S3 E2 - Veteran-Directed Care
What are the core objectives of the Veteran-Directed Care (VDC) program and how does it empower veterans and their caregivers?
Allen Roberts, who supervises four of COAAA’s six impactful programs, joins us to unpack how this initiative empowers veterans to take control of their own care by employing caregivers, managing their budgets, and tailoring services to their individual needs.
We uncover the key aspects of Veteran-Directed Care, from addressing equity gaps and providing autonomy to veterans, to the efficiency of referral systems and the importance of mental health training. Plus, hear success stories and future plans for expansion into every county in Ohio—all designed to enhance the quality of life for our veterans and their families.
Top Takeaways
The Veteran-Directed Care program empowers veterans by providing them a budget to employ caregivers and manage their own care, enabling independence and personalized care solutions.
The program emphasizes giving veterans autonomy and independence, allowing them to choose authorized representatives if they are unable to manage their care due to health issues.
The program offers a wealth of support, including adult day supports, homemaker services, and personal care services, ensuring that veterans receive holistic care tailored to their needs.
Home visits are conducted monthly, and quarterly to assess the needs of veterans and their caregivers, emphasizing relationship-building over formal assessments to spot unnoted requirements or issues.
The program aims to maximize the veteran's budget and access to needed resources, with reassessments triggered by changes in care needs such as post-surgery or post-hospitalization.
While not yet available in every county, the program plans for expansion and connects through the VA, ensuring that veterans across different regions receive care integration and support.
Addressing mental health is crucial, with the program providing training to handle intense situations and emotional responses from struggling families.
Reporting requirements, such as monthly case note submissions and contact tracking, help in setting up performance indicators focused on reassessment, needs assessment, and bridging care gaps.
The program integrates care coordination assistants, community health workers, nurses, and social workers to provide a robust support structure, with various initiatives like MedMutual Care Transitions and the Anthem program addressing broader social determinants of health.
Key Moments
00:00 Active, helpful, challenged by Chamber finances. Business degree.
04:52 Understanding discharge paperwork with in-home support.
08:31 ACL and HHS launched VDC program in 2008.
12:40 Enrollment and onboarding for home care.
17:46 Family wants good care for veteran, adjusts as needed.
20:18 VA offers caregiver programs, support groups, online platform.
24:16 Planning process and route sheet for efficiency.
26:24 Programs require case management documentation in outside systems.
30:05 Planning for social health drivers through analytics.
35:16 Leading the movement, mentoring, and bringing veterans.
38:14 Happy to help in difficult situations. Dedication, passion, awesome.
Let me know what you think of this podcast, as well as any ideas you have for an episode. Email me at kwhite@coaaa.org!
https://creativecommons.org/licenses/by-nd/4.0/
Copyright 2024 Central Ohio Area Agency On Aging
Transcript
Welcome to Pretend I Know Nothing About. I'm Katie White, your host, Administrator of COAAA. On today's episode, we're learning about a new program of COAAA's called Veteran-Directed Care. I'm joined by Allen Roberts, Care Transitions supervisor. Let's get into it. Well, welcome. Thank you. Today, I am joined by Allen Roberts, Care Transition supervisor.
Katie White [:Thank you for being here.
Allen Roberts [:Thank you for having me.
Katie White [:So what I like to start off by doing is just getting to know you a little bit. So talk to me about your previous career, maybe where you went to college. Tell me a little bit about yourself.
Allen Roberts [:Yeah. So, I've been here at COAAA for about 6 months. I started the day after Christmas. Oh.
Katie White [:That's a fun fact.
Allen Roberts [:Yeah. It was a fun time.
Katie White [:Was anyone even here?
Allen Roberts [:It was
Katie White [:probably pretty quiet.
Allen Roberts [:It was just me and Lisa.
Katie White [:That checks out. Yeah.
Allen Roberts [:Yeah. But, let's see. Before here, I worked for, Pickaway County Board of Developmental Disabilities.
Katie White [:Okay.
Allen Roberts [:And so, most of my experience is working with people with intellectual and developmental disabilities.
Katie White [:Okay.
Allen Roberts [:Yeah. Before that, I worked with Ohio Means Jobs and some workforce development stuff. So I have a long history with people with disabilities, some workforce development in there, and they did a small stint at Children's Hospital as a medical social worker.
Katie White [:Oh, okay.
Allen Roberts [:Yeah. A lot of my experience is community based.
Katie White [:Mhmm.
Allen Roberts [:So Children's was a really great place to work, but I want to be more, back in the community. And so that's how I landed. I ended up at COAAA. So I
Katie White [:love that. So you're a social worker?
Allen Roberts [:Yes.
Katie White [:Okay. And you said Pickaway County DD. Yes. And how did you do you live in Pickaway County? I
Allen Roberts [:live in Circle Valley. Yes.
Katie White [:Oh, you do. Okay. So you're involved in the community. What's it like living in Pickaway?
Allen Roberts [:Yeah. So it's I like it because you get the mixture of small town, and then we're super close to Columbus. We're close to Lancaster. We're close to Grove City. So I am involved, in a couple things in Pickaway County. I am the treasurer for the, Pickaway County Chamber of Commerce. I'm on their board of directors.
Katie White [:Oh, wow, Allen. That's cool.
Allen Roberts [:So that's keeps me really busy. I bet. I am also a board member of the Haven House Domestic Violence Shelter in Pickaway County.
Katie White [:Wow.
