1. Message from the Secretary “Even though VA is the largest integrated healthcare system in the country we can't provide all the services our aging veterans need. Working in concert with community providers will help ensure that all of our nation’s veterans have the right care at the right time and the right place.” Anthony J. Principi, Secretary Department of Veterans Affairs

2. Demographics of dying in VA – the need…  Serving an older, sicker population because of WWII generation  674,000 estimated veteran deaths in 2001 (28% total national deaths) – 1,800 per day* *Office of the Actuary, Vet Pop2000

3. Annual Veteran Deaths A small percentage of veterans die as inpatients in VA facilities

4. Veterans Health Administration 21 Veterans Integrated Service Networks VISN 1 – VA New England Healthcare SystemVISN 12 – The Great Lakes Health Care System VISN 2 – VA Healthcare Network Upstate New York VISN 15 – VA Heartland Network VISN 3 – Veterans Integrated Service Network VISN 16 – Veterans Integrated Service Network VISN 4 – VA Stars & Stripes Healthcare NetworkVISN 17 – VA Heart of Texas Health Care Network VISN 5 – VA Capitol Health Care NetworkVISN 18 – Southwest Network VISN 6 – The Mid-Atlantic NetworkVISN 19 – Rocky Mountain Network VISN 7 – The Atlanta NetworkVISN 20 – Northwest Network VISN 8 – VA Sunshine Healthcare Network VISN 21 – Sierra Pacific Network VISN 9 – Mid South Veterans Healthcare NetworkVISN 22 – Desert Pacific Healthcare Network VISN 10 – VA Healthcare System of OhioVISN 23 - Veterans Integrated Service Network VISN 11 – Veterans Integrated Service Network

5. 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 –> 40% of Californian men > 65 are veterans

6. Eligibility  Hospice care – in basic eligibility package for veterans –Enrolled veterans if eligible and desiring hospice care must have it provided – either by VA, VA funding or other reimbursement (Medicare, Medicaid)

7. Scope of Services  Palliative care consult teams – mandated 2003  Home Based Primary Care (HBPC) –Can work cooperatively with community hospices  VA Nursing Homes  Community Nursing Homes

8. Patient Demographics VA Inpatient Deaths  47% over age 75  65% not married  Median annual income < $10,000  25% no reported income VA provides health care for patients who are on average a decade older, generally more seriously and chronically ill, with fewer social support systems

9. VA Dedicated Inpatient Hospices in California  Palo Alto 25 beds  San Francisco 10 Beds  Long Beach 15 beds  Martinez/Northern California 6 beds

10. VA Palo Alto HCS  Established 1979 - in US  25 bed dedicated unit ~ 300 pts/yr  Palliative care consult team > 150 consults> year  Palliative care outpatient clinic

11. VA Palo Alto HCS  Interprofessional Palliative Care Fellowship –2 physicians, post-doc psychologist, advance practice nurse  Non-veteran admissions –Circle of Life Certificate of Honor 2001  Research –Economics, Grief/depression, Culture, Pharmacology

12. Working with VA: Hospice Care at Home  Veteran must be enrolled and VA involved in care –NOT a form of insurance, but coordinated care  Medicare/Medicaid first payer  If otherwise not reimbursed, VA pays using FEE BASIS

13. Working with VA: Hospice Care at Home  Payment usually mimics Medicare  You may negotiate special circumstances: –VA provides all but emergent meds. O2, DME etc. – discount per diem –VA may pay for medical director to assume attending of record duties If using fee basis

14. Working with VA: Hospice Care at Home  Who is in charge – VA or Hospice?  Attending of record – VA or non-VA physician? –VA physicians often no personal DEA # May not be able to use outside pharmacy And no UPIN # –If hospice at a great distance - ? better to have either local physician or medical director assume attending of record responsibilities Potential Problems…

15. Think of the VA when…  Veteran tells you that he/she is enrolled at a particular VA facility  Veteran’s needs cannot be met at home – considering institutional hospice or palliative care  Funding difficulties – ineligible for Medicare, MediCal and non private insurance

16. Things you can do  Incorporate veteran history into your intake procedure: ? Veteran, ? enrolled veteran, if so where?  Survey your hospice population for veteran prevalence  Identify and call VA hospice/palliative care representatives or points of contact for local VAs

17. Things you can do  Collaborate on a project with VA team –VA may provide meeting/conference space, AV equipment etc.  Invite VA trainees to participate in your hospice program  Contact VA Home Based Primary Care (HBPC) program – look for opportunities to collaborate in home care GO THERE, INVITE THEM TO VISIT YOU

18. Things you can do  Invite VA hospice/palliative care programs to join your local chapter of CHAPCA  Start a formal Hospice-Veteran Partnership

19. National Hospice-Veterans Partnerships Program Goals  Strengthen the relationships between VA facilities and community hospice agencies  Establish an enduring network of hospice and VA professionals  Create a comprehensive end-of-life community engagement plan designed to reach veterans and their caregivers

20. A Strategy for Creating Hospice – Veterans Partnerships Getting Started  Identify lead organization and assemble core planning group of stakeholders  Draft vision and mission  Conduct needs assessment  Determine resource needs  Create Action Plan

21. Potential HVP Members 1.State Hospice Organizations 2.Community hospice agencies 3.VA facilities VA Medical Centers Community-Based Outpatient Clinics (CBOC) 4.State Veterans Homes 5.Veterans Service Organizations (VSO) 6.Veterans 7.Military hospitals 8.Established coalitions 9.Other interested organizations

22. Draft Vision and Mission  Vision: All veterans and their families have access to high quality hospice and end-of-life services at time and place of need  Mission: To establish an enduring network of hospice and VA professionals, volunteers, and organizations working to increase access to and delivery of quality hospice and end-of-life services to veterans and their families Strategy (cont.)

23. Conduct Needs Assessment  Understand the nature of existing hospice- VA relationships  Describe what is working well  Identify organizational, legal, and regulatory barriers  Assess needs of hospice and VA providers  Compile names of contacts, experts, and potential leaders Strategy (cont.)

24. Determine resource needs  Assess how available resources can meet needs  Identify potential funding sources –Rallying Points – a RWJF national project that assists community-based coalitions in improving care and caring for those nearing the end of life. –Other state and national funding sources –Legislative appropriations Strategy (cont.)

25. Create Action Plan  Broaden existing or create new community coalitions to include veterans’ EOL issues  Plan educational and outreach activities  Clarify legal, regulatory, and policy issues at local and national levels Strategy (cont.)

26. Resources  VAHPC –Diane Jones (djones@ethosconsult.com) –www.va.gov/oaa/flp  Rallying Points Regional Resource Centers –Life's End Institute: Missoula Demonstration Project Contact: Lilly Tuholske (lillyt@missoulademonstration.org) –Midwest Bioethics Center Contact: Jacqueline Talman (jtalman@midbio.org) –The Hospice of the Florida Suncoast. Contact: Kathy Brandt (kathybrandt@thehospice.org ).  NHPCO Council of States –Judi Lund Person (jlundperson@nhpco.org)