Geriatrics & Long Term Care

Non-Institutional ProgramsNon-Institutional Programs

Inpatient and Community CareInpatient and Community Care

Presented by Nicole Trimble, LCSW-C and Presented by Nicole Trimble, LCSW-C and Eileen Cashour, LCSW-C Eileen Cashour, LCSW-C

By: Crystal Taylor, LCSW-CBy: Crystal Taylor, LCSW-C

Lead Social WorkerLead Social Worker

410-642-6422 Ext. 5379410-642-6422 Ext. 5379

Adult Day Care

Enroll in the VA System ( Cat 7 or less)Enroll in the VA System ( Cat 7 or less) Seen by VA Primary Care Provider at least yearlySeen by VA Primary Care Provider at least yearly Can attend up to two days a week at VA expenseCan attend up to two days a week at VA expense Provide 10/10EZ (financial information) yearlyProvide 10/10EZ (financial information) yearly Copay of 15.00 a day if Cat 8Copay of 15.00 a day if Cat 8 Once in program VA pays indefinitelyOnce in program VA pays indefinitely Currently there is a waiting listCurrently there is a waiting list

Home Health Aide Program

Must be enrolled in VA and seen by VA primary Must be enrolled in VA and seen by VA primary care provider at least yearlycare provider at least yearly

Needs help in three or more ADL’s and has Needs help in three or more ADL’s and has cognitive impairment, orcognitive impairment, or

Needs help in two ADL’s with one of the Needs help in two ADL’s with one of the following; recent discharge from a nursing home, following; recent discharge from a nursing home, 75 or older, clinical depression, living alone75 or older, clinical depression, living alone

Requires aide care as adjunct to hospice careRequires aide care as adjunct to hospice care Copay of 15.00 a day if Cat. 8Copay of 15.00 a day if Cat. 8

32 day contract available for Veterans who are 32 day contract available for Veterans who are Inpatient at VA and discharged to CNH who Non-Inpatient at VA and discharged to CNH who Non-Service ConnectedService Connected

Indefinite contract available for Veterans 70 % or more Indefinite contract available for Veterans 70 % or more Service Connected Service Connected

Indefinite contract available if veteran is in Nursing Indefinite contract available if veteran is in Nursing Home for SC diagnosis Home for SC diagnosis

Respite Placement possible if there the funds are Respite Placement possible if there the funds are availableavailable

Completed 10/10EC for copay eligibility. Copay is up Completed 10/10EC for copay eligibility. Copay is up to 97.00 a dayto 97.00 a day

Contract Nursing Homes

In Home Respite

Enrolled in the VA and following in Primary Care Enrolled in the VA and following in Primary Care Clinic or by VA providerClinic or by VA provider

Caregiver is in need of temporary or intermittent Caregiver is in need of temporary or intermittent relief from day to day care.relief from day to day care.

Allowed up to 30 days a year (could be in Allowed up to 30 days a year (could be in combination with inpatient respite) combination with inpatient respite)

10/10EZ completed for copays10/10EZ completed for copays This is for short term help and not for a referral for This is for short term help and not for a referral for

long term aide carelong term aide care Both of these programs are budget driven with Both of these programs are budget driven with

regard to availability.regard to availability.

Community Residential Care or Medical Foster Home Need placement in VA approved and MD state Need placement in VA approved and MD state

licensed homelicensed home Meet guidelines for levels of careMeet guidelines for levels of care Complete all VA and state referral paperworkComplete all VA and state referral paperwork Veteran agrees to pay for care, no VA contract Veteran agrees to pay for care, no VA contract

funds available for placementfunds available for placement Agree to rules and regulations of homeAgree to rules and regulations of home Will be followed in VA Primary Care ClinicsWill be followed in VA Primary Care Clinics Veterans are eligible for 2 days of ADCVeterans are eligible for 2 days of ADC

Medical Foster Home

MFH can have no more than 3 residents. MFH can have no more than 3 residents. Caregiver must live in the home Caregiver must live in the home Caregiver does not have a job outside of the Caregiver does not have a job outside of the

homehome Home Based Primary Care Team follows Home Based Primary Care Team follows

Veteran in the MFHVeteran in the MFH Veteran must be willing to attend ADC 2 Veteran must be willing to attend ADC 2

days a week. days a week.

VA Assisted Living Referrals

Contact person is:Contact person is: CRC-Eileen Cashour, LCSW-CCRC-Eileen Cashour, LCSW-C Phone 410-642-2411 ext. 5969Phone 410-642-2411 ext. 5969 Fax 410-642-1172Fax 410-642-1172 MFH- Nicole Trimble, LCSW-CMFH- Nicole Trimble, LCSW-C Phone-410-642-2411 Ext. 6094Phone-410-642-2411 Ext. 6094 Fax 410-642-1706Fax 410-642-1706

Veteran Directed Care

For Veterans who need skilled services, For Veterans who need skilled services, case management, and assistance with case management, and assistance with ADLs or IADLs.ADLs or IADLs.

Living alone or their caregiver is Living alone or their caregiver is experiencing burdenexperiencing burden

Veterans are given a flexible budget for Veterans are given a flexible budget for services that can be managed by the services that can be managed by the Veteran or caregiverVeteran or caregiver

Veteran Directed Care

Serves the following counties:Serves the following counties: CecilCecil CarrollCarroll Baltimore CountyBaltimore County Howard CountyHoward County Eastern ShoreEastern Shore

Home Based Primary Care

HBPCHBPC

What is the Home Based Primary Care Program (HBPC)? Direct Care ProgramDirect Care Program: Enables veterans to remain : Enables veterans to remain

in the home while receiving comprehensive in the home while receiving comprehensive healthcare at home healthcare at home

Veteran must be home bound, have a hard time Veteran must be home bound, have a hard time navigating the system, or medically complicated. navigating the system, or medically complicated.

Provides all Primary Care follow up Provides all Primary Care follow up Assess need for durable medical equipment and Assess need for durable medical equipment and

arrange for delivery of equipment to homearrange for delivery of equipment to home

Who are the HPBC Team? Program ManagerProgram Manager Nurse PractitionersNurse Practitioners RN’s RN’s Social WorkersSocial Workers NutritionistNutritionist KinesiotherapistKinesiotherapist PhysiciansPhysicians Program Support AssistantsProgram Support Assistants Consultants: Geropsychiatry, Hospice/Palliative, Consultants: Geropsychiatry, Hospice/Palliative,

Chaplain)Chaplain) Psychologist Psychologist

Other Benefits

Patient/caregiver education and supportPatient/caregiver education and supportReferrals to community agencies for select Referrals to community agencies for select services: wound care, PT, OTservices: wound care, PT, OT

Health Care

Primary care in the homePrimary care in the home Regularly scheduled NP/RN visitsRegularly scheduled NP/RN visits Health ExamsHealth Exams Teach caregiver home health care, skin Teach caregiver home health care, skin

care, medication management. care, medication management.

What Areas are Served

Baltimore City/CountyBaltimore City/County Anne ArundelAnne Arundel HarfordHarford CecilCecil CarrollCarroll HowardHoward

Referral/Eligibility

Outside the VA Outside the VA (veteran/family/agencies/health providers(veteran/family/agencies/health providers

Nurse Practitioner will visit home to Nurse Practitioner will visit home to perform initial assessment within 15 perform initial assessment within 15 working daysworking days

Case is presented at weekly staff meeting to Case is presented at weekly staff meeting to determine whether veteran is accepted into determine whether veteran is accepted into programprogram

HBPC Contacts

Main Line 410-605-7620Main Line 410-605-7620 Office Nurse (referrals) Office Nurse (referrals) 410-605-7639410-605-7639 David BermanDavid Berman 410-605-7640410-605-7640 Stacy HeinzeStacy Heinze 410-605-7623410-605-7623 Winter Wesley Winter Wesley 410-605-7568410-605-7568 Aned RuizAned Ruiz 410-605-4617410-605-4617

Hospice and Palliative Care

Hospice care is now part of the basic Hospice care is now part of the basic eligibility package for all Veterans enrolled eligibility package for all Veterans enrolled in the VA. If hospice care is needed and in the VA. If hospice care is needed and other funding is not available, the VA will other funding is not available, the VA will either provide hospice care directly or will either provide hospice care directly or will purchase it from community hospice purchase it from community hospice agencies.agencies.

