicaid. In its response, it stated "...the benefit to the state is, at best, negligible, when compared to the potential impact on the veterans." It noted that "[t]here may be issues related to the ability of the Augusta University health services to continue to operate its teaching mission based on Medicaid funding." GDVS also noted that "the length of stay for Georgia's war veterans is long term, so using Medicare is not practical because of the funding limits associated with that federal program."
Additional Federal Funding Obtained by Other States
We found that some state veterans affairs offices receive additional federal funding; however, we did not identify any funding that GDVS should be accessing that it is not. Rather, states have made policy decisions about the role their veterans affairs offices will serve that have changed the funding they access. These are examples of federal funds received by other state veterans affairs offices; however, we did not attempt to identify all federal funds allocated to other state agencies for the purposes of serving veterans. Examples of the funding we saw other states using is discussed below.
Additional VA funding VA administers the Homeless Providers Grant and Per Diem Program, which funds programs that provide homeless veterans with supportive housing and services centers. GDVS is not eligible for this funding because it does not provide housing for homeless veterans. However, Salvation Army and Gateway Center in Atlanta are examples of nonprofit organizations in Georgia that provide these services and have successfully obtained these funds. The Washington Department of Veterans Affairs receives these funds directly, because it provides these services. This was a policy decision made by their state.
In previous years, GDVS received funding from the VA Veterans State Domiciliary Care program for an assisted living facility housed at the Georgia War Veterans Home in Milledgeville. However, GDVS closed the facility in 2008 due to state budget cuts, and therefore is no longer eligible for this funding. Alabama and Florida's veterans affairs offices receive this funding as their offices oversee domiciliary care for disabled veterans.
Funding from other federal agencies The Texas Veterans Commission obtains grant funds from the U.S. Department of Labor's (USDOL) Disabled Veterans' Outreach Program to fund employment programs and services it provides for veterans. In fiscal years 2014 and 2015, the Georgia Department of Labor also received this funding. Additionally, Georgia's Department of Labor received funding from USDOL for the Veterans' Employment Program in fiscal year 2014.
Competitive funding VA and other federal agencies such as the U.S. Department of Health and Human Services and USDOL offer competitive funding for programs that serve veterans. States may apply for funding for special projects and initiatives, such as pilot programs. Texas and Virginia's veterans affairs offices received this type of funding from the VA Highly Rural Transportation grant to provide veterans transportation to medical facilities. Competitive funding has also been used as seed money to establish programs continued with state funds. For example, Pennsylvania's FindMyRidePA program started as a pilot project funded through the Veterans Transportation and Community Living Initiative administered by the US

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Department of Transportation. FindMyRidePA, which operates an automated response system to transport veterans to medical appointments and day-to-day activities, is now solely state funded.

Leveraging Through Federal Partnerships
GDVS reports that it has developed partnerships with VA that facilitate its ability to provide services to veterans. GDVS participates in outreach events, such as stand downs, which are coordinated by local VA medical centers in collaboration with other government and community organizations. These events provide homeless veterans immediate assistance such as food, shelter, clothing and benefits counseling. Additionally, several of GDVS' field offices throughout the state are co-located with VA facilities such as medical centers and community based outpatient clinics. For example, GDVS' Appeals office is located at the VA's regional office in Decatur. GDVS cites an advantage that Appeals staff can work closely with VA staff to ensure veterans receive benefits in a timely manner. GDVS reported that 3 of its field service offices are located in VA medical centers and 10 are located in VA community based outpatient clinics. VA also leases space and operates an outpatient clinic in GDVS' medical facility in Milledgeville where the Georgia War Veterans Home is located.

How much funding does GDVS currently get from other state departments and what additional funds could GDVS access through partnerships with other state departments?
None of GDVS' fiscal year 2016 budget is obtained from other state departments. While we found a few examples of veterans affairs offices in other states obtaining funds from other state departments, this practice was not common.
GDVS does not formally collaborate with other state departments to administer veteran programs and services. However, GDVS chairs the Returning Veterans Task Force (RVTF) which is charged with investigating how state services can be provided to veterans returning from military service. Establishing formal partnerships with state agencies, such as the Department of Community Health, could enhance GDVS' ability to reach veterans who may be eligible to apply for VA benefits and provide more comprehensive information regarding state benefits and services. Most state veterans affairs offices partner with other departments both formally and informally to promote programs and ensure veterans are aware of and obtain needed services.

