This is the accessible text file for GAO report number GAO-04-996T entitled 'VA Health Care: More Outpatient Rehabilitation Services for Blind Veterans Could Better Meet Their Needs' which was released on July 22, 2004. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Testimony: Before the Committee on Veterans' Affairs, House of Representatives: United States Government Accountability Office: GAO: For Release on Delivery Expected at 9:30 a.m. EDT: Thursday, July 22, 2004: VA Health Care: More Outpatient Rehabilitation Services for Blind Veterans Could Better Meet Their Needs: Statement of Cynthia A. Bascetta: Director, Health Care--Veterans' Health and Benefits Issues: GAO-04-996T: GAO Highlights: Highlights of GAO-04-996T, a report to the Committee on Veterans’ Affairs, House of Representatives: Why GAO Did This Study: In fiscal year 2003, the Department of Veterans Affairs (VA) estimated that about 157,000 veterans were legally blind, and about 44,000 of these veterans were enrolled in VA health care. The Chairman of the Subcommittee on Health, House Veterans’ Affairs Committee, and the Ranking Minority Member, Senate Veterans’ Affairs Committee expressed concerns about VA’s rehabilitation services for blind veterans. GAO reviewed (1) the availability of VA outpatient blind rehabilitation services, (2) whether legally blind veterans benefit from VA and non-VA outpatient services, and (3) what factors affect VA’s ability to increase veterans’ access to blind rehabilitation outpatient services. GAO reviewed VA’s blind rehabilitation policies; interviewed officials from VA, the Blinded Veterans Association, state and private nonprofit agencies, and visited five Blind Rehabilitation Centers (BRC). What GAO Found: VA provides three types of blind rehabilitation outpatient training services. These services, which are available at a small number of VA locations, range from short-term programs provided in VA facilities to services provided in the veteran’s own home. They are Visual Impairment Services Outpatient Rehabilitation, Visual Impairment Center to Optimize Remaining Sight, and Blind Rehabilitation Outpatient Specialists. Locations of VA Outpatient Blind Rehabilitation Services, May 2004: [See PDF for image] [End of figure] VA reported to GAO that some legally blind veterans could benefit from increased access to outpatient blind rehabilitation services. When VA reviewed all of the veterans who, as of March 31, 2004, were on the waiting list for admission to the five BRCs GAO visited, VA officials reported that 315 out of 1,501 of them, or 21 percent, could potentially be better served through access to outpatient blind rehabilitation services, if such services were available. GAO also identified two factors that may affect the expansion of VA’s outpatient blind rehabilitation services. The first involves VA’s longstanding position that training for legally blind veterans is best provided in a comprehensive inpatient setting. The second reported factor is VA’s method of allocating funds for medical care. VA is currently working to develop an allocation amount that would better reflect the cost of providing blind rehabilitation services on an outpatient basis. What GAO Recommends: GAO recommends that the Secretary of Veterans Affairs direct the Under Secretary for Health to issue, as soon as possible in fiscal year 2005, a uniform standard of care policy that ensures that a broad range of inpatient and outpatient blind rehabilitation services are more widely available to legally blind veterans. In commenting on a draft of this testimony, VA concurred with our recommendation. www.gao.gov/cgi-bin/getrpt?GAO-04-996T. To view the full product, including the scope and methodology, click on the link above. For more information, contact Cynthia A. Bascetta at (202) 512-7101. [End of section] Mr. Chairman and Members of the Committee: I am pleased to be here today to discuss the health care rehabilitation services the Department of Veterans Affairs (VA) provides to legally blind veterans. In fiscal year 2003, VA estimated that about 157,000 veterans were legally blind,[Footnote 1] and about 44,000 of these veterans were enrolled in VA health care. Since the 1940s, the demographics of VA's blind veteran population have changed from young veterans totally blind as a result of traumatic injury to primarily older veterans whose legal blindness is caused by age-related eye diseases. You expressed concern that VA has not updated its delivery of care options for blind rehabilitation programs by offering, in addition to inpatient services, a range of outpatient services closer to where veterans live.