SOCIAL WORK AND COMMUNITY CARE LEBANON VA MEDICAL

SOCIAL WORK AND COMMUNITY CARE LEBANON VA MEDICAL CENTER NON-INSTITUTIONAL CARE (NIC) COMMUNITY CARE PROGRAMS 10 APRIL 2014

Community Care Programs LEBANON VA MEDICAL CENTER Community Health Nurse Coordinators: Gianna Bleyer, BSN, RN Extension 4418 Melissa Mills, MSN/MHA, BSN, RN Extension 4257 Deborah Bishop, BSN, RN Nurse Manager Community Specialty Services Social Work and Community Care VETERANS HEALTH ADMINISTRATION

Community Care Programs NON-INSTITUTIONAL CARE (NIC) Rebalancing: The deliberate increase in the provision of Home and Community Based Services (HCBS) to persons facing the challenges of disability, aging and serious chronic disease, achieving cost offsets from reductions in preventable utilization of nursing home, hospital and emergency department services. VHA continues to progressively increase access to all its HCBS programs and has engaged in modest re-balancing. Additional shifting of resources will be required to achieve desired rebalancing. VETERANS HEALTH ADMINISTRATION

Community Care Programs NON-VA CARE GERIATRIC AND EXTENDED CARE REFERRALS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Adult Day Health Care (ADHC) Bowel and Bladder Caregiver Support Community Residential Care (CRC) Contract Community Nursing Home (CNH) Home Based Primary Care Home Telehealth Hospice In-Home Hospice Inpatient (CNH) LIFE Programs (Lancaster, Lebanon, and Schuylkill Counties) Medical Foster Home Non-skilled (HHA) Respite Care In-Home Respite Care Inpatient (CNH) Skilled Home Health Care Veteran-Directed Home and Community Based Serv. Ices 24/7 Live-in Care Pilot Program VETERANS HEALTH ADMINISTRATION

Community Care Programs NURSING HOME LEVEL OF CARE DEFINITION Through an interdisciplinary assessment, the Veteran has been determined to have the following clinical conditions: (a) Three or more ADL dependencies, or (b) Significant cognitive impairment, or (c) Require H/HHA services as adjunct care to community hospice services, or (d) Two ADL dependencies, and two or more of the following conditions: 1. Has dependency in three or more IADLs; 2. Has been recently discharged from a nursing facility, or has an upcoming nursing home discharge plan contingent on receipt of home and community-based care services; 3. Is seventy-five years old, or older; 4. Has had high use of medical services defined as three or more hospitalizations in the past year or has utilized outpatient clinics or emergency evaluation units twelve or more times in the past year; 5. Has been diagnosed with clinical depression; 6. Lives alone in the community. VETERANS HEALTH ADMINISTRATION

Community Care Programs NON-VA CARE GEC ADULT DAY CARE Provides health maintenance to Veterans in an outpatient group setting in the community. Services may include: Socialization and recreational activities Escorted outings Medication monitoring Music and Pet therapy Behavior Management Hot nutritious meals and snacks Usually provided two or three days per week There may be a $15 per day co-pay starting on the 22 nd day of services. VETERANS HEALTH ADMINISTRATION

Community Care Programs BOWEL AND BLADDER Supportive care provided to quadriplegic and paraplegic Veterans unable to manage these functions independently. Regarded as a skilled home health care service. May be provided by VA trained and certified family member/caregiver. Parameters of care prescribed by a VA Provider. VETERANS HEALTH ADMINISTRATION

Community Care Programs CAREGIVER SUPPORT PROGRAM VA values the sacrifices caregivers make to help Veterans remain at home, and recognizes that caregivers are the critical link to ensure that Veterans have the highest quality care and optimal wellness. VA wants all caregivers to feel supported and to have trust in the VA to assist them in their caregiving roles. The role of the Caregiver Support Program is to honor and engage all Veteran caregivers and to provide meaningful and effective support to caregivers. The Caregiver Support Coordinator will help find the programs and services that will enable the Veteran and caregiver to maintain their physical and emotional well-being. By reaching out to the caregivers, the CSC finds way that will keep the caregivers feeling valued, connected and informed. VETERANS HEALTH ADMINISTRATION

Community Care Programs COMMUNITY RESIDENTIAL CARE (CRC) Provides assistance to Veterans who do NOT require hospitalization or Nursing Home care, but are unable to live independently in their own homes for medical or psychosocial reasons. 12 CRC Homes are affiliated with and inspected by the VA annually and as needed. VA provides monthly SW visits to the Veterans. Payment is made by the Veteran from his own resources. Includes: Room, Board, Personal Care supervision, Medication Supervision, Transportation, and Activities. VETERANS HEALTH ADMINISTRATION

