VA Geriatrics & Extended Care

1. VA Geriatrics & Extended Care National Update AGS May 4, 2006

2. VA GEC • Strategic Planning – GEC, PCS, VHA • Budget • Marsha Goodwin-Beck Awards • Geriatric Research, Education and Clinical Centers (GRECCs) • Geriatric Programs – GEM; Geri Prim Care • Geriatrics and Gerontology Advisory Committee (GGAC)

3. VA GEC 7. Hospice & Palliative Care 8. Home-Based Primary Care and Medical Foster Home 9. White House Conference on Aging

4. Eight for Excellence Strategic Planning: VHA, PCS, GEC VHA Strategy #1: Continuously improve the quality and safety of health care for veterans, particularly those health issues associated with military service. Initiative 1.5: Pursue innovations in services to aging veterans that enhance VA capabilities in long-term care, including care coordination and telehealth technologies.

5. Principle GEC Initiatives (part of PCS plan) • Culture transformation of VA nursing home care • Enhance access to non-institutional home and community-based services • Affirm and enhance GRECC contributions to VHA’s strategic initiatives • Align and integrate chronic care within Geriatrics through a wider care coordination initiative

6. Additional GEC Initiatives • Integration of new veterans with polytrauma into extended care programs • Enhance veterans’ access to hospice and palliative care across all care settings • Provide comprehensive coordinated care for veterans with dementia • Improve primary care management of frail elderly veterans • State Homes quality of care initiative • Unannounced site survey program for VA NHCUs

7. 1. Culture Transformation of VA Nursing Home Care Transforming the current culture of nursing home care from a medical model, driven by medical diagnosis and illness, to a person centered culture of care whereby decisions regarding care and treatment involve the resident and are central to the organization and care processes in the nursing home.

8. 2. Enhance access to non-institutional home and community-based services, including care coordination/telehealth. Expand number of VA facilities offering HBPC and MFH, establish a national HBPC satisfaction survey, and conduct national survey to assess hospice and palliative care programs and services.

9. 3. Affirm and support Geriatric Research, Education, and Clinical Centers’ (GRECC) contributions to VHA’s short-, medium-, and long-range plans for addressing the needs of aging veterans. Public Law 96-330 (1980) mandated Geriatric Research, Education and Clinical Centers (GRECCs) to “advance scientific knowledge regarding the medical, psychological, and social needs of older veterans, and the means for addressing them, through: (1) geriatric and gerontological research; (2) the training of personnel providing health care service to older persons; and (3) the development and evaluation of improved models of clinical services for eligible, older veterans.”

10. 4. Align and integrate, where appropriate, chronic care within Geriatrics through a wider care coordination initiative. The VHA definition of Care Coordination is the use of health informatics, Telehealth and disease management to extend and enhance care and case management. The areas of Care Coordination include: General Telehealth (CCGT); Home Telehealth (CCHT); Store and Forward (Teleretinal imaging). The scope of this initiative is to expand care coordination programs, increasing access to specialty care and to non-institutional care across the continuum.

11. Budget – FY 2007 Proposal More than $4.3 billion for LTC (increase of $229M) • Institutional Care $3.8 billion • Non-Institutional Care $535 million (increase of $48 million or 9.9%) State Home construction $85 million State Home per diem $480 million

12. Marsha Goodwin-Beck Awards 2005 Excellence in Leadership • John Morley, MB, B Ch Director, St. Louis GRECC Excellence in Clinical Care Delivery • Alison Bingman, MSN, APRN-BC Nurse Practitioner at Durham VAMC 2006 Pending

13. GRECC Updates Updating performance measures More relevant to VA, VISN, VAMC Link to strategic plans Re-examine/revise funding Personnel Educational, clinical projects Research collaborations Monthly CME-accredited audioteleconference series beginning 7/06 Annual Reports and Summary Report available at http://vaww1.va.gov/grecc/page.cfm?pg=66 New “Special Fellowships” All GRECC eligible Open to non-MDs and non-geriatrician MDs Request for eligibiilty for NIH Loan repayment Program

14. Geriatric Primary Care Updates • OK for piloting 5 measures based on ACOVE during summer 2006 • End of life, funct. Assmt, UI screening and assmt, falls screening and assmt • Education of primary care providers in geriatrics • Strategic planning among GRECCs 5/2/06 • DSS and Austin data analyses to support reduced geriatric primary care panel size • National Geriatric Primary Care/ACA meeting September 13-14, Philadelphia • Articulation of criteria for “GEM Program of Excellence” • Efforts to raise awareness and knowledge of delirium

15. Geriatrics and Gerontology Advisory Committee • 2005-2006 site visits • Pittsburgh, LA, St. Louis, Gainesville, Madison, Durham, San Antonio • New membership • White Paper submitted to Secretary • Non-institutional workload counting • GRECC support • Impact of VERA on clinical innovations • Follow-up from Mill Act pilots

