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Geriatrics and Extended Care

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Innovative Approaches to Home Based Care

During FY10, VHA launched a range of far-reaching initiatives to implement innovations in services that enhance VHA’s capabilities to provide patient centered alternatives to long term institutional care.

During the next four years, Geriatrics and Extended Care supported the creation of over 150 innovative pilots of patient centered non-institutional extended care in all 21 VISNs.  The shared purpose of all these projects was to enhance options for Veterans choosing to receive their extended care in the home and community rather than in an institution.  The expectation is that these approaches to care will be sustained at the pilot sites, and successful models disseminated more broadly throughout VHA in response to local needs and capabilities.

The funded pilots were developed along multiple models of care that had been reported and validated in the professional literature, including:

  • Care Management/Transitional Care focusing on lowering readmission rate by providing support, follow up, and caregiver assistance during and after discharge from hospital or nursing home.
  • Dementia Case Management for Veterans, families, and caregivers with emphasis on education and support
  • Geriatric Primary Care/ Specialty Care Outpatient Clinics, several with special emphasis on Veterans’ mental health needs
  • Hospice and Palliative Care in the home using home telehealth support
  • Mobile Adult Day Health Care to bring the service to multiple low-density communities.
  • Hospital at Home and Acute Care for the Elderly for reducing need for hospitalization and to reduce post-hospitalization dependency
  • Innovative models of Home Based Primary Care in both rural and urban settings
  • Program for All-inclusive Care for the Elderly (PACE) in both urban and rural settings -VHA partners with PACE centers in the community targeting Veterans that are at high risk for nursing home admission

Anticipated outcomes include increased patient choice and satisfaction, decreased admissions and utilization of institutional services, improved functional status, and enhanced caregiver education and support.  A video presentation describing some of these innovative models of care can be viewed at http://www.va.gov/geriatrics/videos/VA_video_new_VA_home_based_care_options.asp.