1. The Central Texas Veteran’s Directed Home and Community Based Program Thomas Wilson, LMSW AAA VD-HCBS Consultant Anna Hauser, LCSW CTVHCS Advocate

2. The Central Texas Experience

3.  Successful transition is dependent upon several points: 1. Community & Agency co-operation 2. Use of the Aging & Disability Resource Center (ADRC) 3. Strong initial Orientation & Education 4. Integration of all support systems into a cohesive care model directed by the Veteran

4.  Strong capacity within multiple organizations dedicated to community living and formal healthcare  Accessible and high quality medical care  Partnership across health and human service agencies and local governmental entities  Strong military influence (Home of Ft. Hood and the Central Texas VAMC)  Past successes built a foundation for enhanced private/public partnerships.

5. The Aging and Disability Resource Center (ADRC) The ADRC serves as a highly visible, trusted, and valued place where people of all ages and incomes can turn for information on the full range of long term service options. The use of the ARDC allows the Veteran to access resources often unused by the Veterans in the past offering a greater number of community services to the veteran. Access to Aging & Disability Services Community Supports Healthcare Services ADRC’s Focus

6.  Visit One: Presentation of Veteran’s Directed Home and Community Based Program, In-home baseline assessment, provision of a program guidebook, and the completion of an ADL/IADL level of service needed.  Visit Two: The AAA VD-HCBS consultant assists the Veteran in completing the Support and Budget Plan. The Veteran is oriented to become an Employer who is empowered to direct his/her own community services.

7.  Visit Three: The AAA VD-HCBS Consultant assists the Veteran Employer to Orient the Veteran’s employees. In this visit the integration of Veteran Directed Employee with other services the Veteran May have (example of VD-HCBS employee and services interfacing with existing Hospice services.)

8.  The VD-HCBS Consultant meets with the Veteran to assist the Vet in scheduling any non-VDHCBS services in tandem with his VDHCBS services throughout the day to maximize support.  Traditional Services are arranged to stop one day and the next day the VD-HCBS Services begins This is very important for a seamless transition.

9.  LR is a 41y.o. Gulf War/Iraq Vet diagnosed with a service connected melanoma. He is the father of 8 children ages 5 to 20 years old and married.  Selected VD-HCBS because he wanted family to care for him.  Rated score=39/Intermediate need with 8 ADLs and 5 IADLs  Wife & 20 y.o. daughter share caregiver roles in the home.  He is directing all his own care.  Other services accessed: Housing Social Security State Rehabilitation Services Durable Medical Equipment VA benefits

10.  CD was a 66 y.o. Vietnam Vet, retired after 20 years in the Army. He was diagnosed with terminal lung cancer. He had both Hospice and CLP at the time of referral. He lived alone in his apartment after a separation from his wife. He has two children who live out of town  Selected VD-HCBS because he needed more care than Hospice could provide him.  Rated score=25/Intermediate need with 5 ADLs and 5 IADLs  No family Caregiver in home; Transitioned from Agency (CLP) 12 hours week and Hospice to VD-HCBS employee hired 40 hours week scheduled with additional 21 hours of Hospice weekly.  He directed his own care.  Other services accessed: Supportive counseling Reconciliation with family  Died in home with wife and family, on his own terms, no hospitalization or NH placement required.

11.  Tommy is a 82y.o. WWII Vet diagnosed with Lewis Body disease, often described as a combination of Alzheimer’s and Parkinson’s Diseases. He is married and lives in a small rural town, his children live in surrounding cities.  The Vet’s POA, his wife, selected VD-HCBS because he was getting to the point she could not care for him alone.  Rated score=39/Intermediate need with 5 ADLs and 6 IADLs  Transitioned from HHA & CLP Agency services 21 hours week to VD-HCBS two employees hired 40 hours week scheduled with additional 5 hours of Hospice weekly. Total 45 hours  His wife (POA) directs his care.  Other services accessed: GPS Security System Caregiver Support Programs Training for workers

12.  Community & Agency co-operation  Use of the Aging & Disability Resource Center (ADRC)  Strong initial Orientation & Education  Integration of all support systems into a cohesive care model directed by the Veteran