CRP Your Source for Issues and Trends in BRIEF Community Rehabilitation January 2008 Vol. 6, No. 1 Continuum of Care Model for Blind and Visually Impaired Veterans As the number of veterans requiring services from the Department of Veterans Affairs (VA) dramatically increases, the need for community rehabilitation providers to serve this population will increase in kind. One such care model to provide visual services utilizing community resources is outlined in this CRP Brief. We are fortunate to have Ashley Thomas, Visual Impairment Services Team Coordinator at the Dallas VA Medical Center to author this CRP Brief. BACKGROUND The Department of Veteran Affairs (VA) estimates there are more than 1 million visually impaired veterans over the age of 45 in the United States. Fifteen percent of this group, roughly 157,000 veterans, are legally blind. In addition another 1,026,000 are diagnosed with low vision. Overall, about 80 percent of all visually impaired veterans have a progressive disability caused by age- related macular degeneration, glaucoma, or diabetic retinopathy (VA, 2007b). Legal blindness is identified and classifi ed in several ways. A person can have either a central acuity of 20/200, or worse, in the better eye including use of corrective glasses. Another method of diagnosis regards having a central visual acuity better than 20/200 in the better eye, but with visual fi eld defi cits. Persons meeting this second definition must also have a peripheral diameter of 20 degrees or smaller. Low vision is characterized by having a central visual acuity equal to or less than 20/70, but greater than 20/200 in the better eye, with the use of corrective glasses (VA, 2007a). It is estimated that during the 2007 year, the number of legally blind veterans, in total, may top 170,000. Currently listed on the Veteran’s Healthcare Administration (VHA) rolls, are roughly 40,000 legally blind veterans. Due to medical advances, veterans are living longer. This is increasing the overall average age group the VA serves. Additionally, age has been found to be the best predictor of severe visual impairment (Pohl, Washington, Watson, & Williams, 2007). This presents an interesting challenge as the number of veterans needing services from the VA continues to quickly increase. On the other end of the spectrum, veterans returning from Iraq and Afghanistan (Operation Iraqi Freedom, [OIF] and Operation Enduring Freedom, [OEF]) are bringing traumatic brain injury into the field of blind rehabilitation at a rapid rate. Until September 11, 2001, the majority of our veterans were dealing with progressive eye diseases. Our newest veterans (OIF/OEF) are dealing with vision processing disorders instead of the more familiar eye diseases. The VA has been persistent with making sure all medical staff members are educated about traumatic brain injuries and the treatment needed to best care for these veterans. Future services in the field of blind rehabilitation will call for treatment related to traumatic brain injuries coupled with age-related vision loss and eye diseases. HIGHLIGHTS To help our veterans cope with and adjust to life with a visual impairment, the Department of Veteran Affairs (VA) established the Blind Rehabilitation Service (BRS) to provide a variety of rehabilitation programs and services that include inpatient Blind Rehabilitation Centers (BRC), Visual Impairment Service Teams (VIST), Blind Rehabilitation Outpatient Specialists (BROS), and Computer This project is in part supported under a grant from the Department of Education. However, the contents do not necessarily represent the policy of the Department of Education and endorsement by the Federal Government should not be assumed. Access Training (CAT) programs along with a variety of low vision services (VA, 2007a). The BRS program is designed to “improve quality of life for veterans who are blind or severely visually impaired through the development and enhancement of skills and capabilities needed for personal independence, adjustment, and successful reintegration into the community and family environment” (VA, 2007a, ¶8). The goal within BRS is early intervention in an effort to maximize independence of the veterans while reducing dependence of family and friends (VA, 2007b). CONTINUUM OF CARE MODEL The VA Blind Rehabilitation Service is committed to a continuum of care model that extends from the veteran’s home environment to the local VA care site. The model includes regionally-based inpatient training programs that provide a wide array of rehabilitation services. The VA has recently implemented a plan to provide eye care to veterans with visual impairments ranging from 20/70 to total blindness (Pohl, Washington, Watson, & Williams, 2007). The VA will provide roughly $40 million over the next three years to establish and support this wide-ranging rehabilitation system for veterans. In addition, the system will be able to serve active duty personnel with visual impairments (VA, 2007a). A basic level of service designed for veterans with low-vision will be provided at all VA eye clinics. Also every network will offer low-vision services, including a full spectrum of optical devices and electronic visual aids. Blind Rehab services within the VA use to be limited to those veterans with 20/200 visual acuity or worse in the better eye (legal blindness). The newly expanded criteria of 20/70 (low vision) will exponentially increase the caseload of every blind rehabilitation professional within the VA system. Community rehabilitation providers (CRP) will be needed now more than ever to help care for veterans with visual impairments and blindness. IMPLICATIONS FOR CONSUMERS Newly blinded veterans may have concerns ranging from employment and fi nancial matters to their own health needs such as managing their medications on their own and transportation to and from their doctor’s appointments. Emotional and behavioral adjustment to blindness is one of the most challenging issues faced by the veteran and remains a primary concern for the rehabilita tion team. Through individual and team counseling sessions, veterans are taught coping and adjustment strategies that build self-confidence and restore independence. When veterans are unable to attend an inpatient Blind Rehabilitation Center program, often, solutions to some of the more multifaceted problems require outsourcing to CRPs and state rehabilitation agencies in the veteran’s home area. Some of the basic training veterans receive through the VA when they take advantage of the BRS service includes: independent living skills such as communication and activities of daily living; orientation and mobility; computer access training; manual skills classes; and visual skills training. Veterans can also take advantage of the physical conditioning classes, recreational activities, counseling opportunities focusing on adjustment to blindness, group meetings and even the family program involving the veteran’s family in the rehabilitation process. Each VA facility has been