Supporting Returning Service Members and Their Families
Jennifer Perez, LICSWNational Director, Transition and Care Management ServicesCare Management and Social WorkOffice of Patient Care Services
Objectives• Describe the mission of the VA Liaison Program
• Discuss the role of the VA Liaison for Healthcare in assisting Service members transitioning from DoD to VA system of care
• Identify VA Liaisons partners in facilitating a smooth transition from military service to Veteran status
• Recognize the roles and responsibilities of the Transition and Care Management (TCM) teams
• Examine the issues commonly seen with the post 9/11 population
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VA Liaison Program• VA & DoD partnership began in August
2003 • Now 43 VA Liaisons for Healthcare on-site
at 21 DoD Military Treatment Facilities (MTFs)
• Locations based on high concentrations of ill and injured Service members (SMs)
• VA Liaisons are advanced practice, licensed, Masters prepared Social Workers and Registered Nurses
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• Care Management begins at the MTF• Provides critical, early connection to VA for SMs in the transition process• Provides direct access by coordinating initial health care for transitioning
SMs and building a positive relationship with VA
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Case Example: SGT Wind
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Case History:• Suffered amputations of the left leg below the knee, the right leg
above the knee and the right arm as a result of IED• Received 100% disability rating in 2016• Now in the process of transitioning off active duty• Continues to have pain management issues• Suffers from night terrors• Owns numerous weapons
Background:• Having marital problems with wife Jaime and discussing divorce• Considering selling their house• Have an autistic son who is being harassed at school; SGT Wind has complained to
the school’s Principal• Jaime is primary caregiver to both son and husband; has not worked since son was
born• Having financial issues• After transitioning, SGT Wind intends to relocate his family from CA to NC
VA Liaisons for Healthcare
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Coordinate VA healthcare for Service members (SMs)transitioning from DoD to VA
Service members and families/Caregivers…
Coordinate VA healthcare for Service
members (SM) transitioning from
DoD to VA
Collaborate and coordinate with MTF treatment team and
TCM Program Manager throughout the referral process
Provide direct access to VA healthcare and
coordinate both primary and specialty
VA appointments
SMs who are severely injured are connected with the VA Caregiver
Support Program
Are educated about VA Healthcare and
resources, registered for VA care, and have
VA appointments secured prior to leaving the MTF
Discuss VA treatment options and resources
with VA Liaisons so ongoing care is
individualized to their specialized care
needs
Easily access VA Liaisons who are integrated at DoD
facilities with Military Case Managers
May meet with VA treatment teams
via video teleconference at
MTF
Types of ReferralsInpatient transfers:
• Polytrauma Rehabilitation• Spinal Cord Injury/Disorder Rehabilitation • Blind Rehabilitation • Acute/Extended Care• Other Specialty Programs (i.e. Mental Health, Substance Abuse, etc)
Outpatient appointments:• Convalescent leave • Limited duty• Upon separation or retirement
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VA
LIAISONS
VA Liaisons’ CollaborationTCM
Program Manager
TCMCase Manager
Transition PatientAdvocates (TPAs)
Caregiver SupportCoordinators (CSCs)
Specialty TreatmentTeams
Suicide PreventionCoordinator
MTF TreatmentTeams
Veterans BenefitsAdministration
Military CaseManagers
Federal Recovery Coordinators
Recovery Care Coordinators
MTF Command
At the MTF At the VAMC
Service WoundedWarrior Programs Eligibility
VA
LIAISONS
This is the reality: VA can schedule future appointments while the SM is Active Duty VA can treat Active Duty Service members using TRICARE VA can schedule appointments up to 120 days out VA can schedule appointments without a DD214 VA does not need to do a means test before scheduling appointments for
OEF/OIF/OND Combat SMs VA facilities are all TRICARE network providers SMs and Veterans may select a preferred VA facility regardless of their home
address
Transition and Care Management TeamEach VA Medical Center has a Transition and Care Management (TCM) team specially trained in coordinating care for transitioning Service members and new Veterans. TCM team members include: TCM Program Manager (RN or Social Worker): Has overall administrative
and clinical responsibility for the team, and coordinates patient care activities to ensure that Service members and Veterans are receiving patient-centered, integrated care and benefits
TCM Case Manager (RN or Social Worker): Directly coordinates healthcare and community services to meet the needs of the Service member, Veteran and their families, and ensures that all clinicians providing care are doing so in a cohesive and integrated manner
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Transition Patient Advocate (TPA): Serves as an advocate to help Service members, Veterans, and their families navigate the VA healthcare system
Transition and Care Management Team• Screens Veterans for high risk factors
• Lack of family/social support• Lack of stable living situation• Lack of adequate resources• Mental Health Issues• Substance Abuse • Legal concerns/incarceration• Environmental exposures
• Completes Assessment• Develops care plan with Veteran and family• Ensures appointments and referrals to needed VA programs• Links Veteran and family to appropriate resources to meet their needs• Follows up with scheduled contacts to make sure needs are met • On-going follow up care and case management as long as needed
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OEF/OIF/OND Screenings
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• ‘Pop up’ screen in electronic record
• Infectious diseases endemic to SW Asia
• Traumatic Brain Injury• PTSD, depression, substance
use• Suicide screen• Military Sexual Trauma• Environmental exposures
(rabies, burn pits, etc.)
