Aid And Attendance

[sixthscents]

Since I am undergoing this process for R2 or R1 (whichever they decide) I thought it might be a good idea to start a topic and discuss what others went thru to receive it....

Currently my VA Primary Care doctor has stated that I would require skilled care 24-7 at home, or a referral to a nursing home. I filed the claim stating that if they couldn't provide the necessary funding, or some sort of home healthcare providers.. well they would need to place me in a nursing facility.

They came back with this huge list of claims... I was actually shocked.

I wrote them back stating that no I was not attempting to claim this or that... (I thought that listing my claims 1-5 and printing them in bold would be clear enough).. and restated my case. I then went to the medical C&P, and a VERY nice doctor did the eval. I had my primary care person (a CNA I pay for myself) present, and my sister.. a director of nursing at the closest VA contract nursing home.. also an RN. We had a care plan, etc.... and I gotta say the doctor was really really incredible. Now you never know exactly what they type until you pull the record, but she said things like "I not going to check that... its obvious and isnt going to improve" etc. etc... She had a LONG list of things she was supposed to check though, and with my sister/RN and the CNA I am paying a fortune for... $12 hr... (sigh) she was able to answer them without asking me almost anything. I do know that for all the rotation questions she answered no rotation possible due to injury and pain... or at least most of them.

I didn't realize that the VA does not provide home health care except for short periods. This is looking to be a long term issue, and I am honestly debating going into a nursing home. The ONLY thing stopping me right now is my 8 year old daughter.... (sigh)

Anyway, they also set up a psych C&P... thats going to be a joke though, they have me in weekly counseling now so they should have a fairly clear picture with me walking-wheeling in, but I expect a million and one questions. Just me and the wife for this one though.

Like I said its an issue between R1 & R2... I wondered if anyone had any experience with the differences... the applicable reg is CFR 38 3.350 and 3.352, but they are a bit vague to be honest I meet all the critrea for both. Obviously for those who know me this is all new. I have been out of the loop for quite a while, and am only VERY slowly poking around again from my bed (hey it gave me an excuse to buy the 22 inch LCD monitor and wireless keyboard etc.).

Anyway... just wondering. I am classed as "skilled" care if I was in a nursing home... so I wonder if that would make a difference?

Mmmm... probably need to know the new injuries... rupture at L5-S1/L4-L5 L2-L3... incontinence/w indwelling catheter... major pain major muscle spasms constant... (the doctor actually saw and felt them - I thought that was a good thing)in legs and lower back. Loss of ability to balance, loss of memory (pain meds I guess) etc etc..... loss of streangth, mobility, inability to dress or put on ortho aplliances by myself, bath etc. The CNA cooks, cleans -lightly, etc. Rehab has written me off not Voc-rehab... rehab. They say until this is fixed or the muscle spasms reduced physical therapy will do more harm than good. They even annotated this into my records so as to make sure no one tries...

How did it happen? You got me. One day I was bad but stable (had been for 2-3 years)... next morning I woke up with this... go figure.

Anyway... opinions accepted.

[sixthscents]

Sorry for not getting back to you in a more timely manner. I'm glad to see that you have a handle on things and frankly understand that getting to "O" or "N 1/2 + K" is a requirement for you to be evaluated at "R-1." If your impairments are related to your IVDS getting this level of SMC should not be problematic if the evidence is how you have described it. Basically, if you need A&A at even the basic level and are at "O" or "N 1/2 + K" you will be bumped up to R-1.

To reach "R-2" the VA has a requirement that a higher level of care must be certified. I know that there is more information available on this in their M21-1 MR and I will do some more research and get back to you tonight.

theotherguy

Thanks, yeah I understand the prerequisite requirements, and under what I can see I meet or exceed them. Also this C&P "seems" to support the need for A/A at R1. I spoke again with my PCP, and go tomorrow to see another PCP in the same clinic to be relooked and have him write a second opinion that should match hers... a supporting secondary opinion form another VA doc (she thought it might be a good idea, and I thought it couldn't hurt). The visit is a formality since she has already discussed the case and he agreed to review it, and add supporting documentation... but he wanted to physically see me before he wrote that I was bedrideen, needing 24/7 care etc. I can totally understand that, but the doc appointments are getting out of hand it seems.

