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, SecretaryDepartment of Veterans Affairs

Demographics of dyingin 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

Annual Veteran Deaths

A small percentage of veterans die as inpatients in VA facilities

Veterans Health Administration21 Veterans Integrated Service Networks

I J 2002

N ANUARY

W ERE INTEGRATED AND

RENAMED

VISN 13 14

VISN 23

S AND

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

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

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)

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

Patient DemographicsVA Inpatient Deaths

Patient DemographicsVA 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

VA Dedicated Inpatient Hospices in California

Palo Alto 25 beds

San Francisco 10 Beds

Long Beach 15 beds

Martinez/Northern California 6 beds

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

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

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

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

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…

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

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

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

Things you can do

Invite VA hospice/palliative care programs to join your local chapter of CHAPCA

Start a formal Hospice-Veteran Partnership

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

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

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

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.)

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.)

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.)

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.)

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 CenterContact: 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)