HomeVA Spinal Cord Injury SystemSCI CentersSCI Center Home Care (HC) Program

5.13. SCI Center Home Care (HC) Program

SCI-HC at the SCI Center supports the transition and medical needs of patients in the home setting, decreasing the need for hospitalization when possible. The SCI-HC Program renders important medical, rehabilitation, and preventive services determined necessary to sustain Veterans with SCI/D in the community and assists the VA Medical Foster Home (MFH) Care Coordinator in specialized home assessments, the provision of caregiver training for the MFH caregiver, and routine care visits to ensure proper management of bowel and bladder care, skin care, and pain management. SCI-HC consists of interdisciplinary services as an integral part of SCI outpatient services under the clinical and administrative responsibility of the Chief, SCI Service. NOTE: Telehealth care may be used as an adjunctive measure to supplement the SCI-HC program.
  1. All SCI Centers must provide follow-up through SCI-HC. This follow-up consists of interdisciplinary services as an integral part of the SCI outpatient services.
  2. Patients living beyond a 100-mile radius of the SCI Center may be evaluated by SCI-HC if approved by the Chief, SCI Service. NOTE: This specified distance is determined locally by the Chief, SCI Service. However, such patients may be referred to a closer VA medical center and SCI Coordinator for follow-up care.
  3. Veterans with SCI/D who are placed in community nursing homes and MFH must be seen and followed by SCI-HC staff when they reside within the allotted transportation distance of the SCI-HC Program.
  4. SCI-HC Clinics must be set up using clinic stop 215 and dedicated SCI-HC resources will be mapped accordingly in the Decision Support System.
  5. SCI/D MFH visits by the SCI-HC team must be captured using clinic stop 215 as the primary stop code and 162 as the secondary (MFH credit stop).
  6. Before SCI-HC admission, the patient and the caregiver must be evaluated and provided with adequate education to ensure successful participation.
  7. Upon admission to the SCI-HC Program, a treatment plan must be developed in collaboration with the patient and family by the SCI-HC staff. Specific goals of treatment and target dates for accomplishment are to be established. The care plan is to be reviewed and updated by the entire team no less than every 90 days, or as required by accrediting organizations such as The Joint Commission (TJC), and a determination made regarding the need for continuance in the program. An interdisciplinary approach to treatment planning and service delivery needs to be reflected in the medical record.
  8. Medical records documentation must meet VA and appropriate accrediting organization requirements by using CPRS for documentation. In addition, the SCI-HC Program must submit reports to VHA Central Office as requested.
  9. SCI-HC participates in the service-based SCI QI Program.
  10. All Veterans in the SCI-HC Program are eligible for inpatient admission to the SCI Center, if medically indicated.
  11. To be admitted to SCI-HC:
    1. The patient must have a medical need for skilled services in the home and live in the geographic area covered by the SCI-HC program.
    2. The home environment must be physically suitable or adaptable for daily care to be provided at home.
    3. The patient's medical problems must be able to be managed or coordinated by the SCI- HC team.
    4. The patient and family, or MFH caregiver (or others) must: 
      1. Assist in developing the proposed plan of care; 
      2. Give informed consent to be part of the program; and 
      3. Be in agreement with treatment plans.
  12. SCI-HC services provided include, but are not limited to: 
    1. Prevention of complications; 
    2. Education; 
    3. Home evaluation;
    4. Medical management and care;
    5. Psychological and social support;
    6. Community agency referrals;
    7. Nutritional counseling;
    8. Direct nursing care, when indicated;
    9. Assessment of equipment needs;
    10. Education and support to patients, families, and caregivers;
    11. Leisure counseling and training;
    12. Vocational follow up;
    13. Establishment of a therapeutic regimen in the home;
    14. Assessment of needs for homemaker or home health aide services with appropriate referral to community or other resources; and
    15. Training and assistance in ADLs.
  13. Home visits must be ordered by a physician; the frequency of home visits is determined by the individual needs of each patient. Each team member must write progress notes after every home visit. Patients admitted to the SCI-HC Program generally fall into one of three categories:
    1. Intensive Patients. Due to the scope or severity of problems, these patients must receive a minimum of one visit per week by a discipline associated with SCI patient care. Examples of such patients include:
      1. The newly injured who are adjusting to community living following initial discharge from the medical center;
      2. Those with acute problems (i.e., new diagnosis of diabetes or hypertension); and
      3. Any patient with specific changes in the home and/or health environment (i.e., breakdown in community support system, change in attendant or equipment).
    2. Maintenance Patients. Maintenance patients must receive a minimum of one visit every 2 or 3 weeks (or a frequency determined by the SCI team) by a discipline associated with the SCI Center. Examples of such patients include those in need of regular laboratory work, functional rehabilitation evaluations, regular nutritional counseling, or caregiver support.
    3. Preventive Care Patients. Preventive care patients must receive a minimum of one visit every quarter by a discipline associated with the SCI Center. Such patients have no ongoing major problems, but need periodic monitoring for support, assessment, and prevention of problems. These patients include individuals at risk for recurrence of problems; those with a history of high recidivism who may benefit from ongoing monitoring to avoid hospitalization; or those in special programs (e.g., MFH) where monitoring is necessary.
  14. Length of participation in the SCI-HC Program is determined by clinical need. There is an expectation that patients with new injuries will be enrolled in the SCI-HC Program for less than 1 year, as the focus of services needs to be on independent community functioning. All patients are to be re-evaluated every 90 days, or as required by accrediting organizations such as TJC, regarding need for continuation of the program.
  15. As part of the admissions process and on an ongoing basis, patients and caregivers must be offered education and training in home safety, infection control, and handling of emergencies.
    1. Patients are to be given written information regarding procedures of handling emergencies during the program's normal duty hours, as well as after hours. Plans are to be developed to ensure continuing and appropriate care in case of an emergency resulting in the interruption of patient services.