Like I said I am currently rated at L 1/2... so there's a bunch of stuff that goes in, but hopefully the rater will see that I am rated for loss of use of lower limbs, and with the incontinence catch the "o" rating... not discounting the ED (3 limbs and other stuff)

I just really wanted someone to look at all of this and see if the could see a problem or something I had missed. I have never handled an R1 or R2 claim, and it figures that the first would be my own....

Anyway, any opiniion or help would be greatly appreciated.

[theotherguy]

Do you have loss of control of both bladder and bowel? I remember you saying something earlier about having to use an in-dwelling catheter, which certainly helps to support an R-2 level claim. Keep in mind that impaction is every bit as relevant as incontinence under these circumstances. If you do not have the loss of bowel control, you can still reach "O" if your need for A&A is found to be due to your complications of IVDS under 38 CFR 3.350(e)(ii) and the combinations provision.

The VA manual provision on this topic is found in M21-1 MR, Part IV, Subpart ii, Chapter 2, Section H, Subsection 45. This subsection provides:

A statement from a licensed health care professional, who provides or supervises daily skilled health care on a continuing basis in the veteran’s home, is a prerequisite to establishing entitlement to a higher A&A allowance.

The statement must indicate the

• conditions justifying the need for this level of care

• nature, extent, and frequency of the services provided, and

• nature and extent of the supervision being provided, if the services are actually provided by a nonprofessional.

Once this statement is provided, they are directed to:

Request an immediate examination via the Automated Medical Information Exchange (AMIE)/Compensation and Pension Records Interchange (CAPRI) or Veterans Examination Request Information System (VERIS).

VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, should be completed in response to the examination request.

The examiner will certify whether an ongoing daily need for skilled personal care is indicated by completing Item 32 of the form.

Note: Provide a copy of the statement submitted by the licensed healthcare provider to the examiner.

Based on those findings, they are directed to:

Does the examination report show an ongoing need for skilled personal care?

• If yes, grant entitlement to the higher A&A allowance under 38 U.S.C. 1114®(2).

• If no, prepare a rating decision, denying the claim.

The reason I have posted this information is that it may explain the process which you have been going through. Based on what you are saying has been endorsed in those reports, it sounds to me like you should be good to go.

One thing though, I'd have your POA (if you have one) check and see if the VA examiner completed the VA Form 21-2680 or they completed just a basic A&A examination. I'm sure you have been through the CFR already and are aware of the regulatory requirements for the higher level of A&A, but I wouldn't anticipate that your representative is going to be familiar with this situation since these claims are so rare. Paralyzed Veterans of America has the best training when it comes to SMC, so it might be in your interest to seek representation by them if things don't turn out in your favor.

Hope this helps.

Edited November 27, 2007 by theotherguy

[sixthscents]

I am a little confused here-

I thought A & A and the "S" Housebound award are technically included in the SMC "L" award-

???

Yeah it is, actually it is a much larger payment (at L rate) than at "s" - housebound. In my case though I am bedridden... with a need for constant A/A... which is also known as SMC. SMC and Aid and Attendance are really just the same thing. I know you know that, but just wanted to clairify. R1 and R2 as you point out in your later post are "special"... they are DRASTICALLY higher... but trust me, I'm going out of pocket for 24/7 care right now and it's incredibly expensive. Now I COULD go thru Medicare and get someone in here tomorrow practically BUT...

1. I wouldn't get to pick and choose my care providers, and a LOT of the in-home care nurses have... issues (not all) but many. We have dealt with them and my mother in law so I have seen who they send.

2. They would not provide a driver, or allow their staff to drive me to appointments etc. even in my own vehicle.. again I know this because we are dealing with this with my in-law.

3. They would only do minimal housekeeping... minimal food preperation etc. They will only do what they are assigned to do, not what I ask or tell them to do.

I can go on and on, but to be honest, it's either the VA ponies up, or I go into a nursing home. I'm not bringing some of the people they send to care for my in-law into MY home with MY 8 year old... I dont trust them. So many are habitual prescription pain med addicted it's not even funny... we have run into 3 CNA's so far who were dipping into the in-laws meds...

anyway.. you right, but this is a special circumstance are rare in the VA system.

