2012 OEF OIF OND Final Report

Housing Programs

Vocational & Employment

Services

Women’s Support Group

Substance Abuse

SCI

Outreach

TBI Suicide

Prevention

2012 Care Management Survey of

Operation Enduring

Freedom (OEF) Operation Iraqi Freedom

(OIF) and

Operation New Dawn (OND)

Veterans in VHA

Department of Veteran Affairs Veterans Health Administration Office of the Assistant Deputy Under Secretary for Health for Policy and Planning

September 2012

Prologue

In order to assess Veterans Health Administration’s (VHA) Care Management of Operation Enduring Freedom (OEF) / Operation Iraqi Freedom (OIF) / Operation New Dawn (OND) Veterans, the Healthcare Analysis and Information Group (HAIG) (a field office of the Assistant Deputy Under Secretary for Health for Policy and Planning), in collaboration with experts from the Office of Patient Care Services (PCS) and clinicians and coordinators from the field, developed a survey tool to collect data on Care Management of OEF/OIF/OND Veterans in VHA. This report provides quantitative and qualitative data regarding Care Management programs for OEF/OIF/OND Veterans, including information pertaining to services provided, organizational structure, staffing, policy, and practices. It provides staffing information on Case Managers, Program Managers, Transition Patient Advocates (TPAs), Veterans Integrated Service Network (VISN) Lead Program Managers, and VISN Points of Contact. The report also draws from the Care Management and Tracking Reporting Application (CMTRA) reports to supplement case load information for Case Managers. The data collected by this survey reflects the status of VHA Care Management of OEF/OIF/OND Veterans at the time of the survey. A unique response was collected from each of 140 facilities/Health Care Systems (HCS) and from each of 21 Network Points of Contact. The facility and network cooperation in completing this survey is appreciated.

Deborah Amdur, LCSW, ACSW Chief Consultant, Care Management and Social Work Service Office of Patient Care Services Patricia Vandenberg, MHA, BSN Assistant Deputy Under Secretary for Health for Policy and Planning VA Central Office

Healthcare Analysis & Information Group (HAIG) A Field Unit of the Office of Strategic Planning & Analysis within the Office of the ADUSH for Policy and Planning

1 2012 Care Management of OEF/OIF/OND Veterans in VHA

Table of Contents

Prologue ..................................................................................................................................................................... 1

Introduction ................................................................................................................................................................. 3

Survey Methodology ................................................................................................................................................... 3

Key Findings and Recommendations ......................................................................................................................... 4

Survey Results with Select Analysis ........................................................................................................................... 6

Services Provided ............................................................................................................................................... 7

Organizational Structure ...................................................................................................................................... 9

Space ................................................................................................................................................................. 10

Staffing ............................................................................................................................................................... 11

Case Manager ....................................................................................................................................... 12

Program Manager .................................................................................................................................. 14

Transition Patient Advocate (TPA) ........................................................................................................ 17

VISN Lead Program Manager ............................................................................................................... 18

VISN Point of Contact ............................................................................................................................ 18

Staff Orientation ..................................................................................................................................... 19

Policy and Practices ..................................................................................................................................... 21

Care Management Tracking .................................................................................................................. 21

VISN POC Survey Results .................................................................................................................................... 23

Participating Facilities .............................................................................................................................................. 26

Acknowledgements .................................................................................................................................................. 29



Introduction The purpose of the Care Management Survey of OEF/OIF/OND Veterans in VHA was to: • Assess strengths and weaknesses of the Care Management services for OEF/OIF/OND Veterans across VHA;

• Assist in measuring the effectiveness and efficiency of VHA Care Management services for OEF/OIF/OND Veterans;

• Assist in determining adequate resources to support the maintenance and growth of the care management services to this population of Veterans.

