FINDING THE BALANCE IN CAREGIVING EDUCATES AND HONORS MILITARY VETERANS AND THEIR CAREGIVERS

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By Janis Russell

November 11, 2015 (La Mesa)- On November 6th, the Caregiver Coalition of San Diego with the city of La Mesa had an event for caregivers of military veterans called “Finding the Balance in Caregiving- Caring for Veterans.” The event took place at the La Mesa Community Center with resource booths, free lunch provided by AARP, and a drawing. Respite care was available, provided by Heritage Senior Care.

East County Magazine was there- and below are details on many important programs and services to help our local veterans.

Andrea Holmberg, program manager at Sharp Grossmont Senior Resource Center and member of the Caregiver Coalition, gave a welcome. With this event being before Veterans Day, “We decided to do a veterans themed event,” she said.

Marty Dare from the San Diego County’s Caregiver Support Program introduced the first speaker, Wil Quintong. Quintong was the former deputy director of Aging and Independent Services, and is now the Director of the Military and Veterans Affairs office with San Diego County.

“I want to talk to you veteran to veteran. I’m a 28 year veteran,” said Quintong, whose father and grandfather were also veterans. “I understand what veterans go through.”

Out of the 3.2 million citizens in San Diego County, over one-third are associated with the military, Quintong stated. “ Latest studies show that San Diego County is #1 county in the nation where veterans from Afghanistan and the Gulf War settle.” (#2 is Los Angeles County.)  This brings “really good citizens” to our region, but veterans need help, he added.

Earlier this year, Bill Horn, Chairman of the Board of Supervisors declared this the year of veterans. Quintong stated, “As far as I’m concerned, this is the decade of veterans.”

He then talked about what his office has done to help veterans. “We are increasing outreach in the entire county, concentrating in rural areas,” he said. They’ve created a Vet Connect program, where veterans can go to a library, like the library in Julian, and do a teleconference with a veteran outreach rep in the county operations center in Kearny Mesa. “We’re also utilizing county libraries, where I’m rotating county reps.” That way, a veteran can go to the library and talk with a rep directly. He hopes to increase outreach to Campo and Borrego. (See the schedule of libraries where veterans can go to here: http://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/ais/documents/Vet_Connect_Flier.pdf).

The county also just opened up a North Inland Live Well Center at 649 West Mission Ave in Escondido. “I call it the ‘Military Veterans Resource Center.’ I have 15 nonprofits housed free of charge to provide veteran services,” said Quintong adding that this provides a ‘one stop shop for veterans’.  They plan to open up another resource center in South Bay and expand to East County.  San Diego is a model of how we do business and how we help veterans he added. “Helping veterans is the #1 priority now.”

On Tuesday November 17, Chairman Horn is holding a board conference to highlight what the county does for veterans. The event is at 9 a.m. at the North Inland Live Well Center, and it is open to the public. All the supervisors will be there. The keynote speaker is a retired Marine General. A couple other veterans will speak as well. Breakfast will be served at 8 a.m. While at that event, Quintong encouraged those who will be attending to take a tour of the center. There are other programs helping disabled veterans, one in which they partnered with the VA Medical Center. “The county went above and beyond to get this program here. And the Legacy Corp program has been successful. (Learn more at http://www.lcsandiego.org/).” He hopes that they can do more outreach. Currently, they are reaching out to 37% of veterans. Learn more about the Military and Veterans Affairs office at http://www.sandiegocounty.gov/hhsa/programs/ais/veterans_services/.

Then Taylor Dupont, a representative from Supervisor Dianne Jacobs’ office, presented a proclamation to Holmberg and Dare in honor of the Caregiver Coalition of San Diego to recognize them.

Martha Rañón, Director of education and outreach at the Southern Caregiver Resource Center (photo, right), presented some information about the center and their program “Operation Family Caregiver.” She and her staff know that there is a need for caregivers. Caregivers provide health assistance, care management, mental and emotional support, legal and financial advocacy roles, entertainment, and 24/7 supervision. Operation Family Caregiver focuses on the caregivers themselves. There are caregiver coaches. It is not prescriptive, clinical, or therapy.