Community Care Programs CONTRACT COMMUNITY NURSING HOME (CNH) VA establishes contracts with local Nursing Homes in the community. Contracted CNHs are inspected by the VA on an annual basis with continual monitoring by VA staff. Contracts may be authorized for 32 days for short term rehabilitation therapy, or illness management education. Contracts may be authorized indefinitely for Veterans who qualify under the Millennia Bill. There are currently 19 CNHs in the Lebanon VA 9 county catchment area. VA Nurses and Social Workers provide continual oversight and monthly visits to Veterans on contract. VETERANS HEALTH ADMINISTRATION

Community Care Programs NURSING HOME OVERVIEW The Department of Veterans Affairs (VA) provides nursing home services (NH) to Veterans through three national programs: VA owned and operated Community Living Centers (CLC), State Veterans Homes (SVH), and the Community Nursing Home Program (CNH). All Veterans enrolled with VA for their health care eligible for NH services. Veterans who have a 70% service connected disability, Veterans who need nursing home care for a service-connected disability, and Veterans who are rated 60% serviceconnected and have an additional rating of unemployable have mandatory NH eligibility in CNH and CLC. All other Veterans are served as resources are available. VHA Directive 2004 -019, Eligibility for Nursing Home Care Public Law 106 -117, The Veterans’ Millennium Health Care and Benefits Act Each nursing home program has specific admission and eligibility criteria. VETERANS HEALTH ADMINISTRATION

Community Care Programs HOME BASED PRIMARY CARE (HBPC) The mission of HBPC is: To provide comprehensive, interdisciplinary, primary care in the homes of Veterans with complex medical conditions for whom routine clinic based care is not effective. The primary focus of HBPC is longitudinal care. To promote the Veteran’s maximum level of health and independence To reduce hospitalizations and emergency room visits through close monitoring by the HBPC team VETERANS HEALTH ADMINISTRATION

Community Care Programs HOME BASED PRIMARY CARE ADMISSION CRITERIA Impaired mobility due to disability or functional limitation Inability to cope with clinic environment due to cognitive, physical or psychiatric impairment Need for routine interventions provided by an interdisciplinary team Veteran is enrolled for VHA care. Veteran lives within HBPC's service area. Veteran has a disease process that necessitates care by an interdisciplinary team Routine clinic-based care is not effective Does NOT have to be housebound The Veteran and/or caregiver accept HBPC as the primary care team The Veteran's care needs can be met by HBPC program The Veteran has an identified caregiver, if needed The Veteran’s home is the most appropriate venue for care The home environment is safe for the Veteran/caregiver and the HBPC team members VETERANS HEALTH ADMINISTRATION

Community Care Programs HOME TELEHEALTH Care Coordination monitors medical and mental health issues from the comfort of the Veteran’s home using telecommunication technologies increasing access to care and to improve the health of the Veteran. High Blood Pressure Diabetes Chronic Heart Failure Chronic Lung Condition Depression Bipolar Schizophrenia Post Traumatic tress Disorder Obesity There are no co-pays for this service. VETERANS HEALTH ADMINISTRATION

Community Care Programs Veteran’s Responsibility Home Telehealth Answer health questions and take vitals (if required) daily Care Coordinator’s Responsibility Home Telehealth Monitors Veteran’s daily responses Take medications as prescribed Contacts Veteran to address any “out of range” responses Comply with recommended treatment plan Contacts Veteran's provider for evaluation when necessary Clean and care for equipment Can assist in making clinic appointments or help in renewing medications Return equipment if/when discharged from the program VETERANS HEALTH ADMINISTRATION

Community Care Programs HOSPICE CARE The primary goal of Hospice care is the comfort of the Veteran rather than the cure of the disease. All Veterans, with an advanced illness and a documented prognosis of six months or less, are eligible. Emphasizes relief of suffering and maintenance of function. Comprehensive management of the physical, psychological, social and spiritual needs of the veterans. Support for the Veteran's family and caregivers. Bereavement support following the death of the Veteran. VETERANS HEALTH ADMINISTRATION

Community Care Programs NON-VA CARE GEC HOSPICE INPATIENT (CNH) NON-VA CARE GEC HOSPICE IN-HOME Inpatient Hospice provided in VA Contracted Community Nursing Home (CNH) Caregiver may select a provider from the VA list of approved vendors The Veteran’s caregiver may select a CNH from the list of VA contracted CNHs, and apply for Respite admission. • There is no co-pay for Hospice Care. VETERANS HEALTH ADMINISTRATION Provides Nursing, Home Health Aide, Chaplain, and Social Work support weekly in the home.

