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SSVF Health Care NavigatorsAugust 13, 2o2oUpdated Guidance and FAQ availablewww.va.gov/homeless/ssvfLink to Audio1
SSVF HEALTH CARE NAVIGATORS On July 16, 2020 SSVF was awarded 400 million insupplemental CARES funding A portion of this funding will be used by SSVFgrantees to employ designated health carenavigator(s) to work with VAMCs and otherhealthcare systems ensuring appropriate carecoordination for VeteransDATEDOCUMENT TYPE/STATUS2
WHAT IS A SSVF HEALTH CARE NAVIGATOR? SSVF health care navigators will work with Veteranson a variety of issues to assist them in identifying andovercoming challenges to accessing the healthcaresystem or adhering to recommended health care plans SSVF health care navigators are trained to assistVeterans with the following:– Gaining access to health care– Supporting health care plans by identifying barriers to care– Providing education on wellness related topicsDATEDOCUMENT TYPE/STATUS3
WHY DOES SSVF NEED HEALTHCARE NAVIGATORS?Major Health Problems- SSVF Exiters2018 VA Annual Reportindicated that 63% of SSVFVeteran participants had adisabling conditionPTSDMajor depressive disorderSubstance use disorderCardiovascular Disease0August 13, 2020SSVF Health Care Navigators500010000150002000025000300004
WHY DOES SSVF NEED HEALTHCARE NAVIGATORS? One study showed that homeless Veterans havehigher rates of chronic disease than non-veteranhomeless (Goldstein, Luther, Jacoby, & Haas, 2008) Veterans who rely primarily on VA emergency roomsoften receive fragmented care 20% of Veteran emergency room utilizers returned tothe ER again within 30 days (Hastings et al, 2011)August 13, 2020SSVF Health Care Navigators5
WHY DOES SSVF NEED HEALTHCARE NAVIGATORS? (2) Veterans reported that the VA eligibility process canbe overly complicated and difficult to access (BlueHowells, McGuire, & Nakashima, 2008) Veterans may have barriers to accessing care orkeeping health care appointments, lack oftransportation or childcare, for example Veterans can benefit from education about availablehealth related resources and benefitsAugust 13, 2020SSVF Health Care Navigators6
WHAT DO SSVF HEALTH CARE NAVIGATORS DO? Health care navigator programs have been used by VAto assist Veterans with specific health care needs suchas cancer or other chronic illnesses Health care navigators are effective at improvingaccess to care Navigator programs have been successful atdecreasing no show rates and increasing healthscreenings in healthcare systems, (Ali-Faisal et al)August 13, 2020SSVF Health Care Navigators7
WHAT DO SSVF HEALTH CARE NAVIGATORS DO?Assist Veterans in accessing healthcare systems– gaining entry to VA health care (including mental healthcare) or community care when Veterans are not eligible forVHA– connecting Veterans to VA health care by working with theVAMC to facilitate enrollment– helping to gather documentation and complete paperworkrequired for enrollment– following up on enrollment progress to ensure that theVeteran is enrolled in VA or community health careservicesAugust 13, 2020SSVF Health Care Navigators8
WHAT DO SSVF HEALTH CARE NAVIGATORS DO? Help Veterans get access to appointments whenneeded– supporting Veterans in identifying health care needs– working collaboratively with health care teams to facilitateaccess to care Assist Veterans in utilizing available servicesincluding preventative health care– communicating with Veterans and health care teams aboutappointmentsAugust 13, 2020SSVF Health Care Navigators9
WHAT DO SSVF HEALTH CARE NAVIGATORS DO? Help Veterans identify barriers to adhering torecommended health care plans Assist Veterans in understanding and communicatingwith providers to make informed decisions abouthealth care– supporting and encouraging Veteran to discuss questionsabout medication or treatment goals with providers Problem-solve barriers to care (i.e. transportation,childcare)August 13, 2020SSVF Health Care Navigators10
WHAT DO SSVF HEALTH CARE NAVIGATORS DO? Provide education or create linkages for Veterans tolearn about wellness related topics– providing pamphlets or other literature on smokingcessation, diabetes management, exercise– inviting guest speakers to education groups on healthrelated issues for Veterans– linking Veterans to support groups or other programs atthe VA or in the community to support their health goalsAugust 13, 2020SSVF Health Care Navigators11
WHO ARE HEALTH CARE NAVIGATORS? Social workers with an LCSW or equivalentbackground are often hired as health care navigators Health care navigators are familiar with socialservices or healthcare settings Health care navigators communicate effectively withVeterans and health care teams Must be able to establish relationships with Veteran,health care teams, and community service providersAugust 13, 2020SSVF Health Care Navigators12
WHO ARE HEALTH CARE NAVIGATORS? Reminder - SSVF grantees do not provide directhealth care services; navigators are not health careproviders and do not deliver direct patient care Mental health counseling is not an eligible SSVFactivity and therefore not within the scope of theSSVF health care navigator’s job duties SSVF health care navigators do not make treatmentrecommendationsAugust 13, 2020SSVF Health Care Navigators13
INCORPORATING HEALTH CARE NAVIGATORS INTO YOUR TEAM SSVF health care navigators can be hired directly aspermanent or temporary employees– a sample SSVF health care navigator position description isavailable on the SSVF website Health care navigators can be acquired by contractingwith an organization that provides these services– contract staff are required to participate in all SSVF healthcare navigator training and activities– SSVF grantees must provide adequate oversite ofcontracted staff providing servicesAugust 13, 2020SSVF Health Care Navigators14
