National Association of State Veterans Homes Winter Conference
VA Geriatrics and Extended Care Continuum –
Empowering Veterans to Rise Above the Challenges of
Aging, Disability, or Serious Illness
Richard M. Allman, MD
Chief Consultant, Geriatrics and Extended Care
Department of Veterans Affairs
Washington, DC
March 3, 2015
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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
Mission:
Core Values: Integrity, Commitment, Advocacy, Respect & Excellence
Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile & Integrated
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VETERANS HEALTH ADMINISTRATION
Veterans Health Administration
(VHA) Health System
• 21 Veterans Integrated Service Networks (VISNs)
• 150 Medical Centers
• 985 Outpatient Clinics
820 Community-Based
150 Hospital-Based
9 Mobile
6 Independent
• 300 Vet Centers
• 70 Mobile Vet Centers
• 104 Domiciliary Residential
Rehabilitation Programs
Serving 8.9 million enrolled Veterans, half of
whom are age 65 years or greater
• 135 Community Living Centers
Source: FY 2014 1st Quarter Pocket Card
VETERANS HEALTH ADMINISTRATION
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Patient Satisfaction Scores
VA has topped private sector hospitals in patient
satisfaction for a full decade.
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
VHA
Inpatients
82
81
81
84
83
84
83
85
84
85
85
84
VHA
Outpatients
79
79
80
83
80
82
83
81
83
82
83
82
PrivateSector
Hospitals
68
70
73
76
71
74
77
75
77
73
76
76
* Source: American Customer Satisfaction Index
VETERANS HEALTH ADMINISTRATION
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Preparing the Nation’s Health
Professionals for Tomorrow
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.
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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
Blueprint for Excellence Themes
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
GEC Mission
GEC Programs
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VETERANS HEALTH ADMINISTRATION
Veterans Health Administration (VHA)
Organizational Chart
Under Secretary
for Health
Chief of Staff
Research Oversight
Deputy Chief of Staff
Medical Inspector
Principal Deputy Under
Secretary for Health
Readjustment Counseling
Finance
Deputy Under Secretary for Health for
Operations & Management
Patient
Centered
Care
ADUSH for
Clinical
Operations
Geriatrics and
Extended Care
Operations
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VISNs
ADUSH for
Administrative
Operations
Geriatrics and
Extended Care
Policy and Service
Deputy Under Secretary for
Health for Policy & Services
ADUSH for
Policy &
Planning
ADUSH for
Informatics
& Analytics
ADUSH for
Patient Care
Services
Public Health
Research &
Development
Interagency
Health Affairs
Nursing
ADUSH for
Quality, Safety
& Value
ADUSH for
Workforce
Services
Strategic
Integration
Health Equity
Ethics in
Healthcare
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VETERANS HEALTH ADMINISTRATION
Updated October 2013
Geriatrics and Extended Care
(GEC) Vision
Chief Consultant,
Executive Director,
Policy and Services
Operations
Richard M. Allman, MD Thomas Edes, MD
Common Vision: One GEC –
Empowering Veterans and the Nation to rise above
the challenges of aging, disability, or serious illness
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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
Continuum of Vulnerability
Independence
Dependence
End of Life
Portfolio of Geriatrics and Extended Care (GEC) Programs
Ambulatory
Care
Geriatric
Evaluation &
Management,
Geriatric
Primary Care
(Geri-PACT),
Outpatient
Palliative Care
Inpatient
Acute
Home & Community
Based LTSS1
Facility Based
LTSS1
Geriatric
Evaluation and
Palliative Care
Units, Geriatric
and Palliative
Care Consults
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
VA Community
Living Centers,
Community
Nursing Homes,
State
Veterans
Homes
Hospice
Care2
Community
Home Hospice
and VA
Inpatient
Hospice
Geriatric Research, Education, and Clinical Centers (GRECCs), Geriatrics and Extended Care
Field Programs & Data Analysis Center
Innovations in Veteran Care and Healthcare Workforce Development
VETERANS HEALTH ADMINISTRATION
1
LTSS = Long term services and supports;
2
www.WeHonorVeterans.org
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Geriatric Research, Education, and Clinical
Center (GRECC) Locations
Eastern
Colorado
GRECC
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VETERANS HEALTH ADMINISTRATION
Innovations and Improvements in Care
in Geriatrics and Extended Care
167 Innovative, Non-Institutional Long Term Care Models
Implemented FY 2010-14
•
•
•
•
•
•
•
•
•
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
*Recognized by Joint Commission as a Best Practice
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VETERANS HEALTH ADMINISTRATION
Geriatrics and Extended Care Program
Outcomes
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
VETERANS HEALTH ADMINISTRATION
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Numbers of Veterans Using
GEC Services
Total Unique Veterans
390,000
370,000
350,000
330,000
310,000
290,000
270,000
250,000
2006
2007
2008
2009
2010
2011
2012
2013
Source – GEC DAC
VETERANS HEALTH ADMINISTRATION
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Growth in GEC Programs
70
NH Average Daily Census
HCBS Average Daily Census
LTC total recipients
60
Thousands
50
40
30
20
10
0
1995
1997
1999
2001
2003
2005
2007
2009
2011
*Home and community based services
Source: H. Stephen Kaye, Center for Personal Assistance Services, University of California San Francisco. PAS Center funded by National Institute on
VETERANS HEALTH ADMINISTRATION Disability & Rehabilitation Research
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Numbers of Veterans Receiving
Home Based Primary Care
HBPC Uniques
60000
49112
50000
46246
43117
38624
40000
34362
28663
30000
21159
22587
20000
10000
0
2006
2007
2008
2009
2010
2011
2012
Source: GEC DAC
VETERANS HEALTH ADMINISTRATION
2013
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Number of Veteran Enrollees by Age
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VETERANS HEALTH ADMINISTRATION
Projected Enrollees Over 65 Years Old
P1a Doubles in Next Decade
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VETERANS HEALTH ADMINISTRATION
Percentage of P1As for Whom VA Must
Provide Nursing Home Care
VETERANS HEALTH ADMINISTRATION
GEC And Veteran Experience
• 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
1
http://youtu.be/73ypDaRgomA
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VETERANS HEALTH ADMINISTRATION
GEC And Veteran Experience
• Hospice/Palliative Care1
– “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
1
VETERANS HEALTH ADMINISTRATION
http://youtu.be/UNGiZGn2miQ22
GEC And Veteran Experience
• 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)
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VETERANS HEALTH ADMINISTRATION
GEC And Veteran Experience
• Veterans Directed Home & Community Base Services
Program: 2014 Veteran Experience Analysis1
– 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
1
The Veterans Directed Home & Community Based Services Program: Veteran Experience Analysis. Conducted by
The Lewin Group
VETERANS HEALTH ADMINISTRATION
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GEC Progress in Systematically
Capturing Veteran Experience
• 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”
70%
60%
50%
40%
30%
20%
56%
FY09
n=5,016
57%
58%
FY10
n=11,194
FY11
n=11,773
59%
FY12
n=11,019
63%
FY13
n=8,810
65%
FY15 goal
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VETERANS HEALTH ADMINISTRATION
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Small Home Model Supports
State-of-the-Art Care
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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.
VETERANS HEALTH ADMINISTRATION
National Association of State Veterans Homes Winter Conference
VA Geriatrics and Extended Care Continuum –
Empowering Veterans to Rise Above the Challenges of
Aging, Disability, or Serious Illness
Richard M. Allman, MD
Chief Consultant, Geriatrics and Extended Care
Department of Veterans Affairs
Washington, DC
March 3, 2015
30