[sixthscents]

Do you have loss of control of both bladder and bowel?

Yep

I remember you saying something earlier about having to use an in-dwelling catheter,

I do as well as self-cat 5-7 times per doctors orders - with assistance. I csnt keep the indwelling in for more then 7-8 hours at a time. I am allergic to latex, and apparently the VA only has formulary latex foley catheters... go figure.

which certainly helps to support an R-2 level claim. Keep in mind that impaction is every bit as relevant as incontinence under these circumstances.

If you do not have the loss of bowel control, you can still reach "O" if your need for A&A is found to be due to your complications of IVDS under 38 CFR 3.350(e)(ii) and the combinations provision.

Yeah, this is exactly the things I needed to know. The C&P did a IVDS rating section and attributed the changes to its worsening... it's in the stuff I pasted below, just look for the header with IVDS in it.

KILLER I am weak on M21-1 compared to CFR 38 again exactly what I was looking for

The VA manual provision on this topic is found in M21-1 MR, Part IV, Subpart ii, Chapter 2, Section H, Subsection 45. This subsection provides:

A statement from a licensed health care professional, who provides or supervises daily skilled health care on a continuing basis in the veteran’s home, is a prerequisite to establishing entitlement to a higher A&A allowance.

We provided, and I am sending a copy to rater as additional information of a formal care plan. Prepared by my sister who is an RN and director of nursing, as well as my other sister an LPN.. (lots o nurses in the family) Included are copies of their licensure etc.

The statement must indicate the

• conditions justifying the need for this level of care

• nature, extent, and frequency of the services provided, and

• nature and extent of the supervision being provided, if the services are actually provided by a nonprofessional.

Once this statement is provided, they are directed to:

Request an immediate examination via the Automated Medical Information Exchange (AMIE)/Compensation and Pension Records Interchange (CAPRI) or Veterans Examination Request Information System (VERIS).

They already did this, (see pasted C&P below) so I bet the Primary care physicians statement which was "this man needs 24/7 care or nursing home" basically was strong enough,maybe it combined with my application sufficed... in any case I am forewarding the care plan again myself.

VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, should be completed in response to the examination request.

I dont know if this has been done and no one has my POA. How can I find out, besides calling the 1-800 number? Send a letter asking maybe?

The examiner will certify whether an ongoing daily need for skilled personal care is indicated by completing Item 32 of the form.

They had me do a mental C&P as well... I wonder how this impacts...Note: Provide a copy of the statement submitted by the licensed healthcare provider to the examiner.

Based on those findings, they are directed to:

Does the examination report show an ongoing need for skilled personal care?

• If yes, grant entitlement to the higher A&A allowance under 38 U.S.C. 1114®(2).

• If no, prepare a rating decision, denying the claim.

The reason I have posted this information is that it may explain the process which you have been going through. Based on what you are saying has been endorsed in those reports, it sounds to me like you should be good to go.

One thing though, I'd have your POA (if you have one) check and see if the VA examiner completed the VA Form 21-2680 or they completed just a basic A&A examination. I'm sure you have been through the CFR already and are aware of the regulatory requirements for the higher level of A&A, but I wouldn't anticipate that your representative is going to be familiar with this situation since these claims are so rare. Paralyzed Veterans of America has the best training when it comes to SMC, so it might be in your interest to seek representation by them if things don't turn out in your favor.

Thanks and if necessary I will, but to this point the VA has done a good job with all my claims. I handled them without a rep, because a rep for AmVets really tried to shaft me.. so I have handled my claims myself all the way thru... I may contact PVA if things get hinky... but Im just keeping my fingers crossed right now.

Hope this helps.

It helped a great deal and was exactly what I was looking for... if you have any other info please feel free to comment...

Thank you...

Bob Smith

[Guest morgan]

I'm not sure which post I replying to, as I lost track of the original question. I'll keep this directed toward the excerpt:

The only problem is that he is no longer able to come to the VA Clinic for his VA PCP to see him. He is unable to leave the house. Can the VA come to his house to document his disabilities? It is very risky to try to get him in the car. He has fallen 5 times in the last 6 months, broke his back, etc. One time, he fell on my Aunt and almost broke her hip. Its a bad situation and not going to get any better.... only worse. I will go for the highest possible SMC assistance and make the worst-case write-up and see what happens. Currently, he has not even made application or a claim for A&A, yet, but will bypass that and go for the highest SMC assistance. The VA can determine it from there. All his recent hospitalizations (3) in past 4 months are in his VA electronic patient file to include his emergency care at the private Lakeland hospital that was paid for under VA Fee Services (Basis).