[Footnote 2] To determine how VA serves the needs of legally blind veterans and what role outpatient training services could play, we reviewed (1) the availability of VA outpatient blind rehabilitation services, (2) whether legally blind veterans benefit from VA and non-VA outpatient services, and (3) what factors affect VA's ability to increase veterans' access to blind rehabilitation outpatient services. To address these issues, we met with officials from VA's Rehabilitative Strategic Health Care Group, including the Blind Rehabilitation Service Program Office (program office). We also met with VA's directors for ophthalmology and optometry. We reviewed applicable policies and procedures regarding VA's blind rehabilitation services, its strategic plan for blind rehabilitation, and its planning documents for special disability populations. To determine what blind rehabilitation services were available to veterans, we visited five medical centers offering blind rehabilitation services and met with Blind Rehabilitation Center (BRC) officials as well as case managers and rehabilitation specialists who work with legally blind veterans.[Footnote 3] We asked BRC officials and case managers to evaluate veterans on the waiting lists for admission to these BRCs as of March 31, 2004, to identify those who could potentially be better served through access to outpatient blind rehabilitation services, if such services were available. We also interviewed case managers who were located at medical centers without a BRC and representatives of the Blinded Veterans Association to gain their perspectives on the types of care that would benefit legally blind veterans. In addition, we met with officials from state and private nonprofit agencies in Arizona, Illinois, and Washington to learn about the blind rehabilitation programs they offer older citizens.[Footnote 4] Our review was conducted from September 2003 through July 2004 in accordance with generally accepted government auditing standards. In summary, VA provides three types of blind rehabilitation outpatient training services, but they are available only in a few VA locations. These services range from short-term programs provided in VA facilities to services provided in the veteran's own home. VA also believes that some legally blind veterans could benefit from increased access to outpatient blind rehabilitation services. In fact, VA officials reported to us that 21 percent of veterans on the waiting lists for admission to the five BRCs we visited could potentially be better served through access to outpatient blind rehabilitation services, if such services were available. Finally, two factors affect the expansion of VA's outpatient blind rehabilitation services. The first involves VA's long-standing position that training for legally blind veterans should be provided in a comprehensive inpatient setting. This delivery model has not kept pace with VA's overall health care strategy that reduces its reliance on inpatient care and emphasizes more outpatient care. The second reported factor affecting the use of outpatient blind rehabilitation services is its method of allocating funds for medical care. VA's Visual Impairment Advisory Board (VIAB) believes that the funds allocated for basic outpatient care for legally blind veterans do not cover the cost of providing blind rehabilitation outpatient services. The VIAB is currently working with VA's Office of Finance and Allocation Resource Center[Footnote 5] to develop an allocation amount that would better reflect the cost of providing blind rehabilitation services on an outpatient basis, which could provide an incentive to expand this care. We are recommending that VA take action to ensure that a broad range of inpatient and outpatient blind rehabilitation services is more widely available to legally blind veterans. Background: In 1944, President Franklin D. Roosevelt made a commitment that no servicemen blinded in combat in World War II would be returned to their homes without adequate training to meet the problems imposed by their blindness, according to VA. From 1944 to 1947, the Army and Navy provided this rehabilitation training. In 1947, responsibility for this training was transferred to VA, and in 1948, VA opened its first BRC to provide comprehensive inpatient care to legally blind veterans. In 1956, blind rehabilitation services were expanded to include veterans whose legal blindness was not service-connected. Because of this expansion, the demographics of VA's blind veteran population shifted toward predominately older veterans whose legal blindness was caused by age-related eye diseases. Expanded eligibility also caused an increase in demand for services. VA responded to this demand by opening 9 additional BRCs in the United States and Puerto Rico for a total of 10 facilities with 241 authorized beds. (See table 1.) As of May 5 2004, VA reported that there were 2,127 legally blind veterans waiting for admission to BRCs.