Preparing a Case for Transition

Recovery Care Coordinator (RCC) CourseMarch 27, 2019

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Presenter(s)/Moderator

Tomas Fredricks, MSEdSenior Business Analyst

Recovery Coordination ProgramDefense Health Agency (contractor)

Arlington, VA

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Disclosures

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∎ Presenter(s) have no relevant financial or non-financial relationships to disclose relating to the content of this activity; or presenter(s) must disclose the type of affiliation/financial interest (e.g. employee, speaker, consultant, principal investigator, grant recipient) with company name(s) included.

∎ The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, not the U.S. Government.

∎ This continuing education activity is managed and accredited by the Defense Health Agency J7 Continuing Education Program Office (DHA J7 CEPO). The DHA J7 CEPO as well as all accrediting organizations do not support or endorse any product or service mentioned in this activity.

∎ DHA J7 CEPO staff, activity planners and reviewers have no relevant financial or non-financial interest to disclose.

∎ Commercial support was not received for this activity.

Learning Objectives

At the end of this module, participants will be able to:

∎ Identify when and why a transition is required

∎ Organize the transition

∎ Explain the “warm hand-off” process

∎ Conclude a case

∎ Generate a Lead Coordinator (LC) Checklist

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Types of Case Transition

∎ Current Lead Coordinator (LC) transfers case to new a new LC

∎ Current LC closes a case or deems the case inactive

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Facilitating the Transition

Your responsibilities: ∎ Helping the Service member and

family/caregiver through the transition∎ Preparing the next LC for success∎ Obtaining the Service member’s

authorization to release protected health information prior to a warm hand-off to a non-covered entity

∎ Documenting the transition in the Depart of Defense-Case Management System (DoD-CMS)

∎ Letting go emotionally

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Why would a case be transferred?

Transfers may happen for a variety of reasons. The most common include: ∎ Change in location of either LC or Service member∎ Service member and family/caregiver request a different Recovery

Care Coordinator (RCC) or LC∎ WWP determines that the RCC/LC can no longer provide the

necessary services for the Service member and family/caregiver∎ RCC/LC leaves the job ∎ Service member’s medical needs increase and then he or she is

transferred to a medical case manager who serves as LC∎ Service member transitioning from Department of Defense (DoD)

to Veteran’s Affairs (VA)

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Image Source: Hudd, Kate (photographer). (2012) Past-Future .[JPEG file]. Retrieved from epsy5140spring2012.wikispaces.com.

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Release of Information – DD Form 2870

∎ Prior to the transfer of a case, it is essential that the Service member or family/caregiver complete and sign a release of information form, DD Form 2870 – Authorization For Disclosure of Medical Or Dental Information

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Reminder: The “Warm Handoff”

It is vitally important that the transfer of duties between the current LC and the receiving LC be as smooth and efficient as possible. A “warm handoff” will:∎ Set up the new LC for success∎ Ensure care is provided during a critical transition point∎ Include face-to-face, email, and telephone communication as

well as secure transmission of documents∎ Include a referral packet to the VA Liaison for Healthcare (or

to the Transition Care Management Program Manager in the absence of a VA Liaison)

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Why would a case be closed or deemed inactive?

Cases may be closed or given inactive status for a variety of reasons. The most common include:

∎ Achievement of agreed upon, documented outcomes or maximum benefit reached (goals)

∎ Service member and family/caregiver requests discontinuation of services

∎ Service member expires or other conditions make care coordination unnecessary

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The Human Component

For some cases, there may be a strong feeling of loss during or after the transition – for either or both the RCC/LC and the Service member and family/caregiver.

Do not ignore the need for self-care, grief counseling, and resilience support.

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Documenting the Transition

Common problem: RCCs fail to close-out cases after transition. Document, document, document! …or it didn’t happen.

