VA Geriatrics

1
VA Geriatrics Extended Care

• National Update
• AGS May 4, 2006

2
VA GEC

• Strategic Planning GEC, PCS, VHA
• Budget
• Marsha Goodwin-Beck Awards
• Geriatric Research, Education and Clinical
  Centers (GRECCs)
• Geriatric Programs GEM Geri Prim Care
• Geriatrics and Gerontology Advisory Committee
  (GGAC)

3
VA GEC

• 7. Hospice Palliative Care
• 8. Home-Based Primary Care and Medical Foster
  Home
• 9. White House Conference on Aging

4
Eight for Excellence

• Strategic Planning VHA, PCS, GEC
• VHA Strategy 1 Continuously improve the
  quality and safety of health care for veterans,
  particularly those health issues associated with
  military service.
• Initiative 1.5 Pursue innovations in services
  to aging veterans that enhance VA capabilities in
  long-term care, including care coordination and
  telehealth technologies.

5
Principle GEC Initiatives (part of PCS plan)

1. Culture transformation of VA nursing home care
2. Enhance access to non-institutional home and
   community-based services
3. Affirm and enhance GRECC contributions to VHAs
   strategic initiatives
4. Align and integrate chronic care within
   Geriatrics through a wider care coordination
   initiative

6
Additional GEC Initiatives

1. Integration of new veterans with polytrauma into
   extended care programs
2. Enhance veterans access to hospice and
   palliative care across all care settings
3. Provide comprehensive coordinated care for
   veterans with dementia
4. Improve primary care management of frail elderly
   veterans
5. State Homes quality of care initiative
6. Unannounced site survey program for VA NHCUs

7

• 1. Culture Transformation of VA Nursing Home
  Care Transforming the current culture of nursing
  home care from a medical model, driven by medical
  diagnosis and illness, to a person centered
  culture of care whereby decisions regarding care
  and treatment involve the resident and are
  central to the organization and care processes in
  the nursing home.

8

• 2. Enhance access to non-institutional home and
  community-based services, including care
  coordination/telehealth. Expand number of VA
  facilities offering HBPC and MFH, establish a
  national HBPC satisfaction survey, and conduct
  national survey to assess hospice and palliative
  care programs and services.

9

• 3. Affirm and support Geriatric Research,
  Education, and Clinical Centers (GRECC)
  contributions to VHAs short-, medium-, and
  long-range plans for addressing the needs of
  aging veterans. Public Law 96-330 (1980)
  mandated Geriatric Research, Education and
  Clinical Centers (GRECCs) to advance scientific
  knowledge regarding the medical, psychological,
  and social needs of older veterans, and the means
  for addressing them, through (1) geriatric and
  gerontological research (2) the training of
  personnel providing health care service to older
  persons and (3) the development and evaluation
  of improved models of clinical services for
  eligible, older veterans.

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• 4. Align and integrate, where appropriate,
  chronic care within Geriatrics through a wider
  care coordination initiative. The VHA definition
  of Care Coordination is the use of health
  informatics, Telehealth and disease management to
  extend and enhance care and case management. The
  areas of Care Coordination include General
  Telehealth (CCGT) Home Telehealth (CCHT) Store
  and Forward (Teleretinal imaging). The scope of
  this initiative is to expand care coordination
  programs, increasing access to specialty care and
  to non-institutional care across the continuum.

11
Budget FY 2007 Proposal

• More than 4.3 billion for LTC (increase of
  229M)
• Institutional Care 3.8 billion
• Non-Institutional Care 535 million (increase of
  48 million or 9.9)
• State Home construction 85 million
• State Home per diem 480 million

12
Marsha Goodwin-Beck Awards

• 2005
• Excellence in Leadership
• John Morley, MB, B Ch
• Director, St. Louis GRECC
• Excellence in Clinical Care Delivery
• Alison Bingman, MSN, APRN-BC
• Nurse Practitioner at Durham VAMC
• 2006
• Pending

13
GRECC Updates

• Updating performance measures
• More relevant to VA, VISN, VAMC
• Link to strategic plans
• Re-examine/revise funding
• Personnel
• Educational, clinical projects
• Research collaborations
• Monthly CME-accredited audioteleconference series
  beginning 7/06
• Annual Reports and Summary Report available at
  http//vaww1.va.gov/grecc/page.cfm?pg66
• New Special Fellowships
• All GRECC eligible
• Open to non-MDs and non-geriatrician MDs
• Request for eligibiilty for NIH Loan repayment
  Program

14
Geriatric Primary Care Updates

• OK for piloting 5 measures based on ACOVE during
  summer 2006
• End of life, funct. Assmt, UI screening and
  assmt, falls screening and assmt
• Education of primary care providers in geriatrics
• Strategic planning among GRECCs 5/2/06
• DSS and Austin data analyses to support reduced
  geriatric primary care panel size
• National Geriatric Primary Care/ACA meeting
  September 13-14, Philadelphia
• Articulation of criteria for GEM Program of
  Excellence
• Efforts to raise awareness and knowledge of
  delirium

15
Geriatrics and Gerontology Advisory Committee

• 2005-2006 site visits
• Pittsburgh, LA, St. Louis, Gainesville, Madison,
  Durham, San Antonio
• New membership
• White Paper submitted to Secretary
• Non-institutional workload counting
• GRECC support
• Impact of VERA on clinical innovations
• Follow-up from Mill Act pilots