“You can share stories and vent,” Rañón added. This program is tailored to the caregiver, is flexible as far as scheduling, and they can go to the caregiver directly and visit them at their home. It helps with coping skills and has proven effectiveness because it minimizes the stigma, supports and complements other services like the VA, and is completely confidential. Rañón shared of how she was a caregiver to a family member with dementia, and she became client of the resource center. The family member didn’t serve in the military, but she’s had that caregiver experience.

This is an in-home caregiver, tailored caregiver support intervention, where there are four 1 on 1 visits, monthly telephone or Skype availability, and data collection at the beginning and end to see if it helped. The program length is 4-6 months, and the caregiver needs to complete at least 75% of the sessions. There are a few program objectives, two of which are listed: 1) Teach/practice problem solving skills to utilize throughout the caregiving journey. 2) They can then see reductions in burden and depression, and health complaints.

The program philosophy comes from a quote by Lou Tzu: “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.” Desires outcomes for caregivers to reach their goals, having a re-set approach of how to begin working with the care receiver, promoting the caregiver’s desire for autonomy, acquire a better understanding of the importance of self care, and attaining self-confidence. The eligibility criteria is to be a caregiver of a veteran from pre-9/11 to post 9/11 vets, where the vet is living with Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), and/or a physical disability. These can be combat or non-combat related. Rañón mentioned how most caregivers that have come in are caregivers of post-9/11 vets. A diagnosis is not necessary. They are located at 3675 Ruffin Road, Suite 230, San Diego 92123. They can be reached at (858) 268-4432 or (800) 872-1008. Visit them online at: http://caregivercenter.org/.

They also provide respite care, where they partner with different home health agencies. The center itself pays for respite, and there’s no service charge. Two women, who have gone through the program, praised Rañón and the center for the help they received. Lastly, Rañón had everyone write down three things that caregivers would like help with, and then list the name of a person that might be able to help them. Their homework was to ask that person that evening for help. If the person refused, they could come up with another person to ask. The caregiver can also call the center to help them expand their network of care, and they can talk with Dare, who helps run the Legacy Corp program as well. The Caregiver Coalition also has lots of resources available.

Next, Deena Brooks from the VA’s Caregiver Support Program came to speak. She mentioned how this program is small, about 5 people, and they focus on the pre-9/11 era. The program was established in 2011 to support caregivers of veterans. The services the program offers are: home health aides, adult day healthcare (ADHC), home based primary care, aid and attendance, education on respite, and education on long term care placement.

The home health aide is a trained person who can come into a veteran’s home and help the veteran take care of himself and their daily activities. They are not nurses. They provide 2 hours of care each up for up to 7 days a week. If someone had Parkinson’s, for example, they can possibly have 4 hours of care a day. The VA contracts with 6-7 home health care agencies, and can even provide aides to help with vets outside the home. The eligibility criteria is that the veteran must be dependent in 3 activities of daily living (ADLs) like brushing their teeth, shaving, or taking a shower. If the vet has a cognitive disease, like dementia or Alzheimers, they can just be dependent in 2 ADLs. To pursue having a home health aide, the caregiver must talk with their patient aligned care team at the VA, which consists of their primary care doctor, nurse, and social worker. They can then make a referral for this program. The caregiver must be the vet’s power of attorney to access VA services on behalf of the vet.

For Adult Day Healthcare, vets can participate in social activities, get peer support, companionship, and recreation. Vets must have a cognitive deficit in order to meet the eligibility requirements. Talk with the patient aligned care team for a referral. It is 2-5 days a week, and most facilities no longer offer transportation to pick up the vet from their home to the program. Someone could meet the vet if they took public transportation, such as MTS, to get there and then transport them from the station to the program.

Home-based primary care is health care services provided to vets in their home. A VA physician supervises the health care team who provides the service. They replace the patient aligned care team that the vet has assigned at the hospital or clinic. These are home visits. Talk with the primary care physician to pursue this, and they can place a consult/referral. There is a wait list as this is a specialized program and highly sought. The vet needs to be home-bound and have multi-disciplinary needs like having a doctor/nurse, social worker, as well as physical therapy.

