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Home Care Innovation in the VA

An Interview with June Leland, MD, MBA

Medical Director, Home Based Primary Care, James A. Haley VA
Associate Professor, Morsani College of Medicine at the University of South Florida College of Medicine
AAHCM Member and Frontiers Editor-in-Chief

 

This interview is edited for clarity and length.

AAHCM

How did you begin practicing home care medicine and how you first got involved with medical foster care?

June Leland (JL)

I actually started out my career in medicine kind of through the back door. I had graduated from a junior college and became a hospice volunteer in Jacksonville, Florida in the early 80s. The medical director Dr. Collins used to take me on some home visits. After I had a few patients of my own as a volunteer I was asked with two other volunteers to become a bereavement counselor in the community. Nobody knew what a bereavement counselor was, least of all us — me, a construction worker, and a physician pathologist.

As a bereavement counselor I heard the worst stories and the best stories from everyone — horror stories, successes, and I became attached to caring for people at the end of their life and how it is for the people who are left when somebody dies. I realized that hospices could use a few more doctors. This was even before Medicare was reimbursing for hospice, so I went back to school. I got a scholarship at Jacksonville University, studied chemistry and math, and got into University of South Florida medical school, I think in large part because I wanted to take care of people at the end of life. They’d never heard of anybody wanting to do a thing like that. It interested them as much as it interested me.

As a resident with the VA I was allowed to participate in home care visits and then they designed a rotation for me in home care. I did a year of geriatrics in Tampa with Dr. Bruce Robinson where I also led a team for the local hospice as part of my geriatrics training — before hospice and palliative care ever became a specialty. Then I did a year of geriatrics with Dr. John Morley in St. Louis. When I graduated, I came back to Florida and worked as the medical director of a hospice for about a year before I returned to the VA.

I had the opportunity to work with Ofie (Ofelia) Granadillo, who was the program director at the time, and later with Darlene Davis, now the national HBPC program manager, and Bruce Robinson, whose position as medical director in home-based primary care I assumed when he retired. I’ve been there ever since! I have been really been lucky to work with people who are absolute visionaries. 

For example, in the first few years I worked with Ofie we developed a telemedicine program with some wizards in Eden Prairie, Minnesota — we gave patients little charts of where to put a stethoscope and we transmitted this over phone lines and just had a really innovative approach to things in the 90s. And so, when we heard about a medical foster home program in Arkansas in the early 2000s, we went up to visit the home-based primary care program in Little Rock to see how it was going. They had put a few veterans in private homes with just regular people.

Most of them had a background in caregiving because they had a relative they had taken care of. Occasionally there was somebody with a medical background, but that wasn't usually the case. The program gave people who were otherwise un- or under-employed an opportunity to do something that they already were very skilled at and in a way that didn't require them to have a license or formal education. After we did that visit, I was pretty sold on it.

We started out kind of slowly, it was a real learning experience. The people that have come out to be foster caregivers really are from everywhere and they all have a story, a reason behind it. We've had people who are caregivers that have had family members on ventilators who know how to manage a ventilator. We have people caring for complex wounds. We have sister home care programs in spinal cord injury and also in mental health. So, there are homes that sort of specialize based on how they’ve cared for somebody.

 

AAHCM

What exactly is medical foster care and how does it differ from other models like group homes or assisted living facilities?

JL

I think of group homes as smaller, licensed facilities, and the person who runs it doesn't necessarily live there. They specialize in certain medical illnesses, mental health issues, specific disabilities, adults with traumatic brain injuries, things like that. We tend to call those little ALFs, little specialized assisted living facilities. They may also have younger people who have aged out of foster care. There are a lot of foster cares, but by and large those are for children and run and paid for by the state or federal government.

One of the real good points from my perspective of being in a foster care is if you don't have a license, you don't have to defend anything. If you're in your home, your mom, your cousin, your next-door neighbor or friend can assess your well-being. I think that there are 46 states now that have VA medical foster homes across 122 programs. In Tampa alone we have three medical foster home programs scattered over four different counties. And we'll soon have more medical foster homes as we continue to expand.