[Footnote 6] Table 1: Location of VA's Blind Rehabilitation Centers, the Year Each Was Opened, and the Number of Authorized and Staffed Beds, as of May 2004: Location: American Lake, Washington; Year Opened: 1971; Beds[A]: Authorized: 15; Beds[A]: Staffed: 12. Location: Augusta, Georgia; Year Opened: 1996; Beds[A]: Authorized: 15; Beds[A]: Staffed: 15. Location: Birmingham, Alabama; Year Opened: 1982; Beds[A]: Authorized: 32; Beds[A]: Staffed: 32. Location: Hines, Illinois; Year Opened: 1948; Beds[A]: Authorized: 34; Beds[A]: Staffed: 34. Location: Palo Alto, California; Year Opened: 1967; Beds[A]: Authorized: 32; Beds[A]: Staffed: 27. Location: San Juan, Puerto Rico; Year Opened: 1986; Beds[A]: Authorized: 12; Beds[A]: Staffed: 11. Location: Tucson, Arizona; Year Opened: 1994; Beds[A]: Authorized: 34; Beds[A]: Staffed: 27. Location: Waco, Texas; Year Opened: 1974; Beds[A]: Authorized: 15; Beds[A]: Staffed: 15. Location: West Haven, Connecticut; Year Opened: 1969; Beds[A]: Authorized: 34; Beds[A]: Staffed: 27. Location: West Palm Beach, Florida; Year Opened: 2000; Beds[A]: Authorized: 18; Beds[A]: Staffed: 18. Total; Beds[A]: Authorized: 241; Beds[A]: Staffed: 218. Source: VA. [A] Authorized beds are the total bed capacity of the BRC. Staffed beds are the beds available for admission of patients. According to VA's Capacity Report for 2003, the number of staffed beds may be less than authorized beds because the local medical center may have eliminated staff positions, imposed a hiring freeze, or experienced difficulties in recruiting qualified personnel. [End of table] In fiscal year 2003, VA estimated that about 157,000 veterans were legally blind,[Footnote 7] with more than 60 percent age 75 or older. About 44,000 legally blind veterans were enrolled in VA health care. VA estimated that through 2022, the number of legally blind veterans would remain stable. (See fig. 1.) Figure 1: Estimated Age Distribution of Legally Blind Veterans, Fiscal Years 2003, 2012, and 2022: [See PDF for image] [End of figure] The National Institutes of Health (NIH) considers the increase in age- related eye diseases to be an emerging major public health problem. According to NIH, the four leading diseases that cause age-related legal blindness are cataract, glaucoma, macular degeneration, and diabetic retinopathy, each affecting vision differently. (See fig. 2 for illustrations of how each disease affects vision.) Cataract is a clouding of the eye's normally clear lens. Most cataracts appear with advancing age, and by age 80, more than half of all Americans develop them. Glaucoma causes gradual damage to the optic nerve--the nerve to the eye--that results in decreasing peripheral vision. It is estimated that as many as 4 million Americans have glaucoma. Macular degeneration results in the loss of central visual clarity and contrast sensitivity. It is the most common cause of legal blindness in older Americans and rarely affects those under the age of 60. Diabetic retinopathy is a common complication of diabetes impairing vision over time. It results in the loss of visual clarity, peripheral vision, and color and contrast sensitivity. It also increases the eye's sensitivity to glare. Nearly half of all diabetics will develop some degree of diabetic retinopathy, and the risk increases with veterans' age and the length of time they have had diabetes. Figure 2: Vision and Vision Loss Due to Age-Related Eye Diseases: [See PDF for image] [End of figure] To assist legally blind veterans, VA established Visual Impairment Services Team (VIST) coordinators who act as case managers and are responsible for coordinating all medical services for these veterans, including obtaining medical examinations and arranging for blind rehabilitation services. There are about 170 VIST coordinators, who are located at VA medical centers that have at least 100 enrolled legally blind veterans. VIST coordinators are also responsible for certain administrative services such as reviewing the veteran's compensation and pension benefits. Almost all of VA's blind rehabilitation services for veterans are provided through comprehensive inpatient care at BRCs, where veterans are trained to use their remaining vision[Footnote 8] and other senses, as well as adaptive devices such as canes, to help compensate for impaired vision. VA offers both basic and computer training. (See table 2 for examples of the types of skills taught during basic and computer training.) Table 2: Examples of Training Courses Offered at Blind Rehabilitation Centers: Basic training: Visual skills; Examples of skills taught: * Maximizing remaining vision through the use of alternative scanning or viewing techniques; * Using magnification devices or closed circuit televisions to read or