Respite care is a service that pays for a person to come to a contracted nursing home or have care in the home for a brief period while the family caregiver takes a break. The vet must meet the 3 ADL dependency criteria. The in-home respite is for a total of 6 hrs a day, not including the home health aide. The facility provides 24 hour care in the contracted facility. There are 15 day blocks, where they can do two 15 days or one 30 day. Respite is a total of 30 days.

The contract nursing home provides long term care if care gets to be too much for the caregiver, short term care, rehabilitation, hospice, and respite. Short term care and rehabilitation are when deemed necessary by hospital staff post discharge. Hospice is for a six month placement and evaluated by the VA palliative team.

For any questions, call Deena Brooks at (619) 497-8424 or email her at Deena.brooks@va.gov. For more information, go to: http://www.caregiver.va.gov/

Don Barnard spoke after Brooks. Barnard is from the San Diego County Veterans Services. He is also the Vice President of the Vietnam Veterans of America Chapter 472. The Veterans Services helps vets with claims. Their main office is at 5560 Overland Drive inside the new county operations center. Someone asked Barnard about the services they provide vets. Barnard said,

We file claims for veterans, we have a program with the California Department of Veterans Affairs, aid and attendance, and we talk with veterans for any questions in the area of veterans claims and services.” Barnard told everyone that he’s heard that some vets aren’t sure if they’re eligible for anything because they’re in the military. “Records can be accessed,” he added. The benefits are there for vets to use. Someone else commented on how vets generally aren’t whiners, and how they minimize the issues they have. For example, they don’t bring up a back issue they have to their doctor.

Laura Grayson from Sharp Hospice talked about how they honor veterans. We Honor Veterans is a partnership between hospice, Dept of Veterans Affairs, and the National Hospice and Palliative Care Organization. She addressed how veterans are cared for at the end of their lives. This is a national awareness and action campaign, and encourages partnership between community hospices, state hospice organizations, and VA facilities. Their goals are to promote Veteran-centric educational activities, increase organizational capacity to serve vets, support development of strategic partnerships, and increase access and improve quality. This program exists because 26 million vets are alive today, 25% of all deaths in the US are vets, more than 1800 vets die each day, the VA cares for a minority of vets at the end of life and 96% of vets die in the community, and only 33% of vets are enrolled in the VA to receive benefits.

They identify patients who are vets, determine their needs for clinical/bereavement/benefits/and volunteer, educate staff to meet special needs at end of life, work collaboratively with other providers, and improve quality by measuring the impact of VA and community interventions the program performs.

First, they ask the vet to share their experience of serving, when and where, and what did the vet do while in service. They ask these questions because it may influence both the health and quality of life, “and to also pull closure on relationships with others,” Grayson added. Unique needs may be influenced by combat or non-combat experience along with the impact of war and how well they adjusted to life after, which war they served in, if they were Prisoners of War (POWs) which leads to a significant level of trauma, if they had/have PTSD which may require additional level of support when on hospice, the branch of service and their rank, whether they were enlisted or drafted, and the age they were when they served.

As far as psychological needs, facing death may be a strong reminder of the vulnerability vets felt during combat, vets may have faced death while on battlefield and facing their own death in hospice may be a powerful reminder of that experience (They might fight death, which may lead to extra guidance in how to let go.), one’s own death may be a reminder of losses faced as fellow soldiers died on the battlefield, and feelings common at the end of life can activate PTSD. Death/illness can be a PTSD activator because life review can lead to intense anxiety, sadness, guilt, anger and flashbacks. There’s loss of control, feelings of being trapped, and surroundings can trigger flashback.  There are spiritual counselors who are trained and focus on spiritual themes for combat vets.

Vets may experience social isolation by having challenging social ties. They have painful feelings of being forgotten and their service being undervalued, and some vets may be estranged from family and at end of life. They would then be isolated and need to reconcile somehow. For the unique physical needs, vets may have gotten frostbite or a cold injury while serving. This may worsen as vets get older. These cause diabetes, vascular diseases, and at they are at a higher risk for amputation. Another physical need is delirium which is disorganized thinking, where things don’t make sense. There may also be alcohol or substance abuse, and many mental health issues, like PTSD.

