The program’s goal is to improve access to veterans’ healthcare in a 5-county area including Newaygo, Mecosta, Lake, Oceana and Mason. Healthcare professionals (see below) are available to make home visits and to a provide medical outreach at sites within each county.

Administrative
· Streamlined enrollment into VA healthcare system
· Assistance with means testing (copay status for services and medications)
· Provide picture VA IDs
· Transfer of PCP services to NREX provider (at veteran discretion)
· Sign-up and instruction on using MyHealthyVet services
· NREX does not have any role in Compensation and Pension claims or evaluations. C and P is intentionally set up as a separate system to avoid conflict of interest.

Medical Primary Care
· Can become Primary Care Provider (Advanced Nurse Practitioner) with home or site services for medication and lab orders
· Can liaison with existing PCP in Muskegon or Grand Rapids VA Clinics
· Provides referrals and consults to specialty clinics within the VA
· Unable to conduct procedures, such as mole removal, which will be referred as appropriate

Nursing
· Home services if eligible for Home Based Primary Care program (if veteran has chronic and disabling disease condition with need for ongoing medication management, such as uncontrolled diabetes, COPD, MS)
· Administer injections and blood draws as ordered by PCP at community sites
· If veteran has acute care medical needs (more than weekly monitoring or intervention), then NREX will assist with referral to appropriate level of care.

Social Work
· Treatment of outpatient mental health issues, individual and group therapy (groups under development)
· Knowledge of and referral to community resources
· Determining of need for contracted Home Health Aides (up to 4 hours weekly) for ADL assistance and Outpatient Respite for Caregivers/Inpatient Respite
· Monitoring of and supportive counseling for caregivers, as desired
· Liaison for other VA service issue
v.3 2/11/14

Occupational Therapy
· Provides home safety evaluations (e.g. fall prevention; home modification info and recommendations)
· Orders or refers for needed adaptive equipment or training to continue independent living (e.g. reaching devices, sock aids, wheel chairs, etc.)
· Assess and advise on home living adjustments to loss of physical function to continue independent living
· NREX is unable to provide direct hands-on therapy or vocational assistance; Assistance with home modification grants are referred to Veterans Service Officers

Dietitian
· Clinical dietitian available for consultation, assessment and education via phone or, soon, clinical video Tele-health
· Coordination of Move weight-loss Tele-health program
· Dietary materials provided on request for weight loss, diabetes, hypertension, etc.

Pharmacy
· For HBPC, review of medications and labs, matching with problem list
· Review falls reports for possible medication contribution
· Conduct blood thinner clinic via phone contact to adjust medication levels
· Phone monitoring of medications for diabetes and high cholesterol
· Pain management issues are referred to veteran’s PCP

Psychology
· Brief outpatient mental health services as (above) for Social Work, also in home and, eventually, in group format in community locations in each county.
· Psychological Testing for memory concerns, advanced diagnosis, and treatment planning consultation.
· Liaison for Psychiatric treatment and specialized Neuropsychological referrals
· Scope does not include intensive case management services

Community Site Services
· Enrollment and ID facilitation
· PCP consultations (if private room at site)
· Blood draws as ordered
v.3 2/11/14
· Injections as ordered
· Blood pressures
· Group Therapy (under development, site dependent)

Tele-health (services in this area are significantly expanding)
· Tele-dermatology (in coordination with Ann Arbor VA)
· Tele-retinal (in near future)
· Clinical Video Technology from home to numerous providers (dependent on technology capacity
in home and available equipment)
v.3 2/11/14