OEFOIF Care Management Program at the St' Louis VAMC

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OEF/OIF Care Management Program at the St. Louis
VAMC
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Veteran Hospital Administration - Assets

• 21 Veterans Integrated Service Networks (VISNs)

• 153 Hospitals

• 882 Clinics

• 135 Nursing Homes

• 232 Vet Centers

• 46 Domiciliaries

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VAs Newest Combat VeteransYounger---Families---P
arental Involvement
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Lessons Learned from Injured OEF/OIF Service
Members

• Influx of a new mix and new types of injuries
  (e.g. TBI, etc.)
• AD Patients were younger than typical VA
  patient.greater than anticipated interest in RTD
  and Rehab
• Transfer of MTF medical records and nursing notes
• Feelings of abandonment by the military for both
  SM and family
• No one available to
• Coordinate the issuance of Invitational Travel
  Orders/Non-Medical Attendant Orders for family
  members
• Resolve pay problems for SMs coordinate
  financial assistance for family members
• Initiate applications for TSGLI
• Assist SM with Medical Evaluation Board/Physical
  Evaluation Board processing
• Assist SM with convalescent leave make
  transportation arrangements
• Work with VA Volunteer Services and Vets Service
  Organizations in securing donated funds to cover
  emergencies and items not covered by the military

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Lessons Learned from Injured OEF/OIF Service
Members

• Arrange transportation of household goods, JAG
  support, ID cards, etc.
• Need to develop working relationship with
  Services American Red Cross
• Active family and extended family issues
• Spouse or parents take a leave of absence
  or quits work to be with
• AD SM
• Military funded travel, lodging and local
  transportation issues
• Child care issues, at the VAMC or at the
  HOR
• Parents needs, questions and concerns. (A
  mother concerned
• about the care and treatment of her
  son/daughter is a formidable
• force)
• Managing conflict between family members
  (divorces
• separations).
• Addressing health care concerns of visiting
  family members
• Too few Military LNOs, providing coverage for
  other Services
• Working with Reserve National Guard Units
• Visiting dignitaries (Members of Congress GO or
  Flag Officers Senior VA staff and others)
  

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Medical Center OEF/OIF Veteran Support
8 Federal Recovery Coordinators
14 VHA Staff Assigned to Military Treatment
Facilities
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Federal Recovery Coordinators

• New joint DoD / VA program
• As of 7 Jan 08 (with 2 hire actions pending)
• Walter Reed Army MC (3)
• National Naval MC (3)
• Brooke Army MC (2)
• FRCs identify severely injured upon arrival from
  theater, overall responsibility for assuring SM
  has access to all clinical non-clinical
  services
• Coordinates with
• VHA LNOs in MTFs
• Military LNOs in VAMCs
• VHA OEF-OIF Program Managers In VAMCs

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VHA LNOs at MTFs

• Location SW RN
• Walter Reed Army Medical Center, Washington D.C 3
  1
• National Naval Medical Center, Bethesda 1
• Brooke Army Medical Center, San Antonio, TX 1
• Darnall Army Medical Center, Ft. Hood, TX 1
• Madigan Army Medical Center, Puget Sound, WA 2
• Eisenhower Army Medical Center, Augusta, GA 1
• Evans Army Community Hospital, Ft. Carson, CO 1
• Naval Medical Center, San Diego, CA
  1
• Womack Army Medical Center, Ft. Bragg, NC
  1
• Naval Hospital, Camp Pendleton, CA
  1
• Center for the Intrepid, San Antonio, TX 1
• Note VBA also has Benefit Counselors assigned to
  each of the MTFs

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Military LNOs Currently at VA Poly-trauma Rehab
Centers

• Minneapolis
• 2 Army Liaisons
• 2 Marine Liaisons
• 1 AW2 Advocate
• Palo Alto
• 3 Army Liaisons
• 2 Marine Liaisons
• 1 Navy Liaison
• 1 AW2 Advocate
• Richmond
• 1 Army Liaison
• 2 marine Liaisons
• 1 AW2 Advocate
• Tampa
• 3 Army Liaison
• 3 Marine Liaisons
• 1 Navy Liaisons
• 2 AW2 Advocates