authorized to provide various devices (prosthetics) for the veterans who are dealing with vision loss. Each veteran is evaluated with, and taught the use of appropriate devices. If need and aptitude are established, the veteran can then be issued the prosthetic device. Prosthetic devices such as low vision devices, magnifiers, talking devices, computers and adaptive software assists the veteran with adjusting to their visual impairment. Similarly the devices aid the individuals in functioning effectively and effi ciently in their environment (VA, 2007b). Criteria for such devices are based on medical need as well as the utility to improve the veteran’s quality of life. Regardless of whether the veteran wants to return to work or enjoy retirement, the VA is dedicated to helping each veteran achieve their own personal goals and improving the way they manage their healthcare. RELEVANCE FOR CRPS Trends in aging will always have an impact on caseload size within the VA, but more importantly, trends in war injuries will signifi cantly alter the type of services the VA provides. An increase in caseload size along with the learning curve of traumatic brain injury calls for more help from CRPs. One big concern Visual Impairment Coordinators have at local VA hospitals is the long waiting period veterans have to deal with due to the number of veterans that need to be served. As the “baby boomers” start developing age-related vision loss problems, CRPs will see an influx of older adults asking for assistance with independent living skills and computer training unrelated to employment. While the VA’s blind rehabilitation program can provide many of these services, the ratio of professionals to veterans makes it impossible to reach everyone that requests care. Visual Impairment Coordinators hold a caseload of 200 to 1,000 visually impaired veterans at any one time. This will continually increase as the Continuum of Care Model is implemented and services open up to those with low vision. Blindness-related CRPs are benefi cial to veterans who are looking for assistive technology training, living skills training, vocational rehabilitation, Orientation and Mobility training as well as Home Based Primary Care services. While the Visual Impairment Services Team within the VA system does their best to provide healthcare to all visually impaired veterans, there are many who live in rural areas who cannot travel to and from their local hospital or clinic for these services. Collaboration efforts between CRPs and VA healthcare networks can optimize services for all visually impaired veterans. Bridging the gap between the medical model of care (optometrists, ophthalmologists, retina specialists, and new pharmacological treatments) and the field of blind rehabilitation (O&M specialists, blind rehabilitation specialists, occupational therapists, and counselors) can only improve the holistic care these veterans deserve. Through a team approach, a holistic treatment plan should be created for each veteran as it relates to their visual diagnosis. The VA’s Blind Rehabilitation Service has a strong partnership with each state’s vocational rehabilitation agency. While veterans who have a service connected disability can take advantage of the Vocational Rehabilitation and Employment program within the VA, veterans with no service-connected disability have to access care from outside agencies and vocational rehabilitation programs if they are seeking employment or vocational training. It is important for state vocational rehabilitation agencies to make note of whether or not their caseload is comprised of veterans and connect them with their local VA facility for additional services. Many times, veterans are eligible for benefits and healthcare they never knew existed. It is also just as important for the VA’s Blind Rehabilitation Service staff to refer veterans to appropriate community rehabilitation providers to help complete this continuum of care model. SUMMARY Trends in treatment and management of vision loss are changing as caseload compositions start diversifying and expanding. Best practices with in the VA system will continue to focus on the Continuum of Care model. Caseloads are growing ever larger as services are being offered to any veteran with a functional visual impairment. Over the next several years, the field of blind rehabilitation with the VA Healthcare System will be recruiting heavily for more blind rehabilitation specialists, including O&M Specialists, low vision optometrists, certifi ed low vision therapists, social workers, and occupational therapists who have a background with traumatic brain injuries. Despite the large caseload sizes and the rapid introduction of traumatic brain injuries into the field of blind rehabilitation, the VA HealthCare System continues to provide some of the best healthcare in the world to veterans. The future of blind rehabilitation services within the VA promises to be an amazing model of holistic care, emphasizing natural supports and allowing veterans to regain and maintain independence in all areas of their life. WEBSITES AND OTHER RESOURCES • VA Blind Rehabilitation Service: www1.va.gov/ blindrehab • American Foundation for the Blind: www.afb.org • Resource Center for Low Vision: www.lowvision. com REFERENCES Department of Veterans Affairs, (2007a). VA im proves services for blinded and low-vision vet erans. Press release January, 25, 2007, Offi ce of Public Affairs Media Relations. Department of Veterans Affairs, (2007b). Services for Blind and Visually Impaired Veterans. Re trieved August 2, 2007, from http://www1.va.gov/ blindrehab/page.cfm?pg=4 Pohl, S., Washington, W., Watson, G., & Williams, M. (2007, August). State of Blind Rehabilitation Service. Paper presented at the VIST/BROS Annual Conference, Albuquerque, NM. Author’s Biographical Information: Ashley Thomas has been working in the field of Blind Rehabilitation since 2003 when she graduated from the University of North Texas with a Master’s Degree in Rehabilitation Counseling. She currently holds the position of Visual Impairment Services Team (VIST) Coordinator at the Dallas Veterans Administrtation Medical Center. Ms. Thomas is the Vice President of the Dallas Eye Services Visit Our Website Consortium, which meets on a regular basis to discuss legislation, education, advocacy and Dallas area services to people who are blind and visually impaired. She also serves on a number of committees within the VA system including the OIF/OEF Council, some special event planning committees, and heads up the VIST Team committee. The CRP Brief is published 3 times a year by the Region VI CRP-RCEP. It is available on our website: www.crp.unt.edu For more information, reprints, or to comment on subject matter, contact: Linda Holloway or Martha Garber Co-editors University of North Texas - Region VI CRP-RCEP PO Box 311456, Denton, TX 76203 1456 940/565-4000 Region VI CRP-RCEP Meeting the continuing education needs of community rehabilitation providers Discover the Power of Ideas