∎ Timely documentation of a transitioned case is important and required

∎ Make sure the name and details associated with the new LC are included in the final case note

∎ Document whether the Service member and family/caregiver were informed and acknowledged the transition

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Sample Case Note

∎ “Service member is ready and willing to transition to VA. He has been informed that he has been assigned to XXXXXXX, at XXX-XXX-XXXX and has acknowledged the transition. Completed warm handoff and provided LC checklist to the new LC. Service member will continue to use TRICARE. He and family will stay in the local area with possible use of the Veterans’ Affairs Medical Center (VAMC) as well.”

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Discussion/Exercise –LC Checklist Handoff

∎ You are now in the role of transferring a case to a new RCC/LC:

∎ Complete an LC checklist (Tab 12) for SSgt Jones (see next slide or Tab 8) in preparation for the transfer.

∎Discuss the exercise with the class.

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Case 2: SSgt Jones

Case History: TBI from a motorcycle accident 18 months ago Speech and mobility problems Has had many surgeries – cranioplasties (2) at Walter

Reed Bethesda, spent time at the Tamp VA and then Quality of Life Institute in NE.

Assigned to USMC Wounded Warrior Battalion 2 months ago.

Can’t sleep, not doing well with pain meds, poor memory

Image Source: Powerpoint (Office 2007) [Computer Software]. MP900449075_silhouettes. [PNG file]. Redmond, WA: Microsoft.

Background: Father & Stepmother are primary caregivers. Stepmother moved from home in Paducah, KY to live with SSgt Jones in

Camp Lejeune, NC. He wants to move his home of record from Paducah to Lejeune.

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Key Takeaways

The following are examples of important or key “take-away” messages: ∎ The two kinds of case transitions include LC-to-LC and closure of a

case.∎ Key RCC responsibilities in case transition involve preparing the

Service member and family for the change, and preparing the new LC for success.

∎ Vital to an LC-to-LC transfer is obtaining authorization from the Service member/family for release of information (DD Form 2870).

∎ When letting go of a case, an RCC should never ignore the need for self-care.

∎ Case transitions MUST be documented in DoD-CMS or your Service’s case management system.

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References

Department of Veterans Affairs (VA) and the Department of Defense (DoD). (2016).

Memorandum of Understanding (MOU) between VA and DoD : Interagency Complex Care

Coordination Requirements for Service Members and Veterans. Retrieved from:

http://warriorcare.dodlive.mil/files/2016/04/MOU-for-VA_DoD-IC3-Processes.pdf

Department of Defense, Executive Service Directorate. (2003). DD Form 2870 – Authorization for

Disclosure of Medical or Dental Information. Retrieved from :

http://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2870.pdf

Department of Defense, Warrior Care. Overview of DoD-CMS. Retrieved from:

http://warriorcare.dodlive.mil/carecoordination/recovery-coordination/

H.R. 4986 – 110th Congress. (2008). National Defense Authorization Act (NDAA) for Fiscal Year

2008. Retrieved from: https://www.gpo.gov/fdsys/pkg/CRPT-110hrpt477/pdf/CRPT-

110hrpt477.pdf

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How to Obtain CE Credits

To receive continuing education credit (CE), you must complete the program posttest(s) and evaluation(s) before collecting your certificate(s). The posttests and evaluations will be available through 10 April 2019 at 11:59 pm ET.1. Use this link to enroll and access the courses:

https://www.dhaj7cepo.com/registration/?groupid=2500243&course=10836252. Click the link on the bottom to create an Adobe ID: Get an Adobe ID.3. After logging in, click My Learning on the left menu bar. 4. Select the session you would like to evaluate from the Recovery Care Coordinator (RCC)

Course.5. Click the “Start” button. You will be asked to view the Accreditation Statement and then

complete the evaluation and posttest. You must pass the posttest with a score of 80% or higher before you are permitted to proceed with collecting your certificate.

6. Your work will be saved as you progress through the modules. 7. To return to the LMS at any time, visit: https://dhaj7.captivateprime.com.

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