We Honor Veterans at Sharp Hospice is composed of an interdisciplinary team that have obtained education on the vets’ specific needs. There is a Registered Nurse (RN), Psychologist (MSW), spiritual care counselor, and home health aides. There is also a vet to vet volunteer program for vets in hospice who need additional support. The volunteers at Sharp Hospice are vets themselves. There is a potential for a better match of patients and volunteers based on similar areas of interest and background. People who have common life experiences usually begin to trust each other, and trust with vets who have PTSD is especially difficult to establish. Vets form a camaraderie that can penetrate their civilian social roles; matching branch of service or time of service is ideal, but not required. This is important because they can break through the culture of stoicism and societal reactions, and vets can then share their stories. Vets also share a common language, code of conduct and honor, and own culture. Sharing supports life review and healing. The honoring service adds meaning and value.

Sharp Hospice has an honoring ceremony where they pin the vet and give them a certificate. Grayson mentioned that this Veterans’ Day, they went to the vets in hospice to present a flag flown on the USS Midway to thank vets. Grayson added that any hospice organization can partner with the We Honor Vets partnership. Visit: http://www.sharp.com/services/hospice/. For more information about We Honor Vets, go to: http://www.wehonorveterans.org/.

Sharon Landry, program analyst from the VA Fort Rosecrans and Miramar National Cemeteries She talked about the process of laying someone to rest. It would be best to do pre-arrangements if the vet and spouse are still living. Landry is retired and served in the Army. She’s been a program analyst for the last 15 years. Fort Rosecrans is closed for interment, and Miramar is the annex cemetery. Discharge papers or some form of ID will be needed for the deceased to be buried. The family member would then pick a casket or choose a cremation urn. The funeral home would pick up the casket from the place of death. Then, an appointment with the funeral director is set up. The discharge papers are faxed to the national center in St Louis, Missouri, where you schedule the day you want to go to the cemetery. Then, the staff at the cemetery decides where the casket will lay. The husband and wife can be laid together. If one spouse served, one side of the headstone would say the husband’s information and the other side would say the wife’s information. There would be two separate graves by each other if both are vets. Miramar National Cemetery is located at 5895 Nobel Drive, San Diego 92122. The cemetery administration office can be reached at (858) 658-7360. For burial arrangements, call (800) 535-1117. Visit http://www.cem.va.gov/ for more information.

Phillip Lindsley, a certified Elder Law attorney from San Diego Elder Law Center, addressed estate planning for vets. The goal of estate planning is to retain control over life decisions, provide for a person and their family’s care and dignity if one becomes disabled, and preserve as much as one’s assets as is legally possible so upon death the assets go to who the vet chooses. To avoid inadequate planning, have an integrated estate plan.

There are three documents within financial affairs- trust, financial power of attorney, and the will. During one’s lifetime, the financial power of attorney isn’t in the trust and neither is the pour-over-will upon one’s death.

For financial powers of attorney, decisions have to be made about general powers granted to the agent, special powers (like Medi-Cal and public benefits planning language), if it’s springing or immediate, and special consideration for active military. If springing, there’s a method of determining capacity. If one has a power of attorney, consider if the attorney gives needed authority, if special powers are appropriate, and if the agent is appropriate for their situation.

A living trust avoids probate if funded, provides for management of assets during disability, and protects and expands options for management of estate after death and protects the family. The vet gets to decide who is managing, who is entitled to support with the extent and terms, and the retained rights. After death, the trust avoids probate, has terms of spousal support and inheritance, and has special needs or retained assets trusts. If there is already a trust, see if assets are funded, if the trustee is appropriate and has needed authority, and if it addresses “family problems.” Also, consider the unnecessary “A/B” provisions, which are common in older trusts, and may not work today.

Whether or not one has a trust, one needs a will. If you have a trust, a “pour over will” passes any property not funded in trust or with beneficiary designation into the trust. If you don’t have a trust, a “will based plan” will name your heirs and terms and probably without probate. In summary, have an integrated estate plan, decide if your plan incorporates the important language for VA and other benefits, and make sure your estate planning/elder law attorney understands VA and Medi-Cal benefits if benefits eligibility is important to you, and be in control of your life. For more information, call Lindsley at (619) 235-4357 and visit him at https://sandiegoelderlaw.com/. The center is located at 110 W C Street, Suite 1300, San Diego 92101.

