VA Program Transform Veteran’s Life:

A Collaborative Effort

By Christopher Beshears, LMSW

Richard Mealer, a 70-year-old Vietnam Era Veteran, spent over two and a half years in a VA Community Nursing Home. Mobility challenges caused by partial paralysis and the lack of a safe, supportive living environment left him requiring around-the-clock care. Although he wanted to leave the nursing home, he doubted his ability to manage life in a less structured setting and feared he might fail on his own. That changed through the combined efforts of the Nursing Home to Home (NHTH) program, the Community Residential Care (CRC) program, the Spinal Cord Injury (SCI) Clinic, and other essential VA services.

Recognizing the growing need to help Veterans transition out of nursing home care, the VA Central Office (VACO) launched a national initiative to promote more independent living solutions for Veterans. As part of this effort, the Eastern Oklahoma VA Health Care System (EOVAHCS) was honored to be selected as one of three pilot sites for the Nursing Home to Home (NHTH) program. By coordinating every aspect of care and addressing complex barriers, NHTH empowers Veterans to successfully transition into private homes or community-based settings. This innovative program provides Veterans with personalized plans, resources, and support to help them achieve greater independence, improving life satisfaction for Veterans and saving the facility significant critical funds. For Mr. Mealer, NHTH became the foundation of his care and the driving force behind his transformation.

NHTH Tackles Barriers and Coordinates Care

NHTH began working with Mr. Mealer a year ago, focusing on building trust and developing a plan tailored to his specific needs. The team addressed significant challenges, including his fear of motor vehicle transportation and frequent changes in his living arrangements, which disrupted his access to consistent care. One of the most impactful barriers they resolved was his long-delayed access to dental care. Years of transportation challenges and frequent relocations had prevented him from obtaining dentures, but with NHTH’s coordination, he finally completed the process. This improvement not only enhanced his health and nutrition but also laid the foundation for his transition to a more independent and fulfilling life.

SCI Clinic’s Role in Restoring Mobility

As part of NHTH’s coordinated care plan, the Spinal Cord Injury (SCI) Clinic played a vital role in addressing Mr. Mealer’s physical challenges. The clinic introduced adaptive equipment to make daily tasks safer and more manageable, arranged physical therapy to rebuild his strength and mobility, and assessed him for in-home services and equipment. These efforts restored his confidence and equipped him with the tools he needed to succeed in a more independent setting.

CRC and Residential Care Facilities: The Final Step

After months of preparation by NHTH and the SCI Clinic, the Community Residential Care (CRC) program joined the effort to secure the ideal living arrangement for Mr. Mealer. CRC connects Veterans with VA-approved, independently owned community Residential Care Facilities (RCFs) and Assisted Living Facilities (ALFs), which provide support in group-living environments while helping Veterans maintain their independence. Each facility provides essential services such as meal preparation, housekeeping, and medication administration, while fostering social connections and a sense of community. 

The facility recommended by CRC offered Mr. Mealer a lower level of care that promotes independence and fosters personal growth. This supportive yet empowering environment allowed him to reclaim his autonomy and rebuild his life with dignity.

Life After the Transition

During a recent NHTH 90-day post-nursing home discharge appointment, Mr. Mealer reflected on the transformation he has experienced since leaving the nursing home. He described significant improvements in both his mental and physical well-being, crediting the combined efforts of the NHTH and CRC programs for making a positive impact on his life. “These programs have made my life better,” he shared. “I’m so much happier and gaining confidence. I went from taking baby steps to making big ones.”

A recent milestone is that Mr. Mealer is now able to walk the length of the building, a significant achievement considering his previous mobility challenges. He also shared how these programs have restored his sense of dignity, emphasizing the joy of being able to select and purchase his preferred shower gel, cologne, and clothing—items he had little control over in the nursing home. Beyond these freedoms, Mr. Mealer expressed gratitude for the contributions of other VA services, including the SCI Clinic, HBPC, and PCS, which provided critical support throughout his transition. He highlighted his progress in physical therapy, including his ability to increase the weights in his strengthening routine, and shared how these accomplishments have given him a renewed sense of control over his life.

Seth Kindred, NHTH RN, echoed these sentiments, saying, “Mr. Mealer often talked about how he felt hopeless while living in the nursing home. Now, he’s so thankful for our programs for believing in him, giving him hope, and helping him regain his independence. He seems to be rediscovering his individuality and learning it’s okay to be himself again.”

A Holistic Approach to Independence

In addition to the efforts of NHTH, CRC, and the SCI Clinic, Mr. Mealer benefited from ongoing support provided by Home-Based Primary Care (HBPC) and Personal Care Services (PCS). HBPC ensured he had access to medical care tailored to his needs, while PCS helped with daily living tasks, allowing him to thrive in his new environment. Together, these services complemented the foundational work of NHTH and CRC, demonstrating the value of a comprehensive approach to Veteran care.

A Model for Success

The collaborative efforts of NHTH, CRC, and other VA programs demonstrate how innovative initiatives can transform lives by addressing Veterans’ unique needs. As one of three national pilot programs, NHTH is setting a new standard for transitioning Veterans from nursing home care to community living. The success of this initiative highlights the importance of teamwork, personalized care, and empowerment in restoring dignity and independence to Veterans like Mr. Mealer. Moving forward, programs like NHTH and CRC offer a blueprint for expanding these life-changing services to Veterans across the country, ensuring more individuals can experience the profound impact of compassionate and coordinated care.