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How many times have we reviewed a clinical case, attempted to navigate a complex treatment plan with a patient and his or her family, or tried to communicate with a provider outside the VA system only to be left with a sense of frustration and futility? Our conditioned response has often been to refer the patient for case management. Case management, however, needs to be treated as more than a box to check or consult to be placed. Participants in a recent VHA-sponsored Workgroup on Care Coordination/Care Transitions emphasized that case management is a team effort that incorporates care systems– especially around information exchange, care transitions and prospective care planning– involves population health management principles, and uses emerging technologies. Case management must also be evidence-based and outcomes-driven.

Coordinating health care is becoming more difficult as the number of aging Veterans and Veterans with multi-morbid medical conditions and social needs grows. Frequently, these Veterans have limited social supports, challenges navigating complicated treatment plans, limited health literacy, and marginal engagement in chronic care. Coupled with the increase in dual coverage from Veterans aging into Medicare eligibility, the success of the Affordable Care Act in expanding health insurance coverage, and the passage of the CHOICE Act for Veterans, the challenges of coordinating and managing care across multiple health settings and payer systems are more difficult than ever.

Within this context, the field of case management and care coordination has evolved with proven treatment modalities led by professional clinical staff across many different settings and with expertise in many clinical conditions. Several well-established frameworks offer providers a roadmap for considering case management and coordination of complex patients; these include the Robert Wood Johnson Foundation and University of Pennsylvania Transitions of Care Model, the VHA Case Management Standards of Practice (VHA Handbook 1110.04), and the Agency for Healthcare Research and Quality (AHRQ) Care Coordination Measures Atlas.1 The AHRQ framework specifies different elements and components of care coordination that include:

  • Identifying who is accountable and responsible for the care coordination;
  • Enhancing communication, both interpersonal and information transfer;
  • Facilitating transitions across care settings and as coordination needs change;
  • Assessing patient and family needs and goals;
  • Creating a proactive plan of care;
  • Monitoring and follow up;
  • Supporting self-management goals;
  • Linking to community resources; and
  • Aligning resources with patient and population needs.

Similarly, the National Transitions of Care Coalition's Care Transition Bundle identifies seven core intervention categories: medical management; transition planning; patient and family engagement/education; information transfer; follow-up care; health care provider engagement; and shared accountability across providers and organizations.2

It is important to note that VA serves as a leader in the field of care management. The Office of Care Management and Social Work Services and the Office of Nursing Services have developed professional standards and certification for specialized nurse and social work case managers. The development of Patient Aligned Care Teams (PACTs) has transitioned primary care to a medical home care management model with several notable improvements in care. Similarly, several VA programs have developed population-specific clinical programming for those highest risk population groups, including post-deployment clinics, spinal cord injury care, Geriatric PACTs, Homeless PACTs, comprehensive women's health centers, as well as care transition programs like Hospital-to- Home and Home-Based Primary Care.

Unfortunately, despite these efforts, gaps persist and challenges remain. In one recent study, 16 to 20 percent of Veterans 65 years of age and older were readmitted to a VHA hospital within 30 days of discharge.3 Anecdotal reports of complex patients having multiple, concurrently assigned case managers suggest potential redundancies and inefficiencies. A gap analysis conducted by the aforementioned workgroup, while noting best practices for those Veterans enrolled in specialized care and case-managed programs, also described challenges identifying and engaging those in need of these services. These challenges are especially present when providers treat Veterans outside VHA or in care settings not aligned with these efforts.

Maintaining accountability and continuity, especially across care settings and within the community, often underlies poor outcomes occurring during the critical care transitions from inpatient to outpatient care. Communications challenges across disciplines and even among case managers underscore the difficulties of managing care within a large, diverse, and fragmented delivery system. Bringing to scale tested models, better aligning our coordination efforts, or rethinking our approach within a systems design framework are all strategies that need to be considered.

While much has been done within VA that far exceeds the community standard in many settings, there is much more that needs to occur. The expanding scope of care that extends beyond our current VHA care platform, the growing population of increasingly complex, frail, and vulnerable Veterans, and the challenges and opportunities inherent to working in the largest integrated health system within the United States is our reality. It is both our opportunity and obligation to inform these issues with methodologically rigorous and evidence-based research and study.

  1. Care Coordination Measures Atlas, June 2014, AHRQ Pub. No. 14-0037-EF.
  2. National Transitions of Care Coalition, "Care Transition Bundle: Seven Essential Intervention Categories," White Paper, February 2011.
  3. H Mull et al, "Using AHRQ Patient Safety Indicators to Detect Postdischarge Adverse Events in the Veterans Health Administration," American Journal of Medical Quality 2013.

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