1. Home and Community Based Services
Anisa Grabocka, LCSW
Marykate Monroe, LMSW, CCM
113 Holland Ave
Albany, NY 12208

2. Veterans Health Administration Veterans Benefits Administration
WHO WE ARE
Veterans Health Administration
Veterans Benefits Administration
National Cemetery

3. BENEFITS AND ELIGIBILITY
Benefits Fact Sheets
Apply For VA Health Benefits
Health Benefits Co Pays
Community Emergency Medical Care

4. Veteran Service Officers
County Veterans' Service Officers provide an unsurpassed personalized service to Veterans and their dependents. There is no comparable advocacy service for that special group of New York citizens. All services are provided without charge. Strictly controlled confidentiality is maintained under penalty of law.
Service Officers are required to be knowledgeable in federal, state and local laws pertaining to Veterans. Assistance in the following areas is provided to thousands of Veterans, military personnel, and their dependents year after year:
· VA compensation for service-connected disabilities
· VA pension for non-service-connected disabilities
· VA compensation/pension to family members of deceased veterans
· VA burial benefits and grave markers
· VA life insurance
· VA health care
· VA education and vocational rehabilitation
· VA home loan guaranties
· VA, State & Local employment and reemployment
· Military records
· Federal, State & Local medals or awards
· Local real property tax exemption
· NYS blind annuity
· Other Federal, State and Local benefits

6. Stratton VA Medical Center and CBOCs
Stratton VAMC in Albany
Community Based Outpatient Clinics (CBOCs)
Bainbridge
Catskill
Clifton Park
Saranac Lake
Fonda
Glens Falls
Kingston
Plattsburgh
Schenectady
Troy

7. Patient Aligned Care Team (PACT) Model6

8. Comprehensive Medical Care
Preventive Care
Immunizations, Annual exams, Vision and Hearing exams, Screening tests, Health Education Programs, etc.)
Inpatient & Outpatient Diagnostic & Treatment Services
Prescriptions
Prosthetics and Rehabilitative Devices
Dental (limited)

9. Comprehensive Mental Health Care
Walk In Clinic (Rapid Access Clinic)
Outpatient
(Individual/Group, VJO, PTSD, Family Therapy, CWT)
Inpatient Mental Health Unit
Behavioral Health Recovery Center
Substance Abuse Rehab
Healthcare for Homeless Veterans
Vocational

10. Homemaker/Home Health Aid Program Home-Based Primary Care
Geriatric Services
Homemaker/Home Health Aid Program
Home-Based Primary Care
Geriatric Primary Care
Dementia Care Coordinator
Palliative Care
Inpatient Hospice
Adult Day Program
Caregiver Support

11. Telehealth, Telemedicine, Telepsychiatry Virtual Reality
New Era of Services
My Healthy Vet
Secure Messaging
Telehealth, Telemedicine, Telepsychiatry
Virtual Reality
Social Networking
Family Services
Computerized Patient Record System
Caregiver Line ( )
Crisis Line ( and Press 1)

12. Medical Social Work
Support team members with challenging patient-care situations
Eliminate barriers to health care interventions
Build upon and promote strengths and abilities
Educate and motivate Veteran toward health promotion, disease prevention and management of self
Offer strategies to resolve underlying causal factors
Follow Veteran through continuum of health care
Eliminate barriers to care
Reach out to high risk cohorts
Assess underlying causal factors leading to presenting concern
Using short-term and long-term interventions in treatment plans
Monitor high risk discharges to avoid readmission

13. You have a Veteran admitted…. what’s next?
Discharge Planning begins upon Admission
Review services available through the VA
Assess for DME (type, measurements, etc.), medications, services, etc.
Determine follow-up recommendations
Contact with Social Work for a warm hand-off
POC Tricia Kidder, LCSW: Phone#
Contact Utilization Review
POC Vicki Hammersley RN: Phone#
Alert Veteran’s Primary Care Team
UR and Social Work can help make this connection!

14. Behavioral Health Social Work
What we do: comprehensive mental health care (inpatient, outpatient, residential) for eligible Veterans enrolled in VA Healthcare System.
Services provided: Psychotherapy, case management, outreach, housing, employment, addiction/rehab, individual therapy, group therapy, family/couples therapy, diagnostic clarification, linkage to care, collaboration with medical providers and community providers, suicide prevention.
Who do we serve: Veterans diagnosed with different mental health disorders, including: SMI, Mood disorders, addictions, PTSD, MST.
Monitoring high risk patients (for suicide) and provide enhanced care planning for identified Veterans, managing crisis line calls and referrals.
11/11/2018

15. Behavioral Health Social Work, Continued
Referrals: Can come from primary care, community providers, self, Veteran service officers, other VA programs.
Use of evidenced based practices to provide gold standard and efficient care to Veterans.
Week Day walk in services available for acute care needs: assessment for inpatient hospitalization, crisis intervention.
Provide consultation and collaboration with medical social work, geriatric programs to ensure Veterans needs are met with least amount of disruption, reduce gaps in care.
11/11/2018

16. Background OTHER THAN HONORABLE EMERGENT MENTAL HEALTH INITIATIVE
Problem Statement:
Evidence suggests that the rate of death by suicide among Veterans who do not use VA care has increased relative to that among Veterans who do use VA care. There are a little more than 500,000 former Service members with other than honorable (OTH) administrative discharges that the system may not be capturing.
Solution:
The VA will provide emergent mental health care to former Service members with OTH administrative discharges who believe their mental health condition is related to their military service.
Materials to be sent to the field as resources

