VA Home and Community Services

1. VAHome and CommunityServices September 23, 2010 Christine Rovinski-Wagner, ANRP, MSN Lynda Rydman, RN-BC, BS, CCM

2. Case Management Services RNs and Social Workers In-patient, out-patient & community based-outpatient clinic settings

3. VA Medical Center White River Junction

4. Community Based Outpatient Clinics New Hampshire - Littleton Keene (location not yet determined) Vermont - Brattleboro Newport Rutland Colchester

5. Vet Centers White River Junction Berlin South Burlington

6. Fee-Based Community Nursing Home Care Community Adult Day Health Care Hospice and Respite Care Skilled and Unskilled Home Care

7. DIRECT Service Hospice and Respite In-patient Care Coordination Home Telehealth (CCHT) Home Based Primary Care (HBPC) Medical Foster Home (MFH) Mental Health Intensive Case Management (MHICM)

8. Community Nursing Home Care Current contracts with 16 facilities in VT and NH • Individual arrangements at non-contract homes cannot be made • >70% service connection and needs nursing home care for any condition • >60% service connection and rated permanently totally disabled or unemployable by VA • Any % service connection and needs nursing home care for that condition • Non-service connected Veterans are NOT eligible • Covers room and board, medications, supplies, therapies, transportation to VA for LTC or rehab • Some restrictions on obtaining local care while under VA contract; must be requested by VA PCP and approved by Fee-Service physician • Expectation that VA will be used as primary health care source

9. Community Adult Day Health Care • Current contracts with 14 sites in VT and NH • Allows up to 5 hours per day of participation in a local adult day health program • Amount of service driven by Veteran patient’s individual functional needs and co-morbidities • A nurse must be on the premises 4 hours/day minimum • At least one meal must be included • Does not require service connection but may carry a $15/day co-pay

10. HOSPICE Prognosis of less than 6 months No longer seeking active treatment Can be provided: In-patient at VAMC Fee-based in nursing home Fee-based at Veteran’s home

11. Hospice Chorus • Bedside sings to Hospice Veteran patients at the VA medical center or within a 40 mile radius of the medical center.

12. Respite • Service-connected and non-service-connected Veteran patients can receive 30 days of respite care per year • Respite stays occur hospital – suggest 5 stays of 6 days each • Need notification for scheduling • Significant care or supervision (due to wandering) needs may preclude acceptance into in-patient respite • Time at home <24 hours will still count as 1 day

13. Care Coordination Home Telehealth • Veteran patient is monitored at home • Blood pressure, pulse, weight, blood sugars, mental status monitored via telephone equipment • Early identification of potential problems • Daily monitoring by VA Nurses for triage, sharing of significant assessment findings with PCPs, and timely communication of changed care instructions based on assessment findings • No service connection necessary

14. Home Based Primary Care • Brings all primary care services into the home: PCP, nursing, OT, PT, dietician, SW, psychology • No service connection necessary • Tailored for Veteran patients who are failing traditional out-patient/clinic care as demonstrated by repeated emergency/urgent care visits and/or hospitalizations • Currently covers areas surrounding WRJ, Bennington, and Colchester • May have a $15 co-pay associated with each visit

15. Mental Health Intensive Case Management Eligible Veteran patients • have a Severe and Persistent Mental Illness that requires the skills of an interdisciplinary health care team; • live within an hour’s drive of the WRJ VAMC; • are able to function in the community (manage activities of daily living, manage own medication, etc.); • Are not and do not need to be in a nursing home or group home; • accept MHICM as their primary mental health care team; • have a home environment that is safe for the well-being of vet, vets caregiver(s), and the MHICM team members;

16. Mental Health Intensive Case Management Provides: • Frequent home or community visits; • Instruction, education and counseling about severe psychiatric conditions; • Support around developing coping skills; • Assistance with addressing housing, income, vocational and/or family concerns; • Referral to community resources and services; • Care coordination of other VA services and community services according to veterans' needs; • Education and support to family and close friends. May have a $15 co-pay associated with each visit.

17. Medical Foster Home • Private homes in the community are designated as foster care homes. The family/homeowner participates in providing a home for a 1-2 veterans. • Offers an option to individuals who may not want to be in a nursing home but need more health, medical and/or safety supervision than an adult day program can provide. • Veteran pays out-of-pocket. • VA personnel act as liaison and coordinating supervisor. • Veteran patient must be part of HBPC program.

18. Other Home and Community Case Management Services • Operation Enduring Freedom/Operation Iraqi Freedom Case Management • Substance Abuse Treatment • Healthcare for Homeless Veterans • Post-acute Hospital Care Coordination • Advanced Illness and Palliative Care Coordination

19. Questions?