The veteran does pay for it themselves — the financial and care contract is between the veteran or veteran’s representative and the medical foster caregiver. It's negotiated based on what the veteran's needs are and the capabilities of the medical foster home provider. There is a bill, I'm not sure where it is in Congress, that's been put forth to allow the VA to pay for foster care because it’s a huge cost savings over the VA paying for nursing home care, and many of these foster patients are eligible for nursing homes.

 

AAHCM

How do you think medical foster care fits into the bigger trend of care in the home and expanding care outside of the hospital or clinic setting?

JL

I cannot imagine that the country can keep up the way it's doing without home care. At least in this pandemic, nobody wants to go out and have an appointment to begin with. Nobody wants that sort of exposure. Then there’s the explosion of older people, frail people, and the expenses continually going up — I read that in Florida now that the average nursing home stay is 10 to $12,000 a month. How do people do that? To me, home care is the only answer.

 

AAHCM

Do you ever see any elder abuse or any cause for concern in foster arrangements?

JL

I would say no. We've seen people that need some training and encouragement. I have seen people do some unusual things that we had to kind of stop, for example when a foster caregiver offered to take a veteran that was pretty withdrawn and depressed to a bar to cheer him up!

 

AAHCM

Can you think of any particular foster caregivers outside of the immediate medical team who have stood out to you?

JL

It really takes a huge team. In order to open a foster care, we send out safety experts to check the wiring, make sure they can get a patient out the window or out the door in case of fire. Patients are visited by physicians, advanced practice nurses, recreation therapists, dieticians, psychologists, a psychiatrist, a rehab specialist. They get monthly visits from the medical foster home social worker and other social workers. I can't say enough about the individuals in the teams and team as a whole. It's really what makes it work.

One of the most remarkable things that has happened in foster care really exemplifies what we do.

The VA has a jail outreach program to keep tabs on veterans in jail, make sure they're getting their meds and regular checkups. There was a veteran who was in and out of a local jail for a long time. He had about 16 mugshots and he looked like people were beating him up — he just looked terrible. We talked to the jail outreach social worker and I thought, maybe this is crazy, but we took him from the jail to place him in foster care.

He wasn't a harmful person, he some cognitive issues and some mental health issues for sure. We put them in this foster care with a caregiver who specialized in that. She was really excellent at keeping patients calm and engaged. Well, that gentleman gained a much needed 50 pounds. They got him dentures. They got his mental health issues under control. And the social worker found out that he had been some sort of civilian employee of a government agency and found something on the order of $700,000 in back pay that he never got because he was in the jail. It’s really unbelievable.

Mermaid Vicki in the 1950s

Another great story — we had a patient in foster care who needed a lot of care. And his wife, who was younger and less frail, just happened to have been a Weeki Wachee Mermaid in her youth. Well, once in a while we take all these foster care patients and their caregivers on picnics and outings so they can get to know each other and brush up on some training. So, we took this group to Weeki Wachee and the wife of this veteran did this mermaid show with the other mermaids — she was 50 years older than the next mermaid! And then the veterans and caregivers all got to meet the mermaids. Where are you going to see that in other care settings? To me, that's good care. We've taken them to the air force base and put them on boats and taken them around on buses to various places for picnics. We get to do a lot of things with them.

 

Mermaid Vicki circa 1959

AAHCM

Why do you think medical foster care isn’t more widespread?

JL

The challenge is that it depends on such a sophisticated team and resources. That's what allows us to think out of the box and not play with these licensing and funding issues. It's been an act of bravery, really, and resources. For the most part, primary, in-home care is not reimbursed. Skilled care services are on a limited basis. Foster care is a cross between custodial care and medical care, the same as if your family were doing things like accuchecks or wound care. The difference is that because the veteran is part of a “family” there are no licensing issues for performing what would otherwise be skilled care. It is spelled out in an agreement between the veteran and caregiver. In Florida, the state allowed us to have a waiver so that an unlicensed home can have 3 veterans, otherwise the limit is 2 people. But the medical foster home satisfaction scores in our home care program are consistently off the charts. I was recently looking at the data for how many times patients had been hospitalized before coming into foster care. I couldn't find a single person who had been hospitalized at our main hospital from foster care. These people are their family. There is no question about that. They're really bonded.

The way the VA is structured allows us to provide primary care without the “skilled care” rules.

I said something earlier about the team and I listed off professions, but the patient is in the absolute middle of the whole thing, and we don't lose sight of that.

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