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Care
OEF/OIF
Management Team
VISN 15-St. Louis VA Medical Center
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OEF/OIF Care Management Program at the St. Louis
VAMC
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OEF/OIF Care Management Program at the St. Louis
VAMC

• Since 2003, VA has collaborated with DOD and
  Military Treatment Facilities (MTFs) to
  seamlessly transition the health care of injured
  or ill combat veterans and active duty service
  members from MTFs to VHA facilities by assigning
  VHA Social Worker Liaisons/RNs at major MTFs to
  assist with transfers and to provide information
  to active duty, reserves, and national guard,
  (who are demobilizing) patients and families
  about VHA health care services.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• In January 2005, the VA established the Office
  of Seamless Transition to coordinate efforts
  between DOD MTFs and VHA facilities to promote
  and optimize transition assistance for service
  members transitioning to VA.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• As the number of OIF and OEF service members
  and veterans seeking VHA health care increased,
  VHA facilities have been challenged with ensuring
  that they receive necessary health and mental
  health services. Many of these service members
  and veterans suffer from multiple complex health
  and mental health problems, including traumatic
  brain injury (TBI), amputations, burns, combat
  stress and post-traumatic stress disorder (PTSD).
  Therefore, it is critical for each VHA facility
  to have a process in place to ensure that the
  care of all OEF and OIF service members and
  veterans is well-coordinated and that those who
  are severely-injured and/or ill receive case
  management services from a nurse or social worker
  case manager.

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OEF/OIF Care Management Program at the St. Louis
VAMC
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OEF/OIF Care Management Program at the St. Louis
VAMC

• The VHA Handbook 1010.01, Transition Assistance
  and Case Management of Operation Iraqi Freedom
  (OIF) and Operation Enduring Freedom (OEF)
  Veterans, was first issued on 3/23/2007. It was
  rescinded and the next directive, which includes
  VBA responsibilities, took effect on 5/31/2007
  when it was signed by Michael Kussman, MD, MS,
  MACP, Under Secretary of Health.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• The handbook was issued to establish procedures
  in the transition of care, coordination of
  services, care and case management of Operation
  Iraqi Freedom (OIF) and Operation Enduring
  Freedom (OEF) active duty service members and
  veterans by VHA and Veterans Benefit
  Administration (VBA) staff.
• (Please note that the proper order is OEF/OIF
  which came about after the publication o this
  handbook)

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OEF/OIF Care Management Program at the St. Louis
VAMC

• The Handbook also establishes nurse or social
  worker OEF-OIF Program Manager positions at VA
  medical Centers and Transition Patient Advocate
  positions distributed to each Veterans Integrated
  Service Network (VISN) for placement in VA
  medical centers and describing the functions of
  these positions, as well as nurse and social
  worker VA Liaisons assigned to Military Treatment
  Facilities (MTFs).

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OEF/OIF Care Management Program at the St. Louis
VAMC

• It is VHA policy that injured and/or ill OEF
  and OIF active duty service members, to include
  Reserve and National Guard, are transitioned
  seamlessly from MTFs to VHA facilities that the
  care of all OEF and OIF service members and
  veterans treated at VHA facilities is
  coordinated, monitored, and tracked that all OEF
  and OIF service members and veterans are screened
  for the need for case management services and
  that severely-ill or injured OEF and OIF patients
  are case managed.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• The OEF/OIF Care Management Team consists of
  following positions and their duties
• OEF/OIF Program Manager Each VA medical center
  and independent outpatient clinic must designate
  a nurse or social worker to serve as the OEF/OIF
  Program Manager to coordinate care provided to
  OEF and/or OIF service members and veterans.
  This position functions as the facilitys POC for
  the VA liaisons at the MTFs. These positions
  are funded by VA Central Office.

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OEF/OIF Care Management Program at the St. Louis
VAMC
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OEF/OIF Care Management Program at the St. Louis
VAMC

• OEF/OIF Case Managers Each VHA facility must
  have nurse and social worker OEF/OIF case
  managers for those who are severely-injured or
  ill and for those otherwise in need of case
  management services. These positions are funded
  locally. The caseload for nurse and social worker
  case managers will typically be no more than
  twenty-five to thirty patients per case manager.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• The OEF/OIF Nurse Case Manager
• The Nurse Case Manager, as a member of the Care
  Management Program, is responsible for acquiring
  and demonstrating clinical expertise and
  knowledge of health care programs to improve the
  quality of patient care, the use of resources,
  and to facilitate compliance with internal and
  external requirements and standards acquiring
  and demonstrating strength in the areas of
  interpersonal relations, critical thinking,
  problem solving, and conflict resolution
  collaborating with other case managers, the
  Interdisciplinary Treatment Team and other
  clinical and administrative staff as needed to
  ensure patient care needs are met.

