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• VISN number: VISN 10

• Station number: 541

• Facility Name and address: Louis Stokes Cleveland VAMC 10701 East
Boulevard Cleveland, OH 44106

• Name, title, and contact information of the person at the VISN level that can
answer questions about the proposal: Sheila Gelman, VISN 10 Chief Medical Officer,
(513) 247-4621, sheila.gelman2@va.gov.

• Name, title, and contact information of the person responsible for the project at
the Medial Center that can answer questions about the proposal: Dale Goldstein,
Assistant Chief, Social Work Services, (440) 526-3030 ext. 7214

• The Psychosocial Intensive Case Services (PICS) program provides intensive

case services for the elderly veteran population receiving HHA care that have
psychosocial needs that are interfering with health care stabilization. Services will be
geared to in home interventions and visitation. Services can include but are not limited
to; psychosocial assessments and an evaluation of the veteran's living conditions,
assistance in the area of emotional and environmental needs, referral to available
community resources, and follow up for on going support. Nationally the Louis Stokes
Cleveland VAMC has the largest number of veterans (1,500) receiving HHA care of any
VAMC with ADC of 665. Approximately half of that number receive HBPC while the
remainder of this cohort do not have skilled needs but have psychosocial needs thus
creating deficiencies and instabilities in his/her environment.

• Total amount of funding requested: $ 487,674

• Name and contact information for facility fiscal point of contact: Robert Kubec Budget
Analysis (440) 526-3030 ext. 4132

• Fund control point to which resources should be transferred: 76

 Psychosocial Intensive Case Services

1) Program Description
The goal of the Psychosocial Intensive Case Services (PICS) program is to deliver intensive
case management services for the elderly veteran population receiving HHA care that have a high
psychosocial need. "High psychosocial need" can be defined as veterans who have a lack of social
assets such as inadequate communal supports, are socially isolated, have minimal contact with
providers, are living in an unstable home or poorly maintained environment, are high utilizers of
emergency rooms, or have inappropriate behavior that leads to a discharge in HHA services. All of
these factors have a significant impact on veterans' mental health. Research now shows evidence
that there is a link between an individual's mental health and his/her physical well being. The aged
veteran population is plagued by disparities in availability and access to psychosocial services, thus
having a negative impact on a veteran's mental health. Caregiver burn-out is another area of
concern with this population. In many of these cases the caregivers of this frail population are the
veterans' wife who often times themselves are in poor health. This can lead to hospitalization of the
caregiver resulting in the veteran being in a position in which his/her safety is compromised.
Nationally the Louis Stokes Cleveland VAMC has the largest number of veterans of any VAMC
(1,500) receiving HHA care in the VHA with an average 665 daily census. These veterans are
scattered throughout 35 counties many of who live in rural settings. Additionally, these veterans
have few options of community resources that can supplement VA healthcare, and often these
scarce resources are not easily accessible. Approximately half of that population receives Home
Based Primary Care (HBPC) service; while the other segment of this cohort have personal care
services in addition to HHA providers but lack psychosocial interaction. This means there are no
current services to meet their psychosocial needs and there are no psychosocial services provided
by the VHA.
Another aim of the PICS program, in concert with the non-institutional care model, is to keep
veterans out of the hospital and nursing homes and in their own stable home. This objective can be
accomplished by increasing the level of contact by a social worker or rehab tech and decreasing the
incidents of "crisis" or reaction to psychosocial and environmental needs. The activities of PICS are
to use an interdisciplinary team approach to facilitate and implement service delivery by enhancing
the options available to veterans, utilizing other community alternatives, supporting veterans
through transitions to VA health care facilities, and collaborating formal and informal resources. A
key intervention by the social worker in the PICS program is to complete a psychosocial
assessment and an evaluation of the veteran's living conditions. That assessment will be completed
with the veteran in his/her home to give the social worker the opportunity to look at the psychosocial
and environmental inadequacies while supplementing strengths and giving the veteran the ability to
be an active participant in his/her care planning process.

