Lead Coordinator Training

Transcription

1 Lead Coordinator Training DoD / VA Interagency Care Coordination Committee (IC3) Community of Practice Work Group March

2 Objectives After you complete this module, you should be able to: State the definition and purpose of the Lead Coordinator (LC) role Name the tools used by the LC List the steps in an LC-to-LC transition of care Describe post-transition of care responsibilities of the LC 2

3 LC Role Background Scenario: A Change in Medical Status Sam is an experienced Recovery Care Coordinator (RCC). He has been working with SGT Florez and her caregiver husband for several months. When Sam was assigned to this case, SGT Florez was recovering well from a shrapnel wound to the left thigh. It appeared that major medical issues were behind her and the couple s greatest needs could be satisfied with non-medical resources. Sam established a good relationship with both the wounded Service member and the caregiver and assumed the lead in helping them acquire the needed resources. 4

4 LC Role Background Scenario: A Change in Medical Status, continued However, two weeks ago SGT Florez developed a serious blood clot that has her hospitalized in the ICU. Her condition could be life-threatening and may require surgery. Mr. Florez continues to rely on Sam for help and for answers during this trying time. Sam is continuing to act as the lead contact and liaison between the medical staff, various members of the recovery team, and the Florez family. As a nonclinical team member, Sam feels overwhelmed with the medical aspects of the case, and wonders if there is a better, more efficient way he can serve the caregiver and wounded Service member. 5

5 LC Role Background What is the best solution? 1. Maintain the status quo. Sam should continue to do his best as the Lead Coordinator because SGT Florez and her husband trust him. 2. Lead Coordinator duties should be transferred to a medical team member, but Sam should continue being part of the recovery team to offer non-medical assistance as required. 3. Sam should continue being the Lead Coordinator for non-clinical issues and a medical team member should be assigned to be the Lead Coordinator for clinical issues. 4. Sam should be taken off the case while SGT Florez is in the hospital and the medical team should take over. 80% 20% 0% 0%

6 LC Role Defined LC is a Single Point of Contact The LC is best described as a single point of contact within a Care Management Team (CMT). LC assignment may transition from one LC to another as the site and/or level of care changes. The LC function may be performed by a clinical or non-clinical member of the team. Whenever possible, the team member with the LC role will be physically located with the Service member/veteran Prevent Delays Reduce Anxiety Achieve Best Possible Outcome 6

7 LC Role Defined Key Points To-DOs DO ensure all necessary services, are being addressed, documented, and coordinated DO involve SM/V, family, and caregiver in the creation and maintenance of the LC documents Do NOTs DO NOT execute all care, benefits, and services offered to the SM/V DO NOT allow more than one LC to be assigned to each SM/V DO maintain visibility of all Care Management Team (CMT) communication with the SM/V

8 LC Role Defined Service-specific Requirements Each Service and VA have their own internal process of designating a staff member as an LC While in-patient at a Military Treatment Facility (MTF) or VA, LC functions will be assigned to the clinical case manager under the direction of the primary healthcare provider. As the recovering Service member or Veteran moves to outpatient status, in DoD the LC role will usually transition to a non-clinical member of the team; in VA the LC role will be a clinical member of the team. 8

9 LC Role Defined Agency-Specific Guidance DoD Guidance Complex Care: Category III (as per the DoDI ) CAT II per discretion Inpatient: Clinical LC will be assigned by the CMT or Clinical Case Management Supervisor Out-patient: Non-Clinical LC will be assigned by the CMT VA Guidance Complex Care: Clients in Care Management Tracking and Reporting Application (CMTRA) (also defined in MOU and VA 0007 Dec.22, 2014) Clinical LC will be assigned by the CMT, Program Manager, or Transition and Care Manager (TCM) LC may transition from an Inpatient LC to an Outpatient LC

10 LC Tools & Documentation LC Tool #1: LC Checklist LC Checklist is a document that includes A list of tasks that should occur when the Service member/caregiver transitions between LCs Common care-benefits-services categories that should be considered throughout recovery, rehabilitation, reintegration, and ongoing care coordination Four Parts Part I: Initial LC (Recovery) Part II: Ongoing Tasks (Rehabilitation) Part III: Transfer to New LC (Transition/Reintegration) Part IV: ICP Document Elements 10

11 LC Tools & Documentation LC Tool #2: Interagency Comprehensive Plan (ICP) Document The ICP document is a desktop reference prompting LCs to consider the full breadth of care/benefits/services options available for recovery, rehabilitation, reintegration and ongoing care coordination while building a Service member s ICP. 11

12 LC Tools & Documentation LC Tool #3: The National Resource Directory (NRD) 12

13 LC Tools & Documentation LC Tool #4: Documentation Provide details about care, benefits, and services outlined in the LC Checklist Existing systems will remain as the primary source documentation Print-outs from these systems will be produced to provide details referenced at a high-level in the LC Checklist Print-outs from DoD/VA systems will be produced and transferred as already established policies and procedures require 13

14 LC-to-LC Transition of Care The Warm Handoff The "Warm Handoff" is the CORNERSTONE of the LC transition process. It is vitally important that the transfer of duties between the current LC and the receiving LC be as smooth and efficient as possible. A warm handoff should do the following: Set up the new LC for success Ensure care is provided during a critical transition point Include Face-to-Face, , and Telephone communication, as well as Secure transmission of documents Include a referral packet to the VA Liaison for Healthcare (or to the TCM Program Manager in the absence of a VA Liaison) 14

15 LC-to-LC Transition of Care LC-to-LC Transfer Paths There are several transfer possibilities: DoD VA VA DoD VA VA DoD DoD In most cases: 15

16 LC-to-LC Transition of Care Steps in the Handoff of LC Role Receiving LC assumes LC Role Need for LC transfer determined Referral made to next level/site While there is some flexibility in when each step occurs, generally the sequence on the left is to be followed. "Warm Handoff Receiving CMT & sending CMT discuss Receiving CMT determines new LC 16

17 Post-Transition of Care Responsibilities of the Care Management Team (CMT) CMT is responsible for Collaborating with the LC Communicating progress toward goals with the LC Making any necessary recommendations to the LC While the LC assumes role as the primary point-of-contact, CMT members will continue to contact Service member as needed CMT must be able to identify the LC for each of their patients 17

18 Post-Transition of Care Responsibilities of the New LC Plan for a successful initial meeting with Service member and family/caregiver Effectively communicate your new role to the Service member and family/caregiver Review/update ICP with Service member and family/caregiver 18

19 Conclusion Objectives Review Now that you ve completed this module, you should be able to: State the definition and purpose of the Lead Coordinator (LC) role Name the tools used by the LC List the steps in an LC-to-LC transition of care Describe post-transition of care responsibilities of the LC 19

20 Conclusion Knowledge Check Please define the Lead Coordinator concept 20