Veterans Health Administration Office of Community Care State Home Per Diem Program Automated 10-10SH Form (State Home Program Application For Veteran Care Medical Certification) January 08, 2018

Objectives To understand and know what is required to use and submit automated version of 10-10SH To learn how to process and submit admission application via a VA approved encryption method To create an internal workflow process using a shared drive folder To use Adobe Reader for electronic signature To learn how to have your questions/concerns answered The current 10-10SH is under review for revision and will address some of the issues with the current form. The automation of the form cannot change the official VA form 10-10SH format.

Automated 10-10SH Admissions Application Process Key Features of Automated 10-10SH Form Acts as a guide, asking all required information and filling out actual 10-10SH from those answers Includes data field validation, precluding 10-10SH form from being submitted electronically unless all required fields/information has been filled out Provides for and requires an electronic signature or equivalent prior to submission Landing page provides link to 10-10EZ/R to remind SVH to determine if 10-10SH should be paired with a 10-10EZ/R for admission to an SVH and for per diem payments for domiciliary care VAMC portion of application includes business rules to assist VA representatives in making uniform eligibility determinations, will allow VA representative to return incomplete applications to SVH along with notification of errors

Automated 10-10SH Admissions Application Process By law (38 CFR, Part 51.43), as a condition for receiving VA per diem payment, SVH must submit a completed admissions application for each Veteran to VAMC of Jurisdiction, consisting of: completed VA Form 10-10 EZ, Application for Medical Benefits (or VA Form 10-10 EZR, Health Benefits Renewal Form (if a VA Form 10-10 EZ is already on file at the VA)) and completed VA Form 10-10SH, State Home Program Application for Care – Medical Certification Must submit these forms to VAMC POC when eligible Veteran is admitted to SVH, or with any request for change in level of care (Domiciliary, Nursing Home, or Adult Day Health Care) **Remember, Veterans do not have to be enrolled in VA Healthcare when applying for admission to SVH

Automated 10-10SH Admissions Application Process Using this:

Automated 10-10SH Admissions Application Process Will generate this:

This link opens Automated 10-10SH Form

Automated 10-10SH Admissions Application Process VA Approved Encryption for Transmitting Automated 10-10SH All 10-10SH packages will be transmitted to the VAMC by a VA approved encrypted method (Such as Virtru Pro or PIV) Any other method to transmit Personal Identifying Information must be approved by the local VAMC Privacy Officer See Virtru Pro presentation on how to use Virtru Pro for SHPD Program

Automated 10-10SH Admissions Application Process Create a Workflow Process Create a folder on a shared drive for staff to access the form to complete their section Only one staff member can be in the form It is very important when not actively using the form to save and close form (when the form is in use, no one else can complete updates) Changes cannot be made to a section without removing signature Signatures can only be removed by the individual who signed the form

Automated 10-10SH Admissions Application Process Each panel covers a section of 10-10SH Filling out panels ensures required fields are filled. Required fields are marked with an Age is an auto calculated field. A “Signature of State Veterans Home Official” block for the SVH Administrative staff will appear after SVH providers have signed off on the form. This signature block is not a required item, since the header of the form now indicates which providers have signed. The form is built on 22 page platform. Blank pages 12 to 17 are generated for VAMC to complete after pages 1 to 11 are completed and signed at the SVH. The form can expand when data is entered the text fields.

Automated 10-10SH Admissions Application Process When SVH providers sign their section, it is indicated in header There are panels for each SVH clinical provider Primary Physician RN or Physician Therapist or Physician Social Worker

Automated 10-10SH Admissions Application Process To open the Provider data sub tabs, select SH History & Physical There are five tabs for Physician’s H&P section: History X-Ray/Labs Mental Illness Additional Referring Physician Staff can also navigate directly to the signature block by selecting the link built in the “Section Complete:” items Parts II to IV are for the SVH staff Part V for VAMC staff

Automated 10-10SH Admissions Application Process Items needed to be filled out are identified with an “Edit” button and directs user back to appropriate item once the Validate button is selected If all items are complete when Validate ribbon is clicked, Signature block will appear below ribbon Signature block will not show until all fields are completed. Select the “Validate and Complete Signature …” ribbon to show items to edit and it will open the signature icon when all fields are completed. This occurs for all six required signatures on the 10-10SH. If items are missing in the “State Home Administrative” tab will be appear for editing on the “Referring Physician” tab when Validate ribbon is clicked. Typing name of Physician does not meet the requirement for Physician Signature.