Emergency Alert

Referred by Primary Care Provider at the Referred by Primary Care Provider at the VAVA

Alert system provided to Veteran and is Alert system provided to Veteran and is compatible with 911 systemscompatible with 911 systems

Alert system mailed to VeteranAlert system mailed to Veteran Home Based Primary Care sets up Home Based Primary Care sets up

Long Term Care Referrals

All referrals need a Discharge SummaryAll referrals need a Discharge Summary Referrals must be out of Intensive Care Referrals must be out of Intensive Care

Units for 24 hours and no telemetry before Units for 24 hours and no telemetry before admission to LTC admission to LTC

Medically stable Medically stable Sitter Free for 24 hoursSitter Free for 24 hours No NG Feeding TubesNo NG Feeding Tubes

INPATIENT Long Term CareLock Raven CLC

42-bed unit 42-bed unit Wander-guard system in placeWander-guard system in place Wander gardenWander garden Restraint-freeRestraint-free Provides respite careProvides respite care Provides a support group for familyProvides a support group for family For LTC must be 70% or Higher SCFor LTC must be 70% or Higher SC

Admission Criteria

Medically stableMedically stable Non-combativeNon-combative If not yet incompetent, vet must agree to If not yet incompetent, vet must agree to

placement (placement (nursing homes cannot hold nursing homes cannot hold patients against their will)patients against their will)

No tube feedings, no IvsNo tube feedings, no Ivs No SitterNo Sitter

Post Acute Care

Admitted to either LR2 and PP 23A or BAdmitted to either LR2 and PP 23A or B Must need wound care, IV fluid or IV Must need wound care, IV fluid or IV

antibioticsantibiotics On referral need documentation of wound On referral need documentation of wound

sizesize Cannot accept patients needing respiratory Cannot accept patients needing respiratory

isolation and NG tubesisolation and NG tubes

Rehabilitation Services

Acute rehab services located on LR2 Acute rehab services located on LR2 Low level rehab services located at PP23A-Low level rehab services located at PP23A-

B and Nursing Home Care Units at PP and B and Nursing Home Care Units at PP and LRLR

Referrals must include current PT and OT Referrals must include current PT and OT recommendationsrecommendations

Nursing Home Care Units

Units are located at Perry Point on Wards 25A &25B, Wards Units are located at Perry Point on Wards 25A &25B, Wards 14A&14B, Baltimore LR 1&LR214A&14B, Baltimore LR 1&LR2

LTC 1010EC copay test must be completed prior to LTC 1010EC copay test must be completed prior to admission, copay up to 97.00 a dayadmission, copay up to 97.00 a day

Can not admit for IV therapy, Stage 3 or Stage 4 wound care, Can not admit for IV therapy, Stage 3 or Stage 4 wound care, suctioning more than q 4 hours, and respiratory isolation, suctioning more than q 4 hours, and respiratory isolation, and NG tubesand NG tubes

Screening made aware of wandering risksScreening made aware of wandering risks 1010EZ must be current1010EZ must be current Must be 70-100% SCMust be 70-100% SC

Inpatient Respite

Need to have chest x-ray or PPD completed Need to have chest x-ray or PPD completed within one year of date of admissionwithin one year of date of admission

Bring a list of medication and advance directives Bring a list of medication and advance directives upon admissionupon admission

Acceptance is based upon bed availability on the Acceptance is based upon bed availability on the date of the request.date of the request.

Must be out of the hospital at least 30 days prior Must be out of the hospital at least 30 days prior to admission for respiteto admission for respite

Paid caregivers are not eligible for respitePaid caregivers are not eligible for respite 30 days permitted a year30 days permitted a year

Inpatient Hospice

Screening Committee reviews Screening Committee reviews hospice/palliative care admission.hospice/palliative care admission.

Must meet criteria for HospiceMust meet criteria for Hospice Placed in available beds at BRECC or Perry Placed in available beds at BRECC or Perry

Point.Point. No copays for Hospice admissions.No copays for Hospice admissions.

Referral to Long Term Care Screening

Community Referrals are sent to:Community Referrals are sent to:Kelly GrandeKelly Grande

Phone 410-642-2411 ext 6353Phone 410-642-2411 ext 6353Fax 443-693-4976Fax 443-693-4976