At the Lakeland VA Clinic, the Social Worker has been some help. But, getting in to see his VA-PCP is a problem, not only for him, but also just making an appointment that might be 2 or 3 months out. Again, he's really not capable of coming to the clinic, anymore, too risky, and his legs/feet will no longer facilitate walking for him. He used a walker, but now cannot even use it...... so....... ??????

You need to check into VA's Home-Based Primary Care (HBPC). This program was implemented for veterans who are so severely disabled that he or she has great difficulty receiving primary care in the outpatient setting. If HBPC is available in his area, he also needs to enroll in the Health Buddy system which uses a simple telecommunications device for daily tracking vitals and other disease management. Once admitted to HBPC, the veteran or a caregiver will have a direct phone number to a nurse practitioner/care coordinator who can adjust medications or make other changes to help manage conditions in a more timely manner. My husband is in this program and it's a huge help for him (and me) to have the nurse practitioners coming to our home for primary care appointments. They also coordinate with home health provided by Medicare for labs and more extensive skilled care. Of course, all of this is documented in his VA electronic medical record, the same as it is with outpatient services.

The veteran might also be eligible for the adaptive housing grant ($50,000, if not already changed to $60,000) due to "preclusion of locomotion without the aid of a wheelchair, walker, or canes." Based on info discussed, I also think he could get SMC-R1 or R2. These levels are rare, but I think that's because many veterans don't even know about them. And reading the regs is not the simple solution to find out, as I've found that section is the most convoluted and contradictory of all VA regs.

I think this veteran should request that his claim be expedited due to his advanced age and severe condition. I agree with the comment that when one veteran goes ahead of another, that means someone loses their place; however, in the case of a terminal illness or advanced age with severe disabilities, then I think rushing (VA version of "rush") is appropriate. JMO. To me, it's sad that many older veterans didn't know early on that they were eligible for benefits. Had they known, they would have been in line long ago. Fortunately, the VA is making an effort to better inform veterans now.

Edited November 28, 2007 by morgan

[Guest morgan]

I knew nothing about the HBPC until I came across a doctor with the VA in Washington and told him about my husband's poor care at the VA clinic. He was sincerely concerned and got on the phone and in short order guided me to the home-based care. My husband has been in the program for almost three years, and now his HBPC is staffed with geriatric specialists. His geriatric nurse told us last week when she brought his cancer treatment that the VA is implementing changes to do even better things for homebound geriatric patients. The changes are expected in February.

HBPC is even monitoring my husband's warfarin every two weeks with a new finger-stick gadget that gives instant results so we know right away whether we need to make medication adjustments. Warfarin is a dangerous drug that is not monitored very well in the VA system. The order for his labs goes through a new VA anticoagulation clinic and the pharmacist calls me after every lab result to ensure that we have the right dose of medication going. I can hardly believe this kind of care is coming from the VA.

We were told that home nurses can come more often under Medicare if the doctor orders it, and the VA HBPC told us to let them know if he needs more visits. Of course, it doesn't cost the VA anything, but we are grateful that HBPC is cooperative with calling in orders when he needs it. One of my husband's private doctors ordered a nurse three times a week and another ordered daily. We thought three times a week was sufficient, as I am able to be with him 24/7, and we let them know that. They said if anything changed they could increase it to the daily visits. At one time, he had nurses and phys. therapists twice a day. All of that was paid by Medicare, no co-pays at all. So check with your veteran's doctor and ask for an increase in the number of visits if you think that would help.

We changed home health companies many times until we found the one we have now. They are excellent--some we've had were idiots. Don't hesitate to change providers for home health if they aren't doing a good job. One of my husband's private doctors told us that home health services directly affiliated with a good hospital is usually best. It defintely has been that way for us.

Sorry about going on and on. Just know that I wish you the best in helping this veteran. If I can help in ANY way, let me know.