INCORPORATING HEALTH CARE NAVIGATORS INTO YOUR TEAM The health care navigator must understand theirresponsibilities and role in the SSVF team SSVF program managers should introduce the newhealth care navigator to their team and clearly outlinethe role and job duties of the position The health care navigators should be introduced tocommunity providers and VA including the homelessteam, VA enrollment staff and HPACTAugust 13, 2020SSVF Health Care Navigators15
INCORPORATING HEALTH CARE NAVIGATORS INTO YOUR TEAM Role of Housing Navigators– conduct housing barrierassessments– assist with documentation– assist with completing housingrelated paperwork– identity housing preferences– connect Veteran to landlords– assist with lease up process– provide help with move-incosts (deposit, rent, utilities)August 13, 2020 Role of Health CareNavigators– assist with enrollment– help gain access toappointments– identify barriers to health caregoals– help with transportation tohealth care appointments– encourage communicationwith health care providers– ensure coordination of careSSVF Health Care Navigators16
NEXT STEPS The SSVF program office will provide initial trainingto the health care navigators in October 2020 toensure that they understand their role andresponsibilities in terms of providing services toVeterans– training will combine pre-recorded webinars and live(remote) training modules– training will provide SSVF health care navigators with abasic understanding of VA and community health care,mental health and substance use treatment resourcesavailable to VeteransAugust 13, 2020SSVF Health Care Navigators17
QUESTIONSQuestions will be held until all presentations arefinishedDATEDOCUMENT TYPE/STATUS18
CITATIONSAli-Faisal, SF, Colella TJ, Medina-Jaudes N, Benz Scott L (2017) The effectiveness of patient navigation toimprove healthcare utilization outcomes: A meta-analysis of randomized controlled trials. Patient Educ.Counseling 100 (3):436-448Blue-Howells, J., McGuire J., Nakashima J (2008). Co-location of health care services of homeless veterans: acase study of innovation program implementation. Social Work in Health Care, 47, 219-231.Goldstein, G, Luther JF, Jacoby AM, Hass GL, Gordon AJ. A Taxonomy of medical comorbidity for veteranswho are homeless. J Health Care Poor Underserved. 2008;19(3):991-1005. doi:10.1353Hastings, S.N., Smith, V.A, Weingberger, M., Schrader, K.E., Olsen, M. K., & Odone, E.Z. (2011). Emergencydepartment visits in Veterans Affairs medical facilities. The American journal of managed care, 17(6 Spec No.),e215-23DATEDOCUMENT TYPE/STATUS19
Supportive Services for Veteran Families (SSVF)SSVF & VA CoordinationCarolyn Head, MSW, LCSWRegional Coordinator, SSVF Program Office20
VISN 1 Coordination Shara Katsos, VISN 1 DeputyHomeless Coordinator John Chiechi, Grant Per DiemLiaison with VA ConnecticutHealthcare System21
Hotel/Motel Placements in New England 12 SSVF Grantees From March 17, 2020 – July 30, 2020, SSVF Grantees placed434 Homeless Veteran Households in hotel/motels withEmergency Housing Assistance (EHA) in VISN 1– High-risk for COVID-19– Unsheltered– Asymptomatic in need of quarantine22
Risk Factors Increased stress duringglobal pandemic Increased isolation inhotel/motel Impact of demonstrationsagainst racism Reduced access toaffordable ways topurchase and preparefood More limited supportiveservices and ability tosearch for housing23
How does Case Managementincrease Protective Factors forVeterans placed in hotel/motels?24
VAMC & SSVFCoordinationFormalized PlanThe goal is to collaborate with SSVF to provideVAMC services for healthcare eligible Veteransplaced in hotels.25
Process1) Established VAMC SSVF Point of Contact (POC) to ensure VA services(i.e. mental health, substance use disorder, medical, housing ) are inplace for SSVF participants in hotels2) SSVF Grantees will hire Health Care Navigators to work with POC3) Ongoing case conferencing for those in EHA26
What helped make this work?27
Contact InformationCarolyn Head, MSW, LCSWRegional CoordinatorSSVF Program OfficeCarolyn.Head@va.gov28
Natalie Lusk, LCSW - Coordinated Entry Specialist
BackgroundBackground As SSVF grantees began enrolling Veterans in EHA, VA and communitypartners identified the need to track placements and link to VAresources. SSVF grantees submitted HMIS numbers for Veterans enrolled in EHAto the COC Veteran Coordinator and VA CES. We reviewed data in VAand community systems, and then referred to VASH for potentialscreenings.
Data Recognized the need for SSVF and VA points of contact to connect inorder to help facilitate housing plans with the Veteran. Included SSVF and VA points of contact on revised tracker. Recognized the need to also link Veterans in EHA to HPACT, providingmedical support to Veterans and SSVF grantees in the community.
Collaboration& SuccessesEHA – VA TrackerClarity IDNameSSN #AgeRace/EthnicityAcuityScoreCERSprogramVA Notes andPOCHMIS NotesHPACT Assignment:HPACT Team #yes/noVeterans Phone #SSVF POCMotel
The health care navigator must understand their responsibilities and role in the SSVF team SSVF program managers should introduce the new health care navigator to their team and clearly outline the role and job duties of the position The health care navigators should be introduced to community providers and VA including the homeless
