Geriatrics and Extended Care

Overview

Geriatrics and Extended Care (GEC) at the Columbia VA Health Care System provides home- and community-based services, which are part of the Veterans Medical Benefits Package under Title 38 U.S.C 1717 and 1720C, to ensure all enrolled Veterans, for whom it is determined by appropriate health care professionals, that care is needed to promote, preserve, and restore the health and well-being of Veterans with multiple chronic conditions, life-limiting illness, frailty or disability associated with chronic disease, aging, or injury.

GEC service uses a Veteran-centered interdisciplinary (NP, RN, SW) care model which focuses on improving the quality of life, minimizing the effect of life-changing disabilities, and transforming individualized care using the Holistic Approach. GEC is also supported by other interdisciplinary team members who repot to other health care groups or service, such as physical therapist, psychologists, clinical pharmacists, and dietitians. 

 

Purchase Skilled Care Services

Community Nursing Home (CNH) Program

The CNH Program is designed to assist eligible Veterans and their families with making the transition from an episode of hospital or domiciliary care to the community, or to provide indefinite nursing home placement for Veterans who require 24-hour medical care and/or supervision.

The primary goals of the CNH Program are to meet the Veteran’s health care needs, provide rehabilitation services with a goal of returning home, and promote the maximum wellbeing of the Veteran. CNH oversight is provided by an interdisciplinary team, which includes a social worker and a registered nurse.

The CNH team provides direct care and advocacy to Veterans and their families, administrative oversight of the CNH facility, and visits with the Veteran at the CNH every month

Purchase Skilled Homecare

Purchased Skilled Home Health Care (PSHC) are in-home services provided by qualified personnel that include: skilled nursing, physical therapy, occupational therapy, speech therapy, social work services, clinical assessment, treatment planning, treatment provision, patient and/or family education, health status monitoring, reassessment, referral, and follow-up. A VA primary care provider prescribes skilled home health care services when medically necessary and appropriate for enrolled veterans.

Community Adult Day Health Care (C-ADHC)

C-ADHC programs enable elderly and disabled Veterans to reside in supportive home environments rather than in nursing homes and improve the Veteran's quality of life by supporting their caregivers and maintaining the Veteran’s highest level of functioning possible.

The program is for Veterans who need skilled services, case management, and help with activities of daily living. Columbia VA provides this service through contracts with local private centers (C-ADHC).The C-ADHC social worker and community health RN provides advocacy to Veterans and their families and provides oversight of the care provided at C-ADHC facilities by means of annual inspections, medical record reviews, and contact with Veterans.

Home Based Primary Care (HBPC)

Contact - 803-776-4000 ext. 6418

HBPC delivers intensive primary care in the home for homebound Veterans with a history of or at risk for frequent hospitalization due to ambulatory care sensitive conditions. This service provides Veterans with intensive clinical oversight, individual care coordination and chronic disease care management to help keep Veterans safe at home, decrease hospitalization, and the need for institutionalization.

• Disease & medication management by a nurse practitioner
• Care management by a registered nurse
• Coordination of services and resources by a social worker
• Rehabilitation services by PT and OT
• Mental health services by clinical psychologists
• Nutrition counseling by a registered dietician

Homemaker/Home Health Aide Program

The goal of H/HHA Program is to provide family caregivers and other informal social support systems assistance with the demands of daily care, thereby decreasing caregiver burden and supporting the Veteran’s desire to delay or prevent nursing home placement.

H/HHA services may include assistance with Activities of Daily Living (ADLs), such as: bathing; toileting; eating; dressing; aid in ambulating or transfering; active and passive exercising; assistancing with medical equipment; routine health monitoring; and, specific household tasks to maintain environmental safety for the patient.

A VA primary care provider prescribes H/HHA services when medically necessary and appropriate for enrolled veterans. This program is for Veterans who need skilled services, case management, and help with activities of daily living.

Home Respite

The Respite Program is designed to give caregivers of Veterans a break from day-to-day care giving responsibilities. The program is for Veterans who need skilled services, case management, and help with activities of daily living.

The goal is to improve the quality of life for both the Veteran and caregiver, by providing relief and support to caregiver who are at risk for caregiver burnout. Respite Care. Respite care services are personal care and supportive services delivered in the home, nursing home, hospital adult day care center, or assisted living facility, for the express purpose of temporarily relieving the caregiver(s) of caregiving duties.

Respite care services may include various VA-provided services, e.g., H/HHA, and non-VA purchased services. In all cases, respite care remains distinct from the routine use of Geriatrics and Extended Care (GEC) services in that the focus and purpose of respite care is providing relief for the caregiver. VHA respite care services are generally limited to 30 days per year total from all settings in which respite is provided. A VA physician prescribes respite care services.

Hospice/Palliative Care

The Hospice and Palliative Care team provides supportive care for Veterans and their families with advanced illnesses and the terminally ill. The focus of care is a collaborative approach by providing education and support to address quality of life including symptom management/comfort and goals of care conversations. The team works closely with physicians, nurses, care-coordinators, social workers and chaplains to implement a treatment plan that addresses the physical, emotional, social and spiritual needs of the patient and their families. The team currently provides care to Veterans on both, inpatient and outpatient basis, and making referrals to community agencies as needed.

Hospice is the final stage of the palliative care continuum in which the primary goal of treatment is comfort rather than cure for patients with advanced disease that is life-limiting and unresponsive to disease-modifying treatment. Community hospice agencies provide a comprehensive package of bundled home hospice services utilizing an interdisciplinary team of professionals and volunteers.

These programs emphasize relief of suffering and maintenance of functional capacity as long as possible through comprehensive management of the physical, psychological, social, and spiritual needs of the patient. They also provide support for the patient’s family or other caregivers including bereavement support following the death of the patient. A VA physician prescribes hospice care services.