News from the VA

Journey of Care Coordination and Integrated Case Management in the Veterans Health Administration

Stacey Castel, MSW, LCSW, Andrea Macomber, MSN, RN, ACM-RN, Anita Mingo, LICSW, and

Deborah Ramirez, RN, MS, CPUM Veterans Health Administration

The Veterans Health Administration’s Care Coordination and Integrated Case Management (CC&ICM) model stems from evidence-based practice that increases care coordination, communication, and collaboration to improve the health outcomes of the veteran population. CC&ICM builds upon existing care and case management efforts across the Veterans Health Administration (VHA) toward an integrated care model that will standardize, communicate, and elevate the approach to care coordination for veterans accessing care and services across the care continuum within and external to VHA. The VHA is the largest integrated health care system in the United States, serving more than 9,000,000 veterans. The CC&ICM model will provide VHA’s nurses and social workers with the tools to help veterans navigate the VHA health care systems, community care, and telehealth care delivered in their homes.

Today, patients need wound vacuums, intravenous antibiotic therapy, and heart failure monitoring in their homes upon discharge from the acute care setting. Twenty years ago, these therapies and treatments would have been considered acute hospital level of care; however, this is no longer the case. The CC&ICM model expands the transformation of culture and practice through systems and clinical integration of services to provide veterans with quality, safe, efficient, and effective care in across settings and levels of care.

The model deployment will spread across the VHA enterprise in phases. Phase 1 began in in October 2021 with more than 30 Veterans Affairs (VA) medical facilities. The second phase began in April 2022 with 50 additional VA facilities, and the remaining VA sites are scheduled to begin their CC&ICM journey in January 2023.

There are five milestones associated with the full implementation of the CC&ICM framework. The five milestones include 1) leadership awareness, 2) facility readiness, 3) implementation preparedness, 4) systems and clinical integration, and 5) CC&ICM governance structure at the facility and Veterans Integrated Services Network level. In this article, the first two of the five milestones will be reviewed. The first milestone is to achieve leadership awareness, buy-in, and endorsement. Multiple modalities and engagement tactics are used to reach this milestone, including both virtual town halls and smaller site consultation sessions.

The second milestone focuses on VA medical facility readiness. Readiness includes the appointment of CC&ICM executive sponsors, nursing and social work dyad co-champions, and comprehensive stakeholder identification. Stakeholders may consist of various care coordination roles from different areas. Examples of stakeholders include primary care, specialty care, mental health, rehabilitative services, pharmacy, nutrition and food services, acute care, emergent care, community care, telehealth, quality safety and value, whole health, and systems redesign. Stakeholders play a pivotal role

Andrea Macomber

is the Acting VISN 1 Consortium Lead For VANEC. She is ACMA case management certified. Andrea has diverse clinical practice expertise in the areas of cardiology, critical care, case management, VHA care in the community, and utilization review. She is Green Belt Certified in Lean Six Sigma and has worked on numerous process improvement projects that included LOS, decreasing readmissions, utilization review, and transfer flow.

The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, serving more than 9,000,000 veterans. The Care Coordination and Integrated Case Management (CC&ICM) model will provide VHA’s nurses and social workers with the tools to help veterans navigate the VHA health care systems, community care, and telehealth care delivered in their homes.

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