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Orlando VA Community Nursing Home Referral Process & Contacts


Veterans may be eligible for the VA to authorize their care in a Community Nursing Home.  Veteran eligibility is explained in VHA Notice 2020-32 (Refer to the document at the bottom).  Community providers are encouraged to verify eligibility before submitting a referral. 

To determine eligibility, please contact:

  • If discharging from a hospital, please contact the Orlando VA Discharge Planning Coordinator at  407-785-4563 or 321-230-4137.
  • If the Veteran is not currently hospitalized, please contact your Orlando VA PACT Social Worker to verify eligibility. 

Referrals from a Community Hospital

After eligibility is confirmed, the following hyperlink outlines a referral checklist for hospital case managers to follow and provides contact information for follow-up (see Referral Checklist – Hospital at the bottom).

Referrals from outside a Community Hospital

For Veterans being referred for VA-authorized Community Nursing Home placement from a non-VA Skilled Nursing Facility, from a Hospice Inpatient Unit, or from home, please contact your Primary Care Social Worker for eligibility.  This hyperlink provides a referral checklist to follow (see Referral Checklist – Non-Hospital at the bottom).  Records should be submitted to the PACT Social Worker to coordinate the referral.

Community Nursing Home List

  • For Veterans being referred to a Community Nursing Home for short-term rehab, please use the document titled “CCN Optum SNF STR List” for a list of facilities in the Optum/Community Care Network that can accept your referrals with VA approval.
  • For Veterans being referred for Community Nursing Home placement for skilled care without rehab, for long-term care, for respite or for hospice care, please use the document titled “OVAHCS CNH List” for a list of facilities that can accept your referrals with VA payer.
Community Care 

Optum Customer Service 888-901-6613

to join network or check status of recruiting.


Tyra Janke LCSW

Discharge Planning Coordinator

VA Orlando health care

Phone: 407-785-4563

Cherish Krisciunas LCSW

Discharge Planning Coordinator

VA Orlando health care

Phone: 321-230-4137

Megan Barton LCSW

Community Nursing Home Program Coordinator

VA Orlando health care

Phone: (407) 719-2658

Jo Ann Giunta BSN, RN

CCN SNF Program Coordinator, VA Orlando Health Care

VA Orlando health care

Phone: (407) 664-7637

Orlando VA Community Health Nursing: Home Care Discharge Resources & Contacts

Eligibility For Home Care

  • All veterans are eligible for homecare services regardless of service connection disability. Veterans Must be enrolled at time of request.
  • If Veteran is NOT enrolled, please ensure that he/she presents to the VA clinic Interim care clinic to establish care
  • For further enrollment question, please contact the enrollment office at 321-637-3788

Referral for Homecare Services

For homecare referrals to include need for oxygen, DME, Tube feeding, Life vest, IV, Trach, VAC, auth request, and electronic prescription, please access the Homecare Resource forms and complete the necessary referral forms.

Homecare Resource Forms:  

Enteral Feeding Discharge

Dialysis community Care authorizations

1st Step 

Call – 407-484-5381 Please leave a message with the Case manager, contact number, and Veteran’s name and last four of social & Community dialysis unit accepting Veteran if known.


2nd Step 

Please fax separately to the dialysis coordination Fax number 407-643-9238:

*  H&P

*  Nephrology Consult

* Nephrology Notes

* Clear succinct statement of diagnosis AKI or ESRD

* First date of dialysis after ESRD diagnosis (must be clearly documented as the 1st date of dialysis after ESRD diagnosis.  This date is not needed if AKI).


VA Dialysis Contacts

Barbara Earhart LCSW 

Jenkins Taylor LCSW, NSW-C Dialysis coordinator

Email: VHAORL Dialysis Referral


** Please note that 2-3 days are needed for processing Dialysis Authorizations