Va Form 10-0415 - Va Geriatrics And Extended Care (Gec) Referral Page 4
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5VA Geriatrics and Extended Care (GEC) Referral con't
21. Referring to which program? (Check all that apply)
20. Goals of Care (check all that apply)
21.1 Skilled care in home
21.10 Long-term nursing home care
20.1 Rehabilitation (improved function)
21.2 Home Based Primary Care
21.11 Outpatient Respite care
20.2 Skilled nursing care (e.g., manage wounds,
(HBPC)
medical devices, catheters, ostomy)
21.12
Inpatient Respite care
21.3 ADL assistance (personal
20.3 Monitoring/supervision to avoid clinical
care) in home
21.13 Specialized Dementia or
complications
Geropsych Care
21.4 Chore Services (homemaker)
20.4 Improve compliance with
in home
21.14 Inpatient palliative/hospice care
medications/treatments
(in NHCU )
21.5 Adult Day Health Care
20.5 Patient/Family Education
21.15 Outpatient Palliative/ hospice
210.6 Residential care (supervised
care (in home)
20.6 Respite (temporary relief for caregiver)
living)
21.16 All inclusive care or PACE
20.7 Palliative/End of Life Care
21.7 Assisted Living
program
20.8 Reduce hospitalizations and/or ER visits
21.8 Domiciliary care
21.17 Other (specify)
21.9 Short-term nursing home care
20.9 Supervised/supportive living situation
(subacute care, rehab,
20.10 Behavior Stabilization
etc)
22. Estimated Duration of Care
22.1 1 week
22.2 2-3 weeks
22.3 One month
22.4 2-3 months
22.5 4-6 months
22.6 Indefinite
Comments. (Any additional information that may be helpful to the referral program)
PATIENT'S LAST NAME, FIRST NAME, MIDDLE INITIAL
SOCIAL SECURITY NO.
Page 4 of 5
VA FORM
10-0415
MAY 2006
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