Existing Partnerships with Other State Departments
As of 2015, RVTF membership included the Departments of Veterans Service, Community Health, Behavioral Health and Developmental Disabilities, Labor, Defense, as well as the Board of Regents of the University System, Technical College System, Workforce Division of the Department of Economic Development, and Administrative Office of the Courts. The RVTF, which meets quarterly, is responsible for issuing recommendations to each relevant state agency regarding improving the delivery of services to returning veterans. The RVTF is also responsible for making suggestions for legislation designed to assist returning veterans. Over the past two years, the RVTF recommended various tax exemptions and the establishment of veteran courts. It also recommended helping veterans transition into the civilian workforce by expediting the licensure process for in-demand skilled trade occupations. It should be noted that Vocational Rehabilitation and the Brain and

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Spinal Injury Trust Fund Commission also provide services that support veterans, however they are not currently members of the RVTF. To formally change the membership of the task force would require legislative action.
Veterans affairs offices in most states we reviewed participate on councils, commissions, workgroups and task forces with other state departments to coordinate efforts, improve communication, facilitate collaborative relationships, and share data and other information about veterans and their programmatic needs. The Alabama Executive Veterans Network Commission, which consists of representatives from state agencies and organizations, strives for interagency collaboration, public participation and mutual sharing of information to facilitate policy decisions. Florida Vets First team is a collaboration between federal and state agencies, and other veterans and military advocates to facilitate the development and coordination of information, services and programs benefiting veterans. North Carolina's Governor's Working Group on Veterans is an intergovernmental working group charged with facilitating collaboration and coordination among federal, state and local agencies that work with veterans.

Opportunities for Additional Partnerships with Other State Departments

Public Assistance Reporting Information System

The Public Assistance Reporting Information
System (PARIS) is primarily an interstate fraud database. It allows participating states to identify public assistance recipients who might be simultaneously receiving
assistance in other states.

Veterans affairs offices in other states we reviewed have established partnerships with their Medicaid agencies to use the Public Assistance Reporting Information System (PARIS) to identify potentially eligible veterans and assist them with obtaining federal veteran benefits. For example, the Washington Department of Veterans Affairs has a formal partnership with the Department of Social and Health Services to use PARIS to identify clients receiving state social and health services and help them access the maximum federal benefits. Similarly, the Ohio Department of Veterans Service has established partnerships with the Department of Job and Family Services, Department of Medicaid, and Department of Aging to identify Medicaid recipients through PARIS who are potentially eligible for VA benefits.

Establishing a formal partnership with DCH on its public assistance data matching project could help identify additional veterans who may be eligible to obtain VA benefits. DCH's Special Investigations Unit currently uses PARIS to identify Medicaid recipients in Georgia who are receiving Medicaid in another state. DCH sends a list of state Medicaid recipients to the Department of Defense's Defense Manpower Data Center where federal and state data sources are compared and a list of those individuals receiving Medicaid in multiple states is generated. DCH utilizes this information to investigate whether the person should be receiving state Medicaid benefits.

GDVS could enter into a data sharing agreement with DCH to compare the Medicaid data against VA data to identify veterans who may be eligible for VA benefits. GDVS could assist identified veterans with applying for benefits. This partnership could result in cost savings to the state if veterans are awarded VA benefits and are subsequently removed from the Medicaid rolls. It should be noted that in 2013 the two agencies explored using PARIS to identify veterans, however according to GDVS staff DCH did not pursue implementation and GDVS has not followed up.