Allen Roberts [:Yeah. So that's that's, I've been on that board for a little less than a year.
Katie White [:Okay.
Allen Roberts [:I love it. And then I am a member of the Sunrise Rootery Club. Yes. And I serve on a couple of their different committees, so I'm busy.
Katie White [:Allen, that's super cool.
Allen Roberts [:Yeah.
Katie White [:So getting involved in all these community, programs, is that somewhat new or just sort of always been you, like you like to do? Not that I'd call them extracurriculars, but for whatever reason, that's like adult extracurriculars. Yeah.
Allen Roberts [:It's always been me. I enjoy being active. I enjoy helping, and I would say the most challenging actually has been the Chamber of Commerce. So, I actually have a Bachelor's in Business, and so that's kind of where that interest came from. But being a treasurer and learning about all the different finances and how the Chamber great combo when I think about
Katie White [:anyone just a great combo when I think about anyone at COAAA, but in particular in the Care Transitions division, which is a lot about business development, identifying opportunities, and then bringing them to fruition. So, before we get into veteran-directed care, which is what we'll focus on today, give me, the overview of the programs that you supervise.
Allen Roberts [:Yeah. Okay. So right now, I supervise 4 of our 6 programs.
Katie White [:Okay.
Allen Roberts [:So, our medical mutual program, it's a true care transitions model. It's modeled after the Coleman model.
Katie White [:Okay.
Allen Roberts [:Where we have, RNs that do health coaching visits after people have been discharged from the hospital.
Katie White [:Mhmm.
Allen Roberts [:And so there's a MedRid piece to that. So it's important. It's actually required that an RN does it. And so we have 2 RNs working in that program and a social work engagement specialist that does all the scheduling.
Katie White [:Okay. So, someone gets discharged from the hospital, we reach out. We schedule a visit through our social worker, kind of, and get them engaged, and then a nurse goes out and actually does the visit.
Allen Roberts [:Yes. Okay. Yeah. And so with that visit, they do a med rec. They kinda go over discharge paperwork. The goal is to prevent another hospitalization.
Allen Roberts [:Got it.
Allen Roberts [:And so they go, because we have found out that most people, they go back into the hospital because they didn't understand the discharge paperwork or what their medication regimen was or when to stop a med,
Allen Roberts [:when to
Allen Roberts [:start a med, And so that's why the med rec is really important for that piece.
Katie White [:And that I mean, even just when I think about an individual going home from the hospital So like when I have my kids, for example, discharge home, I don't know what a lot of that stuff means on the discharge paperwork. So how nice to have that person come out in your home and really work through it with you.
Allen Roberts [:Yeah. It's really it's a successful program. So that one is keeps us pretty busy.
Katie White [:I bet.
Allen Roberts [:Because the nurses also do we do our SUS tool.
Katie White [:Okay.
Allen Roberts [:So if there are any SUS needs, they are the ones doing the case management as well for that.
Katie White [:Oh, great. So then, is the Med Mutual population 60 and older, or what's the age group for that?
Allen Roberts [:I don't think there actually is a specific age group. We get a lot of Medicare Advantage, so it's
Allen Roberts [:up to
Allen Roberts [:60 60 and older but there have been some younger people in there. I'd say between ages 35 60 is kind of where that population goes.
Katie White [:Okay. Great. Alright. So, you've got MedMutual Care Transitions under you and what else?
Allen Roberts [:So, our second one is our Anthem program. So, we're contracted with Ground Game Health, and they contract directly with Anthem. And that is a We do a health assessment and an SDOH tool, and that Our goal with that program is to help people, close gaps in care.
Allen Roberts [:So, if
Allen Roberts [:they need a specialist, if they don't have a primary care provider, or they need any of the SDOH resources like housing, utilities, transportation, we kinda help bridge those gaps.
Katie White [:Okay.
Allen Roberts [:And Yeah.
Katie White [:So SDOH is social drivers of health, and we've done another episode on this with Lisa and Melissa. So it's the Care Transitions episode, if someone listening wants to get the background on it. But looking at social care needs. So, food insecurity, housing insecurity, things like that. Yeah. Great. Okay. And then the next program?
Allen Roberts [:The next one is our community health worker program.
Katie White [:Okay.
Allen Roberts [:And so our community health workers here are they're boots on the ground. They're going to people's homes, helping them apply for Medicaid, helping them, again, bridge those gaps in care, looking at some of those SDH needs. We're all about SDH.
Katie White [:Yeah. That's right.
Allen Roberts [:Yeah. And then, people who are actually applying for our different types of waivers. So passport, the, nursing home versus living waivers, if they need help gathering information for that or documentation or applying for Medicaid, our community health workers do that as well.
Katie White [:I love well, I love all of our programs, but what I love about the community health workers is they end up being such a great extension and support to the great work that we already do. But it's like an even deeper level of, you know, we might identify that somebody needs something. And then we've also got someone to go out and help you navigate getting whatever that thing is too. So it just really, like you said, closes those gaps.
Allen Roberts [:Yeah. It's a good form of care navigation, really, that they're navigating resources, they're navigating work with community partners, and they kind of have to be people who can jump in and jump out at any time because sometimes situations happen and we have to pivot.
Katie White [:That's right. That's right. And that jumping in and jumping out isn't for everybody. But when you're good at it, it is just so valuable.
Allen Roberts [:Yes.
