Preparing for Long-term Aging: Supporting the Aging Veteran Population

Milwaukee VA Medical Center

Jennifer L. T. Halter, LICSW, DCSW

Jane Hounsell, MSW, LCSW, C-ASWCM

Disclosure

• Presenters are not reimbursed for the presentation

• Presenters have no conflicts of interest

Understanding the VA

• Department of Veterans Affairs (VA)• Veterans Health Administration (VHA)

• Veterans Benefits Administration (VBA)

• National Cemetery Administration (NCA)

• State Departments of Veterans Affairs• Function under State statutes

• Services based on Federal VBA determinations and state benefits

• Oversee state Veterans Homes

• County Veteran Service Offices (CVSO)

State Veterans Homes

•King

•Union Grove

•Chippewa Falls

www.VA.gov

Wisconsin VA Locations for Care

Who are Veterans? National Data

• 20.4 million Veterans from all eras in 2016 (Pew Research Center; DVA)

• Represents <10% of the US adult population

• Profile of Veterans by era as of 2016• 4% WWII 12/7/1941 to 12/31/1946

• 8% Korea 6/27/1950 to 1/31/1955

• 33% Vietnam 2/28/1961 to 5/7/1975

• 33% Gulf War 8/2/1990 to present

• 23% Other peacetime includes Cold War era 1975-1990

Who are Veterans? Wisconsin Data

• Total WI population per census (estimated in 2018): 5.8 million

• Total WI Veterans per census (2013-2017): 350,330 (6%)• 10% are women Veterans (<1% of WI Veterans)

• VA projection: 234,253 Veterans eligible for VA health care

Who are Veterans? Milwaukee Health Care System (HCS)• Enrolled for VA care = 57,113 Veterans

• ~7% of enrolled Veterans are women• >90% assigned to Women’s Health Clinic

• Remember: projected 234,253 Veterans eligible for VA health care

• There are still over 177,000 estimated Veterans not enrolled in care• Veterans who haven’t applied for care• War era Veterans who weren’t injured during service• Veterans who have options (i.e. private health care, Medicare, steady income)

Characterization of Service

• Eligible for VA benefits• Honorable• General (Under Honorable Conditions)• Other than honorable

• Not eligible for VA benefits• Bad conduct (adjudicated in courts-martial)• Dishonorable

• Exceptions• Military Sexual Trauma (MST)• Other than Honorable (OTH)• Felons

Eligibility for Common VA Benefits by Military Character of Discharge

Table I from Veterans’ Benefits: The Impact of Military Discharges on Basic Eligibility, March 6, 2015

What is service-connection?

• Veteran who is injured or ill

• Incurred or aggravated during active military service

• Receives compensation (if more than 0%)

• Receives medical care for the service-connected injury or illness

• May be eligible for other benefits

• Process to become service-connect• Veterans Health Administration gathers medical evidence

• Veterans Benefits Administration determines if it’s compensable

Priority Groups

• Based on service-connection

• Adjudicated by the Veteran Benefits Administration

• 8 priority groups based on percentage of service connection

VA Priority Groups

Eligibility Changes as Veterans Age

• Pension• Honorably discharged• Income and net worth below limits set by Congress• Service requirements (i.e. war era Veterans)• At least 65 y/o• Permanently/totally disabled• Nursing home resident due to disability• Receive SSDI/SSI• 5,348 (1%) enrolled Veterans in Milwaukee HCS receive pensions

• Loss of function• Require assistance with 3 or more Activities of Daily Living (ADLs)

What services are available for eligible Veterans?• Income

• In the form of compensation for service-connected disability

• Limited burial benefits from the National Cemetery Administration• Information available online and at the medical center

• Health care• Inpatient, outpatient, medication• Extended care services

• Home health care, respite, Adult Day Health Care, Geriatric evaluation

• Limited nursing home care• Palliative/hospice care• Plans for long-term aging

Social worker’s role in long-term care planning• Assess acuity of Veteran care needs

• Access care• Housing• Economics• Psychological status• Social Support• Functional status

• Long-term care discussions about preparing for future health care needs• Develop a care plan• Partner with the community to increase awareness• Educate about legal and financial preparations for acute and long-term

care

Legally and financially preparing for long-term aging

• Not unlike Veterans who had to prepare for combat deployments• medically, legally, and financially

• VA offers Advance Care Planning facilitated groups to Veterans, Caregivers, and families

• VA recognizes State Authorized Portable Orders (SAPOs)• aka community DNR bracelets

Legally prepared for long-term aging

• Advance Care Planning• Health Care Power of Attorney

• Living Will

• 6,170 of 57,113 enrolled Veterans completed an Advance Directive (2019)

• Life-sustaining treatment discussion initiative• A VA national initiative began in March 2018 designed to help high-risk

patients outline, describe and document their wishes regarding life-sustaining treatment in the case of a life-threatening medical event. These notes are durable and easy to find in the Veteran’s medical record.

