James Hallenbeck, MD Associate Chief of Staff, Extended Care, VA Palo Alto Health Care System, Associate Professor, Stanford University Anita Shumaker, C.A.,C.M.T.,C.M.P. California Department of Veterans Affairs

California Veterans 2.2 Million (6%) of California population Of these… 94% men, 6 % women 35% of veterans are > age 65 (10.6 % overall pop. > 65) 21% of Californians > 65 are veterans > 60% of Californian men > 65 are veterans

Think of the VA when… A veteran tells you that he/she is enrolled at a particular VA facility Funding difficulties – ineligible for Medicare, MediCal and no private insurance Military/Veteran-related issues arise

Think of the VA when… Special clinical needs – Related to military service – Mental Health issues/PTSD – Needs adjunctive care to stay at home – Homelessness – Blind Concern about benefits

VA Facilities Have discrete catchment areas Associated Clinics (Community Based Outpatient Clinics – CBOCs) Veterans enrolled at a particular facility Encouraged to have primary care provider VA Medical Centers function much like a managed care organization like Kaiser.

Eligibility Prioritization of veterans with Service-Connected Disabilities Differing eligibility standards for Outpatient/Home/Acute care and Nursing Home Care Outpatient/acute: basic eligibility Long Term Nursing Home: highly SC only

Is VA Care a Form of Insurance? Yes and No Yes: for enrolled veterans receiving VA through VA (like Kaiser) Yes: for some care for highly service-connected veterans outside VA (acute care hospitalizations) No: For most other types of care outside the VA

Example: Hospice Care VA Hospice Benefit – mimics Medicare Especially useful for veterans <65 without Medicare For enrolled veterans as ordered by a VA provider Not intended for un-enrolled veterans calling a VA facility to get them to cover care

Home Care Services Home-based Primary Care (HBPC) Homebound, VA primary care provided at home, geographically restricted areas Homemaker/Home Health Care (H/HHA) Very similar to IHSS Purchased from community agencies Contract Adult Day Care (CADHC) Note: VA largely blind to parallel services, such as IHSS

Home Care Services Purchased Home Care Skilled nursing care at home (like Medicare Home Care) Hospice Care (similar to Medicare) Spinal Cord Home Care (by VA providers) Emerging programs: Medical Foster Home program Veteran Directed Care Unlike Medicare, all purchased VA home care prospectively authorized

Nursing Home Care VA Nursing Homes (Community Living Centers, CLCs) Short-stay rehab/post hospital Long term care for highly 60% + SC veterans Community Nursing Home (CNH) program

CalVet State Homes California Department of Veterans Affairs 8 Homes in the state with multiple levels of care Redding Yountville Fresno Ventura West Los Angeles Barstow Lancaster San Diego

CalVet State Homes Open to Veterans and Non Veteran Spouses Independent Living (Domiciliary) Assisted Living (Residential Care for the Elderly RCFE) Intermediate Nursing Care (Intermediate Care Facility) Skilled Nursing Facility Care/Memory Care (SNF)

CalVet State Homes Independent Living (Domiciliary) Ability to perform activities of daily living Non nursing staff supervision Assisted Living (RCFE) Minimal assistance with activities of daily living Licensed nursing staff supervision Memory care program (mild to moderate Symptoms)

CalVet State Homes Intermediate Nursing Care (Intermediate Care Facility) Licensed nursing staff supervision Non nursing staff assistance with activities of daily living Skilled Nursing Care/Skilled Nursing (memory care) 24 hour services of licensed nurses Rehabilitation therapies Activities Dietary

CalVet State Homes Onsite outpatient clinics Providing Primary Care Providing routine health care services Multi-disciplinary Coordinating services with specialists

CalVet State Homes Maintains transfer’s between level of care changes Short Term Skilled Nursing Facility Care Long Term Skilled Nursing Facility Care Hospice Care

CalVet State Homes Community Living Meals Social Activities Organized Community Events Onsite Therapeutic Classes Health Education Barber Fitness Center Bowling Alley Arts and Crafts Libraries Chapels Store

CalVet State Homes The Pathway Home Program Residential Recovery program Serving our nations “New Warriors” Nations Global War on Terror Afghanistan and Iraq Post deployment

CalVet State Homes Community Living Meals Social Activities Organized Community Events Onsite Therapeutic Classes Health Education Barber Fitness Center Bowling Alley Arts and Crafts Libraries Chapels Store

Challenges Two-way lack of knowledge Community organizations do not understand VA Many VA providers equally ignorant of community resources Common complaint about VA – don’t know who to talk with/ poor contact information.

The Great Myth Care of veterans the sole responsibility of the VA Reality: only 26% of veterans cared for by VA in any given year Many of these veterans receive only some of their care through VA Given this, optimal care for veterans requires collaboration between VA and community organizations

Suggestions Incorporate routine inquiry regarding veteran status into assessments Assess enrollment status, service-connection If enrolled – which VAMC Become familiar with unique VA services and where VA can “plug holes”

Special VA Services Some Home Care Services Spinal Cord Injury Mental Health Services PTSD, Substance abuse Care for Homeless Veterans (residential programs, HUD/VASH (voucher) program Hospice/palliative care Blind rehabilitation programs

Cultivate Your Contacts at Local VAMCs! Admissions and Eligibility Caregiver Support Program Home Care Geriatrics and Extended Care Homeless Veteran Program Coordinators Patient Advocate Veteran Service Officers ADRC points of contact Note: Quality of facility websites- variable. When in doubt, call program offices

Summary VA provides excellent healthcare – with some benefits not readily available through the community Navigating the VA labyrinth can be challenging It is all about relationships and communication Together, we can do a better job serving those who have served!