write. Basic training: Orientation and mobility; Examples of skills taught: * Moving around the home; * Traveling through different environments; * Using adaptive devices, such as telescopic devices for reading street signs. Basic training: Living skills; Examples of skills taught: * Cooking and eating; * Doing laundry or changing light bulbs; * Typing or keyboarding. Basic training: Manual skills; Examples of skills taught: * Using hand and power tools; * Problem solving and organization of work. Basic training: Leisure skills; Examples of skills taught: * Going to sporting events; * Playing golf or fishing; * Developing a hobby, such as woodworking. Basic training: Adjustment counseling; Examples of skills taught: * Using counseling, therapy, and social interaction with others who have similar visual impairments to learn to adjust to blindness. Computer training: Computer skills; Examples of skills taught: * Operating a computer; * Searching the Internet; * Sending, receiving, and reading e-mail. Source: VA Blind Rehabilitation Service. [End of table] In fiscal years 2002 and 2003, VA spent over $56 million each year for inpatient training at BRCs. During this same time period, VA spent less than $5 million each year to provide outpatient rehabilitation training for legally blind veterans. Blind Rehabilitation Outpatient Services Are Available in Few VA Locations: VA offers three types of blind rehabilitation outpatient services to legally blind veterans,[Footnote 9] but these services are available in few VA locations. The three types of services include Visual Impairment Services Outpatient Rehabilitation (VISOR), Visual Impairment Center to Optimize Remaining Sight (VICTORS), and Blind Rehabilitation Outpatient Specialists (BROS). The services range from short-term outpatient programs provided in VA facilities to home-based services. Figure 3 identifies the locations throughout the United States and Puerto Rico where these services are offered.[Footnote 10] Figure 3: Locations of VA Outpatient Blind Rehabilitation Services, May 2004: [See PDF for image] [End of figure] VISOR: VISOR is a 10-day outpatient program located at the VA medical center in Lebanon, Pennsylvania, that offers training in the use of low vision equipment, basic orientation and mobility, and living skills. Serving veterans in the surrounding 13-county area, it is primarily for veterans who can independently perform activities of daily living and who require only limited training in visual skills and orientation and mobility, such as traveling within and outside their homes. According to a VISOR official, the program is meant to provide training to veterans while they wait for admission to a BRC or to veterans who do not want to attend a BRC. Veterans who participate in this program are housed in hoptel beds[Footnote 11] within the medical facility. In fiscal year 2003, 54 veterans attended the VISOR program; about 20 to 30 percent of these veterans were legally blind. According to a VISOR official, there is no waiting list for this program and the local medical center provides the necessary funding for it. VICTORS Services: VICTORS is a 3-to 7-day outpatient program for veterans in good health whose vision loss affects their ability to perform activities of daily living, such as personal grooming and reading mail. The program provides the veterans with a specialized low vision eye examination, prescriptions for and training in the use of low vision equipment, and counseling. There are three VICTORS programs located in VA medical centers in Kansas City, Missouri; Chicago, Illinois; and Northport, New York. Veterans are housed in hoptel beds within the medical facility or in nearby hotels. In fiscal year 2003, VICTORS served over 900 veterans; about 25 to 30 percent of these veterans were legally blind. According to VICTORS officials, the wait time for admission to VICTORS varied from about 55 to about 170 days. The medical center where the program is located funds the services. BROS Services: BROS are blind rehabilitation outpatient instructors who provide a variety of short-term services to veterans in their homes and at VA facilities. BROS train veterans prior to and following their participation in BRC programs, as well as veterans who cannot or do not choose to attend a BRC. BROS training addresses veterans' immediate needs, especially those involving safety issues such as reading prescriptions or simple cooking. There are 23 BROS throughout VA's health care system, with 7 located in the VA network that covers Florida and Puerto Rico. In fiscal year 2003, BROS trained about 2,700 veterans, almost all of whom were legally blind. Wait time for BROS services varied from about 14 to 28 days according to the BROS we interviewed. BROS are funded by the medical centers where they are located.[Footnote 12] Outpatient Services Provide Opportunities to Benefit Veterans: VA officials who provide services to legally blind veterans told us that some veterans could benefit from increased access to outpatient blind rehabilitation services. We obtained this information by asking VA to review all of the veterans who, as of March 31, 2004, were on the waiting lists for admission to the five BRCs we visited and to determine whether outpatient services could meet their needs. VA officials reported that 315 out of 1,501 of these veterans, or 21 percent, could potentially be better served through access to outpatient blind rehabilitation services, if such services were available. The types of veterans VA believes could potentially benefit from outpatient services include those who are very elderly or lack the physical stamina to participate in a comprehensive 28-to 42-day BRC program and those who have medical needs that cannot be provided by the BRC. For example, some BRCs are unable to accept patients requiring kidney dialysis. In addition, some veterans do not want to leave their families for long periods of time[Footnote 13] and some legally blind veterans are primary caretakers for their spouses and are unable to leave their homes. VA officials also told us that veterans in good health who can independently perform activities of daily living and require only limited or specialized training could also be served effectively on an outpatient basis. A VA study concluded that there is a need for increased outpatient services for legally blind veterans. In 1999, VA convened a Blind Rehabilitation Gold Ribbon Panel to study concerns about the growing number of legally blind veterans. The panel examined how VA historically provided blind rehabilitation services and recommended that VA transition from its primarily inpatient model of care to one that included both inpatient and outpatient services. In 2000, VA established the VIAB to implement the panel's recommendations. The VIAB drafted guidance for a uniform standard of care policy for visually impaired veterans throughout VA's health care system. This guidance outlined a continuum of care to provide a range of services from basic low vision to comprehensive inpatient rehabilitation training, including use of more outpatient services from both VA and non-VA sources. In January 2004, a final draft of the uniform standard of care policy was forwarded to VA's Health Systems Committee for approval. The committee believed additional information was needed for its approval and requested additional analysis that compared currently available blind rehabilitation services with anticipated needs. VA plans to complete this analysis in the first quarter of fiscal year 2005 and then resubmit the uniform standard of care policy and the additional analysis to the Health Systems Committee. VA officials were unable to provide a timeframe for the Health Systems Committee's approval. Some VIST coordinators have already provided outpatient services to legally blind veterans by referring them to state and private blind rehabilitation services. For example, in Florida a VIST coordinator referred veterans to the Lighthouse for the Blind for computer training at its outpatient facility if they did not live near and did not want to travel to the BRC. A VIST coordinator in Oklahoma arranged contractor-provided computer training in the veteran's home for veterans with a 20 percent or more service-connected disability. The coordinator issued the computer equipment to a local contractor; the contractor then set up the equipment in the veteran's home and provided the training. Another VIST coordinator in North Carolina referred all legally blind veterans to state service agencies, including veterans waiting for admission to a BRC. Each county in that state had a social worker for the blind that referred its citizens to independent living programs for in-home training in orientation and mobility and living skills. The state provided this training at no charge to the veteran and VA paid for the equipment. Recently, VA has begun to shift computer training from inpatient settings at BRCs to private sector outpatient settings. VA's goal was to remove from the BRC waiting list by July 30, 2004, those veterans seeking admission to a BRC only for computer training. In spring 2004, VA issued instructions stating that the prosthetic budget of each medical center, which already paid for computer equipment for legally blind veterans, would now pay for computer training.