Legally preparing for long-term aging

• Surrogate Health Care Decision Maker:

• Encourage your clients to complete a Health Care Power of Attorney (HCPOA) which names someone they TRUST to be their health care decision maker IF they can no longer make decisions for themselves.

• HCPOA only becomes active when 2 medical providers sign a statement the person is no longer able to make their own decisions.

• “A Gift to Your Family”

• An attorney is NOT needed to complete a HCPOA.

Financially preparing for long-term aging

• Preparing for the worst-case scenario

• Assessing risk for an acute medical event

• Preparing for long-term nursing care• Independently wealthy

• Long-term care insurance

• Medicare eligibility

• Medicaid eligibility

Financially preparing:

• Surrogate Financial Decision Maker:

• Encourage your clients to consider completing a Financial Power of Attorney naming someone they trust to handle their finances should they be unable to.

• Depending on their assets, they may need an attorney to create a Financial POA.

VA Resources for Aging Veterans

•Ask:

•Are you a veteran?

•Have you ever had contact with a VA?

How to Apply for VA Health Care

• If no, your client can apply-• On line www.VA.gov

• Text 838255

• By phone Call toll-free hotline at 877-222-8387, Monday through Friday, 8:00 a.m. to 8:00 p.m. ET to get help with your application.

• By mail Fill out an Application for Health Benefits Download VA Form 10-10EZ (PDF)

• In person at a VA hospital or clinic Fill out an Application for Health Benefits Download VA Form 10-10EZ (PDF)

Need help applying for Benefits?

VSO = Veteran Service Officer

VSOs help Veterans Apply for Benefits such as:• Financial support (monthly payments as discussed)•Health care•Burial benefits

These trained professionals also:

• Help gather supporting documents (e.g. medical records or medical test results)

• File a claim or appeal on your behalf

VSO - Milwaukee

VSO - Madison

VSO - Green Bay

What’s your favorite color?

VA Community-Based Outpatient Clinics (CBOCs)• Primary Access Point for VA Health Care

• Referred to as a Patient Aligned Care Team (PACT)• Milwaukee - Gold, Red, Yellow, Blue

• Appleton - Green

• Green Bay - Emerald

• Union Grove

• Cleveland

VA Community Based Programs

• Home Based Primary Care (HBPC)

• Adult Day Health Care (aka Vet’s Club)

• Contract Adult Day Health Care (ADHC)

• Purchased Home Health Care• Homemaker/Home Health Aide• Skilled Care / Home Hospice• Respite Care

• Community Nursing Home

• Veteran’s Self-Directed Program

• Home Telehealth

Home Based Primary Care (HBPC)

Established in VA – 1972

Mission: Provide comprehensive, interdisciplinary, primary care

in the homes of Veterans with complex medical, social and

behavioral conditions.

Think: frail, chronically ill Veterans who have difficulty

travelling to a facility

Milwaukee HBPC Programs

• Milwaukee: Two teams 40-mile radius

• Union Grove: Team 40-mile radius

• Green Bay: Team 40-mile radius

HBPC Interdisciplinary Team

• Provider (typically an NP)

• RN/LPN

• MSW

• Physical Therapist

• Psychologist

• Registered Dietitian

• Medical Director (physician)

• Pharmacist

Adult Day Health Care (ADHC)aka: Vets’ Club

• On-site at the Milwaukee VA Medical Center (VAMC)

• Goals: • health monitoring

• social interaction

• recreation activities

• Outings

• Caregiver respite

Staff: RN, LPN, NA, Recreation Therapy, Dietary Tech, MSW

• Must be enrolled for VA Primary Care

Purchased Home Care Services

• Clinically appropriate services in the home supporting

medically necessary care to restore/improve health

• Supports Veterans who are in jeopardy of placementoutside their homes

Homemaker/Home Health Aide Program

Home Health Aide Services includes assistance with

Activities of Daily Living (ADLs):

