Geriatrics & Long Term Care

1. Geriatrics & Long Term Care Non-Institutional Programs Inpatient and Community Care Presented by Nicole Trimble, LCSW-C and Eileen Cashour, LCSW-C By: Crystal Taylor, LCSW-C Lead Social Worker 410-642-6422 Ext. 5379

2. Adult Day Care • Enroll in the VA System ( Cat 7 or less) • Seen by VA Primary Care Provider at least yearly • Can attend up to two days a week at VA expense • Provide 10/10EZ (financial information) yearly • Copay of 15.00 a day if Cat 8 • Once in program VA pays indefinitely • Currently there is a waiting list

3. Home Health Aide Program • Must be enrolled in VA and seen by VA primary care provider at least yearly • Needs help in three or more ADL’s and has cognitive impairment, or • Needs help in two ADL’s with one of the following; recent discharge from a nursing home, 75 or older, clinical depression, living alone • Requires aide care as adjunct to hospice care • Copay of 15.00 a day if Cat. 8

4. Contract Nursing Homes • 32 day contract available for Veterans who are Inpatient at VA and discharged to CNH who Non-Service Connected • Indefinite contract available for Veterans 70 % or more Service Connected • Indefinite contract available if veteran is in Nursing Home for SC diagnosis • Respite Placement possible if there the funds are available • Completed 10/10EC for copay eligibility. Copay is up to 97.00 a day

5. In Home Respite • Enrolled in the VA and following in Primary Care Clinic or by VA provider • Caregiver is in need of temporary or intermittent relief from day to day care. • Allowed up to 30 days a year (could be in combination with inpatient respite) • 10/10EZ completed for copays • This is for short term help and not for a referral for long term aide care • Both of these programs are budget driven with regard to availability.

6. Community Residential Care or Medical Foster Home • Need placement in VA approved and MD state licensed home • Meet guidelines for levels of care • Complete all VA and state referral paperwork • Veteran agrees to pay for care, no VA contract funds available for placement • Agree to rules and regulations of home • Will be followed in VA Primary Care Clinics • Veterans are eligible for 2 days of ADC

7. Medical Foster Home MFH can have no more than 3 residents. Caregiver must live in the home Caregiver does not have a job outside of the home Home Based Primary Care Team follows Veteran in the MFH Veteran must be willing to attend ADC 2 days a week.

8. VA Assisted Living Referrals • Contact person is: • CRC-Eileen Cashour, LCSW-C • Phone 410-642-2411 ext. 5969 • Fax 410-642-1172 • MFH- Nicole Trimble, LCSW-C • Phone-410-642-2411 Ext. 6094 • Fax 410-642-1706

9. Veteran Directed Care For Veterans who need skilled services, case management, and assistance with ADLs or IADLs. Living alone or their caregiver is experiencing burden Veterans are given a flexible budget for services that can be managed by the Veteran or caregiver

10. Veteran Directed Care Serves the following counties: Cecil Carroll Baltimore County Howard County Eastern Shore

11. Home Based Primary Care HBPC

12. What is the Home Based Primary Care Program (HBPC)? • Direct Care Program: Enables veterans to remain in the home while receiving comprehensive healthcare at home • Veteran must be home bound, have a hard time navigating the system, or medically complicated. • Provides all Primary Care follow up • Assess need for durable medical equipment and arrange for delivery of equipment to home

13. Who are the HPBC Team? • Program Manager • Nurse Practitioners • RN’s • Social Workers • Nutritionist • Kinesiotherapist • Physicians • Program Support Assistants • Consultants: Geropsychiatry, Hospice/Palliative, Chaplain) • Psychologist

14. Other Benefits • Patient/caregiver education and support • Referrals to community agencies for select services: wound care, PT, OT

15. Health Care • Primary care in the home • Regularly scheduled NP/RN visits • Health Exams • Teach caregiver home health care, skin care, medication management.

16. What Areas are Served • Baltimore City/County • Anne Arundel • Harford • Cecil • Carroll • Howard

17. Referral/Eligibility • Outside the VA (veteran/family/agencies/health providers • Nurse Practitioner will visit home to perform initial assessment within 15 working days • Case is presented at weekly staff meeting to determine whether veteran is accepted into program

18. HBPC Contacts • Main Line 410-605-7620 • Office Nurse (referrals) 410-605-7639 • David Berman 410-605-7640 • Stacy Heinze 410-605-7623 • Winter Wesley 410-605-7568 • Aned Ruiz 410-605-4617

19. Hospice and Palliative Care Hospice care is now part of the basic eligibility package for all Veterans enrolled in the VA. If hospice care is needed and other funding is not available, the VA will either provide hospice care directly or will purchase it from community hospice agencies.

20. Emergency Alert • Referred by Primary Care Provider at the VA • Alert system provided to Veteran and is compatible with 911 systems • Alert system mailed to Veteran • Home Based Primary Care sets up

21. Long Term Care Referrals • All referrals need a Discharge Summary • Referrals must be out of Intensive Care Units for 24 hours and no telemetry before admission to LTC • Medically stable • Sitter Free for 24 hours • No NG Feeding Tubes

22. INPATIENT Long Term CareLock Raven CLC • 42-bed unit • Wander-guard system in place • Wander garden • Restraint-free • Provides respite care • Provides a support group for family • For LTC must be 70% or Higher SC

23. Admission Criteria • Medically stable • Non-combative • If not yet incompetent, vet must agree to placement (nursing homes cannot hold patients against their will) • No tube feedings, no Ivs • No Sitter

24. Post Acute Care • Admitted to either LR2 and PP 23A or B • Must need wound care, IV fluid or IV antibiotics • On referral need documentation of wound size • Cannot accept patients needing respiratory isolation and NG tubes

25. Rehabilitation Services • Acute rehab services located on LR2 • Low level rehab services located at PP23A-Band Nursing Home Care Units at PP and LR • Referrals must include current PT and OT recommendations

26. Nursing Home Care Units • Units are located at Perry Point on Wards 25A &25B, Wards 14A&14B, Baltimore LR 1&LR2 LTC 1010EC copay test must be completed prior to admission, copay up to 97.00 a day • Can not admit for IV therapy, Stage 3 or Stage 4 wound care, suctioning more than q 4 hours, and respiratory isolation, and NG tubes • Screening made aware of wandering risks • 1010EZ must be current • Must be 70-100% SC

27. Inpatient Respite • Need to have chest x-ray or PPD completed within one year of date of admission • Bring a list of medication and advance directives upon admission • Acceptance is based upon bed availability on the date of the request. • Must be out of the hospital at least 30 days prior to admission for respite • Paid caregivers are not eligible for respite • 30 days permitted a year

28. Inpatient Hospice • Screening Committee reviews hospice/palliative care admission. • Must meet criteria for Hospice • Placed in available beds at BRECC or Perry Point. • No copays for Hospice admissions.

29. Referral to Long Term Care Screening Community Referrals are sent to: Kelly Grande Phone 410-642-2411 ext 6353 Fax 443-693-4976