Hospices Strategize Sustainable Growth for Veteran Programs

Hospices combat both operational and financial challenges as they seek to grow and evolve their veteran programs around the diverse and complex needs of patients and their families.

Some of the largest expenses associated with offering veteran services include staffing and training costs, according to Carlos Graveran, executive director at Maryland-based Frederick Health Hospice. Graveran is also a veteran.

It takes ample financial resources to fuel a trauma-informed care delivery approach and ensure that staff are trained in the unique challenges that veteran populations face at the end of life, Graveran said. Hospices often turn to philanthropic support and community partners to help fund their veteran programs in the face of lagging reimbursement for these services, he said.

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“We’ve gotten creative in doing events that benefit veteran causes and raised money through all these different things that are put into the pool of helping us with the costs of running our veteran programs — which is primarily the staffing cost,” Graveran told Hospice News. “Keeping everything going and keeping staff current on the information and resources available to veterans and their families is rather difficult and challenging when you don’t have the source of revenue. I think that’s a challenge that a lot of hospices run into.”

Veterans’ complex journeys

Providing quality hospice care to veterans includes having staff well-versed on some of their most significant emotional and mental health challenges and how these impact their end-of-life experiences, according to Sherri Bickley, vice president of patient support services at Oklahoma-based Crossroads Hospice & Palliative Care.

The hospice and palliative care provider last November launched its military program Challenge Coin, which provides individualized recognition of veterans’ accomplishments and accolades. The program has provided services to more than 200 veterans thus far in 2024 and is led by chaplains from various U.S. military branches including the Air Force, Army, Coast Guard, Marine Corps, Navy and Space Force. These services added to Crossroads’ existing veteran programs such as bedside and group memorials.

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Staffing considerations play an important role in developing an environment of trust and open communication with veteran populations, according to Bickley.

“We made the decision early on to have our chaplains at the forefront of our veterans services,” Bickley said. “Some veterans have attached a very bad stigma around mental health support. So if they see a social worker coming in, they may not be receptive. It’s an investment to make sure that we’re providing and staying up to date with the ins and outs of veterans programs and resources available to them. It’s making sure you have that receptivity and information, it’s something that makes a big difference.”

Interdisciplinary hospice teams need a solid foundation of awareness when it comes to the complex challenges that veterans can face, Graveran stated.

Some veterans may have unresolved moral injury and trauma, he said. The moral injury can include experiencing heightened levels of distress, guilt or shame associated with their service that can manifest in self-sabotaging behaviors, isolation and depression, according to Graveran. These issues can become exacerbated by the prognosis of a terminal illness.

Shaping services to meet the needs of veterans takes an understanding of their experiences and sacrifices, Graveran said. In addition to staff training, this includes having ways to honor veterans for their service, assess the social determinant of health resources they may need and identify gaps of caregiver support, he added.

Frederick Health Hospice has a veteran wall that commemorates their designated branch of service. The wall has provided significant meaning for some families in illustrating the importance of their loved ones’ military service, Graveran indicated.

Frederick Health Hospice's veteran memorial wall
Photo courtesy Frederick Health Hospice

Veteran programs should be sculpted with an understanding that these individuals are part of a unique community with a rich culture of history in patriotism and camaraderie, according to Carla Creegan, Program of All-Inclusive Care (PACE) director of clinical services and director of adult day services at Empath Health.

Cultivating services that honor, understand and support veteran culture is an important part of quality outcomes, Creegan said.

“Veterans want you to understand what it meant for them to enlist or get drafted and to work in foreign lands with the threat of harm in their minds,” Creegan told Hospice News in an email. “The best way to care for this population and their families is to show respect … We address [their] needs by showing respect for what they accomplished, asking questions, demonstrating that we also care for our country and valuing their contribution to our liberty and freedom.”

Empath offers hospice, home health, primary and palliative care. The Florida-based nonprofit health system also provides adult day services, PACE, AIDS and sexual wellness care.

In 2022 Empath expanded its adult day services to better address veteran populations. Since then, the nonprofit has expanded the program to host educational community events, caregiving training, ceremonial honor pinning events and work with the St. Vincent DePaul charitable organization to serve homeless veterans across its service region.

Creegan was central to the development of Empath’s caregiver toolkit, which helps educate families on the benefits of advance care planning, adult day services and other resources to ease caregiver burden.

Addressing the physical, emotional, spiritual and practical needs of veterans includes careful consideration of their challenges at the end of life, she indicated. Caregivers can at times be overwhelmed or lack the understanding of these challenges to provide effective patient-centered care, Creegan stated.

Adult day services can provide veteran caregivers with much needed respite support while also educating them about ways to better understand a patients’ unique goals of care, according to Creegan.

Addressing veteran needs

Forming community collaborations with organizations such as We Honor Veterans, Wounded Warriors or the Veteran Affairs’ (VA) Pet Partners therapy program can be beneficial to having a more inclusive care delivery approach, Creegan stated.

Veteran organizations can bring a depth of knowledge around the benefits and resources that can assist hospice patients and their families in impactful ways, according to Graveran. This can include ways to help pay for family caregivers in the home rather than transitioning a loved one to facility-based care. Having resources such as caregiver support can help hospices provide improved goal-concordant care to veterans, Graveran said.

Helping families to tap into the network of local, state and federal veteran benefits can be a complicated and complex process, according to Graveran. Having veteran volunteers, liaisons and trained staff is an essential part of navigating VA systems, but this can include a significant amount of operational resources for hospices, he added.

The return on these investments is providing quality end-of-life care that makes an impactful difference in the lives of veteran families, according to Graveran.

“Our veteran liaisons help to train our clinical teams and educate them about better cultural understanding of the basics and nuances of their care as they approach the end of life,” Graveran said. “The training we offer to our nursing staff lets them understand the processes and terminology that can be very foreign to them. Just putting things in that language gives [veterans] a feeling that someone knows what they’re talking about and they can open up and share more of their experiences. It’s understanding the basic information about veteran culture and understanding that sort of ‘veteran speak.’”

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