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OEF/OIF Care Management Program at the St. Louis
VAMC
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OEF/OIF Care Management Program at the St. Louis
VAMC

• The MSW Case Manager
• The MSW Case Manager is a professional social
  worker whose duties and responsibilities relate
  to the case management of severely-injured
  Operation Iraqi Freedom (OIF) and/or Operation
  Enduring Freedom (OEF) service members and
  veterans treated at the facility. The incumbent
  must use a high level of skill in assessing and
  treating the complicated psychosocial problems of
  OIF and/or OEF service members and/or veterans as
  they transition to Department of Veterans Affairs
  (VA) care. Case management responsibilities also
  include providing supportive services to
  families. In addition, the incumbent assists OIF
  and/or OEF service members and/or veterans in
  coping with acute illness, chronic illness,
  combat stress, the residuals of traumatic brain
  injury (TBI), community adjustment, addictions,
  and other health and mental health problems. The
  social worker case manager addresses home care
  needs, homelessness, and transition across levels
  and sites of care.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• MSW Case Manager cont, Social Work case
  management practice, which includes psychosocial
  assessment, diagnosis, and treatment, is focused
  on helping OEF and/or OIF service members and/or
  veterans and their families maximize
  rehabilitation and treatment potential and
  achieve more adequate, satisfying, and productive
  emotional and social functioning.

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OEF/OIF Care Management Program at the St. Louis
VAMC
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OEF/OIF Care Management Program at the St. Louis
VAMC

• Transition Patient Advocates Each VISN must
  have between three and eight Transition Patient
  Advocates for OEF and OIF service members and
  veterans. Although the positions are distributed
  to the VISN offices, the duty stations for the
  incumbents will be at complexity level 1 and 2
  medical centers within the VISN. These positions
  are funded by VA Central Office.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• TPA cont. The incumbent serves as the VISN
  Directors liaison between the medical centers,
  the patients, employees of the medical centers
  and the community regarding patients rights and
  advocacy. As the liaison the patient advocate
  acts as a communicator, facilitator and problem
  solver. Administrative, organizational and
  educational skills will be utilized. Activities
  will cross all lines of authority and
  responsibility and encompass all medical centers,
  services within a medical center and throughout
  the VISN. Participation in related community
  activities will also be required.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• TPA cont. The Transition Patient Advocate
  will serve as the point of contact to assist
  transitioning OEF and/or OIF veterans and their
  families. As many of these veterans suffer from
  multiple complex health and mental health
  problems, including traumatic brain injury (TBI),
  amputations, burns, combat stress and
  post-traumatic stress disorder (PTSD) and this
  position is dedicated to ensuring severely
  injured service members and veterans have a
  personal advocate as they move through the
  Department of Veterans Affairs (VA) system. The
  Program manager serves as the TPAs supervisor.

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OEF/OIF Care Management Program at the St. Louis
VAMC
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OEF/OIF Care Management Program at the St. Louis
VAMC

