Approximately 5,000 hospice programs operate in the United States. Large and small, non-profit and for-profit, independent and hospital-based, they serve 1.56 million (NHPCO Facts and Figures: Hospice Care in America) terminally ill patients a year, most in private homes or in skilled nursing facilities. Hospices assist family caregivers, and eventually provide bereavement support to family survivors.
VA hospice units have learned a critical lesson in caring for dying Veterans: a patient’s military service history is highly relevant to providing the most appropriate, personalized end-of-life care. Although hospices routinely ask and record their patients’ age, family make-up, racial/ethnic group and religion at the time of enrollment, too few ask about service status.
Now, more than ever, they should ask!
If the Veteran is enrolled at a local VA Medical Center (VAMC) or would like to be, along with burial and other benefits questions, there are likely to be health coverage and related benefit issues. In addition to exploring coverage status, to properly understand a Veteran’s potential needs, hospices must incorporate the following, or similar, questions from the Military History Checklist into their admission process:
- Are you a Veteran?
- Did you see combat?
- What was that like for you?
- Is there anything about your military experience that is still troubling to you?
The National Hospice and Palliative Care Organization (NHPCO) has long advocated that Veterans should receive hospice care and that community hospices should be reimbursed by VA for the care they provide to eligible Veterans.
It’s not just about getting paid, but at the same time, that issue has been a sticking point for hospices. Now, by law, VA is mandated to provide hospice services or purchase them from community hospices, and hospices need to understand that partnering is a two-way street.
Hospices must remember that, often, VA staff have been caring for a Veteran for some time. To let go of caring for that person because he/she has been referred to a local hospice can be difficult for the staff, despite their dedication and commitment to honoring the Veteran’s preferences for care
Often hospices report difficulty in finding the right contact person within the local VA. Although authorization for VA to pay for hospice care has existed for several years, individual programs may still encounter problems. It is imperative that these organizations continue their efforts to work with VAMCs, using national guidelines, to work out kinks in the process at the local level.
Most important, hospices should not approach VA as an insurance plan for covering hospice care in the community: VA is primarily a provider of care, and, sometimes, a payor for care. Hospices and VA staff must learn the subtleties of the relationship and recognize differences in language, and regulations, between VA and Medicare.
Hospices and VA must establish relationships and identify liaisons on both “sides” before individual care decisions are required. As all VAMCs now have a designated Hospice and Palliative Care coordinator, hospices may contact that person and arrange to meet with them.
There are other nitty-gritty issues involved in the relationship, but these can generally be solved through a mutual commitment to conversation and understanding. Policy issues related to VAMCs working with community hospices are described in VA’s Directive: Community Hospice Care, Referral and Purchase Procedures. Search for additional VA Publications and Directives (Policies)
VA Care Facilities and Teams Veterans Integrated Service Networks (VISNs)
VISNs are VA integrated networks of care that are focused on pooling and aligning resources to better meet Veterans’ health care needs. The VA medical system consists of 21 VISNs. Although VISNs are organized geographically, some VISNs cover more than one state, and some states are covered by more than one VISN. To find the VISN(s) that cover your area, visit the VA Website (www.va.gov). Click on Find a Facility, located on the toolbar at the top of the page. Once you are in that section, click on the specific state to produce a list of all VA Medical Centers, Outpatient Clinics, and Vet Centers located within that state. You can also click on Veterans Health Administration on the left side of the Facilities Locator and Directory page to go to the VA map of VISNs. Click on the VISN that covers your area, and you will find contact information for the appropriate VISN.
VA AACT Teams
AACT Teams are VISN-based interdisciplinary teams that provide leadership in hospice and palliative care program development and education to the VA facilities within each of their VISNs. They were created through the Accelerated Administrative and Clinical Training Program for Palliative Care (AACT), a national program of the VA Hospice and Palliative Care Initiative. Ask the VISN in your area to put you in touch with a representative from its AACT Team.
VA Medical Centers (VAMCs)
VA Medical Centers are hospital systems that serve Veterans. Although the exact makeup of these systems will vary, most include ambulatory care and out-patient clinics, nursing home care programs, home care programs, and long-term care domiciliaries. VA Medical Centers are organized under VISNs. It is recommended that HVPs include a representative from each of the VA Medical Centers in their region or state. To find a VAMC that covers your area, visit the VA Web site (www.va.gov). Click on Find a Facility, located on the toolbar at the top of the page and click on the appropriate state. You will then be able to navigate to a list of VA facilities.
VA Palliative Care Consult Team
Each VA Medical Center must designate a Palliative Care Consult Team consisting of, at a minimum, a physician, nurse, social worker, chaplain and administrator. The teams offer consultation throughout the medical center, assisting with planning and guidance on managing a patient’s pain and other symptoms, especially when these are complex or difficult to control. The team also recommends policies and procedures to hospital management, assumes a leadership role in promoting the hospice concept of care, facilitates communications with community hospices and conducts educational programs for VA and community staff.
VA Community-Based Outpatient Clinics (CBOCs)
VA Community-Based Outpatient Clinics provide outpatient medical care to Veterans. They are organized under VA Medical Centers. To locate CBOCs in your area, visit the VA Web site (www.va.gov). Click on “Find a Facility”, located on the toolbar at the top of the page and click on the appropriate state. You will then be able to navigate to a list of CBOCs.
State Veterans Homes (SVHs)
State Veterans Homes are special long-term care facilities that serve qualified Veterans and their spouses. These homes are owned and operated by the state, but through a federal-state partnership, the VA is responsible for conducting annual surveys and providing funding for construction and per diems. State Veterans Homes may follow different state-specific policies, procedures and regulations. To locate state Veterans home in your area visit the National Association of State Veterans Homes Website (www.nasvh.org) Click on “Directory of State Homes” and click on the map or the drop-down list to produce a list of contacts for your state.
Vet Centers serve Veterans and their families by providing a continuum of quality care that adds value for Veterans, families and communities. Care includes professional readjustment counseling, bereavement counseling, community education, outreach to special populations, brokering services with community agencies and providing a key access link between Veterans and other services in the U. S. Department of Veterans Affairs. There are 206 Vet Centers nationwide. To locate Vet Centers in your area, visit the VA Web site (www.va.gov). Click on “Find a Facility”, located on the toolbar at the top of the page and click on the appropriate state. You will then be able to navigate to a list of Vet Centers.
Military Treatment Facilities (MTFs)
Military Treatment Facilities include military hospitals and clinics that provide primary and specialty care. They are designed to serve active duty and retired members of the uniformed services. To find MTFs in your area, use the online TRICARE Military Treatment Facilities Locator.
State Departments of Veterans Affairs
Each state has a Department of Veterans Affairs, although the exact name, structure and services of the department will vary. All states have Veterans Service Officers, and you can usually locate a contact person by visiting your state’s official Web site. Your State Department of Veterans Affairs can be found at www.[State].gov, inserting the state abbreviation used by the postal service, e.g. for Texas: www.tx.gov. Due to the variability in how the Web sites are laid out, you may have to use the search function to locate the Veterans pages. Or, go to the National Association of State Directors of Veterans Affairs (www.nasdva.us), navigate to State VA Departments and click on the desired state. Alternatively, go to www.google.com and search for “(your state) Department of Veterans Affairs”.