The Department of Veterans Affairs (VA) assumed an early leadership role in focusing on care of elderly adults. In 1998, the Federal Advisory Committee on the Future of VA Long-Term Care, appointed by the VA Undersecretary for Health, recommended redirection of VA's extended care programs toward noninstitutional forms. A decade later, VA's Office of Geriatrics and Extended Care (GEC) initiated a strategic planning process by convening experts in geriatrics and health care, policy, and finance in Virginia on March 25 to 27, 2008, to present to VA clinicians and clinical managers the "State of the Art" of VA GEC. Recurring clinical themes included rising numbers and complexity of aging veterans, recent addition of younger veterans to VA's extended care mix, challenges that dementia and mental illness exert throughout GEC, and need for seamlessness in delivery of care across multiple venues. Ongoing research efforts quantifying demand and resources and validating models of care will remain indispensible for meeting clinical challenges. Serious undersupply of clinicians of all disciplines with general or specialty geriatrics knowledge persists. Much of VA's healthcare workforce and leadership are approaching retirement age, driving the need for new educational approaches, recruitment and retention strategies, and innovative delivery systems. Growing dependence on informal caregivers highlights the need for supporting these partners. VA's healthcare budget allocation illustrates how national policy dictates systemic, regional, and local clinical decisions. Rehabilitation of the newest veterans is resulting in systemwide efficiencies. Educating and empowering patients and families results in optimized utilization of health resources.