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I am writing to inform you of some important changes we are making to the Homemaker Home Health Aide (HHHA) services program at VA Pittsburgh Healthcare System. This communication is extensive because this issue is complex, and I would like to provide the most complete information possible.
As you are aware, the Veterans Health Administration (VHA) offers services designed for Veterans who are elderly and have complex needs, and Veterans of any age who need daily support and assistance. Eligible Veterans can use in-home services and/or health care to live in their own homes longer, and avoid institutional long-term care for a time. Through the VA Homemaker Home Health Aide (HHHA) program, private home health care agencies deliver three defined in-home services; VA medical centers authorize the services, and VA community medical care dollars fund the services.
HHHA is comprised of homemaker services which include household task assistance such as light housekeeping; laundering; meal preparation; grocery shopping; and escorting the Veteran to necessary appointments. Health aide includes personal care assistance such as bathing; toileting; eating; dressing; aid in ambulating or transfers; active and passive exercises; assistance with medical equipment; and routine health monitoring by a non-skilled attendant. Through in-home respite, an attendant cares for a Veteran, providing the family caregiver hours of free time.
When compared with other VA medical centers serving approximately the same number of Veterans overall, and with similar demographic populations, VA Pittsburgh Healthcare System (VAPHS) operates a substantial HHHA program by number of Veterans served, and frequency and duration of services, particularly household task assistance.
Historically, local community medical care budgets have funded HHHA services and all medical care delivered by Non-VA providers. Local community medical care dollars are prioritized for critical medical care services, which can include but are not limited to: emergency hospitalizations, specialty care, dialysis and community nursing home care for eligible Veterans. The local community medical care budget varies from year to year, and is sometimes limited.
In February 2016, while funded by local community medical care dollars, HHHA managers initiated an Electronic Wait List (EWL) for new referrals because the program had reached maximum capacity. In April 2016, through a new provision of the Veterans, Access, Choice and Accountability Act of 2014, VHA centrally-managed national community medical care dollars (referred to as Choice funds or Choice) became available to support community care across all VA medical centers. Through a new mechanism, the provider agreement, over time VAPHS began using Choice to fund all existing authorized HHHA services, and began providing HHHA services to those on the wait list. After several months, local community medical care funds were no longer used to provide HHHA services. VAPHS also used Choice to fund other medical care delivered by Non-VA providers.
In June 2017, VHA discontinued the use of Choice funds through the provider agreement mechanism, and shifted VA medical centers – including VAPHS – back to using local community medical care budgets to fund almost all care delivered by Non-VA providers, including HHHA services. Partly due to this unexpected shift, VAPHS projects a budget deficit in local community medical care funds as the end of fiscal year approaches on September 30, 2017.
After an initial community care analysis in late June, HHHA program managers began communicating reductions to some Veterans who were authorized the highest frequency and duration of services. After hearing Veterans’ and family caregivers’ concerns about the significant impact, VAPHS leadership discontinued those changes, and began to reassess the approach.
HHHA is not a benefit that can be guaranteed to every Veteran who is eligible for VA health care. It is not critical medical care, and service availability depends largely on resources. There is no VA directive or standardized tool, and no health care industry standard used to determine clinically appropriate frequency and duration of HHHA services for an individual. Authorizations are determined by clinical judgement, and resource capacity.
Currently, VAPHS has authorized per week approximately 150 Veterans from 16 to 40 hours, more than 400 Veterans from 7 to 15 hours, and more than 400 Veterans from 1 to 6 hours of HHHA services, including personal care and household task assistance in more than half of all cases. Other similar VA medical centers are providing services to fewer Veterans, at lower frequencies (hours per day or week); and shorter durations (months prior to reassessment of further need). In many cases, Veterans at the lowest functional capacity receive between 10 and 20 hours of services per week.
VAPHS is now redesigning how the HHHA program operates for the reasons outlined above. The new model incorporates best practices from other VA medical centers, and will ensure: services are provided to Veterans at appropriate levels in accordance with need; close monitoring of each service provided, tracking hours agencies spend assisting with specific household and personal care tasks; and assessment of continuing needs at regular intervals.
Some adjustments to current authorizations must be made. It is important to again clearly differentiate between two of the HHHA services: Homemaker services are household task assistance, such as light housekeeping; laundering; meal preparation; grocery shopping; and escorting the Veteran to necessary appointments. Health aide includes personal care assistance such as bathing; toileting; eating; dressing; aid in ambulating or transfers; active and passive exercises; assistance with medical equipment; and routine health monitoring by a non-skilled attendant.
Clinicians are currently completing functional assessments for every Veteran receiving any HHHA services to determine appropriate frequency and duration of household task and personal care assistance in line with administrative guidelines, and based on resources available. Some Veterans will see no change, and some will have a reduction in services. Conversation and communication will be clear, and other available resources such as VA Adult Day Health Care and VA Caregiver Support will be offered, and other community resources explored. A letter detailing the changes and list of resources will be sent.
Veterans with the lowest and moderate functional capacity, the majority of those being served by HHHA, will receive no change in authorized personal care assistance hours. Based on the functional assessment, some Veterans may receive a reduction or discontinuation of household task assistance. Veterans with the highest functional capacity who receive only household task assistance will have the service discontinued.
Veterans receiving hospice care will receive no change in household task or personal care assistance. In-home respite may still be available. Arrangements can be made through James Martorella at 412-822-4915.
Changes are expected to take full effect on July 30, 2017 and will occur as gradually as possible. Veterans with any service being discontinued, and Veterans newly referred for personal care assistance or household task assistance will be placed on an EWL for these services.
In-home respite was discontinued for most Veterans effective July 1, 2017, and inpatient respite is available in the Community Living Center located at H.J. Heinz III campus in O’Hara Township. Arrangements can be made through Kathleen Lybarger at 412-822-1651.
VAPHS continues to evaluate the operations of the HHHA program, and all other programs and services to ensure the most cost effective and efficient administration of associated resources. If at any time changes are necessary, there will be clear and expedient communication.
I am personally committed to VA’s noble mission of serving our nation’s Veterans. Please do not hesitate to reach out Kathleen Pomorski, Chief, Public Affairs at 412-822-3578 with any questions.
KARIN L. McGRAW, MSN, FACHE
Medical Center Director
Questions? Contact Kathleen Pomorski, MHA
Chief, Public Affairs
VA Pittsburgh Healthcare System
412-822-3578 (H.J. Heinz III)
412-360-3065 (University Drive)