2) Rational
At this time there are three Home and Community Based Care (H&CBC) social workers who
each field, an average, 40 telephone calls a week concerning HHA problems. One telephone call
can lead to additional telephone calls consuming much the social worker's time leaving a veteran
with feelings that he/she is in a "crisis" situation. These HHA problems include: problems with the
veteran, problem with family members, or problems with the agency. Examples of veteran problems
include inappropriate behavior with his/her aide, unrealistic expectations of the aid, or a sudden
illness resulting in a need for an increase in HHA hours. Family problems include drug/alcohol
addiction of the veteran's caregiver; an unsafe environment; abuse by the family caregiver; role
conflicts with family members, or abuse of veteran funds. Problems with agency can come about
when there is an insufficient number of staff, during times of a no-call/no-show of agency staff, or
when an agency aid unable to make contact with veteran at home. The PICS program supports the

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VHA patient-centric health care system by supporting veterans to stay in their home thus allowing
veterans the freedom to exercise cultural traditions, their personal preferences and values, their
family situations, and their lifestyles. Additionally the PICS program ensures that transitions among
providers, departments, and healthcare settings are respectful, coordinated, and efficient.
The PICS program uses the medical home model by providing case management services to
allow better access to health care, increase satisfaction with care, and improves health. The PICS
program applies the interdisciplinary team based approach by facilitating partnerships between
individual patients, and their personal physicians, and when appropriate, the patient’s family, and
HHA care staff and agency.
The PICS model is cost effective by its early intervention given the psychosocial needs of this
frail veteran population. Early intervention is cost effective, especially where the services are
offered to the chronically ill and enhances patient flow from hospital to his/her home. This
effectiveness results in appropriate clinic use and less emergency rooms visits. Here the activity is
important due to the need for veterans to have easier access to health care who live in communities
far from resources, and those veterans who have felt the impact from funding reductions due to
economic cut backs.

3) Outcomes/Deliverables
The PICS program, with 2 teams, expects to reach 300 plus veterans who have been identified
as having disruptive behavior or being at risk in addition to having severe psychosocial needs. This
will be accomplished through active case management and with frequent visitation the staff will
assist with securing transportation to medical appointments, checking on medication compliance,
individual and family supportive therapy, education in the area of prevention and good self care
practices. As a product of case management intervention the PICS program would then decrease
the number of emergency room visits, unnecessary primary care visits, and caregiver burn out.
The PICS program case management intervention will have several measurable outcomes
based on research and best practices in home health aid and non-institutional care. Accordingly,
the implementation of the program will measure several aspects of the home health care paradigm.
First, the program expects decreases in the number of emergency room visits, acute care visits,
and program discharges due to non-compliance. Second, the program expects to increase the
psychosocial well being of the veteran by measuring the improvements from using a depression
rating scale, a quality of life survey, and a home care satisfaction survey. Third, family care burnout,
if present, will be assessed and will show improvement. Last, social workers, rehab techs, HHA
aides and other agency personnel involved in the home care management of the veteran will be
assessed initially with a survey and will show improvement in their perceptions of risk and their
attitudes and assessment of the veterans’ psychosocial environment.
The ultimate result of this type of care is stabilization of the situation with veterans being able to
maintain themselves in the least restrictive environment thus avoiding nursing home placement and
hospital admission.

4) Timetable for Implementation

As soon as notification is received of program approval we will begin the process of developing
criteria for choosing the veteran client population and then appropriately identify cases. Additionally
at this time we will announce positions to be filled. January 2010 to February 2010 are the projected
dates in which staff will be interviewed, and hired by March 2010. Prior to March 2010 we will
secure both vehicles and IT equipment. March 2010 is the expected date the PICS program will be
fully operational. Veteran clients will then have been chosen and the program will be ready to
implementation clinical work. In the first month of operation staff members will collect data for the
purposes of obtaining a baseline of the population receiving PICS services, again in June, then
quarterly there after.

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5) Resources requested

Two Teams consisting of: IT costs

1 GS 11 social workers @ $83, 712 $167,424 6 laptops $1,000 ea.

2 Rehab Techs @ $ 62,646 $250,584 1 color printer/scanner $1,500
1 GS 5 Clerk for both teams $ 45,666 7 desk phones $150 ea.
3 Cars @ $4,000 $ 24,000 6 cell phones $25 ea.
TOTAL $487,674 TOTAL $8,700

6) Resources in place
The PICS program would fall under Social Work service which oversees all non-institutional
care services, except for HBPC. We currently have provider agreements with117 Homemaker
Home Health Agencies. We will continue to use the same structure that is currently in place such as
program director/ assistant chief of social work services and accounting staff. The resources that
are already in place are office space and office supplies. Additional equipment made available by IT
are 6 lap-top computers, 7 personal computers, 7 computer work stations, 7 telephones, 1 printer,
1 scanner, and 6 cell-phones.