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State Veteran Resource Guide GDVS could also partner with other state agencies to develop a comprehensive resource guide for veterans. Currently, GDVS publishes a booklet intended to provide an overview of state benefits available to veterans. The booklet contains information about the services GDVS provides and also informs veterans about the process for obtaining veteran license plates, tax exemptions, and various discounts and fee reductions. However, the booklet, which was most recently updated in July 2015, provides limited information about services and programs that address education, health, employment and housing needs. GDVS could work with other agencies, including those serving on the Returning Veterans Task Force, to provide comprehensive information about education, employment, health and housing resources available to help veterans transition back into the community, in hardcopy form and/or on its website.
We identified three states that had developed comprehensive resource guides that had information on programs and services useful to veterans. North Carolina's resource guide is an example of one produced through a multi-agency collaborative effort. It is produced and published by the NC Division of Veterans Affairs in conjunction with the NC Department of Health & Human Services and the NC Department of Commerce. In addition to information about federal and state veteran benefits, the guide contains information about employment services, state and local healthcare resources, education and training programs, and housing assistance available to veterans in North Carolina.
GDVS' Response: According to GDVS, it "is reviewing the contents of the current Georgia veterans benefits guide published by the department with the view to expand the contents of the guide for its next publication (probably in late 2016) to include references to other state agencies' offerings that Georgia veterans may be able to access."
Information and Outreach We identified three states that have coordinated with other state agencies to reach veterans.
Ohio's Department of Veterans Services coordinated with the state's Department of Motor Vehicles to include information in the driver's license renewal forms mailed to 3.5 million citizens.
Oregon staff reported that the state recently passed laws requiring that agencies share information and to ask all state government customers if they are veterans. Following passage of these laws, the Department of Veterans' Affairs established agreements with the state's Department of Human Services and Department of Motor Vehicles to obtain information they collect on veterans.
Pennsylvania's Military and Veterans Affairs Department is part of a shared statewide approach designed to provide long term services and supports for all populations, including veterans. This collaborative effort is with the state's Departments of Aging and Public Welfare, as well as several other entities. The intention is to develop a seamless process to conduct outreach, identify those in need of services and provide access to those services.

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How much funding does GDVS currently get from third parties and what additional funds could GDVS access through partnerships with third party entities?

Current Third Party Funds
GDVS' fiscal year 2016 budget includes $3.1 million of "other" funds, which includes all funds that are not obtained from either state or federal sources. These funds represent 8% of GDVS' fiscal year 2016 appropriations. The majority of these funds, $2.4 million (76%), are derived from fees collected from patients at the War Veterans Nursing Homes.10 In 2012, the General Assembly authorized GDVS to collect daily fees from patients to pay a portion of the cost of care. Currently a daily fee is charged to all patients unless they are eligible for a waiver from the fee.11 This fee is $23.53 and is based on the Aid and Attendance (A&A) benefit, which is designed to help veterans cover medical expenses including those associated with nursing home care, provided by VA. In fiscal year 2015, 42% of the patients in the Milledgeville facility and 12% of patients in the Augusta facility received A&A. GDVS helps veterans admitted to the nursing home apply for A&A as well as any other benefit to which they may be entitled. This daily fee is used to offset the state's cost of care.
The War Veterans Nursing Homes receive monetary donations from third party sources; however, they are not part of GDVS' budget. According to GDVS, each veterans nursing home maintains a patient benefit fund to collect financial donations from the public, various veteran service organizations, individuals, churches and other local entities. Donated funds are managed by the veterans nursing homes and are used for social activities and personal supplies for patients. During fiscal year 2015, contributions to the patient benefit fund for both veterans nursing homes totaled approximately $36,000.
GDVS reported that it also receives non-monetary donations from individuals, veteran service organizations, churches, and civic groups. Various organizations donate items such as wreaths and flags for graves at veterans cemeteries. In-kind donations are also made to veterans nursing homes to support social and other activities for veterans. GDVS reported that items valued at $4,850 and 1,036 hours of volunteer time were donated to the Augusta facility during 2014 and items valued at $59,895 and 8,972 hours of volunteer time were donated to its Milledgeville facility.12

Opportunities for Additional Third Party Funding
As shown in Exhibit 11, other states administer trust funds or have established organizations, such as foundations, to receive voluntary contributions to support department and programmatic activities or provide direct services to veterans. In addition, other states receive funds from the sale of special license plates and interment fees. As described in the bullets, states use these funds to administer

10 About $750,000 of the other funds in GDVS' 2016 budget are state matching funds from the Georgia State Financing and Investment Commission to pay for capital expenditures at the veterans cemeteries. Because these are matching dollars for federal funds, they are discussed in the federal section of this report.
11 Patients must have an income below 125% of the poverty level to qualify for the waiver.
12 GDVS valued volunteer time at $22 per hour during 2014.

