Hello everyone, and welcome to the Fresh Focus Podcast, I’m Kerri, one of your Marion VA healthcare system Dietitian Nutritionists. I am also a certified diabetes care and education specialists, a certified specialists in gerontology, and a Home-Based Primary Care Dietitian. I am joined by Adelaida, one of our Home-Based Primary Care Social Worker. Hello, Aida how are you today?

Aida…
Hey Kerri, I’m doing great and I’m excited to be chatting with you on the Fresh Focus Podcast.

Kerri…
Like I stated before I am a Registered Dietitian in the Home-Based Primary Care Program, I will be referring to this as HBPC during the podcast. As the HBPC dietitian, during home visits I assess Veteran’s nutritional status and their nutritional needs. An important role of the HBPC Dietitian is to assess if a Veteran is food secure. We have questions that we ask to determine this, we will be discussing these later. Being in the home versus the clinic setting allows us to have a hands-on approach to see how the patient lives from day to day, what they have access to in regards to food for meals, and what they have available in order to prepare meals. Is there an adequate amount of food in the home? Does the Veteran have adequate equipment to prepare the food in the home? Does the Veteran have adequate fluids in the home for hydration, do they have running water? The Dietitian works with other team members to provide food from the VA food pantry and to provide other resources as needed. One of the team members I work closely with is the HBPC Social Worker. Aida, can you tell us about your role as an HBPC Social Worker?

Aida…
Yeah, I’d love to share my role on the Home Based Primary Care Inter-disciplinary Team. As an HBPC SW, one of my roles is to complete a Biopsychosocial Assessment in collaboration with the Veteran, his significant other/family members and caregivers. The goal of the assessment is to highlight the Veterans strengths, limitations, internal/external supports and service needs in order to optimize the Veteran’s functional status so they can remain in their home, as independently as possible, for as long as possible. Similar to you Kerri, I assess Veterans for Food security, but I also assess them for financial insecurity, offer support to caregivers, I provide grief support to both the Veteran and their family/caregivers and act as an advocate, empowering Veterans to become change agents concerning their medical and mental health needs, and work to ensure Veterans maintain their right to self-determination.

Kerri…
Thank you for that let us talk about Social Determinants of Health. Per health.gov, the social Determinants of Health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks. Looking at data for this fiscal year October 2023 to now, the Marion VA Healthcare Center has had 2,177 ACORN screenings completed. So, what is the ACORN screening? This stands for Assessing Circumstances and Offering Resources for Needs. Out of the 2,177 screenings, 55.4% were positive for a need of resources. The needs that are assessed include social isolation/loneliness, food, digital needs, utilities, transportation, housing, legal needs, equipment, and education. Loneliness was the top need at 26.8%, food was the second highest need at 23.6%, and the lowest need is for education at 1.1%. For Veterans seeking food security, the local resources available are the VA Food Pantry, food pantries, Senior Centers, Meals on Wheels, and other services that Medicare Advantage and Medicaid will cover. Aida, can you provide us with any other resources available to our Veterans in relation to the ACORN screening?

Aida… Kerri, yeah, I think you covered much of the Food insecurity needs, and I’d add that local Senior Centers also provide Veterans with opportunities to participate with social engagement through center activities and the opportunity to establish new friendships and social supports. Also, if I met with a Veteran who screens positive on the ACORN screen for Social Isolation, and they are physically unable to leave their home- I provide them with education on the VA’s Whole Health Initiative and the various programs offered, like one-on-one health coaching, Virtual Tai Chi/Chair, or Meditation courses. If a Veteran does not have digital access to attend a Virtual Tai Chi class, or a Meditation class, I provide education on VA’s Virtual Care and provision of iPads.

Kerri…
Aida, the other day we were discussing HBPC and CCICM which stands for Care Coordination and Integrated Care Management. I know there is confusion between these two programs, can you explain the difference between these programs?