Survey Methodology

Data were collected using a self-administered online survey tool. A Technical Advisory Group (TAG) made up of national program office, VISN, and facility Care Management staff drafted the survey questions. The web-based survey administered by the Healthcare Analysis and Information Group (HAIG) was distributed via VISN offices to VISN Points of Contact (POCs) and to facility Directors for OEF/OIF/OND Program Managers to complete. Where obvious errors were apparent, data were validated with respondents. However, questions may be subject to individual interpretation by respondents and the scope of VHA services did not permit independent confirmation of all data. The survey was available to the field April through May, 2012. One-hundred forty VA Medical Centers and Health Care Systems (HCS) and all 21 VISNs responded to this survey. One facility (Manila, PI) does not have an OEF/OIF/OND program, and was excluded from the survey. Thus, the response rate was 100 percent for both facilities and VISN Offices. 2012 OEF/OIF/OND VHA Care Management Survey Instrument 2012 OEF/OIF/OND VISN POC Survey Instrument



http://vaww.vha.vaco.portal.va.gov/sites/ADUSH/ADUSH%20Web%20Files/2012OEF-OIF-ONVISNPOCSurvey.pdf

http://vaww.vha.vaco.portal.va.gov/sites/ADUSH/ADUSH%20Web%20Files/2012OEF-OIF-ONDVHACareMgtSurvey.pdf

Key Findings and Recommendations

Findings Strengths / Recommendations

1. Ninety-five percent of facilities offer Women’s Support Group/Clinic specifically to OEF/OIF/OND Veterans.

Identify facilities not offering women’s support group/clinics and encourage the OEF/OIF/OND staff to coordinate with Women’s Health staff for this population.

2. Benefits information is provided by both VHA Care Management staff on site (89%) and by referral to VBA (69%).

Continue to encourage closer collaboration between OEF/OIF/OND Care Management and VBA via monthly conference calls, joint training and identifications of both VHA and VBA Case Managers in the record, etc.

3. Caregiver support groups targeted toward OEF/OIF/OND Veterans are provided either on site or referred at 89 percent of facilities.

Share findings with Caregiver Support Program Office. 4. As of the time of survey (May 2012) 78 percent of VA facilities provide an on-site caregiver support group and 34 percent of facilities refer caregivers to the community, thus maintaining partnerships with communities.

5. Child care is provided at four sites (two of which were identified pilot sites in 2011) in VHA. Fifty-four percent of facilities refer child care to community resources.

• Review pilot results and coordinate with Women’s Health staff to identify the need for this type of service for OEF/OIF/OND Veterans.

• Encourage facilities to explore other creative alternatives to provide these services.

6. Program availability to families of OEF/OIF/OND Veterans is limited.

VHA Care Management Program Office to study further and enhance services accordingly.

7. Non-traditional appointments are available to varying degrees – from a high of 83 percent of facilities for Outpatient Behavioral Health to a low of 9 percent of facilities for Rehabilitation Services, such as Physical Therapy/Occupational Therapy.

Share these results with VHA Operations and Management.

8. Ninety-one percent of facilities have designated space for the OEF/OIF/OND Program.

Strength. No recommendations.

9. Nearly 1/3 (30%) of Case Managers have a secondary program assignment. Most secondary assignments are Polytrauma/Traumatic Brain Injury Case Managers or Program Managers.

Share findings with Rehabilitation Program Office.

10. Case Managers spend 80 percent of their time on patient care activities. The rest is devoted to outreach or administrative tasks. (See Q12h. on Page 18 for definitions of activities.)


11. More than half (51%) of OEF/OIF/OND Program Managers have a secondary position, 42 percent of whom act as OEF/OIF/OND Case Managers.

Collaborate and consult with 10N regarding Program Managers having collateral duties; careful consideration is recommended that collateral responsibilities are kept to a minimum.

12. Seventy-four percent of facilities provide an organized orientation program for new OEF/OIF/OND Care Management team members.

• Develop an orientation manual for the OEF/OIF/OND Care Management Program.

• Provide comprehensive education on the use of the manual.

• Tracking of training will occur upon completion of training.

13. Orientation materials for OEF/OIF/OND Program Managers are perceived by staff as lowest quality, when compared to TPA and Case Manager orientation materials.

14. Twelve percent of VHA Case Managers and one (5%) of 21 VISN POCs are certified Case Managers.

VA Central Office (VACO) provided study material to requesting facilities in FY 2012. Continue to encourage and track case manager certification.