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services and programs, provide direct financial assistance, and award grants to organizations and other entities that provide services to veterans.
Voluntary contributions States have various mechanisms for collecting financial donations to support veteran programs and services. For example, Florida and Maryland have established a special fund to collect financial donations from residents. Pennsylvania, Texas and Virginia collect donations to support veterans through a special veteran themed lottery ticket or during state transactions such as applying for state licenses, permits, registrations and filing state income taxes. States have used these funds for providing financial assistance to veterans.
To collect such funds in Georgia, statutory changes would be required to allow, for example, the establishment of a trust fund and there may be additional costs associated with managing a new funding stream. For example, if Georgia began collecting donations to fund emergency assistance to veterans, there would be a cost to collect, distribute and monitor the funds. Based on other states reviewed, Maryland generated $200,000 from general donations and Ohio generated $2 million from an income tax checkoff.
Sale of license plates States also generate revenue to support veteran programs and initiatives from the sale of special license plates. Some states offer the general public special license plates honoring veterans and allocate a portion of the revenue collected to support veterans. Similarly, some states allocate a portion of the proceeds from the sale of special license plates to military service members and veterans. States have used these funds to support veterans nursing homes and cemeteries and award grants to veteran service organizations to assist veterans.
Interment fees While no state charges a fee to bury veterans in state veterans cemeteries, we found that 6 of 10 states that we reviewed charge interment fees to bury spouses and dependents. Georgia does not currently charge for these services. Interment fees ranged from $300 to $700 to provide cemetery services for a casket burial. States use the revenue collected from interment fees to offset costs for the veterans cemetery program.
According to GDVS, the Attorney General's office verbally indicated that charging for these services would require a statutory change. In fiscal year 2015, spousal and dependent burials represented 21% (87 of 414) of the total burials. If the state charged a fee commensurate with what other states are charging, approximately $500 per burial, it would generate $43,500 in additional revenue.

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Exhibit 11 States Use Various Methods to Collect Revenue for Veterans

State
Alabama Florida3 Maryland North Carolina Ohio3 Pennsylvania3 Tennessee Texas Virginia Washington

License Plates



Interment Fees

N/A

N/A N/A



State

Direct

Transactions1 Contributions2























1 State transactions include contributions made while filing state income taxes or applying for state licenses, permits, and registrations. 2 Direct contributions include grants, corporate donations and other contributions made directly to the state for the state veteran service agency. 3 Florida, Ohio and Pennsylvania do not operate a state veteran cemetery program.
Source: State websites and interviews

Private foundations and other philanthropic organizations such as Home Depot and the Community Foundation for Greater Atlanta also support veteran programs. Generally, these organizations offer funding to non-profit organizations that provide specific services, such as housing, employment, and behavioral health, for veterans. While these funds provide an additional resource for veterans, our research indicated that state agencies are not receiving these funds, either in Georgia or other states we reviewed.
GDVS' Response: GDVS communicated concerns about charging interment fees for the burial of spouses and dependents at state veterans cemeteries noting that "[t]he VA does not charge spouses and eligible dependents for interment at National Cemeteries. The GDVS matches the VA policy." It also noted that "charging a nominal fee may discourage veterans from using this benefit for final resting places. Based on the current mix of veterans to non-veterans interred at the state's veterans' cemeteries, the negative messages sent to the veterans of Georgia by charging a fee far outweigh the minimal amount of funds to be generated."
Partnerships with Third Party Entities
GDVS has informal partnerships with numerous veteran service organizations. As of September 2015, GDVS was accredited by eight service organizations, including Fleet Reserve Association and Noncommissioned Officers Association, to assist and represent veterans during the claims process. GDVS employs two claims and appeals officers who also perform duties as a national service officer for a veteran service organization. In addition to their responsibilities in the Appeals division, these employees conduct outreach, train field staff located at local posts, visit patients in veteran hospitals and nursing homes and submit periodic reports for the American

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Legion and Veterans of Foreign Wars. GDVS also reported that representatives of veteran service organizations regularly attend and report at monthly Veteran Service Board meetings.
We found that some state veterans affairs offices partner with county governments, veteran service organizations, or other entities to assist veterans at the local level. For example, state veterans affairs offices in Louisiana, North Carolina, Ohio and Pennsylvania do not operate local field offices, instead the local or county government operates the field offices and the state veterans affairs office trains local or county field office staff. In some cases, such as in Louisiana, the state veterans affairs office shares a portion of the cost of operating these offices. The Washington Department of Veterans Affairs contracts with veteran service organizations to provide claims processing services statewide. The Ohio Department of Veterans Services provides grants to veteran service organizations for salaries, transportation and other expenses necessary to operate field offices.
A study published by Declare Consulting in 2013 noted that private sector advocates and nonprofit providers should be involved in the Returning Veterans Task Force (RVTF). According to the report, involvement of such third party entities could ensure the effectiveness of the various services state agencies provide for veterans. At least one state, Tennessee, reported that it includes citizens and legislators on its veterans council. Veterans affairs offices in other states, including Florida, Maryland, Tennessee, and Virginia are members of a statewide veteran related advisory council consisting of veteran service organizations and other entities organized to focus on veterans issues. GDVS staff noted that representatives of federal agencies, veteran service organizations and legislators have attended RVTF meetings. However, to formally change the membership of the task force would require legislative action.
GDVS could establish additional partnerships with third party entities, such as veteran service and nonprofit organizations, to enhance services at the local level and improve collaboration.