7) Program Evaluation
Stability of the veteran will be evaluated by measures discussed in paragraph three above.
The program evaluation process will begin with the setup of a customized database to house the
data of patient records in the program from CPRS/VISTA, data from the psychosocial instruments
given to the patients, and data from the surveys given to the social workers, rehab techs, HHAs,
etc. The customized database is essential in the ability to create linkages of the many different
instruments and patient variables to each patient and to the providers. Patient records to be mined
from CPRS/VISTA for example, will include demographics, service connected status, Axis IV
diagnosis/problems, and encounters with the medical facility. This data can aid in the analysis of the
population served, and targeting underlying trends and common characteristics of the patients
served.
The psychosocial instruments to be administered to the patients will include the following
instruments: the Geriatric Depression Scale, the World Health Organization’s Quality of Life
Assessment, and the home care satisfaction survey, locally developed. The Zarit Caregiver Burden
Scale will be administered to the veteran's care giver. These instruments were selected for their
proven reliability, validity, and simplicity. These instruments will be given to the patients upon initial
contact and then on a monthly basis. The instruments will be in an electronic format via a secured
SharePoint survey site. The social worker or rehab tech will use their networked laptops to connect
to the secured SharePoint survey site, enter the patient’s name and then ask the patient each of the
survey questions and enter their responses into the SharePoint survey site. A backup hardcopy of
the surveys can be used to circumvent technical issues that may arise from the laptops and entered
into the database manually.
If any family members cared for the patient, the case worker or rehab tech will give a survey to
the person who did the majority of care to evaluate the physical, mental and emotional stresses
from caring for the patient. Social workers, rehab techs, HHAs and other agency personnel involved
in the home care management of the veteran will complete a survey to assess their perceptions of
risk and their attitudes and assessment of the veterans’ psychosocial environment. They will
complete a survey upon initial contact and on a monthly basis.
The intent of the program evaluation process is to collect data to form a comprehensive model that
involves all aspects of the psychosocial and environmental factors of those veteran patients with a
high degree of psychosocial need; which includes inputs from the PICS teams and the HHA

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agencies. Analysis of this comprehensive model is the key to guide the performance of the program
outcomes.

8) Sustainability
There is an anticipated expansion of the PICS program based on the growth of the veteran
population receiving HHA services. Future development would cover the 2nd half of the PICS
program. This would be incorporated into Cleveland VHA budget. There is potential for recognition
as with MCHM and HBPC for inclusion in the Veterans Equitable Resource Allocation model
covering the cost of the PICS program. It is our hope this will then be approved for VERA funds.
After review with the Medical Center Director, he has given his support of the PICS program.

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Department of Memorandum
Veterans Affairs
Date: November 30, 2009
From: Medical Center Director, VAMC Cleveland (541/00)

Subj: RFP for Patient Centered Alternatives to Institutional Extended Care

To: Director of Geriatrics and Extended Care VISN 11

1. The Louis Stokes Cleveland VAMC is pleased to participate in the submission of

this proposal to establish a Psychosocial Intensive Case Services (PICS)
program. The plan supports the supplementation of our existing Home and
Community Based Care program (H&CBC). I believe the H&CBC program is
ideally suited for this supplementation, due to the staff's ongoing provision of
case management services to the elderly veteran population. They enhance
stability and community living through successfully establishing ongoing linkages
with home care agencies.

2. The Assistant Chief of Social Work Service has drafted the enclosed proposal.
Social Work Service at Cleveland is committed to developing this program and
assuring it achieves viability.

3. I support this proposal and the plan of Social Work Service to initiate and carry
out this important effort. If funded, I am committed to ensure that any funds
received will be solely used for the Psychosocial Intensive Case Services
program. The Cleveland VAMC will participate in any current or developed
national monitoring process both administrative and in the area of service
delivery.

WILLIAM D. MONTAGUE
Medical Center Director
Department of Memorandum
Veterans Affairs
Date: November 30, 2009
From: Network Director

Subj: RFP for Patient Centered Alternatives to Institutional Extended Care

To: Director of Geriatrics and Extended Care VISN 11

1. I concur with this attached RFP entitled, "Psychosocial Intensive Case

Services" (PICS), and I support the proposal being submitted by the Cleveland
VAMC, Social Work Service. The Cleveland VAMC had the highest average
daily census in the Homemaker/Home Health Aid (H/HHA) program as
conveyed on the Home and Community Based Care Fourth Quarter Facility
Report Card for FY 2009. This commitment to non-institutional care
alternatives has helped with patient flow thus allowing veterans to live in the
community by supporting patient centered care and keeping veterans in the
least restrictive environment as possible. This additional program will continue
to support those efforts and maximize the utilization of the H/HHA program to
its fullest by managing psychosocial problems that otherwise interfere with
successful stabilization of the veteran.

2. VISN 10 is proud of its performance of exceeding its non-institutional care

measures and will continue excellent care by keeping veterans healthy in the
community.

JACK G. HETRICK, FACHE

Network Director