15. Seventy-one percent of OEF/OIF/OND Teams participate in regular meetings with facility executive leadership.

VACO to develop guidance in the OEF/OIF/OND orientation manual on what to report to facility executive leadership on a regular basis.



Findings Strengths / Recommendations

16. Ninety-six percent of facilities use CMTRA data to assist in managing the OEF/OIF/OND program.

Provide training via monthly conference calls regarding how to use CMTRA data in managing and demonstrating efficacy of the OEF/OIF/OND Care Management Program.

17. Eighty-five percent of facilities report that case management referrals are received via warm handoff (phone, face-to-face, or team meetings).

• Continue to require referrals to the OEF/OIF/OND Care Management Team via a warm handoff versus other methods and follow-up with referring parties to reinforce warm handoffs. (VHA Handbook 1010.01 p.9, Section 11.h.1 and 11.i.)

• Recommend that the Care Management Leadership Council review the warm handoff process.

• Include warm handoff protocol and examples in the orientation manual.

18. Ninety-four percent of facilities case manage OEF/OIF/OND Veterans after the 5-year combat eligibility deadline has passed.

• Strength. • Recommend that facilities appropriately transfer these

Veterans to a PACT or other appropriate case management venue upon completion of the care management plan.

19. Case Managers manage an average of 112 cases, while Program Managers manage an average of 85 cases.

• Further analyze case load by breakdown of intensity level and by facility to determine appropriate staffing ratios. Overall, average staffing levels do increase by facility complexity level, as demonstrated in Figure 1 on Page 16.

• Develop a case management ratio report in CMTRA so VA Medical Centers can monitor ratios on an ongoing basis.

20. All VISN POCs collect, maintain, and forward reports and data prepared by the OEF/OIF/OND Care Management team and submitted by facility senior management to the appropriate VHA requesting office and serve as a liaison between the VA Central Office (VACO), the VISN, VISN Lead, and facility OEF/OIF/OND Program Manager and other agencies and organizations.

• Strength. • Evaluate impact of consolidating / downsizing VISN staff.

21. All VISN POCs brief executive network leadership on the OEF/OIF/OND Program.


22. One-third of VISN POCs attended a formal orientation to their position.

Recommend OEF/OIF/OND Care Management Education Committee develop a formal orientation for VISN POCs.

23. Seventy-one percent of VISN POCs were satisfied with the support provided by VACO.

Recommend VACO Care Management staff seek input from the Care Management Leadership Council and VISN POCs for feedback on how to better meet their needs.



Survey Results with Select Analysis



Services Provided 1. What types of Post Deployment Clinic services does your facility/Healthcare System (HCS) utilize for OEF/OIF/OND

Veterans?

(choose all that apply) (n=140) Count % Consultative Model 76 54% Post Deployment Clinical Model 61 44% Cohort Model 34 24% Other 13 9%

2. Are the following services available for OEF/OIF/OND Veterans at your facility/HCS?

(choose all that apply)

(n=140) Available

at VA Referred to Another VA

Referred to VBA

Referred to Vet Center

Referred to Community

Service not Available

Group Therapy 138 7 1 76 33 1 99% 5% 1% 54% 24% 1% Peer-to-Peer Support Groups 85 2 50 33 20 61% 1% 36% 24% 14% Individual Counseling 137 4 2 85 40 98% 3% 1% 61% 29% Substance Abuse 140 21 22 41 100% 15% 16% 29% Women's Support Group/Clinic 127 7 34 23 7 91% 5% 24% 16% 5% Housing (Homeless Services) 140 4 3 8 58 100% 3% 2% 6% 41% Financial Hardship Resources 99 4 29 13 98 1 71% 3% 21% 9% 70% 1% Legal Issue Services 75 1 2 6 104 4 54% 1% 1% 4% 74% 3% Vocational/Employment 128 6 57 15 64 91% 4% 41% 11% 46% Couples Counseling 117 3 92 54 3 84% 2% 66% 39% 2% Parenting Classes 22 1 20 101 22 16% 1% 14% 72% 16% Family Psychosocial 72 1 47 68 19 Educational Classes 51% 1% 34% 49% 14% Caregiver Support Groups 109 2 6 47 16 78% 1% 4% 34% 11% VA Benefits Information 125 3 96 20 26 89% 2% 69% 14% 19% Recreational 107 3 1 19 85 8 Activities/Opportunities 76% 2% 1% 14% 61% 6% Transportation 125 4 1 4 83 4 89% 3% 1% 3% 59% 3% Childcare* 4 2 75 65 3% 1% 54% 46% * Onsite childcare was provided on a pilot basis at three VA facilities (Northport, NY, Tacoma, WA, and Buffalo, NY) by Public Law 111-163 in 2011. Tacoma did not indicate in this survey that it offers onsite childcare, while New Jersey HCS and Washington D.C. VAMC did respond that they offer onsite childcare.