Katie White [:Yeah. Okay. So then that brings us to, a new program that we have here at CO COAAA. So tell us about your 4th program.
Allen Roberts [:Yes. It is the veteran directed care program. So that program is new to us here at Central AAA, but it's not new. So it's been around since 2008.
Katie White [:Okay.
Allen Roberts [:And it was in 38 states, And by the end of this year, they wanna expand the federal government wants to expand that program to off of these states. Okay. And yeah.
Katie White [:And so, was are we the 1st AAA in Ohio to do it, or are we kind of coming in as a cohort?
Allen Roberts [:So we're coming as a cohort. We're not the 1st AAA in Ohio.
Katie White [:Okay. Okay. So the program, was rolled out in 2008 by ACL on behalf of the Department of Health and Human Services. So the HHS partnered with the Veterans Health Administration to say, hey, there's a lot going on in, health and human services that we think could be replicated into veterans with their own, you know, specific veteran spin on it. So the vision of this program, as I understand, is to provide those long term services and supports, LTSS, which is a lot of what we do as area agencies on aging, but within the veterans system. Is that right? Yes. Okay. And so kind of in your own terms, what does the VDC program do?
Allen Roberts [:So what we do is the VDC program makes sure that people are able to stay in their homes
Allen Roberts [:as
Allen Roberts [:long as possible and get the care that they need.
Katie White [:Okay. And so it's all about this self direction for the veteran to direct their own long term care services and supports. So in a lot of our case management, we get the referral and we go out and we're helping to coordinate all of the things. But in self directed, it's a little bit different. Right? So tell me about that first home visit or assessment. What all goes on there?
Allen Roberts [:Yeah. So the first assessment, it's our longest appointment with a veteran and their family. So our goal is enrollment. So the the VA has already determined them eligible for the program.
Katie White [:Okay.
Allen Roberts [:And so, when we get out there, we have to assess what their, care needs are.
Katie White [:Okay.
Allen Roberts [:Who's going to be their primary caregiver? So, in this program, we don't help them find the caregiver, which is different than other forms of case management.
Katie White [:Okay.
Allen Roberts [:And
Allen Roberts [:so since it's self directed, they have to find the caregiver.
Katie White [:Okay.
Allen Roberts [:So, typically, it is a family member. It's a spouse, an adult child. It is a friend of the family. I'm so weird saying adult child.
Katie White [:Yeah. That's right. Yeah.
Allen Roberts [:A neighbor, whoever they have within their kid network.
Katie White [:Okay. So that person has to already be identified if they want to enroll in this veterans directed care? Yes. Like, when when we get out for the home visit, that person's already identified?
Allen Roberts [:Yes.
Katie White [:Okay. And are they at the home visit too?
Allen Roberts [:Yeah. Most yeah. Most of the time, it's actually a family member that lives in the home too.
Katie White [:Okay.
Allen Roberts [:So a lot of times it's the spouse. Okay. And if the veteran so it's all directed by the veteran. And, we what really made me interested in this program is we had self directed programs when I worked for DD. Oh.
Allen Roberts [:And so,
Allen Roberts [:I was a little familiar with the way they operate. Okay. And so, it is just empowering the person to be in charge of their own care. Interesting. And so, yeah. It's a really neat model. And so, the caregiver's already there.
Katie White [:Okay.
Allen Roberts [:And what the program does, is once they're enrolled in the program, the veteran is starting their own business per se, and they're employing that caregiver.
Allen Roberts [:Okay.
Allen Roberts [:And so they actually get paid. So they get a budget based on what their care needs are through the VA. And there's a multitude of services that can be authorized through this budget. So, the veteran authorizes the services Okay.
Katie White [:And
Allen Roberts [:they determine who the caregiver is. And so, it can be if they need, adult day supports, if they need homemaker services, personal care services, even if they need equipment that's not covered by health insurance, It can all go in this program.
Katie White [:Wow.
Allen Roberts [:Yeah. And so
Katie White [:So we okay. So the VA says you're eligible. A veteran reaches out and says, hey, I'm interested in this. The VA determines eligibility. They send us the referral. We go out, and we are assessing what they're eligible for?
Allen Roberts [:That's already the budget is already determined. So part of the eligibility process is determining what their budget would be.
Katie White [:Oh, the budget's already determined. Okay. Yeah. Okay. So we go out. The budget's already determined. We're working with the veteran and their caregiver just to kinda explain, like, here's how you run the business.
Allen Roberts [:Yeah. So there's a third piece to this too. So the VA is actually contracted with Penny Ryle Area Agency on Aging in Kentucky. So they do all the financial management part of it.
Katie White [:Interesting.
Allen Roberts [:Yeah. And then we do the case management. So they I I explained it to people when we got to their homes. They do the money part, we do the people part.
Katie White [:Okay. Oh, I like that.
Allen Roberts [:And so what happens is is our goal is to enroll them, see exactly what's going on in the home. How much how many hours are they looking to, need care? Okay. So, first visit, I go in. I have 2 packets of paper. 1 for the veteran to fill out to actually start the business. 1 for the caregiver to apply like they're being employed somewhere else. So it's that same, onboarding paperwork that we get when we start a new job.
Katie White [:Interesting.
Allen Roberts [:Yeah. And it's the interesting part is sometimes they all get confused. They're like, woah. This is tax paperwork.
Katie White [:Yeah.
Allen Roberts [:And so, we have to explain that Penny Rattle takes on the tax liability. That's where they come in. Or I would say tax responsibility, not liability.
