VA Eastern Colorado Health Care System
Home-based care expands for vulnerable Veterans
To improve intensive management and care coordination for Veterans, VA Eastern Colorado Health Care System expanded its home-based primary care program in Southern Colorado. An interdisciplinary team is now offering comprehensive primary care in the homes of Veterans.
“There was a need down here to expand, to serve some of these Veterans who are vulnerable,” said Dr. Karen Shea, VA ECHCS home-based primary care medical director, about relocating to Pueblo in August 2019. Carrying a blue physician’s bag packed with equipment, she was on the doorstep of a Navy Veteran who’s lived decades with Parkinson’s disease.
Since 2014, the Southern Colorado home-based primary care team had a physician, registered nurse, nurse practitioner and social worker. In 2020, Shea added another nurse practitioner, a registered dietitian and an occupational therapist. She formed a full patient-aligned care team to offer more Veterans personalized, whole-person care at home.
“All of our team members come and see them in their home, and provide that care and that continuity,” said Shea, highlighting visits in Pueblo, Colorado Springs and surrounding areas. “We see them so often that they generally don’t have to go to the hospital or the emergency room. We’re able to consolidate their care and keep them in their home.”
Most patients are medically or socially complicated, or multiple medical problems make travel tough. Family members and caregivers of Veterans who need close monitoring get resources and education. They learn about medications, advanced care planning and palliative care, which optimizes quality of life and mitigates suffering through serious illness.
“Our goal is to help them remain in their homes for as long as possible,” says Shea.
Navy Veteran Francisco Montez, 82, served on the USS Lexington in the early 1960s. He recalls operating an aircraft elevator during war games on the Pacific coast. He had battled Parkinson’s disease for nearly 30 years when living independently got tough. In October, he moved from Denver to Pueblo County to live with his sister.
“Since we were young, him and I have been close,” said Maria Montez about her brother, “all through childhood, through high school, when he came home from the service.” To avoid the expense and restrictions of assisted living, she connected with the Southern Colorado home-based primary care team.
“Without this program, it would be so much harder for me to keep in touch with his doctors, and what his illness is doing, and what to expect with it,” said Maria Montez, after an appointment with Shea. “This program has made it so much easier for me to understand him and understand his disease.”
Francisco Montez said his care team knows him personally and compares him to “Grandma Moses.”
Self-taught artist Anna Mary Robertson Moses started painting at an advanced age, as arthritis limited other activities, according to the National Museum of Women in the Arts. She exhibited her work through her 90s and painted until 101.
Francisco Montez first noticed his artistic talent during classroom projects in the 1940s. He grew up in Delagua, a former coal-mining town south of Aguilar. A quiet child, he mostly enjoyed playing with siblings. He was reminded of his talent in 2017 during a social event in Denver. He had been handed water, paint and sponges with paper and brief instructions.
Transitioning on his own from sponges to brushes, Francisco Montez completed more than 200 watercolor paintings — some he sold at exhibitions, others he gave away. He starts with an idea in mind, often inspired by scenes in books. But the wet layers of pigment rarely finish as intended. When a tremor pushes his hand, the brush blends it in.
“The brush needs my hand, I don’t need the brush,” he says. “I know what I want to do but it doesn’t turn out that way. It completely turns itself around and it’s a different painting … that’s why I say, ‘the brush needs my hand.’”
“They’ll say, ‘don’t stop, you’re doing good,’” said Francisco Montez about his care team. Shea displays his work in her office at the Community Living Center in Pueblo.
“One of the really special things about our program,” said Shea, “is how well we get to know our Veterans, and how they really become part of our team.”
“The VA is really there for you,” said Maria Montez, explaining how the team shares resources to increase home accessibility, including a walk-in shower and a ramp, when needed. She had just learned about options that would let her take a vacation while knowing her brother is cared for.
“They’ve been there to help us in every step of the way,” she said.