Recovery Team s Roles and Responsibilities

Transcription

1 Recovery Team s Roles and Responsibilities Recovery Care Coordination (RCC) Course December 3, Medically Ready Force Ready Medical Force

2 Presenter(s)/Moderator Lenora B.P. Weatherford, MSM Policy and Instruction Program Analyst or Policy Advisor Headquarters, Navy Wounded Warrior Safe Harbor Commander, Navy Installations Command Washington, DC 2

3 Disclosures 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) in collaboration with the Professional Education Services Group/AffinityCE (PESG/ACE), DHA J& CEPO and PESG/ACE as well as all accrediting organizations do not support or endorse any product or service mentioned in this activity. DHA J7 CEPO and PESG staff, as well as activity planners and reviewers have no relevant financial or non-financial interest to disclose. Commercial support was not received for this activity. 3

4 Learning Objectives When you complete this lesson, you should be able to do the following: Define Recovery Team Distinguish possible members of the Recovery Team Differentiate the Recovery Team s roles and responsibilities Explain the collaboration process of the Recovery Team 4

5 What is a Recovery Team? The Recovery Team (often referred to as a Care Management Team) is a group of professionals from diverse disciplines who come together to provide the following: Comprehensive assessment Consultation Care Plan development for Service members and their families and caregivers Image Source: Powerpoint (Office 2010) [Computer Software]. Team-building1. [JPEG file]. Redmond, WA: Microsoft. 5

6 Recovery Team Members DoDI , Enclosure 3, 4a All Recovery Teams shall include the recovering Service member s (RSM s) commander, RSM, a Recovery Care Coordinator (RCC) or Federal Recovery Coordinator (FRC), a Medical Care Case Manager (MCCM), and a Non-Medical Care Manager (NMCM). They may also include medical professionals such as primary care managers, mental health providers, physical and occupational therapists, and others such as Physical Evaluation Board Liaison Officer (PEBLO), Veterans Affairs Medical Services Coordinators (MSC), chaplain, and family support program representatives. Variations in the Field Medical Care Case Managers: Primary Care Physician/Manager, Nurse Case Manager, Behavioral Health Providers Non-Medical Care Managers: RCC, FRC, Advocate, Liaison Commander/Chain of Command: Squad Leader, Platoon Sergeant 6

7 Recovery Team Roles & Responsibilities Develop and continually evaluate the Care Plan with the recovering Service member Provide "checks and balances" to ensure that the interests and rights of the Service member and family/caregiver are addressed Identify gaps in support services Evaluate the support system (family/caregiver) of the Service member Collaborate with the recovering Service member and family/caregiver to resolve difficult issues 7

8 Key Recovery Team Roles Recovery Care Coordinator (RCC) Primarily responsible for the review and assistance of recovering Service member and family care management throughout the Continuum of Care Oversees the development and execution of the Care Plan Non-medical Care Manager (NMCM) Assists the Service member in resolving problems involving financial, administrative, personnel, transitional, and other matters that arise during care, recovery and transition Caregiver and Family Caregiver/family control their own level of involvement in the care and support of recovering the Service member Caregiver is designated by the Service member 8

9 Key Recovery Team Roles, cont. Medical Care Case Manager (MCCM) Assists Service member throughout the Continuum of Care in the 1) receipt of medical care and 2) review of medical status Federal Recovery Coordinator (FRC) Provides assistance and coordination for the care, management and transition of catastrophically injured Service members on active duty and veteran status Image Source: Warrior Care staff. (c. 2013) _b84f02c07d _injury (photograph). [JPEG file]. 9

10 Recovery Team Meetings Recovery Teams meet based on policy and recovering Service member s needs and the RCC should attend if possible. What happens in the Recovery Team meeting? Review current status (health care, mental health, well-being) Gather input from all team members Create and implement plans for the future Recovery Teams are from diverse disciplines. Some teams may work together very well, others may not They vary in their level of formality The role of the RCC may vary on different teams Image Source: Powerpoint (Office 2007) [Computer Software]. Calendar-Planning-photo. [JPEG file]. Redmond, WA: Microsoft. 10

