supporting returning service members and their …...• having marital problems with wife jaime and...

Supporting Returning Service Members and Their Families

Jennifer Perez, LICSW National Director, Transition and Care Management Services Care Management and Social Work Office 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

Presenter

Presentation Notes

A partnership between VA & DoD was established in 2003 to place VA Liaisons for Healthcare at Military Treatment Facilities to assist with the transition of healthcare from DoD to VA First at Walter Reed and Bethesda We connect while they are still in the MTF We now have 43 Liaisons at 21 Military Treatment Facilities Contacts with the Liaisons are often the Service Member and their families first contact with the VA - We know that this is not your father’s VA - but they don’t so making this a smooth transition is very important in creating trust and a sense of security that VA can meet their needs.

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Presenter

Presentation Notes

Updated map

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

Presenter

Presentation Notes

Why are VA Liaisons needed? Why is this role so important? Liaisons are onsite at the MTF to coordinate VA healthcare for a Service member during the transition from DoD to VA The Liaisons have a standardized process ensure continuity of care Ensure there is no gap in medical care and that no Service member or new Veteran falls through the cracks Liaisons collaborate the MTF treatment team and participate in team meetings and care planning to provide consultation Prior to this program, Service members were told to go to the VA once they arrived home, the Liaisons are responsible for making the VA connection prior to leaving the MTF SMs should leave the MTF with a VA appointment to continue care for treatment initiated while at the MTF Liaisons work closely with the OEF/OIF/OND Program Managers at the VA Medical Centers nationwide Liaisons refer SMs who are SI to the VA Caregiver Support Coordinator for evaluation and facilitate initiation of caregiver applications as indicated For the SM who is severely injured, the Liaison facilitates a release of his or her contact information to their home State Department of Veterans Affairs. This alerts the state of the returning SM and allows them to contact them to provide education about benefits available through the state. SMs and families have the opportunity to meet with the Liaison to learn more about the VA HCS and services available in their home state/city Liaisons have been co-located at many sites with the MTF case managers to enhance the collaboration Liaisons serve as both an VA ambassador and consultant and the MTF in developing individualized treatment plans Liaisons facilitate the use of video teleconferencing for VA and MTF treatment teams to coordinate as well as for families and patients to meet the VA team prior to leaving the MTF

Types of Referrals Inpatient 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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Presenter

Presentation Notes

VA Liaisons receive referrals to transition healthcare in both in and outpatient settings. Inpatient transitions are predominantly Polytrauma and Spinal Cord Centers. Outpatient care coordination occurs upon military separation, but also for those on Convalescent leave and limited duty, who could receive interim care closer to home and the support system.

V A L I A I S O N S

VA Liaisons’ Collaboration TCM

Program Manager

TCM Case Manager

Transition Patient Advocates (TPAs)

Caregiver Support Coordinators (CSCs)

Specialty Treatment Teams

Suicide Prevention Coordinator

MTF Treatment Teams

Veterans Benefits Administration

Military Case Managers

Federal Recovery Coordinators

Recovery Care Coordinators

MTF Command

At the MTF At the VAMC

Service Wounded Warrior Programs Eligibility

V A

L I A I S O N S

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 Team Each 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

Presenter

Presentation Notes

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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Presenter

Presentation Notes

Orient both to health care and benefits

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.)

Presenter

Presentation Notes

If initial screening indicates a need for case management, the Case Manager coordinates with Veteran and family to complete a full assessment, establish a care plan and set goals to meet the needs identified. All SI Veterans are assigned a case manager.

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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Presenter

Presentation Notes

The Recovery Team includes Physician, MCM, RCC, Section Leader/Command, SM/family/Caregiver and others as indicated

Transition and Care Management

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One Integrated, Interdisciplinary Care Plan Veteran-Generated Goals and Objectives

Care Review Team Integrated Partners

Mental Health

Primary Care

Traumatic Brain Injury

Transition & Care Management Team

Women’s Health

Post Deployment Integrated Care

Blind Rehabilitation

Spinal Cord Injury

Polytrauma Rehabilitation

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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Presenter

Presentation Notes

Vital that we liaison with these key groups - represent the at risk factors for OEF/OIF/OND Veterans - VSOs and State Veterans Association Connection to community is also vital – we need to know the community agencies and they need to know us – if they identify a veteran in need – we want them to know who to contact and how – and know there will be follow up.

Transitions from Military Treatment Facilities to VA Coordinated by VA Liaisons

Cumulative Transitions through end of FY 2017

91,818

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Transitions FY 2014 11,019




Presenter

Presentation Notes

This slide shows activity for the Liaisons since the Program’s inception in 2003 Liaisons engage in both referrals and consultations Referrals are generated from the MTF case manager and identify ongoing treatment needs of a SM Consultations account for much of the workload at the MTF as significant collaboration, consultation and education occurs before a referral is ever initiated. Consultations include informal interactions with SMs, families and MTF care providers who are planning for VA healthcare OEF/OIF/OND combat SMs currently dominate the referrals and consultations to the Liaison

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Cases That Transferred From Military Treatment Facility to VA Medical Center

October 2016-September 2017

Presenter

Presentation Notes

October 2016– September 2017. Does not include WCNs.

Service members and Veterans receiving Case Management

Current Case Management

As of the end of September 2017

~29,039

~5,283 Severely Ill/Injured

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Presenter

Presentation Notes

Points of Contact To 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:

[email protected]

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http://www.oefoif.va.gov/caremanagement.asp

http://www.oefoif.va.gov/valiaisons.asp

mailto:[email protected]

Questions?

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Jennifer Perez, LICSW National Director, Transition and Care Management Services 202-461-6065 [email protected] Kathy Dinegar, LICSW National Program Manager, VA Liaison Program 202-461-0504 [email protected] Adrienne Weede, LCSW Acting National Program Manager, Transition Care Management Program 202-461-6532 [email protected]




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