Automated 10-10SH Admissions Application Process If any item is not completed when the Validate ribbon is activated, it will provide a link to that item to be completed (signature box is not visible) Once required fields are completed, signature box will appear for electronical signature Select the “Validate and Complete Signature …” ribbon to show items to edit and it will open the signature icon when all fields are completed. This occurs for all six required signatures on the 10-10SH. If items are missing in the “State Home Administrative” tab will be appear for editing on the “Referring Physician” tab when Validate ribbon is clicked.

Automated 10-10SH Admissions Application Process If any information is missing on the “State Home Administrative” tab, it will appear for editing on the “Referring Physician” tab when Validate ribbon is selected and will not allow Physician signature until item is entered Selecting the edit button will take user back to the page of missing information Required information missing in the “State Home Administrative” tab will appear for editing on the “Referring Physician” tab when Validate ribbon is clicked.

Automated 10-10SH Admissions Application Process Part III Evaluation signature page There are three screens for Part III of the form to be completed by the Physician or RN and Physical Therapist.

Automated 10-10SH Admissions Application Process Part III PT signature page

Automated 10-10SH Admissions Application Process Part IV Social Work signature page Part III & IV Remarks Field is open text and can be entered after signature Since this field is not signed the individual entering comments needs to print name and date entry. Remarks: from RN, Physical Therapy, and/or Social Worker (item 64). remarks field can be typed after each discipline enters data and makes comments after signature. This field does not identify who or when comments are entered; print name (initials can be used if individual previously signed the form) and date after each entry.

Automated 10-10SH Admissions Application Process Electronic signatures can be created in Adobe Acrobat Reader and used in form Attached document is a tutorial for setting up electronic signature in Adobe Acrobat Reader Instructions are for 2010 Adobe Acrobat.

Automated 10-10SH Admissions Application Process When 10-10SH form arrives from SVH to VAMC of Jurisdiction, Administrative Reviewer will need to verify date admitted, enter date received, and identify level(s) of care SVH is recognized by VA to provide and requesting per diem Admission Package was submitted for the level of care is automated from Part II (SH History & Physical) tab Based on level of care requested by SVH; the form generates appropriate questions for Administrative and Clinical reviewers to answer The “VA Administrative Reviewer” tab is the same for all three levels of care. VA Administrative Review tab provides questions based on Veteran eligibility. If individual does not meet definition of a Veteran, then per diem is not authorized. The initial Admin tab is same for all three levels of care

Automated 10-10SH Admissions Application Process VA Administrative Review covers eligibility for NHC, Dom, and ADHC Selecting anything but “None of the Above” will make Veteran eligible for per diem Selecting “None of the Above” will prepopulate “No” answer for Eligible for Per Diem The question “Does Veteran Meet one of the following Categories” is the same for all three level of care. The last three questions are for NHC, which drives questions in the Clinical Reviewer tab

Automated 10-10SH Admissions Application Process Clinical Reviewer tab inherits the Administrative Reviewer’s answers for all three level of care Clinical Reviewer will answer each question to make the determination if NHC is required and type of per diem If the Clinician selects yes for admission due to SC; then a required text box will open to enter SC condition(s) When the Clinical Reviewer denies per diem, then a text box will open to enter reasons for denial The Notification and Reason text box will show up on all three levels of care.

Automated 10-10SH Admissions Application Process Resources include: VAMC of Jurisdiction SHPD Program State Veterans Home (SVH) Per Diem Payment Program , VHA Directive 1601SH.01 Policies, Laws, and Regulations Forms Training Presentations Conference Call Minutes If you find that you have exhausted all of these resources, then please send your questions/concerns to: VHA10D1B3StateHomePerDiemInquiries@va.gov

Automated 10-10SH Admissions Application Process Highlights SVH submits the 10-10SH Package with Virtru Pro or VA approved encryption system Communication between the SVH and VAMC is the key to avoid delays and improper payments Establish an internal work flow process Review current Directives, guides, and attend trainings

Questions regarding the SHPD Web Application may be directed to the VHA10D1B3StateHomePerDiemInquiries@va.gov email group.

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