The Problem
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- Veterans recently discharged with congestive heart failure (CHF), new medications, or home safety risks face high 14-day readmission rates.
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- VA and skilled care teams provide excellent clinical care but are often stretched thin.
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- Many veterans lack the day-to-day, in-home support needed to safely recover after discharge.
The Solution: V-PACT
V-PACT is a structured, 14-day post-discharge support program delivered by Care Plan Inc.
- Provides non-medical caregiver support and registered nurse oversight
- Focuses on CHF symptom monitoring, medication adherence, and home safety
- Reinforces existing VA and skilled care plans with no duplication of services
- Fully aligned with VA 2025–2030 goals
- No cost to the VA
Program Structure
Week 1
Caregiver Support
- 28 hours of dedicated caregiver support
- Daily monitoring of CHF indicators (weight, fatigue, shortness of breath)
- Medication reminders and adherence support
- Fall-prevention reinforcement and light mobility assistance
RN Oversight (1 Visit)
- Medication reconciliation
- Nutrition and hydration assessment
- Home safety evaluation
- Verification that the care plan is being followed
Week 2
Caregiver Support
- 24 additional hours of caregiver support
- Ongoing CHF symptom monitoring
- Continued medication reminders and review
- Mobility and home safety assistance
- Implementation of updated care plan instructions
Care Coordination & Reporting
- Weekly care report prepared by Care Plan Inc.
- Shared with VA social worker
- Shared with veteran’s physician
- Shared with skilled agency (if involved)
Why It Matters
- Reduces unnecessary hospital readmissions
- Extends continuity of care between VA and skilled visits
- Supports VA priorities in safety, partnerships, and care coordination
- Fully operated by Care Plan Inc. at no cost to the VA
Ask us how our pilot-ready program can be customized to meet the unique needs of your VA health system.
Let’s Support Veterans Beyond Discharge Together, we can extend hands-on support where it matters most, at home.
Ask us how our pilot-ready program can be customized to meet your VA health system’s unique needs.