17. Assumptions OTHER THAN HONORABLE EMERGENT MENTAL HEALTH INITIATIVE
If not already determined by VBA to be ineligible for medical care, an OTH former Service member, seeking mental health care in emergency circumstances for a condition the former Service member asserts is related to military service qualifies for tentative eligibility under 38 C.F.R
A 90-day episode of care will allow VA Mental Health providers time to stabilize the mental health emergency.
Facilities will be able to use existing processes for patients seen using tentative eligibility to register these individuals in the system.
Facilities will be able to use existing capacity and resources to provide this initiative.
Materials to be sent to the field as resources

18. OTHER THAN HONORABLE EMERGENT MENTAL HEALTH INITIATIVE
Accessing the System
Patients may access the system for this initiative by visiting the VA Emergency Room/Urgent Care Center, or Vet Center or calling the Veteran Crisis Line.
Services CANNOT be paid for if the former Service member presents to a VA Community Based Outpatient Center (CBOC) or if the former Service member is referred to a community Emergency Department.

19. Homemaker/Home Health Aide Program
Clinical eligibility
Focus of program is to assist Veterans with management of Activities of Daily Living (ADLs).
ADLs include: bathing, toileting, grooming, dressing, eating, transferring, and ambulation.
IADLs – Instrumental Activities of Daily Living – medication management, financial management, grocery shopping, meal preparation, using a telephone and housework
Need for the program is evaluated on an ongoing basis and it is recommended that Veteran maintains an annual Primary Care visit with VA provider.
VA contracts/has agreements with Licensed Home Care Agencies in the community in order to offer the H/HHA services to Veterans.
Interagency Collaboration Program Executive Office “Enabling Seamless Access across the Federal Enterprise”
11/11/2018

20. Veteran Directed Home and Community Based Services
VDHCBS is a package of services that the VA purchases from Area Agencies on Aging on behalf of eligible Veterans. Currently active in Otsego County.
It is a self-directed program to support aging in place and to enable the Veteran avoid institutionalization.
Veterans enrolled in VDHCBS manage their own flexible budgets and decide for themselves what mix of goods and services best meet their needs, as well as hire and supervise their own workers.
The Aging Network provides facilitated assessment and care/service planning, arranges fiscal management services, and provides ongoing options counseling and support to Veterans.
You may also find additional information by following the link below.
Interagency Collaboration Program Executive Office “Enabling Seamless Access across the Federal Enterprise”
11/11/2018

21. Home Based Primary Care
Provides primary care services to Veterans in their home environment
Designed to meet the needs of Veterans who have difficulty leaving their home because of illness to access primary care services either at the Albany VA or one of the Community Based Outpatient Clinics
Team of health care professionals (Medical provider, Nursing, Social Work, Psychology, Dietician, and Physical Therapist)
Interagency Collaboration Program Executive Office “Enabling Seamless Access across the Federal Enterprise”
11/11/2018

22. Outpatient Daytime Program (7:30am-4:30pm, M-F)
ADULT DAY HEALTH CARE
Outpatient Daytime Program
(7:30am-4:30pm, M-F)
Goal is to maintain or improve the health of patients by focusing on both their social and health needs
Enables caregivers to continue caring for their loved one at home
Care is provided in a safe, structured setting
Veterans may attend program daily or a few times a week depending on their needs
Contract Adult Day Program in order to serve veterans who are not able to attend program at the Albany VAMC
Interagency Collaboration Program Executive Office “Enabling Seamless Access across the Federal Enterprise”
11/11/2018

23. VA Funded Institutional Care: Community Living Center (CLC) and Contract Nursing Home
VA provides nursing home care to any Veteran in need of such care and who meets the following criteria:
Indication for NH care is directly related to a Service Connected (SC) disability (determined by VA physician) or
Rated 60% SC and Unemployable or
Combined SC disability at 70% or higher
AND
Clinical Eligibility:
PRI – assessment tool to determine level of care. It looks at Veteran’s overall functioning and level of care needed to meet the needs.
VA institutional hospice care for end-of-life is available to all Veterans (no matter the service connection) who meet clinical eligibility criteria for hospice and require nursing home level of care.
Interagency Collaboration Program Executive Office “Enabling Seamless Access across the Federal Enterprise”
11/11/2018

24. VA Funded Institutional Care: Community Living Center (CLC) and Contract Nursing Home
VA contracts with community nursing homes in order to provide care in the Veteran’s community if so desired.
Currently we have 14 contracts with community facilities
Monthly oversight around care provided to the Veterans
Review of facilities’ State Surveys and ratings
CNH Office can be reached at
Community Living Center or CLC is the Albany Stratton VA Medical Center’s nursing home:
Unit located on the 9th floor of the medical center
Currently long term care only
Interagency Collaboration Program Executive Office “Enabling Seamless Access across the Federal Enterprise”
11/11/2018

25. Caregiver Support Program
Comprehensive Assistance for Family Caregivers
Stipend paid to Caregivers of Veterans who served post 9/11 and incurred/aggravated an injury that renders them in need of caregiving
General Caregivers
Caregivers of Veterans of all eras
Support and educational groups available at the Medical Center and nationally
Interagency Collaboration Program Executive Office “Enabling Seamless Access across the Federal Enterprise”
11/11/2018

26. Remember the VA is here to help! Communicate early and often!
Summary
Remember the VA is here to help!
Communicate early and often!
Thank you for serving those who served!

27. Questions? Comments? Feedback?