VA Geriatrics and Extended Care Continuum – Empowering Veterans to Rise Above the Challenges of Aging, Disability, or Serious Illness 1 March 3, 2015 Richard M. Allman, MD Chief Consultant, Geriatrics and Extended Care Department of Veterans Affairs Washington, DC National Association of State Veterans Homes Winter Conference

VETERANS HEALTH ADMINISTRATION Presentation Goals Describe organizational structure, vision, mission, and goals for VHA Geriatrics and Extended Care (GEC) programs Provide an overview of the comprehensive nature of GEC programs and the opportunities they provide to address VHA challenges Promote discussion of the value of the partnership between the NASVH and VHA

VETERANS HEALTH ADMINISTRATION VA Mission 3 Mission: Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile & Integrated Core Values: Integrity, Commitment, Advocacy, Respect & Excellence

VETERANS HEALTH ADMINISTRATION Veterans Health Administration (VHA) Health System 135 Community Living Centers 300 Vet Centers 150 Medical Centers 985 Outpatient Clinics 820 Community-Based 150 Hospital-Based 9 Mobile 6 Independent 104 Domiciliary Residential Rehabilitation Programs 4 70 Mobile Vet Centers Source: FY st Quarter Pocket Card 21 Veterans Integrated Service Networks (VISNs) Serving 8.9 million enrolled Veterans, half of whom are age 65 years or greater

VETERANS HEALTH ADMINISTRATION * Source: American Customer Satisfaction Index Patient Satisfaction Scores VA has topped private sector hospitals in patient satisfaction for a full decade. 5

VETERANS HEALTH ADMINISTRATION VA is the largest provider of health care training in the United States and maintains more than 5,000 individual affiliation agreements at more than 1,800 educational institutions. In FY 2013, VA provided clinical traineeships and fellowships to more than 117,000 students in more than 40 professions. Preparing the Nation’s Health Professionals for Tomorrow 6

VETERANS HEALTH ADMINISTRATION Geriatrics and Extended Care – Providing Solutions for Veterans Facing Challenges Geriatrics and Extended Care (GEC) Mission: Empowering Veterans and the Nation to rise above the challenges of aging, disability, or serious illness 7 GEC Mission GEC Programs Triple AIM for VHA Improving Performance Promoting a positive culture of service Advancing healthcare innovation for Veterans and the country Increasing operational effectiveness and accountability Blueprint for Excellence Themes

VETERANS HEALTH ADMINISTRATION Veterans Health Administration (VHA) Organizational Chart 8 Updated October 2013 Under Secretary for Health Principal Deputy Under Secretary for Health Finance Nursing ADUSH for Quality, Safety & Value ADUSH for Workforce Services Strategic Integration Health Equity Research Oversight Medical Inspector Readjustment Counseling Deputy Under Secretary for Health for Policy & Services ADUSH for Policy & Planning ADUSH for Patient Care Services ADUSH for Informatics & Analytics Public Health Interagency Health Affairs Ethics in Healthcare Research & Development Chief of Staff Deputy Chief of Staff ADUSH for Clinical Operations ADUSH for Administrative Operations 21 VISNs Patient Centered Care Deputy Under Secretary for Health for Operations & Management Geriatrics and Extended Care Operations Geriatrics and Extended Care Policy and Service

VETERANS HEALTH ADMINISTRATION Geriatrics and Extended Care (GEC) Vision Chief Consultant, Policy and Services Richard M. Allman, MD Executive Director, Operations Thomas Edes, MD 9 Common Vision: One GEC – Empowering Veterans and the Nation to rise above the challenges of aging, disability, or serious illness

VETERANS HEALTH ADMINISTRATION GEC MISSION Honor Veteran’s preferences for health, independence, and well-being in the face of aging, disability, or illness by advancing expertise, programs, and partnerships.

VETERANS HEALTH ADMINISTRATION Geriatrics and Extended Care Programs (GEC) for All Veterans 11 IndependenceDependenceEnd of Life Ambulatory Care Inpatient Acute Facility Based LTSS 1 Home & Community Based LTSS 1 Hospice Care 2 Geriatric Evaluation & Management, Geriatric Primary Care (Geri-PACT), Outpatient Palliative Care Adult Day Health Care, Home Based Primary Care, Homemaker & Home Health Aide, Community Residential & Medical Foster Care, Respite, Skilled Home and Palliative Care, Veteran Directed Care Geriatric Evaluation and Palliative Care Units, Geriatric and Palliative Care Consults VA Community Living Centers, Community Nursing Homes, State Veterans Homes Portfolio of Geriatrics and Extended Care (GEC) Programs Continuum of Vulnerability Geriatric Research, Education, and Clinical Centers (GRECCs), Geriatrics and Extended Care Field Programs & Data Analysis Center Innovations in Veteran Care and Healthcare Workforce Development 1 LTSS = Long term services and supports; 2 Community Home Hospice and VA Inpatient Hospice

VETERANS HEALTH ADMINISTRATION Geriatric Research, Education, and Clinical Center (GRECC) Locations 12 EasternColoradoGRECC