Katie White [:Sure. Sure.
Allen Roberts [:Mhmm.
Allen Roberts [:And then, so they handle all that piece for them. And so, since there's never an exchange of money from the budget to the veteran, it doesn't affect their taxes. It doesn't affect their income. Wow. Okay. So, that's the good part is that Yeah. Truly is being paid for by the, VA. So instead of That's smart.
Allen Roberts [:Yeah. It's it's good. So instead of paying a third party to provide the care, someone that knows them, especially people who are very private, and they don't want, like, someone they don't know in their home. Yeah. And it's makes them more comfortable.
Katie White [:And we don't have enough caregivers as it is.
Allen Roberts [:Yeah.
Katie White [:We know there's a lot of unpaid family or informal caregiving. This feels like the best of both worlds of we got the caregiver, and we can pay him. Yeah. That's pretty great.
Allen Roberts [:Yeah. And to me, it closes the equity gap because a lot of these spouses have to quit their jobs. Yes. So then they lose their income. And then that's where all those other things fall into place. Like they may have an SDH need now, because they can't afford to pay their entire mortgage anymore, you know, afford to live the way they used to. So this gives them income.
Katie White [:That's the first visit, and you're really walking them through starting up this business and looking at needs, which again, just like blowing my mind that it's the perfect combination for your business and your social work degree. How amazing. I'm sure it's just like I would imagine you love this.
Allen Roberts [:Yeah.
Katie White [:And then, do we provide ongoing case management, or what do we do after that first assessment visit?
Allen Roberts [:So, yeah. After that, so we do what's called a mental emotional behavioral health assessment that comes with from the VA. And to me, it's it's like a psychosocial mix with a health assessment.
Katie White [:Okay.
Allen Roberts [:And so we complete that there. We have them go over the paperwork. Once we get everything finalized and submitted to Penny Rowe, they process it.
Katie White [:Okay.
Allen Roberts [:And then once a person is completely enrolled, we do the ongoing case management.
Katie White [:Okay.
Allen Roberts [:So we have to do a monthly contact every month to see if they're satisfied with the program. If their needs have changed, and kind of assessing like, is this employee working out for you?
Katie White [:Okay.
Allen Roberts [:Now, have you and we explained it a couple of different ways.
Katie White [:That sounds complicated. Right? Yeah.
Allen Roberts [:It is complicated. In theory, you can hire anyone that you want. So, if the veteran wants to advertise and hire someone that they've never met before, they can't do that. Or a friend of a friend. And so, we're kinda making sure those relationships are being built and maintained. In practice, a lot of times, it's a family member, someone that they know. So, there's not a lot of personnel issues. But if there were personnel issues, then veteran has to handle them.
Allen Roberts [:And we can kind of help facilitate that process. But we're also assessing, are their needs constantly changing? Do they need a higher, budget from the VA? Do they need a higher level of care? Do they need more than one caregiver? So that's what we do. And then we do a home visit once every quarter.
Katie White [:So the monthly contact's just by phone?
Allen Roberts [:Just by phone.
Katie White [:And then the home
Allen Roberts [:visit is quarterly. Yeah. The monthly contact can also be by
Katie White [:home visit if needed. So it'd be monthly
Allen Roberts [:contact can also be by home visit if needed. So if we call and there's something going on there and
Allen Roberts [:we really need to get out there,
Allen Roberts [:we can do that. Okay. So then,
Katie White [:the monthly contact checking in, the home visit quarterly, are you reassessing, or is it not that formal as an assessment, but it's just important to actually, you know, lay eyes and have an in person?
Allen Roberts [:It's yeah. It's not as formal as an assessment. We're just going out there and making sure everything's fine and checking in. They want us to have that face to face contact to build the relationship And to see if there's something that we may notice, that the family may not notice. And so that's sometimes it's helpful because the families are just used to doing everyday things. And they're like, not knowing that you can get help in this area. Or, oh, there's, you know, this person's having issues, navigating the house. And we can say, as the experts, oh, yeah.
Allen Roberts [:We can have we can get a resource where you can get, grab bars or shower chairs and different things like that. So things that they may not notice, we can kinda help when we go out there and take a second look.
Katie White [:Okay.
Allen Roberts [:Oh.
Katie White [:And then if we did recommend a grab bar or a rollator or something like that, then does the veteran have to order it through their business? Is it part of their monthly budget, or is that separate?
Allen Roberts [:Both.
Allen Roberts [:Oh.
Allen Roberts [:So yeah. So if the so my first go to is always because, I want to maximize the veteran's budget in the best way possible. So, it is to always, is that paid? Can that be paid, through insurance? Does the VA have another program? Or do you have insurance through the TRICARE, is what they call it. Veterans insurance, that can help you for this. If not, then let's look at this, budget, and we have to reassess.
Katie White [:I see.
Allen Roberts [:Because most of the times, the family wanna family wants to maximize that, veteran, using personal care, home and good care, because that's the bulk of the services. Okay. So that, and that's another part of the reason why we assess every month. I don't wanna say assess, but why we why we just look into things and see how things are going. Just checking in. Yeah. Just checking in. Because if there is a need that's coming off from the budget, we have to readjust and say, okay, caregiver, you may have to work this many hours or we're changing this up just because the veteran needs this.
Allen Roberts [:Or, if both needs are, I don't want to say equal, but like they need this equipment, but they also still really need that personal care, we would take that. We would then initiate. We can initiate an assessment at any point.
