1. 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

2. 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.

3. 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

4. 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 EZ, Application for Medical Benefits (or VA Form EZR, Health Benefits Renewal Form (if a VA Form 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

5. Automated 10-10SH Admissions Application Process
Using this:

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

7. This link opens Automated 10-10SH Form

8. 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

9. 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

10. 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.

11. 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

12. 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

13. 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.

14. 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.

15. 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.

16. 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.

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

18. 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.

19. 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.

20. 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

21. 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

22. 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.

23. 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:

24. 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

25. Questions regarding the SHPD Web Application may be directed to the group.

26. Thank You
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