Lead Coordinator (LC) Role Key Points:
• Provide a primary point of contact within a DoD or VA Care Management Team who will be assigned to the SMs/Veterans, their families and Caregivers during their recovery, rehabilitation and transition– LC assignment may transition from one LC to another as the site and/or level of
care changes• Not a new position: LC functions are formalized responsibilities conducted by an
existing member of the DoD or VA Care Management Team. • LC function may be performed by clinical or non clinical member of the team• Whenever possible, the team member with the LC role will be physically located
with the SM/Veteran• Will document Comprehensive Plan (CP) in Service specific Information
Management/ Information Technology (IT) System of Record until DoD/VA Interagency Comprehensive Plan (ICP) IT solution is implemented (Proposed 2016)
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Lead Coordinator Role (continued)
Each Service and VA has own internal process of designating staff as LC • While inpatient at MTF or VA, LC functions will be assigned to the clinical
case manager under the direction of the primary healthcare provider • As SM/V moves to outpatient, the LC role may transition to a non clinical
member of the team Key goal is to provide a standardized process for a warm hand-off from one
LC to another Determination of LC transfer made by the DoD or VA Care Management
Team (CMT) LC responsible to ensure ICP is developed in coordination with other
members of the CMT, the SM/V, family and Caregiver Until a common ICP is developed, each Service/VA will document in their
respective CP
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Transition and Care Management
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One Integrated, Interdisciplinary Care Plan Veteran-Generated Goals and Objectives
Care Review TeamIntegrated Partners
Mental Health
Primary Care
Traumatic Brain Injury
Transition & Care Management Team
Women’s Health
Post DeploymentIntegrated Care
Blind Rehabilitation
Spinal Cord Injury
PolytraumaRehabilitation
Dedicated Case Manager/Lead Coordinator Continuous care plan review for completion
Lead Coordinator
Important Partners• Recovery Care Coordinators
• Federal Recovery Coordinators
• Homeless Outreach Team
• Veterans Justice Outreach Team
• Suicide Prevention Coordinator
• Veteran Service Organizations
• State Veterans Offices
• Key Community Agencies
• Faith-Based Organizations
• Wounded Warrior Programs
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Transitions from Military Treatment Facilities to VA Coordinated by VA Liaisons
Cumulative Transitions through 6/30/18
101,056
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Transitions FY 2015 11,243
Transitions FY 2016 11,087
Transitions FY 2017 10,712
Transitions FY 2018Thru 6/30/2018
9,240
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Cases That Transferred From Military Treatment Facility to VA Medical Center
October 2017-June 2018
Service members and Veterans receiving Case Management
Current Case Management
As of the end of April 2018~29,400
5,136Severely Ill/Injured
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Points of ContactTo find a Transition and Care Management Team:http://www.oefoif.va.gov/caremanagement.asp
To contact a VA Liaison for Healthcare:http://www.oefoif.va.gov/valiaisons.asp
For assistance resolving referral issues, please email our national office:
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Questions?
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Jennifer Perez, LICSWNational Director, Transition and Care Management [email protected]
Kathy Dinegar, LICSWNational Program Manager, VA Liaison Program [email protected]
Janet Belisle, MHA, RHIA, FACHEHealth System Specialist, Transition and Care Management [email protected]