Aida…
CCICM promises to elevate the standard of healthcare delivery for Veterans. The primary focus of CCICM is to improve collaboration, communication, and coordination within an integrated healthcare system for Veterans with Chronic healthcare needs, and who have a high percentage of hospitalizations and ED visits. A Lead Coordinator is assigned in CCICM. I’ve had the privilege to serve as a Lead Coordinator for Veterans in the CCICM program and guided Veterans during their CCICM journey by coordinating one seamless plan of care resulting in a decrease in the utilization of services and cost.
HBPC is an essential part of VA’s Primary Care service and provides health care services to eligible Veterans also who have complex health care needs for whom routine clinic-based care visits are just not feasible. We also serve as part of an Interdisciplinary Team, or IDT, (PCP, RN, RD, OT and SW), and together provide Veterans with comprehensive patient care. Our team teaches Veterans and caregivers about health problems, medications, healthy food choices, and more. In HBPC, the IDT remains in the Veterans home until a Veterans End of Life, or until the Veteran moves into a nursing home due to increased care needs or until a Veteran meets their goals or decides they want to be discharged from the program.

Kerri…
I know with HBPC our interdisciplinary teams work close together to help with meeting the needs of our Veterans. I asked some other team members what their role is in HBPC and what they enjoy about HBPC? Here are some of the comments I received when asking staff these questions:
Mrs. Lomax, a Registered Nurse Care Manager, when asked What is your role in HBPC? She states, “As CM (care manager) we assist Veterans/families with developing a medical plan of care that results in completing the goals that the Veteran has voiced are the most important to him/her.” When asked What do you enjoy most about HBPC? She states “Seeing people in their home environments. Being in the home you can see why past plans have failed or succeeded based on the actual living conditions and available resources. Helping a Veteran reach personal medical goals is satisfying to me and the Veteran/family.”
Mrs. Martin-Leitzen, a Clinical Pharmacist, when asked What is your role in HBPC? She states “I perform initial and quarterly medication reviews for HBPC veterans. These reviews look for medication adherence, appropriate use/dose/indication of medication therapies, drug interactions, adverse drug reactions, and lab monitoring. We also aid in medication education and appropriate ordering/refills when needed. Pharmacist also view falls that assess if medications use could be resulting in higher fall risk.” When asked What do you enjoy most about HBPC, she states “I really enjoy that I can follow a veteran’s medical care over the length of his/her HBPC involvement and help the team improve his/her way of life through medication intervention. Also, I love working with my multidisciplinary team as I always learn a lot.”

Aida…
Mrs. Adams’s role in HBPC is a Nurse Practitioner. When asked what she enjoys most about HBPC she states “being able to provide services to Veterans who have trouble obtaining their medical care in the traditional clinic setting. We can go into their homes and partner with the Veteran and their family to offer great patient-centered care.”
Mrs. Dykes’s role in HBPC is a RN/Care Manager. When asked What she enjoys most about HBPC she states, “I enjoy getting to know my Veterans and families and providing them with the best care.”
Another HBPC RN/Care Manager states “I feel like HBPC is a wonderful program offered through VA. It allows the veteran’s healthcare team to see the veteran in their own environment, assist with any needs and have the opportunity to get to know their family and their role in the veteran’s healthcare. It is an honor to take care of our country’s veterans, and I feel very fortunate to be able to get to know these veteran’s and assist them in their home environment.”

Kerri…
Aida, we have discussed our roles with HBPC, I would like us both to answer the question of what we most enjoy about HBPC. I enjoy working the Veterans and love how they will welcome us into their homes and being able to see how they live. Being able to go into the home allows us to see the whole picture of the Veteran and help them in so many ways. Aida, what do you enjoy most about HBPC?

Aida…
I enjoy establishing a rapport of trust and collaboration with Veterans, their caregivers/family, providing them with a safe space to share their fears concerning the Veterans End of Life Care goals and needs, and challenging Veterans to focus on their healthcare goals, while encouraging them to focus on the positive things in their lives- despite their physical/healthcare limitations. And I enjoy providing Veterans with Grief support, as they learn to navigate their lives without their loved ones, or with increased health issues. I also enjoy engaging and providing support to Veterans Caregivers/family- without them, Veterans with complex needs would not be able to remain in their homes and continue to receive our services.

Kerri…
We want to say thank you for listening and hope you have enjoyed the Fresh Focus Podcast series focused on VA Home-Based Primary Care. Please contact your local VA Healthcare Center to see if HBPC is available in your area or if you have any questions about the program. Thank you again for your time.

Aida…
Thank you, bye.