Katie White [:Okay.
Allen Roberts [:So, if I go out there and that person's like, I really need some some medical equipment, that's not covered and I wanna get it through the VDC program. Or sometimes stuff happens and Medicare and Medicaid only pays for like a wheelchair or certain things every 2 or 3 years, and you're within that period, and you wanna buy something else. Sorry, I can get really in the weeds with this.
Katie White [:I want you to get in the weeds.
Allen Roberts [:And they wanna use that budget, we would then be like, okay, but we can't. We cannot risk your health and safety. Right. We still need this certain level of personal care. I would initiate another MEBH assessment, send that to the VA, and justify why they need an increase in their budget.
Katie White [:Okay. And if the VA denied it, and I don't know the VA as well as some other programs that we work with, but there are some times when things get denied. What I love about us is that then we've got either a bunch of equipment that is in the basement that's been donated or we've got aging solutions where you can go to and say, you know, they really need this. So we always have sort of that next level of support, that next level of option in case whatever's 1st or second or third isn't going to work.
Allen Roberts [:Yeah. And that's the beauty that, of us doing the program.
Katie White [:I agree.
Allen Roberts [:And I've explained that to families because they're like, well, what happens if this person, you know, we have to change the way we do things and they need a higher level of care. Mhmm.
Allen Roberts [:So, we're
Allen Roberts [:the people that assess that. Yep. What happens if they need community resources or the caregiver needs resources? Or are the people that do that? I've already, and the VA has caregiver support programs, too.
Katie White [:They do.
Allen Roberts [:Okay. And, I actually went to Tammy, Good. Last week. Nice.
Allen Roberts [:And I
Allen Roberts [:was like, hey, we got this program with the, the VA, and it's a BDC program. 1 of the caregivers needs some help. And she they're connected. Anya and Tammy are connected with the VA for their caregiver program. So they were giving me that resource.
Katie White [:That's awesome. So the VA has their own caregiver programs, but they could also utilize and come to some of our support group or education, or maybe they wanna sign up for Geralta, our online caregiver platform. Okay. Great. Yeah. So it's it's looking at the whole person and the whole family, quite honestly, a lot of times in this, program and just plugging in all those different pieces that they need to be able to stay in their home as long as possible.
Allen Roberts [:Yeah.
Katie White [:Very cool. Okay. My last question specifically about visiting is, if there's a hospitalization or something like that, do we then go back out and reassess? Do that trigger like an another assessment?
Allen Roberts [:I think that's at our discretion. So
Katie White [:Okay.
Allen Roberts [:My very first consumer that we enrolled in the BDC program had a knee surgery. And so, I had to assess at that point, you know, what's your care gonna look like after? Is it gonna increase permanently or is it gonna be like a short term, need? And he explained it and he actually had some supplemental help, I think, through his insurance. They have like a nurse and OT and stuff come in.
Allen Roberts [:Great.
Allen Roberts [:So he didn't need additional care.
Allen Roberts [:Okay.
Allen Roberts [:But if they were to come from the hospital and they're like, this is gonna change, whether it be 3 or 6 months or it's gonna be a permanent change, we then reassess.
Katie White [:Okay. Okay. Got it. Great job. I feel like I, like, totally get it, and that's not always the case. So that's what the program looks like. And, obviously, you're having a very intimate experience because you're creating this. So you're not just talking about here's how a visit would go, but you're saying here's how it goes when I'm there.
Katie White [:So you're truly building this program, from the start on up. And you've hired some folks in who will eventually, you'll train and will take over some of the case management. What I'd like to know is, what is it like to create a new program like this?
Allen Roberts [:Yeah. It's really I love it. So, really, I've created programs in the past Okay. Within other places. And what I like about creating this program, because Penny Ryle, the financial management company, they also do case management.
Katie White [:Okay.
Allen Roberts [:And so they've been able to give us their tips and tricks. But then we've been able to use our expertise from our care transitions program to help determine, like, what really works, what processes are gonna be best for us. Some people don't love it, but I like writing out processes. Oh.
Katie White [:Okay. I love
Allen Roberts [:seeing stuff from start to finish and being able to say, but the added part that makes this even better is that I'm doing the home visits too. Mhmm. So I can say this is what's working and this is what's not.
Katie White [:Yeah.
Allen Roberts [:And we have Brianna's a care coordination assistant in our department. She's wonderful. So she's been helping because we have been hit with we started in June Mhmm. And we have a caseload of about 30.
Katie White [:So we are, almost to the end of July. And so in 6 weeks, we've got a lot of referrals.
Allen Roberts [:Yes. And they keep coming. They're not slowing down, which is really You're doing
Katie White [:too good of a job.
Allen Roberts [:And so, really, the whole team has pitched in. Melissa Great. Lisa has pitched in. Lisa has been like, I can do home visits if I need to bring it on. I've been tag teaming. I
Katie White [:mean Great.
Allen Roberts [:In the
Allen Roberts [:first week and a half, I did 11 home visits.
Katie White [:Oh my gosh.
Allen Roberts [:Because the families are like, this is such a huge need for us.
Katie White [:Yeah. Well, and when we're creating something that is it's not totally unfamiliar, but it's kind of another version of pulling together some of the things we already do from different programs.
Allen Roberts [:Yeah.