16
Hospice Palliative Care (HPC)

• Dr. Scott Shreve is our National Director of HPC
• Survey on VA Palliative Care services completed.
  Distributed to VISN CMOs past week.
• Annual Report for FY2005 distributed.
• Vision for VA End of Life Care

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Actions to improve care

• Partnering
• - Hospice-Veteran Partnerships
• - Acute care (recruiting partners)
• Raise Expectations (reduce variability)
• - Reporting variation
• - Targeting program development
• Accountability
• - Outcome measure implementation
• - Request For Proposal Initiative (seed money)
• Enhanced Expertise
• - Audio conferences, face to face and online
  curricula
• - AACT Little Rock May 23-25 Kansas City
  July 25-27

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VA-Paid Home Hospice Care
Average Daily Census
19
of Inpatient VA Deaths with a Palliative Care
Consult
20
Palliative Care in VA Home-Based Primary Care
(HBPC)
of veterans served with v66.7 code
21
Home-Based Primary Care

• Expansion 74 to 105 programs ADC 8081 to
  11,063 keep pushing
• Performance Measure both ADC and
• 6 of 9 HCBC programs at all facilities
• Challenges to HBPC at every site
• Misperception that HBPC similar to Medicare
• Perception that HBPC is too costly
• Lack of awareness of benefits to veterans and
  facilities

22
VACO Support for HBPC

• Encourage HBPC at all facilities
• VACO support
• National cost analysis 24 net cost avoidance
• Demographic analysis of anticipated population
  need for HBPC
• Proposal guidance
• Mentor for HBPC Program Director and HBPC Medical
  Director

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What is Medical Foster Home?

• Alternative to nursing home placement for
  veterans who can no longer live alone and have no
  caregiver
• Merges adult foster home with VA Home-Based
  Primary Care (HBPC)
• VA helps find a person in the community who will
  take a dependent veteran into their private home
• MFH caregiver provides daily personal assistance
  and supervision
• VA HBPC provides comprehensive medical care and
  management caregiver education
• VA MFH Coordinator provides oversight
• Veteran pays for MFH

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What is Medical Foster Home?

• Partnership of Foster Care with HBPC
• Alternative to nursing home placement for
• - dependent, chronically ill, or terminally
  ill veterans
• - unable to live independently, and
• - prefer a family setting for their long-term
  care.
• Average age 72yrs Number of major
  problems 8
• Prominent Dx Dementia, CVA, Heart Disease,
  COPD
• All eligible for nursing home care
• VA finds caregivers provides oversight and HBPC
• Foster care costs paid by veteran, from VBA

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How did MFH start?

• Two social workers at Little Rock VA
• Problem Veterans in HBPC declined and could no
  longer live alone, refused NH
• Opposing ethical principles
• Unsafe at home, or force out of home?
• Solution find a willing caregiver, meet medical
  care needs through HBPC
• Pilot 2002 cautiously optimistic success

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Target Population for MFH

• Eligible veterans who
• Are unable to live independently due to
  functional, cognitive, and/or psychiatric
  impairment chronic or terminal illness
• Have no suitable caregiver to provide needed
  monitoring, supervision, and assistance
• Meet nursing home criteria
• Have complex medical conditions requiring care
  from an interdisciplinary team and
• Are able to pay for MFH (VBA SS)

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Risks of MFH

• Potential for abuse and neglect
• Caregiver selection background Long-term
  commitment Work will increase over time
• Accept unannounced visits
• Oversight (similar to Community Residential Care)
• VA liability concerns for veterans and caregivers
  
• Manage similar to Community Residential Care
• Cost to VA
• Experience lowers cost to VHA, because some 70
  SC veterans choose MFH. Cost neutral for VA.

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Benefits of MFH

• VA offers an option to NH care, in a less
  restrictive environment
• Veteran can choose a home environment
• MFH less costly than nursing home
• For 70 SC veterans, cost savings to VA
• Net savings to VA facility in current year
• Benefits to caregivers
• Benefits to community

29
Medical Foster Home Expansion

• View video VISN libraries and HBPC programs
• Training program in July 2006
• Preliminary inquiries sent last week to all HBPC
  Program Directors
• MFH Program Guide draft completed
• Contact thomas.edes_at_va.gov

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2005 White House Conference on AgingFrom
Awareness to Action

• VA GEC Update

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Update on WHCoA

• Implementation strategy highlight report
• Letters to Governors
• Responses from Governors
• www.whcoa.gov look at News for Speakers and
  Presentations and Input from Governors
• Working on Final Report

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Choose your favorites

• Resolution 48 Ensure Appropriate Recognition
  and Care For Veterans Across All Healthcare
  Settings.
• Resolution 42 Promote Innovative Models of
  Non-Institutional Long-Term Care

33
Choose your favorites

• Resolution 40 Attain Adequate Numbers of
  Healthcare Personnel in All Professions Who are
  Skilled, Culturally Competent, and Specialized in
  Geriatrics.
• Resolution 32 Evaluate Payment and Coordination
  Policies in the Geriatric Healthcare Continuum to
  Ensure Continuity of Care.
• Resolution 34 Improve The Health And Quality Of
  Life Of Older Americans Through Disease
  Management And Chronic Care Coordination.

34
Update on WHCoA

• Encourage collaboration and participation
• Contact your Governor identify priorities
• Work with AGS
• Work with Area Agency on Aging state, county and
  local organizations