• Bathing

• Toileting

• Dressing

• Grooming

Homemaker/Home Health Aide Program

Homemaker services include assistance with Instrumental Activities of Daily Living (IADLs):

• Light housekeeping to maintain safe, sanitary environment

• Laundry assistance for Veteran’s care only

• Meal preparation & shopping

Respite Care

Respite care = relief for an unpaid caregiver

Variety of setting respite care can be provided:

• Veteran’s home – up to 6 hours per week

• community nursing home – up to 30 days per federal fiscal year

• adult day care program – 2 – 3 days/week

• VA physician prescribed

Purchased Skilled Care

• Purchased Skilled Care - skilled RN services in the home.

• Up to 1x/day nursing care

• Includes IV Infusions

Hospice Care

If patient meets acute hospice criteria:

• In homeEnd of life care from licensed Home Hospice agencies

• Inpatient care at:

Contract nursing homes

VAMC Palliative Care units

Milwaukee VAMC, Madison VA Hospital, Tomah VAMC

Community Nursing Home

• VA paid benefit for eligible Veterans

If 70%-100% service-connected (SC)

If 60% SC and rated as unemployable

If less than 60% SC but in need of NH placement for SC condition

• 32 active contracts at present.

• Veteran receives monthly visits by VA RN or MSW

State Veterans Nursing Homes

Locations:

• Wisconsin Veterans Home at King

• Wisconsin Veterans Home at Union Grove

• Wisconsin Veterans Home at Chippewa Falls

Eligibility:

• Must have served active duty and have honorable discharge

• Not automatically funded because patient is a Veteran• Highly SC – the same as other VA contracted nursing homes OR• Medicaid eligible or private pay

Veteran Self-Directed Program

• Started as a pilot in Wisconsin

• Veteran in need of traditional H/HHA services and some non-traditional services, who wish to “self-direct” their care.

• Processes:• Assess functional abilities

• Establish a care budget

• Veteran becomes the employer

• Veteran hires care/service provider

Home TeleHealth

• Allows physician or RN to monitor Veteran’s medical condition remotely using home monitoring equipment provided by VA

• To improve the health of designated individuals and populations to provide the right care in the right place at the right time.

• Targets chronic conditions including:

• CHF, DM, COPD, CKD, HTN, PTSD and mental health including depression.

• If RN notes a change in condition, they contact Provider for direction promoting early intervention.

Home TeleHealth

• Home TeleHealth targets the 2-3% of Veterans with chronic illnesses who incur 30% of costs and are frequent clinic attendees, ER visitors and require urgent hospital admissions.

• Home TeleHealth in the VA has demonstrated reduced hospital admissions, clinic and emergency room visits.

• Daily disease monitoring leads to tighter disease management and improved self-management which contributes to a better quality of life.

Guardian Alert

• VA’s version of Lifeline or similar emergency response services.

• Accessed through the Veteran’s VA clinic provider or social worker when determined to be medically necessary

• No charge if eligible; requires no service-connection

If Veteran is Homeless or At Risk of Being Homeless…

The National Homeless Veterans Call Center

• Free, confidential support 24 hours a day, 7 days a week, 365 days a year

•Call 1-877-424-3838 (1-877-4AID VET)

• Send a Text to 838255

Veteran’s Homeless Programs

• The Veteran does NOT need to already be enrolled in VA health care to be eligible for Homeless Programs.• i.e. they need to be eligible for care; however, enrollment and

homeless service may occur simultaneously

• The Veteran DOES need to be eligible for VA Health Care

“Old Soldier’s Home” or “Old Main”

Parting thoughts

•Ask if your client is a Veteran

•Ask if enrolled in VA•Refer them to their VA SW

•How to get connected to VA:•VA medical center or clinic OR•On line www.VA.gov•By phone toll-free 877-222-8387,•Veteran Service Office (VSO)

References

Congressional Research Service “Veterans’ Benefits: The Impact of Military Discharges on Basic Eligibility”, 7-5700, March 6, 2015, www.crs.govhttps://fas.org/sgp/crs/misc/R43928.pdf

The Changing face of America’s veteran population, Nov 10, 2017, FactTank, https://www.pewresearch.org/fact-tank/2017/11/10/the-changing-face-of-americas-veteran-population/

Department of Veterans Affairs, www.va.gov

US Census Bureau WI quick facts https://www.census.gov/quickfacts/WI, August 14, 2019