[Footnote 14] Additionally, the Blind Rehabilitation Service Program Office asked BRCs to identify all the veterans waiting for admission for computer training and refer them back to their VIST coordinator for local computer training. If BRC and VIST coordinator staff determined that local computer training was not available or appropriate for a veteran, they were to provide an explanation to the program office. On May 5, 2004, 674 veterans were waiting for admission to a BRC for computer training. As of July 1, 2004, 520 veterans were removed from the BRC waiting list because arrangements were made for them to receive computer training from non-VA sources or they no longer wanted the training. Factors that Affect Expansion of Blind Rehabilitation Outpatient Services: There are two factors that affect VA's expansion of outpatient services systemwide. One factor is the agency's long-standing belief that rehabilitation training for legally blind veterans can be best provided in a comprehensive inpatient setting. The second reported factor is VA's method of allocating funds for blind rehabilitation outpatient services, which provides local medical center management discretion to provide funds for them. Some VA officials told us that one factor affecting veterans' access to outpatient care has been the agency's traditional focus on providing comprehensive inpatient training at BRCs. VA has historically considered the BRCs to be an exemplary model of care, and since 1948 BRCs have been the primary source of care for legally blind veterans. However, this delivery model has not kept pace with VA's overall health care strategy that reduces reliance on inpatient care and emphasizes outpatient care. VA's continued reliance on inpatient blind rehabilitation care is evident in its recent decision to build two additional BRCs in Long Beach, California, and Biloxi, Mississippi.[Footnote 15] We have, however, observed some recent changes that may affect this reliance on inpatient services. For example, VA has new leadership in its blind rehabilitation program that has expressed an interest in providing a broad range of inpatient and outpatient services to meet the training needs of legally blind veterans. Further, as previously discussed, the VIAB's draft continuum of care policy recommends a full range of blind rehabilitation services, emphasizing more outpatient care, including VICTORS, VISOR, and BROS. VA blind rehabilitation officials also told us that they believe changes to VA's resource allocation method could provide an incentive to expand blind rehabilitation services on an outpatient basis. The VIAB believes that the funds allocated for basic outpatient care for legally blind veterans do not cover the cost of providing blind rehabilitation services. Veterans Integrated Service Networks (networks)[Footnote 16] are allocated funds to provide basic outpatient care for veterans, which they then allocate to the medical centers in their regions. Both the networks and the medical centers have the discretion to prioritize the use of these funds for blind rehabilitation services or any other medical care. Some networks and medical centers have made outpatient blind rehabilitation training a priority and use these funds to provide outpatient services. For example, the network that covers Florida and Puerto Rico has used its allocations to fund seven BROS that are located throughout the region to provide outpatient blind rehabilitation services to legally blind veterans in their own homes or at VA facilities. Currently, the VIAB is working with VA's Office of Finance and Allocation Resource Center to develop an allocation amount that would better reflect the cost of providing blind rehabilitation services on an outpatient basis, which could in turn, provide an incentive for networks and medical centers to expand outpatient rehabilitation services for legally blind veterans. Conclusions: Many legally blind veterans have some vision, which frequently can be enhanced with optical low vision devices and training that includes learning to perform everyday activities such as cooking, reading prescription bottles, doing laundry, and paying bills. Since the 1940s, VA's preferred method of providing training to these veterans has been through inpatient services offered by BRCs. Because of its predisposition toward inpatient care, VA has developed little capacity to provide this care on an outpatient basis uniformly throughout the country. For the last 10 years, VA has been transitioning its overall health care system from a delivery model based primarily on inpatient care to one incorporating more outpatient care. Outpatient services for legally blind veterans, however, have lagged behind this trend. Recently, VA drafted a uniform standard of care policy that recommends a full range of blind rehabilitation services, emphasizing more outpatient care, including more services provided by VISOR, VICTORS, and BROS type programs. Making inpatient and outpatient blind rehabilitation training services