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VA 101 Hospice and Palliative Care in VA

VA 101 Hospice and Palliative Care in VA. Content. Evolution of the VA Hospice and Palliative Care (HPC) Program VA Hospice and Palliative Care Policies and Guidance VA Hospice and Palliative Care Program VA Hospice Benefit Working Together to Serve Our Veterans.

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VA 101 Hospice and Palliative Care in VA

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  1. VA 101Hospice and Palliative Care in VA

  2. Content • Evolution of the VA Hospice and Palliative Care (HPC) Program • VA Hospice and Palliative Care Policies and Guidance • VA Hospice and Palliative Care Program • VA Hospice Benefit • Working Together to Serve Our Veterans

  3. VA Hospice and Palliative Care Program’s Mission To Honor Veterans’ Preferences for Care at the End of Life

  4. The Evolution of HPC in VA • 1997: Palliative Care Summit convened by Secretary Ken Kizer • 1998: VA Faculty Leaders Project • 2000: TAPC Program • Survey of VA facilities • Interprofessional Palliative Care Fellowship • TAPC Toolkit (www.va.gov/oaa/flp)

  5. The Evolution of HPC in VA • 2001 - 2003: VA HPC Initiative • AACT Program • VISN-wide teams supporting the ongoing development of hospice and palliative care programs and clinical training in all VA facilities • Hospice-Veteran Partnership • Stakeholder groups inside and outside VA working together to help ensure quality hospice and palliative care is available for veterans across all settings and levels of care • 2004: National HPC Program formalized • Scott Shreve, DO, appointed National Director • Christine Cody, RNC, MSN, appointed National Manager

  6. VA HPC Priorities • Access (in and outside of VA) • Collaborate with acute and other services • Expand non-acute alternatives (HPC units) • Strengthen relationships with State Veterans Homes • Expand Hospice-Veteran Partnerships • Quality • Bereaved Family Member satisfaction • Other measures • Expertise • AACT (Accelerated Administrative and Clinical Training) • National AACT – HVP Audioconferences

  7. HPC Directives • Directives establish mandatory VHA policies • 2 Hospice and Palliative Care Directives • September 2002: Workload Capture for Hospice & Palliative Care • February 2003: Palliative Care Consult Teams

  8. HPC Handbooks • Handbooks prescribe mandatory VHA procedures and/ or operational requirements • 3 Hospice and Palliative Care Handbooks • August 2004: Home Health and Hospice Care Reimbursement Handbook • March 2005: Community Hospice Care: Referral and Purchase Procedures • July 2006: Purchased Home Health Care Services Procedures

  9. Ms T is a 58 year old Vietnam veteran with a diagnosis of end stage liver disease and a history of sexual trauma, alcohol abuse and depression. She has been treated in the past at the local Vet Center for Posttraumatic Stress Disorder and is now admitted to the VA Medical Center for management of pain, dyspnea and ascites related to the end stage liver disease. Her son, from whom she is estranged, lives in a distant state. She has had minimal contact with her sister, who lives in the local area. Ms T

  10. Ms T • Receives Palliative Care Consult on acute medical unit • Discharged on home hospice through a community hospice agency • Admitted to Palliative Care Unit in VA Nursing Home

  11. VA Hospice and Palliative Care (HPC) Program • Veterans’ Health Care Eligibility Reform Act of 1996 • "VA must offer to provide or purchase hospice and palliative care services that VA determines an enrolled veteran needs."  38 CFR 17.36 and 17.38 • Hospice and palliative care are equal to other VA Services in Medical Benefits Package • Purchased or provided whether needed in an inpatient setting or in the home

  12. VA Hospice Eligibility Criteria • Diagnosed with a life-limiting illness • Has treatment goals focused on comfort rather than cure • Has a life expectancy, deemed by a VA physician, to be 6 months or less if the disease runs its normal course • Accepts hospice care

  13. VA Provided HPC • Palliative Care Consult Teams • Inpatient settings throughout VA facility • Outpatient Clinics • Inpatient Hospice Care • VA provided in inpatient settings • VA purchased through Community Nursing Home • Home Based primary care (HBPC) • VA provided palliative care

