VHA's SCI/D System of Care is required to provide and maintain access to a full continuum of care for Veterans with SCI/D, including long-term care. The mission of certain SCI Centers emphasizes the provision of long-term care; however, facilities without an SCI Center may also provide long-term care for Veterans with SCI/D. The goal of long-term care is to assist the Veteran with SCI/D to attain or maintain a community level of adjustment, and maximal independence despite the loss of functional ability due to the aging process, loss of a primary caregiver, or medical complications. No Veteran with SCI/D is to be discharged to a nursing home solely because of their SCI/D.
Long Term Care Services. The continuum of extended care services for Veterans with SCI/D is a mix of services designed to meet eligibility requirements, individual need, personal preference (choice), and promote independent community living whenever possible. A patient centric team approach must be used in planning for the long-term care needs of the Veteran. The following list is not all-inclusive; however, provides options for care as patient resources allow:
Care at a designated VA SCI long-term care unit,
VA Community Living Centers (CLC),
Home care services,
Medical Foster Homes (MFH),
Homemaker and/or home health aide services,
Adult day health care,
Contract home health care,
Home-based primary care,
SCI home care (SCI-HC),
Community residential care,
Geriatric Evaluation and Management (GEM),
Geriatric Research and Education Clinical Center (GRECC),
State or Veterans homes,
LTC Placement Considerations. Regardless of the location where Veterans with SCI/D receive care, there are general guidelines to ensure appropriate services are provided. These include:
Patients are not to be discharged to a nursing home, unless the patient's general health status and social circumstances necessitate such placement.
The aging Veteran with SCI/D has special needs (e.g., supplies, quality of life concerns, and desires for less restrictive and supportive living environments); such needs are to be incorporated into the patient's treatment plan.
When it is appropriate for the Veteran to be discharged to a nursing home based on achievement of maximum hospital benefit, consultation with the Veteran, the Veteran's guardian, the appointed Veteran advocate and/or family member (at the request of the Veteran or guardian, as appropriate), and the SCI/D physician occurs. All other placement alternatives need to be considered before making such a decision.
VA's CLC or community nursing home needs to be as close as possible to the Veteran's selected domicile or home, and close to the Veteran's social support unless a brief stay at another location is indicated for specialized health care needs or timeliness of placement.
The nursing home must be a functionally accessible unit for the Veteran, and be in accordance with the current Americans with Disabilities Act (ADA) and Architectural Barriers Act (ABA). In discharge planning, the SCI team needs to make every reasonable effort, by assurances and report, that essential equipment (e.g., lifts, bowel-care chairs, gurneys, etc.) is appropriately maintained and configured for the Veteran.
The nursing home must provide for an appropriate and full-range of support, and rehabilitative services as needed by the Veteran. Clinical negotiations must be used to meet the individual needs of Veterans with SCI/D.
The nursing home must conform to all required state and Federal regulations.
The nursing home referral is to include a summary of the interdisciplinary team's recommendations on the specific services and resources that the Veteran requires to maintain functional status, achieve maximal independence, reduce social role limitation, and enhance quality of life.
During the pre-placement planning process, the review of the needs and expected outcomes of the Veteran with SCI/D needs to be compared to the expertise that can be provided by the nursing home. Before the prospective nursing home placement, a site visit by members of the SCI/D team with appropriate clinical qualifications may be made to verify that the nursing home provides the level of care needed by the individual. The Veteran's guardian, the appointed Veteran's advocate, representative and/or family members will be encouraged to visit the nursing home during the planning process.
SCI/D personnel are to maintain a pro-active educational approach to the care of Veterans with SCI/D in community nursing homes. Appropriate educational activities may include offering educational brochures, training sessions, and consultative visits.
The placement plan must include the designated SCI/D health care provider who is the point-of-health-care-contact for nursing home personnel. Within the parameters of the nursing home's policies regarding credentialing and privileging, recommendations of SCI/D specific care and expected outcomes are to be monitored. Reports of contact or progress notes are to be included in the Veteran's VA medical record. The SCI/D provider serves as a specialty resource on a regular recurring (preferably at least monthly) basis with the frequency of contact based on the Veteran's clinical condition.
Veterans who develop urgent medical conditions need to be transferred to an appropriate medical center.
The designated SCI Center needs to continue to offer comprehensive preventive health evaluations, acute care, and follow-up care as needed.