16. Hospice & Palliative Care (H&PC) • Dr. Scott Shreve is our National Director of H&PC • Survey on VA Palliative Care services completed. Distributed to VISN CMOs past week. • Annual Report for FY2005 distributed. • Vision for VA End of Life Care

17. Actions to improve care: • Partnering • - Hospice-Veteran Partnerships • - Acute care (recruiting partners) • Raise Expectations (reduce variability) • - Reporting variation • - Targeting program development • Accountability • - Outcome measure implementation • - Request For Proposal Initiative (seed money) • Enhanced Expertise • - Audio conferences, face to face and online curricula • - AACT: Little Rock May 23-25; Kansas City July 25-27

18. VA-Paid Home Hospice Care Average Daily Census

19. % of Inpatient VA Deaths with a Palliative Care Consult

20. Palliative Care in VA Home-Based Primary Care (HBPC) # of veterans served with v66.7 code

21. Home-Based Primary Care • Expansion: 74 to 105 programs; ADC 8081 to 11,063; keep pushing • Performance Measure – both ADC and “6 of 9 H&CBC programs at all facilities” • Challenges to HBPC at every site: • Misperception that HBPC similar to Medicare • Perception that HBPC is too costly • Lack of awareness of benefits to veterans and facilities

22. VACO Support for HBPC • Encourage HBPC at all facilities • VACO support: • National cost analysis: 24% net cost avoidance • Demographic analysis of anticipated population need for HBPC • Proposal guidance • Mentor for HBPC Program Director and HBPC Medical Director

23. What is Medical Foster Home? • Alternative to nursing home placement for veterans who can no longer live alone and have no caregiver • Merges adult foster home with VA Home-Based Primary Care (HBPC) • VA helps find a person in the community who will take a dependent veteran into their private home • MFH caregiver provides daily personal assistance and supervision • VA HBPC provides comprehensive medical care and management; caregiver education • VA MFH Coordinator provides oversight • Veteran pays for MFH

24. What is Medical Foster Home? Partnership of Foster Care with HBPC Alternative to nursing home placement for - dependent, chronically ill, or terminally ill veterans - unable to live independently, and - prefer a family setting for their long-term care. Average age: 72yrs; Number of major problems: 8 Prominent Dx: Dementia, CVA, Heart Disease, COPD All eligible for nursing home care VA finds caregivers; provides oversight and HBPC Foster care costs – paid by veteran, from VBA

25. How did MFH start? • Two social workers at Little Rock VA • Problem: Veterans in HBPC declined and could no longer live alone, refused NH • Opposing ethical principles • Unsafe at home, or force out of home? • Solution – find a willing caregiver, meet medical care needs through HBPC • Pilot 2002 – cautiously optimistic success

26. Target Population for MFH Eligible veterans who: • Are unable to live independently due to functional, cognitive, and/or psychiatric impairment; chronic or terminal illness; • Have no suitable caregiver to provide needed monitoring, supervision, and assistance; • Meet nursing home criteria; • Have complex medical conditions requiring care from an interdisciplinary team; and • Are able to pay for MFH (VBA; SS)

27. Risks of MFH • Potential for abuse and neglect • Caregiver selection: background; Long-term commitment; Work will increase over time • Accept unannounced visits • Oversight (similar to Community Residential Care) • VA liability concerns for veterans and caregivers • Manage similar to Community Residential Care • Cost to VA • Experience: lowers cost to VHA, because some 70% SC veterans choose MFH. Cost neutral for VA.

28. Benefits of MFH • VA offers an option to NH care, in a less restrictive environment • Veteran can choose a home environment • MFH less costly than nursing home • For 70%+ SC veterans, cost savings to VA • Net savings to VA facility in current year • Benefits to caregivers • Benefits to community

29. Medical Foster Home Expansion • View video – VISN libraries and HBPC programs • Training program in July 2006 • Preliminary inquiries sent last week to all HBPC Program Directors • MFH Program Guide – draft completed • Contact thomas.edes@va.gov

30. 2005 White House Conference on AgingFrom Awareness to Action VA GEC Update

31. Update on WHCoA • Implementation strategy highlight report • Letters to Governors • Responses from Governors • www.whcoa.gov look at “News” for “Speakers and Presentations” and “Input from Governors” • Working on Final Report

32. Choose your favorites… Resolution 48: Ensure Appropriate Recognition and Care For Veterans Across All Healthcare Settings. Resolution 42: Promote Innovative Models of Non-Institutional Long-Term Care

33. Choose your favorites… Resolution 40: Attain Adequate Numbers of Healthcare Personnel in All Professions Who are Skilled, Culturally Competent, and Specialized in Geriatrics. Resolution 32: Evaluate Payment and Coordination Policies in the Geriatric Healthcare Continuum to Ensure Continuity of Care. Resolution 34: Improve The Health And Quality Of Life Of Older Americans Through Disease Management And Chronic Care Coordination.

34. Update on WHCoA • Encourage collaboration and participation • Contact your Governor – identify priorities • Work with AGS • Work with Area Agency on Aging; state, county and local organizations