Case Manager Home Health Care by xbr21121

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									     VA Liaison Program:
Transitioning Health Care from
          DoD to VA




         Kathleen Dinegar, LICSW
Acting National VA Liaison Program Manager
 Care Management and Social Work Service,
            Patient Care Services,
Department of Veterans Affairs Central Office
“To care for him who
shall have borne the
battle and for his
widow and his
orphan…”
Abraham Lincoln




                       2
VA’s Newest Combat Veterans




                          3
         Department of Veterans Affairs


 Veterans Health Administration
   – VA Medical Centers (VAMC), Community
     Based Outpatient Clinics (CBOC), Vet Centers
 Veterans Benefits Administration
   – Compensation, Pension, Voc Rehab, Home,
     Loan Guarantee, etc.
 Veterans Cemetery Administration
   – Maintains national cemeteries across the
     country

                                                4
            Locating VA Staff at Military Treatment
                           Facilities


 VA & DoD partnership began
  in August 2003
 Veterans Health
  Administration (VHA) placed
  VA Liaisons for Health Care
  to assist Military Service
  Members (Active Duty,
  National Guard, or Reserves)
  with transitioning their
  health care from DoD to VHA

                                               5
             VA Liaisons for Health Care

 VA has 27 full time social workers and nurses
  working as VA Liaisons in 13 Military Treatment
  Facilities (MTFs)
 National funding for VA Liaisons from VA Central
  Office
   -Sites determined in coordination with the
    Department of the Army and Department of
    the Navy
 Programmatically assigned to Care Management
  and Social Work Service (CM/SWS) at VA
  Central Office; administratively assigned to local
  VA Medical Center (VAMC)

                                                 6
                                    VHA Staff Assigned to
                                 Military Treatment Facilities

   3 VA Liaisons



      Ft. Lewis
                                                                             1 VA Liaison


                            1 VA Liaison

                                                                   1 VA Liaison   NNMC        5 VA Liaisons
                                 Ft. Carson                                       WRAMC
                                                                    Ft. Knox
                Camp                                                        Ft. Bragg        2 VA Liaisons
                Pendleton
                                           2 VA Liaisons                   Ft. Gordon
                  Balboa                                                                     2 VA Liaisons
                                                                   Ft. Benning
                                                     Ft. Hood
                                                                                  Ft. Stewart 1 VA Liaison
2 VA Liaisons
                                                    Ft. Sam Houston
                 2 VA Liaisons                                             1 VA Liaison
                                                           4 VA Liaisons




                                                                                                  7
                   VA Liaisons for Health Care


 MTFs identified for future VA Liaison
  Assignments
   –   Ft.   Eustis
   –   Ft.   Bliss
   –   Ft.   Drum
   –   Ft.   Riley
   –   Ft.   Campbell




                                                 8
            VA Liaisons for Health Care

 Standardized Social Worker and Nurse
  Functional Statements for all VA Liaisons
 Utilize a standardized Referral Form to the VA
  Liaison from the MTF Case Manager which
  outlines the health care needs of the service
  member
 Expectations outlined in Memorandum of
  Agreement between each MTF and
  corresponding Veterans Affairs Medical Center
 Standardized Documentation in VA’s
  Computerized Patient Record System (CPRS)
                                              9
              VA Liaisons for Health Care

 VA Liaisons coordinate VA healthcare for service
  members transitioning to VA (Severely
  Ill/Injured and Non-Severely Ill/Injured) that are
  referred to the VA Liaison from the MTF Case
  Manager
 VA Liaisons are integrated with staff at the MTF
  to coordinate health care and provide onsite
  consultation/collaboration about VA resources
  and treatment options
 A majority of VA Liaisons
  are co-located with
  Military Case Managers


                                              10
              VA Liaisons for Health Care

 Educate veterans, service members and families on
  VA healthcare resources and the system of care
 Participate in video teleconferencing between MTF
  and VA staff
 Register service members/enroll veterans in VA to
  schedule appointments or secure inpatient beds
  prior to leaving the Military Treatment Facility
 Coordinate referrals with OEF/OIF Program
  Manager at the receiving VA Medical Center
 Release information to State Department of
  Veterans Affairs for patients who are severely
  injured
                                              11
               VA System of Care
 153 Hospitals
 Over 900 Ambulatory Care and Community Based
  Outpatient Clinics
 Over 200 Vet Centers – Readjustment Counseling
  Centers – also treats family
 Women’s Health Program
 Spinal Cord Injury Rehab (SCI)
 Blind Rehab Centers (BRC) – VIST, BROS, etc.
 Residential/Inpatient/Outpatient PTSD Programs
 Polytrauma Rehab Centers (PRCs)
 Polytrauma Network Site (PNS)
 Polytrauma Support Clinical Teams (PSCT)
 In-Home Care
 Prosthetics and Sensory Aids
 Healthcare for Homeless Veterans
 Any many more….
                                              12
                 Types of Referrals


 Referrals initiated by MTF clinical team member
 Inpatient transfers to VA Medical Centers:
  Polytrauma Rehabilitation Centers, Spinal Cord
  Injury Rehab, Blind Rehab, etc.
 Outpatient follow up for service members going
  home on convalescent leave or limited duty
 Assistance with registration and appointments
  for Active Duty Service Members separating
  from the military, including while on terminal
  leave


                                             13
                Referrals from the MTFs to VAMCs through
                      the VA Liaisons for Health Care


          900                                      837
          800
          700
          600    475             437         478
          500
          400                          315                     322        300
          300                                            227
          200            74                                          74         101
          100
            0




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Numbers for Calendar Year 2008


                                                                                      14
           VA OEF/OIF Care Management Teams

At each VA Medical Center:
 OEF/OIF Program Manager
   – Serves as POC for referrals from MTF; coordinates
     clinical care and oversees transition and care for
     OEF/OIF service members and veterans; assigns case
     managers and Transition Patient Advocates
 OEF/OIF Case Manager
   – Provides case management services to Severely
     Ill/Injured patients and to those identified in need of
     case management
 Transition Patient Advocate (TPA)
   – Serves as an advocate across episodes and sites of
     care for patients who are severely ill/injured
                                                        15
             Additional VA Staff at MTFs



 Veterans Benefits
  Administration (VBA)
 Polytrauma Nurse
  Liaison
 Federal Recovery
  Coordinators (FRCs)
  (joint VA/DoD
  Program)


                                           16

								
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