STATE VETERANS HOME

1. STATE VETERANS HOME FEBRUARY 25, 2014

2. GENERAL COMMENTS Public Law 104-262,Section 104(a) of the “Veterans’ Health Care Eligibility Reform Act of 1996,” established a system of annual patient enrollment, in order of priority, for the provision of Department of Veterans Affairs (VA) hospital care or medical services (see Title 38 United States Code (U.S.C.) 1705. Under this system, VA must enroll in Priority Group 4, Veterans who are catastrophically disabled (see 38 U.S.C. §1705(4)).

3. PRIORITY GROUP FOUR INCLUDES: • Veterans who are receiving aid and attendance or housebound benefits • Veterans who have been determined by VA to be catastrophically disabled

4. VHA Directive 2010-054 • As per VHA Directive 2010-054 “Catastrophically disabled Veteran evaluation, enrollment, and certain copayment-exemptions,” (Par. 2 b): “Veterans with catastrophic disabilities must still pay applicable copayments for the receipt of nursing home care.” • Catastrophically disabled Veterans do not automatically qualify for State Veterans Home care. • How does VA define and identify which Veterans are catastrophically disabled Veterans?

5. DEFINITION OF CATASTROPHICALLY DISABLED VETERAN • As per Attachment A of VHA Directive 2010-054: • “Catastrophic disability (CD) is a permanent severely-disabling injury, disorder, or disease that compromises the ability to carry out the activities of daily living (ADL) to such a degree that the individual requires: • a. Personal or mechanical assistance to leave home or bed, or • b. Constant supervision to avoid physical harm to self or others. “

6. HOW VA IDENTIFIES CATASTROPHICALLY DISABLED VETERANS • As per Attachment A of VHA Directive 2010-054 • Determination of whether a Veteran is considered catastrophically disabled is made through a review of a Veteran’s previous and current medical records that documents to assess that the patient meets, will continue to meet , or would continue to meet such criteria (permanently) without the continuation of on-going treatment.

7. Examples of Medical Criteria Establishing Veteran as Catastrophically Disabled • Examples of evaluation criteria include, but are not limited to one of the following permanent conditions: • Dependent in three or more ADLs; (i.e., eating, dressing, bathing, toileting, transferring, incontinence of bowel or bladder) with at least three of the dependencies being permanent with a of bowel or bladder) with at least three of the dependencies being permanent with a score of 1, using the Katz scale. • A score of 10 or lower using the Folstein Mini-Mental State Examination (MMSE). • A score of 2 or lower on at least four of the thirteen motor items using the Functional Independence Measure (FIM). • A score of 30 or lower using the Global Assessment of Functioning (GAF).”

8. Determining whether Veterans are eligible for SVH based on need for nursing home care (NHC) for their SC disability Catastrophically disabled Veterans must meet eligibility criteria for admission to SVHs as per 38 CFR 51.41 – “Contracts and provider agreements for certain veterans with service-connected disabilities,”- “(a)Contract or VA provider agreement required. VA and State homes may enter into both contracts and provider agreements. VA will pay for each eligible veteran's care through either a contract or a provider agreement (called a “VA provider agreement”). Eligible veterans are those who: (1) Are in need of nursing home care for a VA adjudicated service-connected disability, or (2) Have a singular or combined rating of 70 percent or more based on one or more service-connected disabilities or a rating of total disability based on individual unemployability and are in need of nursing home care.”

9. Determining whether Veterans are eligible for SVH based on need for nursing home care (NHC) for their SC disability The physician at the VA Medical Center reviews the 10-10SH form that has been provided to them by the local State Veterans Home. This form has the Veteran’s medical information on it from the SVH that will be used by the VA physician to validate nursing home level of care for the Veteran.

10. Determining whether Veterans are eligible for SVH based on need for nursing home care (NHC) for their SC disability (continued) • The VA physician responsible for CAPRI reviews for the VA Medical Center goes into the Veterans Benefit Administration (VBA) computer software system “CAPRI” to determine if the Veteran has VA adjudicated service-connected conditions and provides this information to the VAMC physician evaluating the Veteran for the SVH. • This physician reviews the CAPRI information, along with the 10-10SH form and then validates or invalidates that Veteran is eligible for nursing home level of care, based on his/her reported medical condition and eligibility status. • When there are questions concerning the information provided by the SVH on the Veteran’s 10-10SH form, the VAMC physician and the SVH physician should communicate directly to ensure the most accurate decision is made regarding nursing home eligibility of Veteran. This communication is vital to best serve the Veterans.

11. SVH Policy Oversight Program • GEC – Policy contacts for the SVH: • Deborah Stevens • State Veterans Home Program Analyst • 202-461-6751 • Deborah.Stevens@va.gov • Nancy Quest • Director, Home & Community Based Services • 202-461-6064 • Nancy.Quest@va.gov

12. SVH Clinical Oversight Program • QUESTIONS / COMMENTS • THANK YOU!