Transition a and Care M e Managem emen ent S Services es FY2020 Adrienne Weede, LCSW National Program Manager Transition and Care Management Program Care Management and Social Work Patient Care Services Predecisional / For Internal VA Use Only 1
The History of Transition and Care Management Services (TCMS) TCMS Director position established to TCMS Co-Leads CC&ICM VA Office of Seamless Initiative with ONS Transition established oversee both VA Liaison and OEF/OIF/OND Programs 2003 2007 2016 2019 2015 2005 2017 OEF/OIF/OND renamed TCM to reflect VA Liaison Program approved for VA Liaison Program established; OEF/OIF/OND Care Management scope to serve all Post 9/11 era Joint Incentive Funds for virtual VAMCs assign POCs to receive Program established VA Liaisons referrals Servicemembers and Veterans 2
VA Liaisons for Healthcare Coordinate VA Healthcare for Service members transitioning from DoD to VA Collaborate and Provide direct SMs who are coordinate with Coordinate VA access to VA health severely injured are Military Treatment health care for SMs care and coordinate connected with the Facility (MTF) and transitioning from both primary and TCM Program VA Caregiver specialty VA DoD to VA Manager throughout Support Program appointments the referral process Service members, families, & caregivers… Are educated about Easily access VA Discuss VA treatment May meet with VA VA Healthcare and Liaisons who are options and resources treatment teams resources, registered integrated at DoD with VA Liaisons so for VA care, and have via video ongoing care is facilities with VA appointments teleconference at individualized to their Military Case secured prior to MTF specialized care needs Managers leaving the MTF 3
VA Liaisons for Healthcare Across the Country 4
Virtual Liaisons for Healthcare (Site Map) Syracuse (Region 1) Eastern Colorado Eastern Kansas (Region 4) (Region 3) Louisville (Region 2) San Diego (Region 5) Philippines Guam Hawaii American Samoa Virgin Islands Puerto Rico Virtual Liaison Sites Syracuse Eastern Kansas HCS San Diego Eastern Colorado Louisville 5 5
Warrior Care Network Sites 6
Transition and Care Management Program Multidi discipl plina nary T TCM t team m membe bers: – Available at every VA Medical Center – Experts in Post 9/11-era Service member and Veteran reintegration needs and specially trained in Post Deployment Care – Proactive in screening all new Post 9/11-era Service members and Veterans for the need for case management services – Develop individualized care plans that encompass Service members/Veterans holistic care needs. – Deliver case management to Post 9/11-era Service members/Veterans with complex care needs – Partner with DoD and community organizations 7
Transitioning Servicemember and Post 9/11 era Veteran Proactive Risk Identification Post 9/ 9/11 11 Patie ient Transition a and C Care Managem emen ent Rep eport ------------ ---------- ----- ------ ----- ---- -- Identif ifie ies a all t transit itionin ing Serviceme memb mbers a and Vet eteran ans n new ew t to a VAHCS Natio ional l Post 9/ 9/11 11 Case M e Managem emen ent Screen eening Iden entification ---------- ------------ ----- ------ ----- ---- -- 165,725 V 165, 725 Veterans Screened i in FY2019; Y2019; 45% 45% i increase over F FY2018 Y2018 Lead C Coordin inator ( (LC) Assignment a and Indiv ivid idualiz lized, Ho Holistic ic Screen eening Care P Planning ------------ ---------- ----- ------ ----- ---- -- FY2019: Y2019: 39, 39,233 233 Veterans Acces essed ed L LC Services es 8
Transition and Care Management (TCM) One integrated, interdisciplinary care plan Dedicated Case Manager/Lead Coordinator Veteran-generated goals and objectives Continuous care plan review for completion Polytrauma Post Mental TBI Deployment Integrated Health Care Primary Blind Care Rehab Lead Coor Coordin inator Spinal Homeless Cord Program Injury Car Care Re Review w Team Integrated Partners Women’s TCM Health 9
POINTS OF CONTACT To find a map and contact list of Transition and Care Management Teams, visit: htt ttps://www ww.oefoif.va.gov/caremanagem gement.asp To contact a VA Liaison for Healthcare, visit: http://www.oefoif .va.gov/valiaisons.asp To contact the national program office, email: VHACMLiaison onGrou oup@va. a.gov 10
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