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Appendix A: Objectives, Scope, and Methodology
Objectives This report examines the Department of Veterans Service Availability of Other Funds. Specifically, our examination set out to determine the following:
1. What are the outcomes of programs implemented by GDVS? 2. What are GDVS' expenditures by program? 3. How much funding does GDVS currently get from federal sources and what
additional funds could GDVS access through partnerships with federal entities? 4. How much funding does GDVS currently get from other state departments and what additional funds could GDVS access through partnerships with other state departments? 5. How much funding does GDVS currently get from third parties and what additional funds could GDVS access through partnerships with third party entities?
Scope This special examination generally covered activity related to the Department of Veterans Service that occurred between fiscal year 2011 and fiscal year 2015, with consideration of earlier or later periods when relevant. Information used in this report was obtained by reviewing relevant laws, rules, and regulations, interviewing agency officials and staff from GDVS, reviewing annual reports and Veteran Service Board minutes, analyzing funding data, comparing funding and expenditure data across fiscal years, reviewing existing studies by other organizations, and compiling information from other states. Funding data was used to inform multiple objectives. This data was obtained from the state's accounting system.
Information from similar veterans affairs offices in other states was also used to inform multiple objectives. We obtained additional information by interviewing agency officials from state veterans affairs offices, compiling and reviewing program information from agency websites, reviewing state veteran benefit guides, and examining agency annual and strategic reports and related documents. This information was compiled for similar veterans affairs offices in six southeastern states, as well as selected other states that implement best practices relevant to our objectives and have a comparable veteran population.
Methodology To examine program outcomes we interviewed GDVS staff about its process for collecting, monitoring and reporting program data for field operations. We examined GDVS performance data submitted to the Office of Planning and Budget for publication in the Performance Measures Report and the Governor's Budget Report for fiscal years 2012-2014. We also examined applicable internal policies guiding this process. We also obtained and analyzed data from VectraSpec, which is GDVS' electronic system for tracking claims, and its manual system used for tracking activity data.

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To determine program expenditures, we interviewed GDVS staff about trends in program expenditures. We also obtained and analyzed funding and expenditure data by program from the state's accounting system for fiscal years 2011-2015.
To determine GDVS' funding from federal sources and identify additional funds GDVS could access through partnerships with federal entities, we interviewed GDVS staff. We obtained and reviewed information from VA and other federal agency websites about funding provided for veteran programs and services. We reviewed reports published by GDVS and external entities about federal funding for programs and services assisting veterans. We also examined Medicare and Medicaid guidelines.
We conducted a search of the USASpending.gov database to identify the types of federal programs for which state veterans affairs offices included in our sample receive funding. We limited our review to programs administered by the U.S. Departments of Veterans Affairs, Defense, Labor, and Health & Human Services. USASpending.gov contains data about public and private organizations that receive federal funds for contracts greater than $3,000 and grants greater than $25,000. We obtained additional information about the programs identified in the results our search of USASpending.gov from the Catalog of Federal Domestic Assistance (CFDA). This online database contains detailed descriptions for federal assistance programs available to state and local governments, public and private profit and nonprofit organizations and institutions, specialized groups and individuals. We used this information to identify programs from which GDVS may be eligible to seek additional funding.
To determine GDVS' funding from other state departments and identify additional funds GDVS could access through partnerships with other state departments, we interviewed GDVS staff about its partnerships with other state departments. We also interviewed representatives of other state departments that participate in the Returning Veterans Task Force, as well as other agencies identified during our fieldwork that have responsibility for providing programs and services beneficial to veterans, for information regarding existing and potential funding for GDVS. We examined the Returning Veteran Task Force's meeting minutes and reviewed information from other state department websites about the programs and services they provide for veterans. We examined Georgia's state benefit guide for veterans for information about specific services and programs other state departments provide for veterans. We compared this information with that included in state benefit and resource guides other states publish to provide veterans information about available services and programs.
To determine GDVS' funding from third parties and identify additional funds GDVS could access through partnerships with third party entities, we interviewed GDVS staff about formal and informal partnerships with entities outside of federal and state government. We also interviewed representatives of veteran service organizations that have a visible presence in Georgia. We examined relevant reports and studies about third party funding targeting veteran populations.
This special examination was not conducted in accordance with generally accepted government auditing standards (GAGAS) given the timeframe in which the report was needed. However, it was conducted in accordance with Performance Audit Division policies and procedures for non-GAGAS engagements. These policies and procedures require that we plan and perform the engagement to obtain sufficient,