    2. Patients must be provided education regarding basic home safety, the safe and appropriate use of medical equipment, and the identification, handling, and disposal of wastes in a safe and sanitary manner.
      1. The program must have infection control procedures that address personal hygiene, isolation precautions, aseptic procedures, staff health, transmitted infections, and appropriate cleaning and sterilization of equipment.
      2. All staff, patients, and caregivers must be instructed regarding their responsibilities in the infection control program.
      3. A system must be developed to report and document all accidents, injuries, safety hazards, and infection control.
  16. Any of the following situations provide sufficient reason to discharge a Veteran patient from the SCI-HC Program.
    1. The patient has achieved the goals identified in the care plan and no longer needs SCI- HC intervention.
    2. The patient is admitted to the medical center for an extended stay of more than 15 days.
    3. The patient requests termination.
    4. A persistent and intentional refusal of a Veteran, family, and/or significant other to cooperate with SCI-HC Program staff, resulting in an inability to provide services safely or effectively. Before the final decision is made, the situation must be discussed with the Veteran or, with the Veteran's approval, their representative, family, and/or significant other and documented in the record. The Veteran to be discharged must be notified in person and in writing. If a family member or significant other's interference in the provision of care through the SCI-HC Program results in discharge from the program, a referral will be made to an appropriate health care professional for additional intervention, services, or referral.
  17. The SCI-HC supports the development of SCI MFH as resources allow and supported by state laws. SCI-HC provides home health care, and monitors care provided by the MFH caregiver. SCI-HC will:
    1. Provide home health care services to Veterans in MFH in accordance with national program policy for Home Based Primary Care (HBPC) or SCI-HC;
    2. Educate the MFH caregiver and relief caregivers in specialized Veteran care needs;
    3. Evaluate the need for adaptive medical equipment and appropriate home improvements and assist eligible Veterans in applying for HISA grants when indicated;
    4. Identify any need for community resources and coordinate the purchase of community home care services;
    5. Support the MFH caregiver and Veteran through timely communication and problem solving;
    6. Update the Veteran's family or surrogate regarding changes in the Veteran's medical condition in accordance with VA privacy policy and procedures;
    7. Assist the MFH Coordinator in monitoring the MFH environment with special emphasis on safety, potential for abuse and neglect, signs of caregiver stress or burnout, and any other issues and concerns that may arise;
    8. Report any MFH violations or medical, psychiatric, or psychosocial concerns to the MFH Coordinator; and
    9. Assist in scheduling respite care to alleviate caregiver stress and fatigue. 
  18. Responsibilities of SCI-HC Personnel. 
    1. SCI Chief. The SCI Chief is responsible for:
      1. The SCI-HC program, both clinical and administrative. NOTE: The SCI Chief may delegate the administrative responsibility for SCI-HC to the Program Coordinator.
      2. Ensuring that written policies and procedures are developed in compliance with all applicable VHA Central Office and accrediting organization standards and requirements, and that these be reviewed bi-annually, and updated as necessary.
      3. Selecting an SCI-HC Program Coordinator in conjunction with the respective service chief.
      4. Assigning the physician in charge of SCI-HC staff.
      5. Providing input to the performance evaluation of all SCI-HC staff.
      6. Providing liaison with other services.
      7. Ensuring SCI-HC actively participates in the SCI QI Program.
      8. Considering continuing education participation as a part of annual staff evaluation reports and in credentialing and privileging activities.
    2. SCI-HC Program Coordinator. The SCI-HC Program Coordinator is responsible for:
      1. Providing administrative direction to the program interpreting national SCI-HC, local VA medical center policy, and accreditation guidelines to the SCI-HC team and the Medical Center;
      2. Developing and implementing local policies and procedures;
      3. Coordinating the provision of services and administrative functions of the program;
      4. Facilitating appropriate referrals to the program;
      5. Monitoring and controlling program operation expenditures and advising the SCI Service Chief on budgetary requirements;
      6. Coordinating and participating with selecting officials in the filling of SCI-HC personnel vacancies;
      7. Arranging orientation of new SCI-HC staff;
      8. Preparing and maintaining program reports and statistics;
      9. Evaluating program effectiveness;
      10. Providing input to the performance appraisals of team members and forwarding input through the SCI Service Chief;and
      11. Designating an SCI-HC QI representative; 
      12. Ensuring appropriate documentation is entered in CPRS, according to agency policy; 
      13. Maintaining appropriate records for reporting purposes.
    3. SCI-HC Team. The SCI-HC staff must be interdisciplinary and with appropriate personnel to meet the patient's identified needs and treatment goals, and include the SCI-HC Program Coordinator.
      1. Staff members are selected and assigned by their respective service chiefs; however, the Chief, SCI Service, in consultation with the SCI-HC Coordinator, must concur in each selection.
      2. All staff are programmatically accountable to the Chief, SCI Service. 
      3. All team members need to: 
        1. Participate in administrative and clinical team meetings; 
        2. Document in CPRS according to agency policy;
        3. Provide input to the QI process;
        4. Conduct and arrange home visits and home evaluations as appropriate;
        5. Share new developments pertaining to the patient, caregiver, and home situation with other team members;
        6. Participate in inpatient discharge planning activities; 
        7. Evaluate safety and emergency preparedness in the home; 
        8. Participate in planning each patient's discharge from the program; 
        9. Report program needs, problems, or concerns to the coordinator; 
        10. Maintain required credentials and, if appropriate, clinical privileges;
        11. Participate in orientation of new SCI staff;
        12. Be involved in on-going staff development and continuing education activities for the SCI-HC Program; and
        13. Comply with the professional standards and guidelines of their respective disciplines.


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