Katie White [:The team and division that you're in is interdisciplinary, which is awesome. So you've got your care coordination assistants, community health workers, nurses, social workers. So together with all these lenses, then we're creating kind of the policy and and the toolkit for how to do it. Is that right?
Allen Roberts [:Yeah. So they we, through ACL and Penny Brow, we have a handbook of operations. Right? How the program should be operated, but we have the creative ability to make our own processes.
Allen Roberts [:Mhmm.
Allen Roberts [:And so to switch up some of the paperwork to make it more efficient for us.
Katie White [:Okay.
Allen Roberts [:And so, we've really sat down and said, from start to finish, what's this gonna look like? And Lisa and I made a route sheet. Great. And that's constantly being changed right now because with new programs, it's always changing. Uh-huh. And so we've got it to a good point to where when the 2 new case managers start, we can say, here's what this process looks like. Let's train you. And then they can hit the ground running because then we can take more referrals.
Katie White [:That's excellent. So we've got the sort of end goal or boundaries that we operate within.
Allen Roberts [:Yes.
Katie White [:But then we've got the autonomy and flexibility to be creative, to create our own efficiencies, to work in are we working in our SDOH screen?
Allen Roberts [:So we yes. We have initiated that. We're trying to figure out the best and I've talked talked to Melissa about this. Like, there's so much paperwork in the beginning. Oh. We're like, we're not gonna do that the first, assessment. So, probably the 3 month, the home visit.
Katie White [:Gotcha. Smart. Visit after. Yeah. Yeah. So then we've got our manual of how we're pulling in all the additional resources and things that we have. Yeah. We're following our clinical excellence.
Katie White [:We are meeting all the needs. We're being financially responsible and all of those different pieces.
Allen Roberts [:Yeah.
Katie White [:That is so cool. Now what documentation system are we using? Are we documenting in the VA system?
Allen Roberts [:No. So we are using MonaMe. They so we can use our whatever documentation system we want.
Katie White [:Okay.
Allen Roberts [:So we're using MonaMe. They built us a, a section or whatever, our own program in MonaMe
Katie White [:Okay.
Allen Roberts [:For us to do this.
Katie White [:So MonaMe is a it's a case management platform that we use for some other projects, but you're saying now we have a VDC portion of Monomi. Great. Okay. So then did you have a hand in helping to build that?
Allen Roberts [:A little bit. See here and there, Melissa had it. So before my time here, Melissa and Lisa had already I don't know how long ago, but I would say at least a year had already been planning for this.
Katie White [:Okay.
Allen Roberts [:So the idea to have it in MonaMe was already gonna work like when MonaMe reached out to, Melissa, she had the BDC. So when we do a case note, we have to put a subject and kind of like the format of case noting. Melissa had that ready to go, and she emailed it to them and they built it, And now we've been doing the case noting there.
Katie White [:Okay. That's awesome. So a lot of the programs that we do case management, we actually document right in the other people's system that's sort of required. So when we think about some of the insurance companies that we're working for, the managed care organizations, it's their database Yeah. Which means we don't necessarily have full authority over pulling reports and analysis and things like that. So anytime we get programs that go into our MonaMe database that we're utilizing here, I just I just love that because, again, it builds in our tools. That's where our SDOH screening lives.
Allen Roberts [:Yeah.
Katie White [:And then it allows us that full capacity for reporting.
Allen Roberts [:It's it's great. And then, we also so there was, not a program in a different area of Ohio, so Perry County. And so they reached out to us and said, Hey, we have some families in Perry County that would really be They would love this program and they need it. So we have one right now. Oh. But we are taking, referrals from the program from Perry County. We're gonna do those, virtually right now just because of how far it is.
Katie White [:Okay.
Allen Roberts [:But, if they need a home visit, we'll make it work. Wow. So yeah. So we're even saying, let us do more if we can.
Katie White [:Yeah. Especially if we're putting all this time and effort in. If there's, you know, 5 or so referrals in Perry County, it wouldn't make sense for that area agency on aging to create this entire system when we can more efficiency, efficiently and effectively do it. Okay. So you're going out. You're doing the visits. You're creating the manual, the policies, and the procedures. What are the, reporting requirements like? And how are you going about ensuring that we're meeting those?
Allen Roberts [:So we have to monthly, we have to submit our case notes.
Katie White [:Okay.
Allen Roberts [:Submit our contact. We have a spreadsheet that says when we contacted the person, and was that telephonic or was it a home visit?
Allen Roberts [:Okay.
Allen Roberts [:And so we have to submit that to Penny Rau.
Katie White [:Okay.
Allen Roberts [:And so then they kind of assess that. And actually, throughout the entire time we've been doing it, we've been submitting stuff saying, can you give us feedback? Can you give us examples of how you do it? Because we want to be successful.
Katie White [:Okay.
Allen Roberts [:But we wanna do it, they're the experts. They've been doing it for years.
Katie White [:Yeah.
Allen Roberts [:And so we kinda wanna learn from them. And then while we have our autonomy, add in our expertise as well.
Katie White [:Okay. And then are there any is there anything you're tracking at this point? I mean, I know it's super new, but or anything that you're like, okay. These are some things once I train other people that I'm gonna be checking in on. Like, I don't know, any performance indicators that you're thinking about?
Allen Roberts [:So, yes. I think for the most part is like, how often are we gonna be reassessing people?
Katie White [:Okay.
Allen Roberts [:What are the needs of, you know, are there things that the program isn't doesn't cover Mhmm.
