The Unique Needs of VETERANS AT END OF LIFE Scars unseen The Unique Needs of VETERANS AT END OF LIFE

Objectives Review Statistics of Veterans’ Illness and Death in PA Describe the Differences between VA Model of Care and Community care Develop an Understanding of the “WE Honor Veterans” Campaign Develop an Understanding of the “No Veteran Dies alone” Mission

Pennsylvania Statistics Rank 5th in the nation for Percent of Veteran Population > 65 years

Pennsylvania Statistics Ranks 5th in the nation for Veteran Deaths

Pennsylvania Statistics Veterans Enrolled in VA Total Veterans = 1,014,884 War Time = 708,200 Gulf War = 183,500 Vietnam = 320,400 Korean Conflict = 117,700 WWII = 109,800 Peacetime = 255, 900 OIF/OEF/OND = 51, 784 National Center for Veterans Analysis and Statistics, 2010 VISN 4 OIFOEF Dashboard, 2012

Demographic Imperative Only 4% of Veterans die in VA (~21,000) ~642,370 Veterans will die in 2012 Open with slide and then back to Scott when he begins to talk about the 642,370 Veteran deaths if you use Almanac to identify Veterans with just 4 serious illnesses, CHF, CRF, COPD and XX, you’ll get more a figure of more than 800,000 Veterans suffering from these illnesses. This is before we even add in ANY Veterans with serious cancers which likely numbers in the 100,000s as well. I applaud all the advances in coordinating cancer care. Many of these concepts, such as being evidence based, matching goals of care to appropriate services and improved care coordination are equally applicable to the care of non-cancer serious illness. MANY with advanced serious illness PTF file and VetPop for 2012

Selected Characteristics Source: U.S. Census Bureau, American Community Survey PUMS, 2009 Prepared by the National Center for Veterans Analysis and Statistics

VA Care vs. Community Care Veteran Affairs (VA) Community Culture Quasi- Military Nurse-led Movement Role Provider and Payer Provider Funding Fixed appropriation and budget Entitlement-Medicare/Medicaid hospice benefit: 3rd party reimbursement Accountability Congress Governing body, CMS, Fiscal Intermediaries, and State Location Large Medical Centers CBOC’s Private Homes

VA Hospice and Palliative Care Film clip

VA Palliative Care Holistic Interdisciplinary Model Nursing Spiritual Psychosocial Symptom Management Medical Management

Palliative Care Even if a Veteran meets eligibility criteria for Hospice Care, he might not be mentally ready for Hospice care. Palliative care (skilled nursing care symptom management) is offered until the Veterans symptoms are managed to an acceptable level set by the veteran. Palliative Care continues until the skilled need or the goals of therapy are met or the veteran elects Hospice care.

Palliative care cont’ Palliative care falls under the homecare umbrella of insurance coverage and can be offered through a home health and hospice agency. Not all homecare/hospice agencies have palliative care teams available. The Veteran must have a skilled need and be homebound in order for insurance to pay for it.

Veterans in Community Hospice / Palliative Care Home Hospice Care is provided wherever the Veteran calls Home The VA purchases Community Hospice Service as a Comprehensive Bundled per Diem Service for a Specific Period of Time. If a Veteran has Medicare or Other Private insurance, he may elect to have the VA pay or his other insurance pay. If a Veteran does not have insurance to pay for hospice care, the VA will pay through FEE basis, for the care the Veteran needs, through a community hospice agency.

Veterans in Community Hospice The VA will pay for 3 levels of community hospice care Routine home care Continuous care Inpatient Care when indicated For inpatient care, the hospice agency is to contact the VA for authorization prior to admission to an contracted facility.

Veterans in VA Health care A VA Facility should be considered before a community facility Reasons for Inpatient Admissions for Hospice and Palliative Care Uncontrolled Symptoms Inadequate Care or No Caregiver Caregiver Burden

What Influences Veteran Needs ? Cultural Impacts Fears Different War Eras Where They Served, How They Served

Cultural Impacts Military Service Combat influences Military Values Stoicism Combat influences Heroic Measures Advance Directives Pets

Fears 65% Veterans : Have Poor Support Systems Have Psychological Stress Prefer the “Strength of many and the power and wisdom of the group” Oppose Institutionalization at End-of Life Desires Open Communication with Professionals

Different War Eras WWII Cold Injuries Mustard Gas Effects PTSD vs. Delirium Radiation Exposure Korean Conflict Cold sensitivity PTSD Minimizing of Experiences

War Eras Con’t Vietnam Alcohol/Substance abuse Agent Orange Exposure Homelessness Increased need for care Gulf war/OEF/OIF Exposure to Toxins Gulf war Syndrome TBI Chronic Fatigue Syndrome

PTSD- Post Traumatic Stress Disorder What is PTSD? 3 Major Symptoms Re-experiencing Avoidance Increased Arousal Management Spiritual and Emotional Distress Interdisciplinary Approach to Care

How can We IMPROVE Care to Veterans? We Honor Veterans No Veteran Dies Alone

Designed to empower hospice professionals to meet the unique needs of dying Veterans : Military Check list Honoring Veteran Medical Needs PTSD & Psychosocial Needs Veteran Healthcare Benefits

How to Become Involved… Enroll Learn Complete Activity Reports Network

VA Provides Tiered Recognition Level 1- Commit to Program Level 2- Provide Education to Staff Identify Veterans Level 3- Strengthen Relationships with VA Level 4- Increase Access and Quality Care to Veterans

No Veteran Dies Alone “No one should die alone…. Each human should die with the site of a loving face” -Mother Teresa of Calcutta What is it? Who may help? How to help? Many years ago friends and family surrounded dying loved ones as they reached the final stage of their life. Today many people are living longer due to medical advances and frequently outlive their family and friends. Working in a health care setting, hospital staff observe many patients are dying alone. For this reason a program called ‘No One Dies Alone’ was originated. The ‘No One Dies Alone” program is a volunteer Companion Program for Dying Hospital Patients. The program is designed to train volunteers in assisting with the care of veterans at the end of life.

No Veteran Dies Alone National initiative The Department of Veterans Affairs says its mission is "to fulfill President Lincoln's promise ... 'To care for him who shall have borne the battle.' “ VA hospitals around the country, provide the special care that Veterans desire when their final battle is coming to an end.

A Veteran’s Story Jim Cooper Navy Frogman Korean War Veteran Advanced COPD

Home Care Agencies’ Best Friends Federal Guide to Veteran & Dependent Benefits (on line & in print) www.va.gov (VA benefits, especially healthcare) www.vba.va.gov (general VA benefits) VHA Handbook 1140.5 (Community Hospice Referral & Purchase Procedures) Your local VA facility Hospice/ Palliative Care POC, Community Home Health Coordinator and Pre-registration staff County Veteran Representatives – located usually in county courthouses

Summary Growing Numbers of Veterans Unique Needs How can WE honor Veterans? Collaboration Use of tools and Expertise Partnerships