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appropriate evidence to provide a reasonable basis for the information reported and that data limitations be identified for the reader.

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Appendix B: Funding by Source and Program

Fiscal Years 2011 to 2016

FY

Program

State

Federal

Other

Total

2011 Actual

2012 Actual

2013 Actual

Administration

Georgia Veterans Memorial Cemetery

Georgia War Veterans Nursing Home

Veterans Benefits

FY 2011 Total

Percent

Administration

Georgia Veterans Memorial Cemetery

Georgia War Veterans Nursing Home

Veterans Benefits

FY 2012 Total

Percent

Administration

Georgia Veterans Memorial Cemetery

Georgia War Veterans Nursing Home

Veterans Benefits

Percent1

FY 2013 Total

Administration

Georgia Veterans Memorial Cemetery

Georgia War Veterans Nursing Home

Veterans Benefits

FY 2014 Total

Percent

Administration

Georgia Veterans Memorial Cemetery

Georgia War Veterans Nursing Home

Veterans Benefits

FY 2015 Total

Percent1

Administration

Georgia Veterans Memorial Cemetery

Georgia War Veterans Nursing Home

Veterans Benefits

FY 2016 Total

$1,248,724 570,076
13,445,780 5,055,618
$20,320,198 55%
$1,367,900 542,786
12,827,417 5,602,212
$20,340,315 55%
$1,474,015 484,954
12,015,888 5,858,770
$19,833,627 55%
$1,570,145 498,935
11,813,565 6,253,353
$20,135,998 49%
1,758,956 738,697
10,843,895 6,257,793
$19,599,341 47%
$1,801,404 661,086
11,951,352 6,398,475
$20,812,317

$0 55,636 11,970,517 3,020,294 $15,046,447
41% $0
199,499 12,662,830
2,129,553 $14,991,882
41% $0
234,502 13,765,322
1,119,816 $15,119,640
42% $0
219,665 15,823,705
976,427 $17,019,797
42% $0
166,653 17,471,406
678,973 $18,317,032
44% $0
178,004 13,300,386
1,377,440 $14,855,830

$0 0 0
1,607,520 $1,607,520
4% $0
0 0 1,454,938 $1,454,938 4% $0 0 1,124,605 268,128 $1,392,733 4% $0 0 3,194,140 334,990 $3,529,130 9% $0 0 3,059,333 410,312 $3,469,645 8% $0 0 2,381,422 750,000 $3,131,422

$1,248,724 625,712
25,416,297 9,683,432
$36,974,165 100%
$1,367,900 742,285
25,490,247 9,186,703
$36,787,135 100%
$1,474,015 719,456
26,905,815 7,246,714
$36,346,000 100%
$1,570,145 718,600
30,831,410 7,564,770
$40,684,925 100%
$1,758,956 905,350
31,374,634 7,347,078
$41,386,018 100%
$1,801,404 839,090
27,633,160 8,525,915
$38,799,569

2014 Actual

2015 Actual

2016 Budgeted

Percent 1Values may not add due to rounding.

54%

38%

8%

100%

Source: PeopleSoft data

The Performance Audit Division was established in 1971 to conduct in-depth reviews of state-funded programs. Our reviews determine if programs are meeting goals and objectives; measure program results and effectiveness; identify alternate methods to meet goals; evaluate efficiency of resource allocation; assess compliance with laws and regulations; and provide credible management information to decision-makers. For more information, contact
us at (404)656-2180 or visit our website at www.audits.ga.gov.