Post Deployment Clinics are provided through a variety of models. The majority (54%) of facilities use the consultative model, in which OEF/OIF/OND Veterans are assigned to all Primary Care Providers. Medical/Mental Health/Social Work staff with specialized knowledge and skills is identified to assist in a consultative role.



3. What kind of programs are available for families of OEF/OIF/OND Veterans?

4. Does your facility/HCS have appointments available outside the traditional business hours of Monday-Friday, 8:00 am-

5:00 pm for OEF/OIF/OND Veterans?

If yes, a. Please indicate the non-traditional hours your facility/HCS has appointments available outside of the traditional

business hours for the following programs: (choose all that apply)

Evenings after 5:00 pm Weekends Holidays None for

this Service (n=90) Count % Count % Count % Count % Total PACT (formerly Primary Care) 30 33% 10 11% 1 1% 54 60% 95 Behavioral Health (Outpatient) 75 83% 6 7% 0 0% 15 17% 96 OEF/OIF/OND Care Management 45 50% 8 9% 3 3% 45 50% 101 Post Deployment Clinic 23 26% 6 7% 0 0% 65 72% 94 Rehabilitation Services (i.e., PT, OT, etc.) 8 9% 2 2% 0 0% 81 90% 91 Polytrauma/ Traumatic Brain Injury Care 13 14% 3 3% 1 1% 77 86% 94 If weekend or evening hours,

b. When evening or weekend hours are offered, are these appointments slots being utilized by OEF/OIF/OND Veterans?

(n=90) Count % Yes 85 94% No 5 6% If yes, 4.b.1. On average, what percentage of these appointment slots is being booked for OEF/OIF/OND

Veterans? (n=85) Count %

0 – 25% 40 47% 26 – 50% 15 18% 51 – 75% 12 14% 76 – 100% 18 21%

4.b.2. On average, what percentage of appointments are “no-shows” for OEF/OIF/OND Veterans?

(n=85) Count % None 0 0% Less than 10% 36 43% 11 – 20% 33 39% 21 – 50% 13 15% More than 50% 2 2% Note: May not total 100% due to rounding

(choose all that apply) (n=140) Count % Family support groups 74 53% Family workshops 37 26% Individual counseling 95 68% Other 52 37%

(n=140) Count % Yes 90 64% No 50 36%

Frequently cited “Other” responses included: Couples counseling (11), caregiver support/counseling (10), and refer to Vet Center (7).



4.b.3. Are these “no-show” percentages similar to regular daytime appointment “no-shows” for OEF/OIF/OND Veterans?

(n=85) Count % Yes 58 69% No 26 31%

ORGANIZATIONAL STRUCTURE 5. Where is Care Management aligned within your facility/HCS or network's organizational chart?

(n=140) Count % Social Work Service 50 36% Chief of Staff 24 17% Ambulatory/Primary Care 15 11% Mental Health 15 11% Medical Center Director 9 6% Nursing 4 3% Associate Director for Patient Care 8 6% Physical Medicine and Rehabilitation 2 1% Associate Director 2 1% VISN Care Line (Product Line) 0 0% Other 11 8%

6. Which of the following VA services do OEF/OIF/OND Case Managers/Care Management Team members

collaborate with? (choose all that apply) (n=140) Count % Women’s Health 140 100% Caregiver Support 140 100% Mental Health 140 100% Traumatic Brain Injury 138 99% VBA Staff 137 98% PACT/Primary Care 136 97% VA Liaison 135 96% Polytrauma 134 96% Rehabilitation Services 131 94% Spinal Cord Injury 129 92% DoD Liaison 127 91% Visual Impairment Services 124 89% Federal Recovery Coordinator 119 85% Amputee Clinic 106 76% Fee Basis Providers 106 76% Other 52 37%

