Care Management and Social Work Service

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Care Management and Social Work Service

• October 2007 VHA established Care Management and
  Social Work Service (CM/SWS)
• Addressing the needs of wounded and ill service
  members and Veterans as well as
• CM/SWS is part of the Office of Patient Care
  Services and has responsibility for five national
  programs
• VA Liaison Program
• OEF/OIF Care Management Program
• National Social Work Program
• Caregiver Support Program
• Family Hospitality Program (Temporary Lodging
  Fisher Houses)

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VA OEF/OIF Care Management Teams

• At each VA Medical Center
• OEF/OIF Program Manager
• Coordinates clinical care
• oversees transition and care
• for OEF/OIF Service members and Veterans
• serves as POC for referrals from MTF
• assigns case managers and Transition
• Patient Advocates
• OEF/OIF Case Manager
• Provides care management services
• to Severely Ill/Injured patients and to
• those identified in need of case management

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Care Management Team(contd)

• Transition Patient Advocate (TPA)
• Serves as an advocate across episodes and sites
  of care for OEF/OIF patients who are severely
  ill/injured and others as needed

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Outreach Activities

• Care Management Team coordinates
• - Welcome Home Event yearly
• - Job Fairs
• - VAMCs Focus groups quarterly
• - Assists with Operation Stand Downs
• - Mini Stand Downs outside of catchment area
• Active Outreach Partner
• - Yellow Ribbon/PDHRA
• Demobilizations

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Welcome Home Event
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Care Management Pro-Active Assessment and
Referrals

• OEF/OIF Care Management is generally the first
  point of contact for new OEF/OIF Service Members
  and Veterans coming into the VA system
• Initial referral from MTF from VA Liaison to a
  VAMC PM
• (if indicates potential homeless situation,
  VA Liaison
• schedules meeting with homeless team prior
  to
• discharge)
• Care Management team notified of all OEF/OIF
  inpatient admits and outpatient appointments
• All OEF/OIF Veterans are assessed for care
  management needs (including potential
  homeless/housing issues)

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Care Management Model of Care

• Care Management Model of Care step by step
  process
• Assignment to a Lead Case Manager
• (based upon both psychosocial and
• medical needs)

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Active Duty Inpatient Referral Care
Management Model of Care Referral from MTF to a
VAMC/ Referral from VAMC to VAMC Slide 4
FRC, if assigned, monitors case and provides
ongoing care management as needed
Military Case Manager provides ongoing care
management as long as patient is active duty
Referrals from MTF for inpatient admissions to a
VAMC VA Liaison contacts OEF/OIF Program Manager
and Specialty Program Admissions Coordinator
concurrently (when applicable). Specialty
ProgramsPRC, SCI and Blind Rehab
Program Manager Assigns TPA for PRC Or Non-PRC
No
END
OEF/OIF Program Manager Non-Specialty Program
Admissions
Specialty Program Admissions Coordinator
Specialty ProgramsPRC,SCI and Blind Rehab
YES
Business Office contacted - Eligibility/Enrollment
registers patient into VA system MMSO/Tricare
Authorization Processed and Maintained

• Home TPA Notified
• Contacts patient and family when appropriate
• Continues to provide support and address needs as
  identified

Designated
Admissions Coordinator Contacted (If not
already completed by the Specialty Program
Admissions Coordinator)
Referring and Receiving Teams

Medical records reviewed Communications
between referring and receiving teams
(Video
teleconference, email, fax, phone)
Case Manager Contacts patient/family prior to
admission to coordinate family arrangements
Acceptance of Patient - Admission date scheduled
- Case Manager assigned
VA Liaison / Referring team notified - Travel
coordinated - Military orders arranged
Patient Is
Admitted
ONGOING

• Discharge Planning includes
• Military Case Manager, VA Liaison, TPA, FRC (if
  assigned) kept
• informed and authorization is obtained if
  needed
• If VA care is provided, Post Deployment
  Integrated Care or
• specialty care is scheduled
• Case reviewed by Care Management Review Team
  -Determination of follow-up care (MTF or VA)

Care Management Review Team -Patients case
is reviewed in the Care Management Review Team
meeting led by OEF/OIF Program Manager Lead
Case Manager (LCM) identified
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Care ManagementFluid Process

• OEF-OIF CM team works closely with the Homeless
  Program and the flow of Veterans between the
  teams is fluid
• OEF/OIF Care Management has no end
• the Veteran is always OEF/OIF with oversight
  by the OEF/OIF Program Manager and Care
  Management team with full case management or
  relationship basis
• Care Review Team meets on regular basis
• Status changes - Lead Case Manager is updated

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OEF/OIF Care Team Collaboration

• Integrated Team Meetings - CM team members have
  regular contact with VA Homeless Coordinators and
  HUD VASH Coordinators
• CM staff has regular contact with community
  homeless programs to give and receive referrals
• Assists Veterans who reside in domiciliary
  facilities
• CM team participates in Behavioral Health daily
  reports

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Veterans Story

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