Coordinated Caring for Veterans
At VA Detroit, Veterans must navigate a confusing puzzle of services, room locations and other integrated care, at times when they may be lacking physical or mental strength or potentially encountering confusion as to where they must go next.
They are in luck as Veterans can work with the Care Coordination and Integrated Case Management, or CC&ICM, Initiative. Managed by RN coordinator LaShonda Baker and Social Work Coordinator Cassandra Ponder, VA established the CC&ICM initiative to achieve a high quality of coordinate care across a Veterans health care continuum.
“Before 2019, services to our veterans were delivered in a fragmented manner with care coordination and case management disciplines working in silos across the continuum of care,” said Cassandra Ponder. “This fragmentation created unnecessary duplication of services and service delivery gaps within VA.”
Studies have shown that leaving Veterans to navigate the system alone results in redundancy of care, poor resource allocation, areas of increased potential for error due to multiple points of transfer, increased ER utilization, staff/provider burnout, frustration, and role confusion.
Adoption of the CC&ICM framework across the VA is achieved through a phased implementation approach, including three phases. Phase 1 facilities have completed implementation, and lessons learned from Phase 1 sites contribute to the readiness required to initiate implementation with Phase 2 sites and, subsequently, Phase 3 sites. Detroit has been grouped into Phase 2, meaning your facility is in the second grouping of sites to implement the framework, with a target completion date of September 30, 2024. Phase 3 sites have a target completion date of September 30, 2025.
The CC&ICM initiative is a partnership between the Offices of Nursing Services and Care Management and Social Work who have the dual responsibility for case management service implementation. The individuals involved in the process will include a multidisciplinary team consisting of providers, nurses, social workers, and case managers. The focus is to integrate communication, collaboration, and coordination for the Veterans to:
- Enhance the Veteran experience
- Enhance access for Veterans
- High Performing Collaborative Networks
- Be transparent and accountable
- Adapt to meet Veteran's needs
- Veteran perspective shaping operations and delivery of care
All Veterans may not be eligible to participate, and they will be identified based on predictive analytics, risk stratification, and facility-determined processes, and is generally for the most vulnerable of the Veteran patient population.
Staff are also eligible to participate in CC&ICM training as it offers structured education, training, and support through safer care transitions through better communication in addition to standardized processes, practices, and tools for all staff. Additionally, trained staff can offer improved coordination and collaboration within interdisciplinary teams directly involved in the Veteran's care.