Notable frequent “Other” responses include: Veteran Service Officers, HUD VASH / Homeless Programs, and Vet Centers



7. Does your facility/HCS have a written formal process/procedure/policy in place for transfer of services for all OEF/OIF/OND Veterans? (n=140) Count % Yes 61 44% No 79 56%

If yes,

a. Are these transfers: (choose all that apply) (n=61) Count % To a VA Facility within VISN 60 98% To a VA Facility outside of VISN 53 87% To Community 45 74% Transfer to DoD 34 56%

SPACE 8. Does your facility/HCS have designated space for the OEF/OIF/OND Program?

(n=140) Count % Yes 128 91% No 12 9%

If yes,

a. Is this a “shared” space with another office or clinic? (n=128) Count % Yes 54 42% No 74 58%

b. Does this space include a private/confidential office? (n=128) Count % Yes 110 86% No 18 14%

c. Do OEF/OIF/OND Case/Program Managers share an office with more than one person? (n=128) Count % Yes 31 24% No 97 76%

If yes,

8.c.1. Do Case/Program Managers need to leave the office for privacy of the Veteran and/or family member?

(n=31) Count % Yes 27 87% No 5 16%

Less than half (44%) of VHA facilities have a procedure for transfer of services for all OEF/OIF/OND Veterans. Of those that do, nearly all transfer to a VA Facility within their VISN, but also provide for transfer to other types of facilities.



9. Does your facility/HCS have any space specifically designated for OEF/OIF/OND Veterans for the following services? (choose all that apply) (n=140) Count % Post-deployment Clinic 71 51% Private Meeting Space 77 55% Conference Room 36 26% V-Tel (Videoconference) Access 45 32% OEF/OIF/OND Waiting Rooms 49 35% OEF/OIF/OND Family Play Space 27 19%

10. Is your facility/HCS currently renovating space for the OEF/OIF/OND Care Management program?

(n=140) Count % Yes 25 18% No 115 82%

If no,

a. Does your facility/HCS have future plans to renovate space to be dedicated to the OEF/OIF/OND Care Management program? (n=115) Count % Yes 27 23% No 88 77%

STAFFING 11. Please indicate whether the following barriers to recruitment/retention exist in your facility/HCS for OEF/OIF/OND

Program staff: (choose all that apply) (n=140) Count % No barriers 53 38% Stress 52 37% Patient acuity (nature of the job) 35 25% Difficult hiring process (USA Jobs, HR, etc.) 35 25% Inadequate backup (other personnel to work with) 30 21% Perceived internal support 32 23% Medical Center concurrence with hiring 27 19% Number of working hours required 19 14% Inadequate salary 12 9% Geography/Location 11 8% Benefits issues 0 0% Other 19 14%

Three facilities did not offer any of the services listed (Ann Arbor, Saginaw, Iron Mountain) specifically designated for OEF/OIF/OND Veterans.

The top three barriers to staff recruitment and retention were: stress, patient acuity (nature of the job), and a difficult hiring process.



CASE MANAGER 12. How many Case Managers (Head Count) are currently assigned to the OEF/OIF/OND Program at your facility/HCS?

*V6 Asheville, NC (637) and V19 Sheridan, WY (666) Did not have any Case Managers at time of survey.

Figure 1.

d. Case Manager disciplines

(choose all that apply) (n=406*) Count % Social Work 285 70% Nursing (RN, LVN/LPN) 121 30% Mid-Level Provider (NP, PA, CNS) 1 0% **Other 1 0%

**Mental Health Specialist

e. Grade Level for Case Managers

CASE MANAGERS (n=140) Total Average Number of Case Managers (Head Count) *406 2.90 VA FTEE of currently filled positions (not acting) 372.4 2.66 VA FTEE of currently vacant/recruiting positions 50.5 0.36 Fee/Contract FTEE 4.55 0.03

(n=404) Count % GS 9 8 2% GS 11 199 49% GS 12 85 21% GS 13 1 0% Nurse 1 7 2% Nurse 2 64 16% Nurse 3 40 10%

*Although vacant at the time of the survey, Sheridan and Asheville indicated the clinical disciplines of the positions. These site responses for questions 12 e-i were removed from survey responses. Therefore, the number of Case Managers decreases to 404.