Allen Roberts [:Where
Allen Roberts [:we can bridge those gaps. Mhmm. What kind of case management are we gonna do? Because so there's some case management where it's hands off, where it's like, oh, we're just doing the contacts and we're meeting the metrics for Pennywise, so we turned it in. But I wanna know, are we gonna need to up our, you know, home visits? Are we gonna need to be do more care navigation?
Allen Roberts [:Mhmm.
Allen Roberts [:Are we gonna have to make additional referrals? Because sometimes people think just because it's the VA, they have a comprehensive care plan and a lot of care services, which they do. A lot of them do. But sometimes, we have to know where to bridge gaps.
Allen Roberts [:And that's
Allen Roberts [:kind of what we're assessing. What gaps are there that they may not know that the that gap could be, Hey, here's a service that this veteran doesn't know the VA has. Mhmm. And us reaching out and saying, Here's how we can connect you there. We have a really good relationship with the Columbus VA.
Katie White [:Yeah.
Allen Roberts [:And so, where are those gaps in care? That's kind of where what we're assessing. Where are the gaps in care and how can we fill those gaps?
Katie White [:Okay. And so, especially thinking about how you'll start working in at the 3 month mark, the social drivers of health tool, that will continue to even further let us know what needs are there. And then over time, we'll be able to start looking at some trends. Right? What's the, food insecurity like with the veterans population? What's the housing insecurity like? And and really getting into some of those predictive analytics to know, okay, now we need to build right up front. We know we need to talk about housing or whatever it is.
Allen Roberts [:Yes. Yeah. It'll kind of help us do that. And then, really, sometimes the veterans are, they have I think of one person I worked with, recently. I went into their home and all of this was new to him.
Allen Roberts [:He
Allen Roberts [:had had a major, healthcare change and he went from being super independent to having to rely on other people to do lots of things for him.
Katie White [:Okay.
Allen Roberts [:And so one thing we assess is, what experience or what level of training do our case managers have to have? Because it's been a lot of, it's been real mental health heavy.
Katie White [:Yeah.
Allen Roberts [:So, a lot of the times they are connected to a mental health counselor. But you go in and these are very unique and very intense situations. So, I have to assess, how do we handle that when we go in there? And you have family members that are emotional. You have people that are angry because of what their situation is now.
Katie White [:Yeah.
Allen Roberts [:And so, we have to be very, cognizant of what, what's going on with the person, and how can we what's our clinical response? Yeah. So and sometimes the families, the individuals have, memory problems. So what are how can we go in and explain? Because when you say you're from CO Triple A, because we're working with the aging population, I've had someone says, oh, you're trying to put me in a nursing
Katie White [:Yeah.
Allen Roberts [:Or, like, no, it's the opposite. Mhmm. You know, we do have that program where people can apply for a nursing, home waiver. Mhmm. However, our goal is to keep you at home as long as possible. Yeah. And so being able to explain that or pivot when a family has an emotional response because they're watching the decline in health.
Katie White [:Yeah. It's really I mean, our role there is it's the Veterans directed care. So if they decided they did want to move into a long term care facility, you know, we would help we would help do that. But if their goal is to stay at home, then that's our goal too. Yeah. And I wanna make sure it's in it's veterans of all ages.
Allen Roberts [:Yes.
Katie White [:Not just older adults.
Allen Roberts [:Not just older adults.
Katie White [:All ages. So so any age, if you're a veteran and you wanna do veteran directed care and you're in Central Ohio, then we would be case managing that.
Allen Roberts [:Yes. Okay.
Allen Roberts [:Yeah. Yeah. So yeah. Anywhere. So we have right now, enrolled, we have people in Newark. So Licking County, Madison County, Franklin, Delaware. I think some of our southern counties like Fayette, Pickaway are served by a different AAA. Okay.
Allen Roberts [:And so just because that I cannot remember what AAA, but that AAA already had the program. And so, really any age, I have had a gentleman who was in his nineties. Wow. And someone else who was, 37. Okay. So, the age range varies.
Katie White [:Yeah. That's a real range.
Allen Roberts [:And I do want one thing I wanna say about the program that I didn't mention earlier is if the veteran is cannot direct their care, they get to choose who can.
Katie White [:Oh. Tell me more about that.
Allen Roberts [:So if someone is having some, you know, cognitive cognition issues, and they're like, you know or they don't have a health status where they can do that. So, a situation where a guy is actually in palliative care Mhmm. And he doesn't have the, energy, and he's just like, I really don't wanna direct my own care.
Allen Roberts [:Mhmm.
Allen Roberts [:And so he, made his daughter the authorized representative. So they can assign the authorized rep to direct the care for them.
Katie White [:And do they have to qualify for that in a certain way? Or it's just like, I I don't want to or I don't feel like I can and I can have somebody else do it for me?
Allen Roberts [:Both. Yeah.
Katie White [:Okay. Okay. Yeah. So it's not like you have to meet a certain criteria to be able to have an authorized rep. It's just if you want it. The autonomy in this program is awesome. I mean, it really is.
Allen Roberts [:It's
Katie White [:I don't know every single program in and out, but it feels just so much more dedicated to individual autonomy and independence and self efficacy than a lot of the programs I know about.
Allen Roberts [:Yeah. It's really empowering people to like It is. Yeah. And that's what I like about it, is that, it's the same with the self directed program that DeeDee had is, we're empowering people to put their care in their own hands. And we're just coming alongside them saying, how can we help you? Yeah. What can we do to make your life better?