• The main mission, as described above, is to
  manage the Seriously Ill returning veteran.
  Fortunately in our catchment area we presently
  have 16 seriously ill veterans. This, indeed, is
  a blessing so we have taken on other missions to
  ensure that as many OEF/OIF veterans as possible
  are ensured of the care they deserve. We do this
  by informing newly registered OEF/OIF Veterans of
  their benefits, screen them for any problems and
  ensure that they have an appointment with their
  newly assigned Primary Care Provider and OEF/OIF
  PTSD Clinic and/or TBI Polytrauma Clinic.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• PDHRAs
• We staff the Post Deployment Health
• Reassessment (PDHRA). PDHRA is a team effort
  between DoD Contract staff, Reserve National
  Guard Commanders and the VA. The DoD Contract
  staff have the lead role in conducting the PDHRA
  Screen. PDHRA is a global health assessment to be
  conducted 90-180 days post-deployment. The
  Purpose of doing these is to provide information
  on VA care and benefits enroll veterans in VA
  healthcare assist in scheduling follow-up
  appointments provide information on VA benefits
  and promote referral linkages with Reserve
  National Guard Units.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• Yellow Ribbon Re-Integration Program (YRRP)
• This program started in 2008 and was authorized
  by Congress. The YRRP provides deployment and
  reintegration programs for National Guard and
  Reserve members and their families. Families
  and family members include spouse, children,
  parents, grandparents, siblings, and/or
  significant others. Programs, at a minimum, will
  include sufficient information, services,
  referral and proactive outreach opportunities
  across the United States and its territories
  throughout the deployment cycle. To minimize the
  stresses of military service, particularly the
  stress of deployment and family separation.
• Deployment support and reintegration programs
  will be provided in all phases of deployment,
  including but not limited to pre-deployment,
  deployment, demobilization, and post deployment
  and reconstitution.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• Welcome Home Celebration
• The number of OEF and OIF service members and
  veterans continues to increase, and VHA has an
  obligation to offer all necessary health and
  mental health services. Many of these service
  members and veterans are unaware of VHA health
  care services and may be confused about
  eligibility for services. It is imperative that
  these services members and veterans are fully
  educated about VHA health care services and
  eligibility and that they are made aware that
  their service to the United States is appreciated.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• Welcome Home Celebration
• It is VHA policy that, at least annually, each
  facility must provide a "Welcome Home" event for
  OEF and OIF service members, veterans, and their
  families and/or significant others. This event
  must provide information on
• (1) Department of Veterans Affairs (VA)
  benefits and is to include participation by
  Veterans Benefits Administration (VBA) staff
• (2) VHA Health care services
• (3) Supportive services for families and/or
  significant others and
• (4) Services of the OEF-OIF Program Manager,
  Transition Patient Advocates, and OEF-OIF Case
  Managers.

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OEF/OIF Care Management Program at the St. Louis
VAMC
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OEF/OIF Care Management Program at the St. Louis
VAMC

• Our next Welcome Home Celebration will be on
  May 30, 2009 at the Soldiers Memorial at 15th
  and Chestnut in downtown St. Louis. We invite all
  veterans to attend. We also need volunteers and
  donations. Call me at 314-289-7641 for more
  information.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• Focus Groups
• Conducting a focus group with returning
  members and their families in our area of
  operation or service area can be useful,
  beneficial and productive. Focus groups allow
  veterans and family members to openly and
  honestly talk about their thoughts, feelings,
  opinions and beliefs pertaining to topics
  concerning the VA. The main emphasis for the
  focus group is to elicit and collect information,
  rather than give information. Pertinent
  information will be given, but on a limited
  basis. This format is different than the usual
  pre and post deployment and follow-up
  presentations that are usually given to service
  members in that they focus on the VA getting
  input from veterans and family members. The end
  result is to have service members and family
  members give and express their honest opinions
  and thoughts about the VA, VA services and
  service delivery, and any issues or barriers to
  care.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• Focus Group Goals
• Ask open ended/qualitative questions regarding
  the service members thoughts about the VA, its
  services, identify barriers to care and their
  thoughts about how to improve or better meet
  service members needs.
• Conduct AAR (After Action Review) with service
  members on how this focus group can be improved.
• Be available afterwards for questions and/or to
  schedule appointments with service members at the
  VA for clinical interview and/or other needed
  services.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• Focus Groups Goals Continued
• Report information back to OIF/OEF Program
  Manager, VSC staff, OIF/OEF Task Force, VISN
  POC/Administrative POC, VA local administration,
  and Network for feedback and comments, and work
  on possible solutions to the needs stated by
  service members and family members in our area of
  operation.
• Serve as a pilot for other groups (we can adapt
  or change as needed for future groups based on
  the service members ARR comments).

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OEF/OIF Care Management Program at the St. Louis
VAMC

• We also staff other functions as requested as
  we know that community outreach is one of the
  most important things we can do to alert the
  OEF/OIF Veterans of the services we provide.

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OEF/OIF Care Management Program at the St. Louis
VAMC

• Statistical Tracking
• I, as the program manager, also have to track
  data showing how well we are doing with our
  Traumatic Brain Injury and OEF/OIF Post
  Deployment Screens and other data.

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