Rehabilitation and long term care division (rltc) | veterans affairs

HOME AND COMMUNITY-BASED SERVICES (HCBS) HCBS consists of several programs that provide supportive services to Veterans, their families, and caregivers: Home Based Primary Care (HBPC),

Purchased Skilled Home Care, Home Hospice, Home Infusion, Homemaker/Home Health Aide, In-Home Respite, Community Adult Day Health Care, Veteran Directed Care, and Community Nursing Home.

Contact Number: 360-905-1741   HOME BASED PRIMARY CARE (HBPC) HBPC provides Primary Care in the home to eligible Veterans for whom routine clinic based care is not effective. Team includes

Physicians, Nurse Practitioners, Registered Nurses, Licensed Practical Nurses, Social Workers, Dieticians, Physical and Occupational Therapists, Psychologists and Pharmacists, with support

from administrative staff. Geographical areas covered include the Portland/Vancouver Metro area, Salem and Bend. Contact your PACT team for more information and eligibility criteria.

PURCHASED SKILLED HOME HEALTH CARE Purchased Skilled Home Health Care provides professional services in the home by community agencies in good standing with Medicare.  The services is

generally episodic and focused on specific short-term needs and goals.  Agency staff can provide skilled nursing services, social work, occupational therapy, physical therapy, and

speech-language pathology.  At times, these agencies can also provide a bath aide.  The program is current accessed through a consult placed by an inpatient or outpatient VA provider.

IN-HOME HOSPICE In-Home Hospice provides comfort care to Veterans who are in the final phase of their lives, typically six months or less.  Community agencies employ interdisciplinary teams

who support Veterans and their families during end of life care.  Hospice can be provided at home, in a facility, or in an inpatient setting.  The program is currently accessed through a

consult placed by an inpatient or outpatient VA provider. THE HOME INFUSION PROGRAM  This service provides infusion services, most often for chemotherapy or IV antibiotics, in the home. 

Community agency staff provides the supportive services needed to receive these treatments in a comfortable and familiar setting rather than in a skilled nursing facility or hospital

setting.  The program is currently accessed through a consult placed by an inpatient or outpatient VA provider. THE HOMEMAKER/HOME-HEALTH AIDE This program is designed to help Veterans who

are in need of nursing home placement to remain supported in their homes.  Services, which are provided by community agency staff, may include bathing and personal care, as well as grocery

shopping, cooking, laundry, errands, and transport to medical appointments.  The program is currently accessed through a consult placed by a VA Primary Care Provider. HOME RESPITE * Home

Respite provides temporary relief, assistance, and support to those Veterans and their primary caregivers who are dealing with long-term disability or chronic illness in their home. 

Non-skilled care is provided to Veterans by agencies operating in the community.  The program is currently accessed through a consult placed by a VA Primary Care Provider. * Community Adult

Day Health Care Centers in the community contract with the VA to provide supportive services and socialization to Veterans in an outpatient setting.  The day center staff provide health

maintenance, social interaction, and rehabilitation services to frail elderly Veterans in the community.  The program is currently accessed through a consult placed by a VA Primary Care

Provider. VETERAN DIRECTED CARE Veteran Directed Care gives Veterans who would otherwise need nursing home level of care the opportunity to self-direct the care needed in order to remain

safely at home.  Veterans in this program are given a flexible budget for supportive skilled and nob-skilled services that can be managed by the Veteran or caregiver.  They are assisted

through the process by a case manager from the local Area Agency on Aging who has a long history of consumer-directed programs.  The program is currently accessed through a consult placed by

a VA Primary Care Provider. This service contracts with multiple Oregon and SW Washington nursing facilities which can provide both long and short-term care services to Veterans in need. 

VA staff provide oversight and case management of each placement, support Veteran’s and families in discharge planning, and monitoring each home to ensure that the facility remains in good

standing with Medicare.  This benefit is currently accessed through the Social Workers assigned to either an inpatient team or a VA Primary Care Provider.