  14. Palliative Care Consult Teams • Palliative Care Consult Teams (PCCT) • Composition • Physician, Nurse, Social Worker, Chaplain, Administrator • Role • Advance Care Planning, Symptom Management, Counseling, Education, Bereavement • PCCTs collaborate with Community Health Nurse Coordinators for referrals to community hospices

  15. In-patient Hospice Care • VA-Provided Inpatient Care • Preferred option for many veterans • Provided directly in VA Nursing Home Care Unit (NHCU) or in an acute care setting • VA-Paid Nursing Home Care • Purchased from contract facility • Hospice services may be purchased separately from community hospice • Certain conditions apply

  16. In-patient Hospice Care • VA-Paid Inpatient Care • Admission to VA facility preferred • VA authorization required for inpatient care at a non-VA facility • Medicare-Paid / VA-Enrolled Inpatient • Veterans can access in-patient care in a VA facility • VA supports this practice; however hospices may be required to discharge patient from Medicare Hospice Benefit during the VA inpatient stay • Inpatient care in non-VA facility • VA authorization is NOT required for inpatient care at a non-VA facility

  17. Home-Based Primary Care • Major features • Provide home visits from members of VA health care team • Limited service area (30-100 mile radius) • Home visits during week • No homebound requirement • Interface with hospice • HBPC and hospice may be provided concurrently • Requires close coordination between VA and hospice

  18. Palliative Care Referrals to Community Providers • VA may refer veteran to a community agency that offers palliative care • Medicare hospice agencies • Medicare home health agencies • Payer source can be VA-paid, Medicare, Medicaid or other 3rd party • VA physician may be the attending • Veteran can receive both VA and community services concurrently

  19. Hospice Referrals to Community Providers • Enrolled veterans may be eligible for hospice care in the community • Different options to pay for care • VA-Paid Hospice Care • Medicare • Medicaid • Private Insurance

  20. VA Paid Hospice Care • May be purchased from community hospice provider if: • VA Physician and patient/family agree care is appropriate • VA and Hospice have a written agreement (effective June 2008) • Reimbursement • Bundled services mirror the Medicare Hospice Benefit • Per Diem payment – VA uses locally calculated Medicare Hospice Benefit rates • Statement of Work includes 4 levels of hospice care

  21. VA Paid Hospice Care Average Daily Census FY03 - FY06

  22. VA Paid Hospice Care • Options for Purchasing Services • Basic Ordering Agreement • Bid Contract • Statement of Work • Pricing • Hospice Responsibilities • VAMC Procedures • Quality Improvement

  23. VA Paid Hospice Care Quality Oversight and Monitoring • VA • Follow-up supervision visits and progress report review on VA patients • On- site inspections of Hospice’s operating facilities • Contracting Officer’s Technical Representative (COTAR) progress report • Hospice • Evidence of quality assurance and performance improvement activities • Record of VA patient complaints, problem resolution and all Quality Improvement activities

  24. VA Paid Hospice Care • Referral Process • PCCT assesses for hospice referral • Community Health Nurse Coordinator makes referral and arranges for hospice • Attending Physician • VA physician certifies patient • Encouraged to act as attending physician

  25. VA Paid Hospice Care • Care Plan • Treatment issues identified and coordinated • Hospice controls care plan • Communication/Coordination • Both hospice and VA identify primary liaisons • VA requires ongoing communication to ensure services fit the patient’s needs

  26. Working Together to Serve Our Veterans • Meeting the unique needs of veterans • Military history • VA benefits and resources • Communication • Changes in patient condition • Changes in level of care • Patient discharge/death

  27. Working Together to Serve Our Veterans • Hospice-Veteran Partnerships • Coalitions of people and organizations working together to meet veterans’ end-of-life needs • State-wide and local partnerships • Improve veterans’ access to quality hospice and palliative care • Enhance communication among providers of care and services to veterans

  28. Coordination Challenges • Who’s directing the care? • Transitions between homehospice and inpatient care • Transportation responsibilities • VA physicians as attendingphysician • Medications and equipment

  29. Understanding Differences

  30. Resources

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