Community Care Programs LIFE PROGRAMS ( LIVING INDEPENDENTLY FOR ELDERS): LANCASTER, LEBANON, SCHUYLKILL COUNTIES Health care co-management by partnership between VA and Community LIFE programs. Enables eligible Veterans needing nursing home level of care to remain in their homes. Provides ADHC, HHA, medications, showers, therapies, hot meals on campus and at home (Meals On Wheels), medical and nursing care and supervision. VETERANS HEALTH ADMINISTRATION

Community Care Programs NON-VA CARE GEC NON-SKILLED HOME HEALTH CARE Offers Veterans personal care services in the home to help maintain independence. Personal Care includes: Bathing Toileting Activities related to personal hygiene Assistance with grooming and dressing Assistance with transferring/ambulation (No lifting) Light meal preparation Light housekeeping services may be provided after personal care is completed. No errands or transportation are provided. There are no co-pays for non-skilled services. VETERANS HEALTH ADMINISTRATION

Community Care Programs MEDICAL FOSTER HOME (MFH) For Veterans who meet nursing home level of care but prefer a non-institutional setting for their care. Veterans are cared for by a caregiver in the community who takes the Veteran into their home and provides 24 -hour supervision and needed personal assistance. The Veteran pays the caregiver a monthly fee depending on the care received. Veterans are monitored monthly by Home Based Primary Care and Social Work visits. The home is inspected annually by the VA Annual Survey Team. VETERANS HEALTH ADMINISTRATION

Community Care Programs NON-VA CARE GEC RESPITE Provides caregivers temporary relief of their care-giving responsibilities. Allows them time away from their duties in order to feel refreshed. Respite Care must be planned with the Respite Care Coordinator in advance. 30 days per fiscal year are provided in any combination of In. Home Respite and/or Inpatient Respite There may be up to a $97 per day co-pay for inpatient Respite services. VETERANS HEALTH ADMINISTRATION

Community Care Programs NON-VA CARE GEC RESPITE INPATIENT (CNH) NON-VA CARE GEC RESPITE IN-HOME Inpatient Respite is provided in VA Contracted Community Nursing Homes (CNH) Up to 6 hours per day = 1 day Respite Caregiver may select CNH from VA list of CNHs and apply there for Respite admission Caregiver may select a provider from the VA list of approved vendors Possible co-pay starts on 22 nd day VETERANS HEALTH ADMINISTRATION

Community Care Programs SKILLED HOME HEALTH CARE In-home short-term medically necessary services provided by qualified personnel from community agencies that include: Skilled nursing such as: Wound Care, IV Therapy, and post-op assessments Physical, Occupational and/or Speech therapy Care includes: - Assessment - Education - Monitoring - Treatment VETERANS HEALTH ADMINISTRATION

Community Care Programs SKILLED HOME HEALTH CARE A VA medical provider refers skilled home health services when medically necessary. If Veterans are not homebound other means of supplying the needed service may be investigated. Home infusions and initial tube feeding set up and education are provided in the Veteran’s home. These services are for short duration only. There are no co-pays for Skilled Home health Care services. VETERANS HEALTH ADMINISTRATION

Community Care Programs VETERAN-DIRECTED HOME AND COMMUNITY BASED SERVICES The VD-HCBS program provides Veterans of all ages the opportunity to receive home and community based services in a consumer-directed fashion that enables them to avoid nursing home placement and continue to live in their homes and communities. VA provides local AAAs an authorization for a monthly budget for each individual Veteran enrolled in the program. The AAA works with the Veteran in planning this capped monthly budget to purchase goods and services, based on an in-depth, person-centered assessment. The Veteran and/or Veteran representative is supported by: a VHA program coordinator to oversee quality, satisfaction and service delivery; an options counselor from the AAA to assist in finding and training workers within the budget; and a financial management service, from the AAA to pay the bills and taxes and ensure the integrity of the budget. VETERANS HEALTH ADMINISTRATION

Community Care Programs REFERENCES • • • Community Hospice Care: Referral and Purchase Procedures, VHA Handbook 1140. 5, March 1, 2005 Community Residential Care Program, VHA Handbook 1140. 1, February 10, 2014 Eligibility for Nursing Home Care, VHA Directive 2004 -019, May 17, 2004 Home-Based Primary Care Program, VHA Handbook 1141. 01, January 31, 2007 Home Telehealth Equipment Management Procedures, VHA Handbook 1173. 17, March 4, 2008 Medical Foster Home Procedures, VHA Handbook 114. 02, November 10, 2009 Public Law 106 -117, The Veterans’ Millennium Health Care and Benefits Act Purchased Home Health Care Services Procedures, VHA Handbook 1140. 6, July 21, 2006 Respite Care, VHA Handbook 1140. 02, November 10, 2008 Veteran-Directed Home & Community Based Services. Executive Decision Memo, Office of Geriatrics and Extended Care VHA Community Nursing Home Oversight Procedures, VHA Handbook 1143. 2, June 4, 2004 VETERANS HEALTH ADMINISTRATION

Community Care Programs THANK YOU! QUESTIONS? VETERANS HEALTH ADMINISTRATION