11 RCC Daily Activities Recovery Rehabilitation Reintegration Collaborate with Recovery Teams to ensure the recovering Service member and family/caregiver have access to all available services Develop, implement and oversee the Care Plan in accordance with governing program guidance Coordinate with key personnel to facilitate effective rehabilitation and reintegration Address and support family/caregiver s needs as they relate to the Care Plan, and assist in coordination of local and state resources Coordinate and monitor non-medical services and identify gaps in non-medical service; assist with coordination or resources needed to develop and improve the outcome for enhanced delivery of nonmedical services 11

12 Discussion: What can you, as an RCC, contribute to the team? 12

13 What Can You Contribute to the Team? Connect the team to a wealth of resource knowledge Share prior interventions that have proven to be successful/unsuccessful Build a bridge of communication between multiple resources Clarify the role of a resource Build resource networks Discuss relevant concerns expressed to you by the recovering Service member and family/caregiver with their permission Image Source: Warrior Care staff. (2016). Connect graphic. [BMP file]. 13

14 What Can You Contribute to the Team? (cont.) Communicate clearly Understand each member s role, how you can work together, and what is expected of you Ensure realistic expectations Follow up do what you say you will Provide flexibility and creative solutions Exhibit an open mind Image Source: Warrior Care staff. (2017). Dialogue graphic. [BMP file]. 14

15 Small Group Activity Recovery Team for Staff Sergeant (SSgt) Jones Each table is to assign a note-taker, time keeper, and a spokesperson. Using the SSgt Jones scenario and working in table teams, determine who needs to be on the Recovery Team, both medical and non-medical professionals. Based on those roles, hold a 10-minute Recovery Team meeting to discuss SSgt Jones case. Develop a plan of action to be reflected in the Comprehensive Recovery Plan, which establishes the recovering Service member s issues, who will address each issue, and how the team will work together going forward. Share the results of your Recovery Team s conversation with class. 15

16 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 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. Image Source: Powerpoint (Office 2007) [Computer Software]. MP _silhouettes. [PNG file]. Redmond, WA: Microsoft. 16

17 Possible Recovery Team Members Command Leadership Medical Care Case Manager Non-Medical Care Manager Recovery Care Coordinator Federal Recovery Care Coordinator Advocate Primary Care Managers Mental Health Providers Chaplain Physical Therapist Orthopedic Therapist Speech Therapist Physical Evaluation Board Liaison Officer (PEBLO) Military Liaisons Family Support Programs Department of Veterans Affairs/Transition and Care Management Services Occupational Therapist Caregiver/Family Member 17

18 Key Takeaways The following are examples of important or key take-away messages: Working together, the Recovery Team provides assessment, consultation, and Care Plan development. Recovery Team members ensure there are checks and balances in addressing the interests and rights of the Service member and family/caregiver. Key Recovery Team members include RCC, NMCM, caregiver/family, MCCM, and FRC. There is a long list of other possible members including chaplain, physical therapist, mental health specialist, PEBLO, Command leadership, etc. 18

19 References Department of Defense Instruction. (2009). DoDI Recovery Care Coordination. Retrieved from : Coordination_ pdf 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: 19

20 References (continued) Department of Defense Task Force on the Care, Management, and Transition of Recovering Wounded, Ill, and Injured Members of the Armed Forces. (2014). Reference Handbook of Key Topics and Terms, Including updates from NDAA Retrieved from: Hussein M. Tahan PhD, RN & Teresa M. Treiger RN-BC, MA, CHCQM-CM/TOC. (2016). CMSA Core Curriculum for Case Management, 3rd Edition. Retrieved from: 20

21 How to Obtain CE Credit After the activity, go to URL Select the activity titled Recovery Care Coordinator Course. You will be taken to the login page. Enter your address and password. If this is your first time visiting the site, enter a password you would like to use to create your account. Select continue. Verify, correct, or add your information, including your profession(s). Proceed and complete the activity evaluation. You may be required to pass a posttest. Upon completing the evaluation, you may view, download, or print your certificate and/or statement of participation. Your CE record will also be stored here for later retrieval. The Web site is open for completing your evaluation for 14 days. After the Web site has closed, you can come back to the site at any time to print your certificate, but you will not be able to add any evaluations. 21