The last speaker was Scott Stewart from California Estate and Elder Law LLP. Stewart talked about Caring for Veterans: Aid and Attendance. Elder law is a subset of estate planning, as defined by the California Bar Association.

Long Term Care (Life) Planning is when you take care of your own needs. “The AARP estimates that the 2/3 of seniors will need some type of long term care assistance. Have a conversation about what you want to have happen with your kids,” Stewart said.

Payment of long-term care comes in form of limited payment from Medicare, your assets and savings, long term care insurance, children or other family members, Medi-Cal (which assists middleclass seniors with long-term health care costs. You’ll need to prove your medical needs and the assets have to fit within a certain parameter), and aid & attendance. A vet gets benefits from their pension and service connection. The vet typically needs 20 years of service to retire with a full pension. For the service connection, you must have an injury or disability that occurred or was worsened while in service.

Aid & Attendance is a special non-service connected improved pension, and is part of the pension program. For this, you won’t need to show you had 20 years in service. Aid & Attendance helps you pay for care at home or in a facility. To qualify, the vet must show their DD214 original form. They must show they had 90 days of service, 1 day war time. This includes specific dates you served in WWII, Korea, Vietnam I (must have served in country), Vietnam II, and Mideast conflicts. You must also show that you had medical needs and that you are “home bound”, needing help with 3 ADLs. You also must show your asset test and non-exempt assets are below an unpublished threshold. There’s also an income test for the VA, and income after unreimbursed medical expenses must fall below the maximum amount of the pension.

Advantages of Aid & Attendance are free access to VA services, including medication; and it interacts well with other government benefits including Medi-Cal in home benefits. Now, it is recommended that you review your estate plan and see if it reflects your wishes and allow others to pursue your long-term care goals, review different care options (know the differences between types and levels of care), and consider creating a care plan. Also, stay ahead of the problem and memorialize your wishes. Stewart can be reached at (858) 200-1925 and at scott@estate-elderlaw.com. He is located at 9820 Willow Creek Road, Suite 460, San Diego 92131. There is another office at 3636 Nobel Drive, Suite 450, San Diego 92122. Visit http://estate-elderlaw.com/.

Someone asked if it would breach the fiduciary duties if the person is the trustee and caregiver. Lindsley said that depends on what the trust says. “It won’t be breached if it’s fair or prudent,” he added. Stewart agreed. “Transparency and prudency is important,” Stewart said.

Homlberg ended the program with a raffle drawing and thanked Heritage Senior Care for providing respite care. They also provided two of the raffle items.

The Caregiver Coalition of San Diego has many resources available online, including webinars (like a 30 minute mini movie). These are shown at 12 noon the day of. Go to: http://caregivercoalitionsd.org/. To register for a webinar, go to the webinar registration tab.

The Southern Caregiver Resource Center has a free caregiver support group for spouses/significant others of post-9/11 service members and vets with PTSD and/or TBI. A diagnosis of either isn’t necessary. These support groups are professionally facilitated by Michelle Schachtel (IMFT) and are a place where participant can freely share experiences, coping strategies, concerns, helpful tips and resources. They meet on the first Thursday of every month from 10am to 11am at the Holiday Inn Oceanside board room, 1401 Carmelo Drive, Oceanside 92054. For more information about this group, contact Schachtel at (858) 268-4432 ext 115 or mschachtel@caregivercenter.org.

The center also has a “Caregiver Education Series” in partnership with the Jewish Family Accredited, hosted by Temple Adat Shalom. These are free, and you can learn more about caregiving, communication and stress management techniques, obtain helpful resources and get answers to your most pressing questions. You can even bring a friend. The temple is located at 15905 Pomerado Road, Poway 92604. For more information and to RSVP, contact Jodi Rudick at her office (858) 674-1123 or email her at jodir@jfssd.org. You can also visit http://www.jfssd.org/site/PageServer.