VA Blind Rehabilitation Services

1. VA Blind Rehabilitation Services

2. Mission Deliver blindness and vision services that provide the right care in the right place at the right time to enable Veterans to maintain their independence, quality of life, and successful integration into family and community life.

3. Who Do We Serve? Veterans/Servicemembers --- Legally Blind --- Low Vision --- Excess Disability

4. Definitions of Legal Blindness Blind by loss of visual acuity: Legal blindness exists when best corrected central visual acuity in the better-seeing eye is less than or equal to 20/200. OR Blind by loss of visual fields: visual field dimension in the better-seeing eye is less than or equal to 20 degrees at the widest diameter, even if central visual acuity is better than 20/200.

5. Definition of Low Vision There is no universal consensus on the definitions for low vision and blindness. In its broadest sense, low vision can be defined as any visual impairment that results in disability and that interferes with the ability to perform everyday activities and cannot be corrected medically, surgically, or with conventional eyeglasses.

6. Definition of Excess Disability Excess disability is characterized by problems and task performance difficulties related to vision loss that have a substantial impact on the person's functional independence or personal safety, and that are out of proportion to the degree of visual impairment as measured by visual acuities or visual fields. Veterans whose vision is better than legal blindness may have excess disability due to:

7. Excess Disability (continued) (1) Sudden or traumatic visual disorder (especially related to military service). (2) Disabling co-morbidities (e.g., hearing impairment, mobility impairment, etc.); (3) Systemic diseases that cause fluctuating visual impairment; (4) Combined losses of other vision functions (e.g., contrast sensitivity, stereopsis, etc.); (5) Sudden changes in caregiver status; and (6) Other reasons.

8. Blind rehabilitation services utilizes an interdisciplinary team approach, within an integrated system of care Coordinates with other key VA programs: Ophthalmology, Optometry, Social Work Service, Veterans Benefits Administration (VBA), Polytrauma System of Care Blind rehabilitation services include: Comprehensive rehabilitation Adjustment to blindness counseling Patient and family education Assistive technology Clinical research that advances evidence-based practices Intensive case management, life-long care and access to services Blind Rehabilitation Services

9. Blind rehabilitation Services include: • Comprehensive rehabilitation • Adjustment to blindness counseling • Patient and family education • Assistive technology • Clinical research that advances evidence-based practices • Intensive case management, life-long care and access to services

10. Patients referred from: • VHA Eye Care (ophthalmology, optometry) • VHA Social Work Service • VHA Polytrauma System of Care • Other VHA health care providers • Department of Defense (DoD) liaisons and Federal Recovery Coordinators • Veterans Benefits Administration (VBA) Vocational Rehabilitation and Employment (VR&E) • Private sector eye care specialists, other physicians • Local area vocational rehabilitation programs, low vision clinics, and blind services • Blinded Veterans Association (BVA) • Patient self-referral • Family members

11. Levels of blind rehabilitation clinical services: Intermediate (moderate visual impairment) Low vision therapy/visual skills training; activities of daily living training; communication training Advanced (moderate-severe visual impairment) All of the above services, plus orientation and mobility training; adjustment counseling Outpatient (severe visual impairment) All of the above services, plus computer access training Inpatient (severe impairment to blindness; need for intense care) All of the above services, plus manual skills training (woodworking, household and small engine repair), psychology and social work services, recreation therapy; inpatient medical care for co-occurring conditions Blind Rehabilitation Services

12. Program Components • Visual Impairment Services Coordinators and Teams • 157 VIST Coordinators • Blind Rehabilitation Outpatient Specialists (BROS) • 77 BROS • Inpatient Blind Rehabilitation Centers • 10 Centers currently • Outpatient Vision and Blind Rehabilitation Clinics (new) • 55 Low Vision Clinics

13. Program Components Visual Impairment Services Team • Visual Impairment Services Team Coordinator: • Duties include identifying new cases of severe visual impairment, referring for services, providing adjustment counseling, arranging reviews of benefits and health care, and education related to VIST and blindness • Case manager with responsibility for coordinating services for visually impaired Veterans, and their families • Visual Impairment Services Team (VIST): • Local teams of medical professionals who ensure that severely disabled visually impaired Veterans are identified, evaluated, and provided health and rehabilitation services to maximize adjustment to sight loss • Ongoing lifetime case management at local VA medical center • Liaison with Military Treatment Facilities for Service Members receiving services

14. Program Components Blind Rehabilitation Outpatient Specialists • Blind Rehabilitation Outpatient Specialists (BROS): • Provide blind rehabilitation assessment and training in home, community, and job sites as well as clinical care • Prevent or reduce the need for inpatient blind rehabilitation program, and meet the needs of those Veterans who are unable to attend inpatient Blind Rehabilitation Center program • 77 BROS assigned nationally • BROS assigned to Walter Reed Army Medical Center and National Naval Medical Center • BROS assigned to all Polytrauma Rehabilitation Centers and Sites

15. Program Components Blind Rehabilitation Centers • Inpatient Blind Rehabilitation Centers: • Provide comprehensive, interdisciplinary, residential Blind Rehabilitation Services • Also provide specialized health care, wellness education, and adjustment counseling support • Average length of stay is 5 weeks • 10 Blind Rehabilitation Centers nationally, all accredited by Commission on Accreditation of Rehabilitation Facilities (CARF)

