New VA practice simplifies care for Veterans

A VA practice framework called Care Coordination and Integrated Case Management (CC & ICM) seeks to engage, coordinate, and collaborate with health care professionals and community partners. It’s designed to ensure comprehensive, Veteran-centered care that enhances access, health outcomes, and social and emotional well-being.

The facility Care Coordination Review Team (CCRT) assigns lead coordinators to high-risk Veterans who frequently use VA care. With a lead coordinator, the Veteran doesn’t need to reach out to multiple providers. Instead, they can use their assigned Lead Coordinator to help them manage the many parts of their VA care.

Program helping Veterans at Martinsburg VAMC

CC&ICM is progressively rolling out across all VA facilities and has been successful at the Martinsburg VA in West Virginia. The Martinsburg facility was the first in its VISN to implement CC&ICM.

Debbie Jolliff, certified case manager and registered nurse, assisted with the CC&ICM implementation. She reviews Veterans who could benefit from Lead Coordinator assignment. The team looks for Veterans with a history of co-morbid conditions and complex case management needs.

When the review team came across Sarah Johnson’s* application, they recognized she was a Veteran with various mental and physical conditions and multiple emergency room visits. The team was confident that assigning a Lead Coordinator could help her.

Felicia Jenkins, registered nurse, became Johnson’s lead coordinator. Jenkins is a patient-aligned care team nurse at a community-based outpatient clinic. As a lead coordinator, Jenkins keeps close contact with Johnson and her different care teams.

Since meeting, the pair have built a rapport through weekly calls and interventions.

“She hears everything from me,” said Jenkins. “Instead of calling a million different people, if she has any questions, I’m the one that identifies those answers.”

Coordinating with home telehealth

Because Johnson lives two-and-a-half hours away from the Martinsburg VA, Jenkins enrolled her in the Remote Patient Monitoring Home Telehealth (RPM–HT) program. The program enabled Jenkins to keep a close eye on Johnson’s vitals remotely.

“Home telehealth along with CC&ICM is a great collaboration,” Jenkins said. “With high-risk patients, they could end up back at the emergency clinic at the drop of a hat. These programs help us to stay on top of everything and avoid emergency room visits.”

Through the RPM–HT program, Johnson tracks her blood pressure, blood sugar, heart rate, oxygen levels and weight.

Heather Lapp, a home telehealth care coordinator, conducts Johnson’s home telehealth assessments and can see the information Johnson sends in.

Helped Veteran physically and mentally

“In-home telehealth, we’re not an acute care or emergency clinic, but we really are the frontline,” said Lapp. “We are seeing the Veteran’s vitals Monday through Friday. With this program, I really think collaboration is key.”

Any inconsistencies in Johnson’s vitals cause an alert message to be sent to Lapp. She then notifies Jenkins and they integrate care to respond to the Veteran’s needs.

Since working with the lead coordinators, Johnson has seen a significant decrease in hospitalizations and an increase in motivation. She is now able to spend more time with her grandchildren and has even bought herself a treadmill.

“This program has helped her emotionally, physically, and mentally,” Jenkins said. “She’s enjoying her life outside of medical appointments.”

* The name of the Veteran in this story has been changed to protect her privacy.