Katie White [:And isn't that what we all want? Yeah. I mean, that's what I would want. Yeah. Right? Okay. Excellent. Anything else that you wanna share about the program or things that you feel like people should know about VDC?
Allen Roberts [:It's, may not be in every, county in Ohio yet. But the plan is for it to grow. So if it's not, reach out to the the VA, and they'll get you connected to the closest program near you. That's Yeah.
Katie White [:And per usual, we're at the forefront of this movement and we are dedicated to making sure it's successful. And so when other AAA's come on, I'm sure we'll be mentoring folks because, you know, that's part of our mission is making sure that we find the programs that work. We make them excellent. And then we help replicate that where needed. And so we've got 2 people coming on board that will take over. And one of them is a veteran, I don't know, enhancement to the program too.
Allen Roberts [:Oh, absolutely. It's,
Allen Roberts [:one
Allen Roberts [:of the things, so, I'm not a veteran. And so, it's really neat for me to go in and learn and work with this population. But to have someone be in there, I mean, that truly is what cultural competence is to have a veteran working at.
Katie White [:So well said. So well said. Awesome. Okay. Well, before we close out here, I wanna give you the opportunity, to either share a success or favorite story. So, it doesn't have to be VDC, but if it is, even better.
Allen Roberts [:Our CHW program. So Roz, one of our community health workers, was working with this member who needed housing.
Katie White [:Okay.
Allen Roberts [:She'd been working with this member for, a long time. And she lived in a hotel. She was homeless, so she was spending a lot of money living in a hotel every month. And was having a difficult time. And she had some complex health needs. So she'd be in and out of the hospital. Roz was able to help this person secure affordable housing. Wow.
Allen Roberts [:Get the furniture she needed. And this person is successfully living on their own.
Katie White [:Oh my God.
Allen Roberts [:And they're having Ross helped to bridge those gaps in care. So they have the specialist they need, they have a PCP they need, they have the housing and everything to make sure she maintains our housing. Wow. That that would be and then another success story was a partnership that we all did at c o triple a with, the housing department. And I know Grant had a lot of work when the Sandridge Apartments.
Katie White [:Yes.
Allen Roberts [:We did the housing fair. Terrence was big in that as well. But I just wanna say, like, the success story of that is how we all came together as a team to help those people find housing. And I think several of them did. And we were actually able to I know when I worked for that day, there were 2 people who needed, And the And
Allen Roberts [:the fact
Allen Roberts [:that it's COAAA, we can do that and help these families, it's it's huge. And this lady was, she was like, I live by myself. I make money to pay my rent, but just because of this circumstance, I don't have the money to pay all this upfront. And so we were able to help her. She didn't she's on that, like, that middle line where it's like, I make too much money to qualify for help. I don't have any kids. She goes,
Allen Roberts [:do you want
Allen Roberts [:me to go adopt a kid? And I remember laughing with her.
Katie White [:Help me qualify. Yeah. Yeah.
Allen Roberts [:And I
Allen Roberts [:was like, there's a program or something out there for you. So with our through our housing assistance program, we were actually able to help her.
Katie White [:It makes me so it feels funny to say it makes me so happy because I know it's working in really difficult situations, but it's, it does make me happy that we're in these situations because I know the level of dedication and passion that we have here. And I know that our staff will not give up until we figure out what's needed. Yes. Right? So that's the happiness. It's I'm happy for the community members that CR Triple A is here because we're awesome.
Allen Roberts [:Yeah. We are. I don't know.
Katie White [:No other way to put it.
Allen Roberts [:It's good teamwork.
Allen Roberts [:We're
Katie White [:It really is.
Allen Roberts [:Great team.
Katie White [:Yeah. Okay. And then the last thing is, the miracle question. So what is one thing you would change or add about CRAAA?
Allen Roberts [:So normally, when people ask us at jobs, I say, I want a dog. But we have dogs all the time. Yeah.
Katie White [:You have dogs. The wellness lab.
Allen Roberts [:Wellness lab. Yeah. So but that, I was thinking a 4 day work week. Oh. I love a 4 day work week.
Katie White [:I too would love a 4 day work week. I will say our colleagues up in Toledo just rolled out a 4 day work week. So they piloted it, they tested it, and they just rolled out a 4 day work week. So Interesting. It's not impossible.
Allen Roberts [:Community Action in Pecos County does that. And that's where I first heard it. And I was like, it's possible in this word.
Katie White [:It is possible. Yeah. And I think, you know, we're doing a lot around staff welfare and making sure that we support the people that are supporting the people. Right? Yes. And because what we do is so it it's intense and it's difficult and it's not like you hang up the phone and that person's whole life and, you know, challenges go away. And so having that extra day to really kind of decompress and, just spend time on yourself or whatever it might be with your dog or yeah. Okay. 4 day work week.
Katie White [:Noted. Well, thank you so much for being here, for starting BDC, and for doing such a fabulous job and making sure this program is gonna be great.
Allen Roberts [:Thank you. I couldn't have done it on my own. So it's teamwork. Lisa, Melissa, Brianna, Brianna is fantastic. So I if I didn't have the we didn't have the team behind us, it would not we would do it, but it wouldn't be as successful as it is.
Katie White [:I know exactly what you mean. Kudos to the team. Thanks. Thanks, Allen. I hope now you know something about Veterans Directed Care.