available to meet the needs of legally blind veterans will help ensure that these veterans are provided with options to receive the right type of care, at the right time, in the right place. Recommendations: We are recommending that the Secretary of Veterans Affairs direct the Under Secretary for Health to issue, as soon as possible in fiscal year 2005, a uniform standard of care policy that ensures that a broad range of inpatient and outpatient blind rehabilitation services are more widely available to legally blind veterans. Agency Comments: We provided a draft of this testimony to VA for comment. In oral comments, an official in VA's Office of the Deputy Under Secretary for Health informed us that VA concurred with our recommendation. Mr. Chairman, this concludes my prepared remarks. I will be glad to answer any questions you or other Members of the Committee may have. Contact and Acknowledgments: For further information regarding this testimony, please contact Cynthia A. Bascetta at (202) 512-7101. Michael T. Blair, Jr., Cherie Starck, Cynthia Forbes, and Janet Overton also contributed to this statement. FOOTNOTES [1] VA defines "legal blindness" as when the patient's best-corrected central visual acuity, with ordinary glasses or contact lenses, is 20/ 200 or less in the better eye (measured by the Snellen Visual Acuity Chart), or when the field of useful vision is 20 degrees or less in the better eye. For example, a legally blind person can read only the big "E" on the eye chart or sees as if looking through a paper towel tube. [2] This work was requested by the Chairman, Subcommittee on Health, Committee on Veterans' Affairs, House of Representatives and the Ranking Minority Member, Committee on Veterans' Affairs, United States Senate. [3] We visited the BRCs located in Tucson, Arizona; West Palm Beach, Florida; Augusta, Georgia; Hines, Illinois; and American Lake, Washington. These BRCs were selected based on differences in geographic location and the number of beds available at the BRC. [4] We selected these states because they were in the same geographic location as three of the BRCs we visited. [5] The Allocation Resource Center is responsible for developing, implementing, and maintaining management information systems that provide data for the Veterans Health Administration's budget process. [6] See U.S. General Accounting Office, VA Needs to Improve Accuracy of Reported Wait Times for Blind Rehabilitation Services, GAO-04-949 (Washington, D.C.: July 22, 2004). [7] All legally blind veterans are given priority 4 status and currently are eligible to enroll in VA health care. [8] About 85 percent of those who are legally blind have some usable vision. [9] Some VA low vision eye clinics also provide limited outpatient rehabilitation training to legally blind veterans whose remaining vision can be enhanced through the use of magnification devices. However, while VA has overall workload data for its eye clinics, it cannot disaggregate the data to identify how much low vision training is provided to legally blind veterans. [10] All of VA's outpatient programs also treat low vision veterans in addition to those veterans who are legally blind. VA defines low vision as when the patient has significant uncorrectable visual impairments of 20/70 up to, but not including, 20/200. [11] A hoptel is temporary lodging where no medical care is provided. [12] In connection with VA's fiscal year appropriations for 1995, the Senate Committee on Appropriations had recommended including $5 million for blind rehabilitation services to alleviate the lengthy waiting lists for such services. The conference committee agreed. See S. Rep. No. 103-311 (1994), H. Conf. Rep. No. 103-715 (1994). In addition to the BROS, these funds were also used to establish a BRC in Augusta, Georgia, and additional staff positions for VIST coordinators and computer specialists. [13] A 2003 study of 150 veterans located in the southeastern United States who were recommended for BRC training by their VIST coordinators but who did not attend, found that 59 percent cited a reluctance to leave home for an extended period as an important reason for non- participation. Williams, M., Help-Seeking Behavior as a Predictor of Participation in Department of Veterans Affairs-Sponsored Visual Impairment Rehabilitation. A Dissertation (Decatur, GA; 2003). [14] According to VA officials, the funds allocated for prosthetics maybe used only for prosthetic care--e.g. purchase of prosthetic items and veteran training in the use of these items. [15] See Department of Veterans Affairs Capital Asset Realignment for Enhanced Services (CARES): Secretary of Veterans Affairs CARES Decisions. (Washington D.C; May 2004). [16] VA has organized its medical facilities into 21 regional health care networks.