VETERANS HEALTH ADMINISTRATION 167 Innovative, Non-Institutional Long Term Care Models Implemented FY Advanced Care Planning Shared Decision Making Care Management Delirium Care Dementia Programs Geriatric Consultation Geriatric Patient Aligned Care Teams (GERI-PACT) Hospital at Home* Home Based Primary Care Hospice and Palliative Care Medication Reconciliation Rehabilitation Mobile Care Units Programs of All Inclusive Care for the Elderly (PACE) Staff Geriatric Education Transitional Care 13 Innovations and Improvements in Care in Geriatrics and Extended Care *Recognized by Joint Commission as a Best Practice

VETERANS HEALTH ADMINISTRATION 14 Using appropriate risk stratification and population health strategies, GEC programs improve health, safety, independence and purpose: – Reduce mortality – Reduce hospital readmissions – Reduce total health care costs – Shorten length of hospital stays – Minimize adverse drug reactions – Enhance patient and family satisfaction – Improve patient function and independence – Delay or reduce need for nursing home stays – Lower risk of hospital acquired complications such as delirium Geriatrics and Extended Care Program Outcomes

VETERANS HEALTH ADMINISTRATION Numbers of Veterans Using GEC Services 15 Source – GEC DAC

VETERANS HEALTH ADMINISTRATION 16 Growth in GEC Programs *Home and community based services

VETERANS HEALTH ADMINISTRATION Numbers of Veterans Receiving Home Based Primary Care 17 Source: GEC DAC

VETERANS HEALTH ADMINISTRATION Number of Veteran Enrollees by Age 18

VETERANS HEALTH ADMINISTRATION 19 Projected Enrollees Over 65 Years Old P1a Doubles in Next Decade

VETERANS HEALTH ADMINISTRATION Percentage of P1As for Whom VA Must Provide Nursing Home Care

VETERANS HEALTH ADMINISTRATION Medical Foster Homes 1 – “ I would say that if you want to have some comradeship, some fun and enjoyment and get along with the other guys and people, do it. Do it. It gives you more security, more feeling of belonging. It’s good.“ – Veteran – “Freedom. I have freedom. I just appreciate all the VA has done to make living here more comfortable and safe, definitely safe.” - Veteran 21 GEC And Veteran Experience 1

VETERANS HEALTH ADMINISTRATION Hospice/Palliative Care 1 – “ All the love I’ve ever needed in my life is here. I have a leukemia that right now I’m living on blood transfusions and I could get to a point where I really don’t care about much of anything. And the people here provide me with the love to never have to go in that direction. It keeps me alive that love.” - Veteran – “I have been emotionally drained, really emotionally drained, and they lift me. They really do. We didn’t even know that this was available and I need to say how wonderful it’s been. I can’t say enough for the care. I thought it would be kind of sad but it’s happy, clean. I love it.” - Caregiver 22 GEC And Veteran Experience 1

VETERANS HEALTH ADMINISTRATION Home Based Primary Care – “They kept me out. Yeah, I haven’t even had to go to the emergency room, not one time that I remember. As far as I remember, I wasn’t in there at all. So I’m just thrilled, you know. When you go from five [ER visits] to none, somebody is doing their job.” – There would have been a lot of times, like now, that I couldn’t hardly make it…. But now in this program, I believe that I can keep him right here in the house.” (Caregiver of WWII Veteran) 23 GEC And Veteran Experience

VETERANS HEALTH ADMINISTRATION Veterans Directed Home & Community Base Services Program: 2014 Veteran Experience Analysis 1 – Veterans report a high level of satisfaction regarding choice and control – Veterans strongly agree or agree (99%) that caregivers do things the way they want them done (79 respondents) – Veterans strongly agree or agree (91%) that they control how they spend their VD-HCBS budget (53 respondent) – Veterans reported that the VD-HCBS is highly successful in maintaining independence while improving the quality of the Veteran’s life 24 GEC And Veteran Experience 1 The Veterans Directed Home & Community Based Services Program: Veteran Experience Analysis. Conducted by The Lewin Group

VETERANS HEALTH ADMINISTRATION GEC Progress in Systematically Capturing Veteran Experience 25 Experience with Palliative Care: The Bereaved Family Survey – Families rate aspects of care in the last month of life; communication, emotional and spiritual support, pain & PTSD management, personal care needs, Veteran benefits % of Families Rating End of Life Care as “Excellent”

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VETERANS HEALTH ADMINISTRATION Small Home Model Supports State-of-the-Art Care 27

VETERANS HEALTH ADMINISTRATION Goals to Guide The Way Forward Provide leadership and oversight for a well-integrated, system-wide continuum of evidence-based, Veteran-centric GEC programs and services to meet the needs of Veterans, families, and their caregivers. Establish infrastructure, promote innovation and the use of data, tools, and continuous quality improvement approaches to ensure personalized, proactive, Veteran-centered care. Ensure Veterans have reliable access to quality care in facility, community, and home-based settings, delivered by appropriately trained health care professionals, teams, and caregivers.

VETERANS HEALTH ADMINISTRATION Goals to Guide The Way Forward Achieve exceptional outcomes including exemplary Veteran, employee, and other stakeholder satisfaction with our programs and services. Be excellent financial stewards in delivering high-value programs and services through accountability, collaboration, engagement, and alignment of GEC resources with VACO, VISN, medical centers, clinics, and external partners.

VA Geriatrics and Extended Care Continuum – Empowering Veterans to Rise Above the Challenges of Aging, Disability, or Serious Illness 30 March 3, 2015 Richard M. Allman, MD Chief Consultant, Geriatrics and Extended Care Department of Veterans Affairs Washington, DC National Association of State Veterans Homes Winter Conference