Geriatrics and Extended Care - Miami VA Healthcare System
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Miami VA Healthcare System

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Geriatrics and Extended Care

Service Mission

The mission of the Miami VA Healthcare System's Geriatrics and Extended Care Service is to provide quality patient care utilizing an interdisciplinary approach.

Program Descriptions and Specialties

Adult Day Health Care 

Adult Day Health Care (ADHC) is a therapeutically oriented outpatient day program that provides health maintenance and rehabilitative services to frail elderly and functionally impaired Veterans in a congregate setting. The program encourages socialization with other Veterans of the same age group. Individualized programs of care are delivered by an interdisciplinary team of health professionals and support staff with an emphasis on helping participants and their caregivers to develop the knowledge and skills necessary to manage care in the home.

Care Coordination/Home Telehealth

Urban, care coordination programs utilizing technology and a team approach to assist in coordinating the care of elderly Veterans at-risk for hospitalization and emergency department visits. The Care Coordination/ Home Telehealth (CCHT) Programs use technology to monitor certain chronic health conditions in the home. The goal of these programs is to reduce resource utilization (ED visits, hospitalizations) and delay onset of long term care placement, while improving the quality of care provided to the Veterans.

  • T-CARE - This care coordination program utilizes technology and a team approach to assist veterans with diabetes, hypertension, heart failure, and/or chronic lung disease.
  • Telephone Linked Care for Dementia – The Telephone Linked Care (TLC) program utilizes technology and a team effort to coordinate care for veterans' with dementia. TLC uses technology to educate and support caregivers of Veterans with dementia in the home.

Community Living Center

Provides a home-like environment to Veterans during their stay at the Bruce W. Carter VA Medical Center. The VA Community Living Center (CLC) program specializes in care for patients who are at maximum hospital benefit and have restorative potential, but still need skilled nursing care, supportive personal care, and individual adjustment services.

Geriatric Primary Care

Provides high-quality primary care that is specialized and designed to assess evaluate and establish a comprehensive plan of care for elderly patients on an outpatient basis.

Geriatric Evaluation and Management 

A specialized program for a targeted group of older patients who will benefit from comprehensive interdisciplinary evaluation and management. The Geriatric Evaluation and Management (GEM) team develops a comprehensive plan of care to address geriatric syndromes and the issues related to the elderly.

Home Based Primary Care 

The Home Based Primary Care (HBPC) Program provides primary health care in the home to Veterans with multiple chronic medical and psychosocial problems.  HBPC offers patients and their families an alternative to nursing home placement, help to maintain optimal physical, mental and social functioning, and help to reduce frequency of hospitalization. HBPC consists of a team of hospital-based interdisciplinary group of professionals including Medical Doctors, Nurse Practitioners, Dietitians, Social Workers, Physical Therapists, Psychologist, Psychiatrist and Registered Nurses functioning in distinct, yet overlapping roles to provide comprehensive primary health care to the Veteran in the home environment.

Hospice and Palliative Care 

Hospice and Palliative Care collectively represent a continuum of comfort-oriented and supportive services provided in outpatient, or inpatient settings for persons with advanced life-limiting disease. Programs emphasize on the relief of suffering and comprehensive management of the physical, psychological, emotional, social and spiritual needs of the patient.

Medical Foster Home

Medical Foster Home (MFH) is a unique partnership of adult foster home and Home Based Primary Care (HBPC) operating under Community Residential Care (CRC) guidelines.  Medical Foster Home finds a caregiver in the community who is willing to take a Veteran into their home and provide 24-hour supervision and personal assistance.  This would be a long-term commitment, where the Veteran may live for the remainder of their life.   Veterans who enter MFH all meet nursing home criteria.  As their condition declines, they generally will need more care.

Purchased Skilled Home Health Care

The goals of the Purchased Skilled Home Health Care Services Program are to ensure that clinically appropriate services are available in the home as a component of the medical care necessary to support Veterans in restoring or improving their health status, maintaining their independence, or providing supportive services.  The Purchase Skilled Home Health Care Program offers enrolled Veterans a documented medical referral through their primary care provider, intermittent, short-term or long-term services for transitional rehabilitative therapies and skill care services.

Respite Care

Provides medical center or community living center care that is of limited duration. It is care which is being provided to a Veteran who is suffering from a chronic illness and who resides primarily at home and is designed to support the caregiver's role in caring for the chronically ill Veteran at home. This care will not exceed 14 days, and is permitted twice annually.

Contact Information

For further information please contact the Geriatrics and Extended Care at:

Adult Day Health Care, 305-575-7000, ext. 13799
Care Coordination (T-Care & TLC), 305-575-7150 or 3583
Geriatric Clinic, 305-575-7101
Geriatrics & Extended Care Administration, 305-575-3559
Home Based Primary Care, 305-575-3173
Hospice and Palliative Care, 305-575-7000, ext. 13246

Contact Info

Location

  • Bruce W. Carter VA Medical Center

Contact Number(s)

  • 305-575-3559

Hours of Operation

  • Monday-Friday
    8 a.m.-4 p.m.