Determining whether Veterans are eligible for SVH based on need

Report
STATE VETERANS HOME
FEBRUARY 25, 2014
GENERAL COMMENTS
Public Law 104-262,Section 104(a) of the “Veterans’ Health Care
Eligibility Reform Act of 1996,” established a system of annual
patient enrollment, in order of priority, for the provision of
Department of Veterans Affairs (VA) hospital care or medical
services (see Title 38 United States Code (U.S.C.) 1705. Under
this system, VA must enroll in Priority Group 4, Veterans who are
catastrophically disabled (see 38 U.S.C. §1705(4)).
VETERANS HEALTH ADMINISTRATION
PRIORITY GROUP FOUR INCLUDES:
• Veterans who are receiving aid and attendance or housebound
benefits
• Veterans who have been determined by VA to be catastrophically
disabled
VETERANS HEALTH ADMINISTRATION
VHA Directive 2010-054
•
As per VHA Directive 2010-054 “Catastrophically disabled Veteran evaluation,
enrollment, and certain copayment-exemptions,” (Par. 2 b): “Veterans with
catastrophic disabilities must still pay applicable copayments for the receipt of
nursing home care.”
•
Catastrophically disabled Veterans do not automatically qualify for State Veterans
Home care.
•
How does VA define and identify which Veterans are catastrophically disabled
Veterans?
VETERANS HEALTH ADMINISTRATION
DEFINITION OF CATASTROPHICALLY DISABLED
VETERAN
•
As per Attachment A of VHA Directive 2010-054:
•
“Catastrophic disability (CD) is a permanent severely-disabling injury, disorder, or
disease that compromises the ability to carry out the activities of daily living (ADL)
to such a degree that the individual requires:
•
•
a. Personal or mechanical assistance to leave home or bed, or
b. Constant supervision to avoid physical harm to self or others. “
VETERANS HEALTH ADMINISTRATION
HOW VA IDENTIFIES CATASTROPHICALLY DISABLED
VETERANS
•
As per Attachment A of VHA Directive 2010-054
•
Determination of whether a Veteran is considered catastrophically disabled is
made through a review of a Veteran’s previous and current medical records that
documents to assess that the patient meets, will continue to meet , or would
continue to meet such criteria (permanently) without the continuation of on-going
treatment.
VETERANS HEALTH ADMINISTRATION
Examples of Medical Criteria Establishing Veteran as
Catastrophically Disabled
•
Examples of evaluation criteria include, but are not limited to one of the following
permanent conditions:
•
Dependent in three or more ADLs; (i.e., eating, dressing, bathing, toileting,
transferring, incontinence of bowel or bladder) with at least three of the
dependencies being permanent with a of bowel or bladder) with at least three of
the dependencies being permanent with a score of 1, using the Katz scale.
A score of 10 or lower using the Folstein Mini-Mental State Examination (MMSE).
A score of 2 or lower on at least four of the thirteen motor items using the
Functional Independence Measure (FIM).
A score of 30 or lower using the Global Assessment of Functioning (GAF).”
•
•
•
VETERANS HEALTH ADMINISTRATION
Determining whether Veterans are eligible for SVH based on
need for nursing home care (NHC) for their SC disability
Catastrophically disabled Veterans must meet eligibility criteria for
admission to SVHs as per 38 CFR 51.41 – “Contracts and provider
agreements for certain veterans with service-connected disabilities,”“(a)Contract or VA provider agreement required. VA and State homes
may enter into both contracts and provider agreements. VA will pay for
each eligible veteran's care through either a contract or a provider
agreement (called a “VA provider agreement”). Eligible veterans are those
who:
(1) Are in need of nursing home care for a VA adjudicated serviceconnected disability, or
(2) Have a singular or combined rating of 70 percent or more based on
one or more service-connected disabilities or a rating of total disability
based on individual unemployability and are in need of nursing home
care.”HEALTH ADMINISTRATION
VETERANS
Determining whether Veterans are eligible for SVH based on
need for nursing home care (NHC) for their SC disability
The physician at the VA Medical Center reviews the 10-10SH form that
has been provided to them by the local State Veterans Home. This form
has the Veteran’s medical information on it from the SVH that will be
used by the VA physician to validate nursing home level of care for the
Veteran.
VETERANS HEALTH ADMINISTRATION
Determining whether Veterans are eligible for SVH based on
need for nursing home care (NHC) for their SC disability
(continued)
•
•
•
The VA physician responsible for CAPRI reviews for the VA Medical Center goes
into the Veterans Benefit Administration (VBA) computer software system “CAPRI”
to determine if the Veteran has VA adjudicated service-connected conditions and
provides this information to the VAMC physician evaluating the Veteran for the
SVH.
This physician reviews the CAPRI information, along with the 10-10SH form and
then validates or invalidates that Veteran is eligible for nursing home level of care,
based on his/her reported medical condition and eligibility status.
When there are questions concerning the information provided by the SVH on the
Veteran’s 10-10SH form, the VAMC physician and the SVH physician should
communicate directly to ensure the most accurate decision is made regarding
nursing home eligibility of Veteran. This communication is vital to best serve the
Veterans.
VETERANS HEALTH ADMINISTRATION
SVH Policy Oversight Program
GEC – Policy contacts for the SVH:
Deborah Stevens
State Veterans Home Program Analyst
202-461-6751
[email protected]
Nancy Quest
Director, Home & Community Based Services
202-461-6064
[email protected]
VETERANS HEALTH ADMINISTRATION
SVH Clinical Oversight Program
QUESTIONS /
COMMENTS
THANK YOU!
VETERANS HEALTH ADMINISTRATION

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