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:

VHACMLiaisonGroup@va.gov

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Questions?

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Jennifer Perez, LICSWNational Director, Transition and Care Management Services202-461-6065Jennifer.Perez@va.gov

Kathy Dinegar, LICSWNational Program Manager, VA Liaison Program 202-461-0504Kathleen.Dinegar@va.gov

Janet Belisle, MHA, RHIA, FACHEHealth System Specialist, Transition and Care Management Services202-714-8520Janet.Belisle@va.gov