16. Blind Rehabilitation Service Department of Veterans Affairs Blind Rehabilitation Centers 10 Centers Nationwide

17. Outpatient, Vision, and Blind Rehabilitation Clinics • VHA is the only national healthcare system to completely integrate rehabilitation services for patients with visual impairments into health benefits • Provides early intervention for patients whose vision loss results from progressive diseases • Provides intermediate and advanced care for patients who have moderate visual impairment: • Cannot see to drive • Cannot see to read or write • May be at risk for falls • May be non-compliant with healthcare regimens

18. Intermediate Low Vision Clinics

19. Advanced Low Vision Clinics

20. Outpatient BRCs “VISOR” Clinics • VA Western HCS, Buffalo, NY • East Orange Campus of New Jersey HCS, East Orange NJ • Lebanon VAMC, Lebanon, PA • Washington, D.C. • Hunter Holmes McGuire, VAMC, Richmond, VA • Lexington VAMC, Lexington, KY • Louis Stokes VAMC, Cleveland, OH • Battle Creek VAMC, Battle Creek, Michigan • Kansas City VAMC, Kansas City, MO • Michael E. Debakey VAMC, Houston, TX • VA Eastern Colorado HCS, Denver, CO • Minneapolis, MN

21. BRS Services and OEF/OIF/OND • BRS Services and OEF/OIF/OND • All Blind Rehabilitation Service program components actively support veterans and Servicemembers of OEF/OIF/OND. • Visual Impairment Service Team (VIST) Coordinators • Involvement with Military Treatment Facilities through liaisons • Case management in support of Polytrauma Rehabilitation programs • Ongoing case management at local medical centers • Blind Rehabilitation Outpatient Specialists (BROS) • BROS assigned to Walter Reed Army Medical Center and Bethesda • BROS assigned to all Polytrauma Rehabilitation Centers • Treat patients in homes, communities, and local VAMCs and CBOCs

22. TBI & Visual Consequences & Disturbances • Estimated that 30%-85% of all TBI cases involve visual disturbances: • Blurred vision • Photo-sensitivity (most common) • Pain & headaches caused by vision • Source: Journal of Behavioral Optometry, vol. 18/2007/number 3, pg. 58

23. TBI & Visual Consequences & Disturbances • Change in Field of Vision • Symptoms: missing movement or objects not in front • Misplacing /getting lost • Lack of hygiene on one side (shaving, combing) • Leaning while talking, tilting head • Bumping into or tripping over obstacles • Knocking things over

24. Visual Consequences of TBI • Oculomotor Dysfunction/Binocular Disorders • Abnormalities of vergence (aiming the eyes, either converging or diverging, in order to see something). • Symptoms: results in occasional or constant eye strain or sense that the print on a book is "shimmering" or "floating" on the page • - Images seem to jump and move • - losing place when reading • - skips or rereads words, letters, lines or phrases • - Words running together • - reverse numbers/letters • - Diplopia: double vision • - Closing one eye

25. Services and Resources Services for Visually Impaired Veterans • Catastrophically disabled exemption for legally blind • Special disability ratings for blindness • Prosthetic devices and technology available Referral to Community Resources • Talking Books • Groups • Transportation • National Parks • Property tax credits • Other state initiatives for vision loss • Local community agencies • SSA • Vocational Rehabilitation

26. Vision Loss and the Family • Blind Rehabilitation Service works with the families as well as the Veteran through all program components: VIST, VISOR, Low Vision Clinics, BRCs and BROS • Support & Adjustment: care giving; helping to motivate Veterans for blind rehabilitation

27. VIST Coordinators in Virginia • Myisha Norris • Washington DC VAMC • 50 Irving Street NW • Washington DC 20422 • 202-745-8000 ext. 8621 • E-Mail: Myisha.norris2@va.gov • Evelyn Cabrera-Heatwole • Richmond VAMC • 1201 Broad Rock BLVD • Richmond, VA 23249 • 804-675-5221 • E-Mail: evelyn.cabrera-heatwole@va.gov • James Stephens Hampton VAMC 100 Emancipation Drive Hampton, VA 23667 757-722-9961 ext. 2420 E-Mail: james.stephens@va.gov • Stephanie Sackett (Ayers) Salem VAMC 1970 Roanoke BLVD Salem, VA 24153 540-982-2463 Ext. 3356 E-Mail: Stephanie.ayers@va.gov

28. REFERRALS OF VETERANSWITHVISION IMPAIRMENT TO A VA MEDICAL CENTER • Veteran needs to be Honorably Discharged from the Military and eligible for VA Healthcare. • All Veterans with Legal Blindness who have been Honorably Discharged and who are eligible for VA Healthcare are eligible for VA Blind Rehabilitation Services. These include both Veterans that are already enrolled into the VA Healthcare System and those who have never been seen in a VAMC. • If it is a Veteran with vision impairment (not legally blind) who is already enrolled into VA Healthcare, then VIST is able to see the patient in a timely manner and provide blind/vision rehabilitation services. • All newly enrolled Veterans with low vision and/or vision impairment (not legally blind) that are within the income limits set forth by Congress are also eligible for VA Blind Rehabilitation Services. • For those Veterans with vision impairment (not legally blind) who are not enrolled in the VA Healthcare System and who are over the income limits set forth by Congress, then the Veteran will not be eligible for VIST, VISOR or BROS Services within the Veterans Health Administration. • WHEN IN DOUBT, JUST REFER