Supporting Returning Service Members and Their Families

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1 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

2 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 2

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

3 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 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 3

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Case Example: SGT Wind 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

5 Case Example: SGT Wind 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 5

6 VA Liaisons for Healthcare Coordinate VA healthcare for Service members (SMs) transitioning from DoD to VA 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 Service members and families/caregivers 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 6

Types of Referrals Inpatient transfers: Polytrauma Rehabilitation Spinal Cord Injury/Disorder Rehabilitation Blind Rehabilitation Acute/Extended Care

7 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 7

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VA Liaisons Collaboration At the MTF MTF Treatment Teams Veterans Benefits Administration V AV A At the VAMC TCM Program Manager TCM Case Manager Military Case Managers Federal Recovery Coordinators

10 VA Liaisons Collaboration At the MTF MTF Treatment Teams Veterans Benefits Administration V AV A At the VAMC TCM Program Manager TCM Case Manager Military Case Managers Federal Recovery Coordinators Recovery Care Coordinators MTF Command Service Wounded Warrior Programs L I A I S O N S Transition Patient Advocates (TPAs) Caregiver Support Coordinators (CSCs) Specialty Treatment Teams Suicide Prevention Coordinator Eligibility

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

11 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.

12 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 Transition Patient Advocate (TPA): Serves as an advocate to help Service members, Veterans, and their families navigate the VA healthcare system 12

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

13 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 13

14 OEF/OIF/OND Screenings 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.) 14

15 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) 15

16 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 16

Transition and Care Management One Integrated, Interdisciplinary Care Plan Veteran-Generated Goals and Objectives Dedicated Case Manager/Lead Coordinator Continuous care plan review for completion

17 Transition and Care Management One Integrated, Interdisciplinary Care Plan Veteran-Generated Goals and Objectives Dedicated Case Manager/Lead Coordinator Continuous care plan review for completion Mental Health Lead Coordinator Polytrauma Rehabilitation Primary Care Traumatic Brain Injury Transition & Care Management Team Care Review Team Integrated Partners Women s Health Spinal Cord Injury Blind Rehabilitation Post Deployment Integrated Care 17

18 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 18

19 Transitions from Military Treatment Facilities to VA Coordinated by VA Liaisons Cumulative Transitions through 6/30/18 101,056 Transitions FY ,243 Transitions FY ,087 Transitions FY ,712 Transitions FY 2018 Thru 6/30/2018 9,240 19

20 Cases That Transferred From Military Treatment Facility to VA Medical Center October 2017-June

21 Service members and Veterans receiving Case Management Current Case Management As of the end of April 2018 ~29,400 5,136 Severely Ill/Injured 21

22 Points of Contact To find a Transition and Care Management Team: To contact a VA Liaison for Healthcare: For assistance resolving referral issues, please our national office: VHACMLiaisonGroup@va.gov 22

23 Questions? Jennifer Perez, LICSW National Director, Transition and Care Management Services Kathy Dinegar, LICSW National Program Manager, VA Liaison Program Janet Belisle, MHA, RHIA, FACHE Health System Specialist, Transition and Care Management Services

4. Responsibilities: Consistent with this MOU, it is AGREED that the Parties shall:

4. Responsibilities: Consistent with this MOU, it is AGREED that the Parties shall: MEMORANDUM OF UNDERSTANDING BETWEEN DEPARTMENT OF VETERANS AFFAIRS (VA) AND DEPARTMENT OF DEFENSE (DoD) FOR INTERAGENCY COMPLEX CARE COORDINATION REQUIREMENTS FOR SERVICE MEMBERS AND VETERANS 1. PURPOSE: