Home-based care expands for vulnerable Veterans in Southern Colorado

Dept. of Veteran Affairs

To improve intensive management and care coordination for Veterans, VA Eastern Colorado Health Care System expanded its home-based primary care program in Southern Colorado. An interdisciplinary team is now offering comprehensive primary care in Veterans’ homes.

Since 2014, the Southern Colorado home-based primary care team had a physician, registered nurse, nurse practitioner and social worker. In 2020, Dr. Karen Shea, a home-based primary care medical director, added another nurse practitioner, a registered dietitian and an occupational therapist. She formed a full patient-aligned care team to offer more Veterans personalized, whole-person care at home.

“There was a need down here to expand, to serve some of these Veterans who are vulnerable,” Dr. Shea said, about relocating to Pueblo in August 2019. “All of our team members come and see them in their home, and provide that care and that continuity. We see them so often they generally don’t have to go to the hospital or the emergency room. We’re able to consolidate their care and keep them in their home.”

Montez, 82, explains his watercolor works at his home in Pueblo County, Colorado.

Most patients are medically or socially complicated, or multiple medical problems make travel tough. Family members and caregivers of Veterans who need close monitoring get resources and education.

They learn about medications, advanced care planning and palliative care, which optimizes quality of life and mitigates suffering through serious illness.

“Our goal is to help them remain in their homes for as long as possible,” she added...

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