Generally, as facility complexity levels increase, so too does the average number of Case Manager FTEE per facility, as demonstrated in Figure 1. Level 1a facilities are the most complex, and level 3 are the least complex. Texas Valley Coastal HCS and James Lovell FHCC are excluded from the 2011 Facility complexity model, and display in the “Excl” portion of Figure 1.

3.64

2.84

2.92

2.45

1.61

1.67

0 1 2 3 4

1a

1b

1c

2

3

Excl

Average FTEE per Facility

Faci

lity

Com

plex

ity L

evel

Avg. Case Manager FTEE per Facility by Complexity Level



f. Case Manager primary program assignment (n=404) Count %

OEF/OIF/OND Case Manager 331 82% Polytrauma/Traumatic Brain Injury Case Manager 28 7% OEF/OIF/OND Program Manager 13 3% Mental Health Case Manager 10 2% Social Work Case Manager 5 1% Registered Nurse Case Manager 3 1% Spinal Cord Injury Case Manager 3 1% Outreach Coordinator 2 0% Blind/Visual Impairment Team Coordinator 1 0% Other 8 2%

g. Do Case Managers have a secondary program assignment?

(n=404) Count % Yes 120 30% No 284 70%

If yes, 12.g.1. Case Manager secondary program assignment

(choose all that apply) (n=120) Count % Polytrauma/Traumatic Brain Injury Case Manager 40 33% OEF/OIF/OND Case Manager 23 19% Social Work Case Manager 12 10% Registered Nurse Case Manager 7 6% Caregiver Support Coordinator 6 5% Mental Health Case Manager 6 5% OEF/OIF/OND Program Manager 5 4% Spinal Cord Injury Case Manager 4 3% Amputee Case Manager 3 3% Outreach Coordinator 2 2% Blind/Visual Impairment Team Coordinator 1 2% DoD Clinical Case Manager 1 1% Women Veterans Program Manager 1 1% Other 40 33%



h. Overall what percentage of time do Case Managers spend completing the following tasks?

(n=404) Total % Range of responses

Direct Patient Interaction Care (virtual or face-to-face) (i.e., initial screening, care/case assessment,

treatment planning, ongoing case management, etc.) Seriously Injured 9,324 23% 0 – 90% Non-Seriously Injured 15,744 39% 0 – 100%

Indirect Patient Care 7,496 19% 0 – 92%

(i.e., activities which support direct patient care, such as follow-up with other community agencies or stakeholders, research, referrals/care coordination, identifying and making resource contacts, etc.)

Outreach 3,095 8% 0 – 60% (i.e., education, recruiting, enrollment, registering, etc.)

Administrative 4,727 12% 0 – 50% (i.e., committee meetings, data entry, education, training, program development, supervisory duties, etc.)

i. In addition to licensure, do Case Managers hold certification in case management?

(n=404) Count % Yes 50 12% No 354 86%

If yes, 12.i.1. What organization(s) certifies OEF/OIF/OND Case Managers?

(choose all that apply) (n=50) Count % Commission for Case Manager Certification (CCMC) 27 35% American Nursing Credentialing Center (ANCC) 6 1% American Case Management Association (ACMA) 12 3% National Association of Social Workers (NASW) 13 3% City University of New York, Hunter College Brookdale Center on Aging 1 1%

If no, 12.i.2. Case Managers in the process of obtaining certification?

(n=354) Count % Yes 56 16% No 298 84%

PROGRAM MANAGER

13. How many OEF/OIF/OND Program Managers are currently employed in your facility/HCS? Two facilities have a vacant position with no acting Program Manager. PROGRAM MANAGERS

Number of Program Managers (Head Count) 139 VA FTEE of currently filled positions (not acting) 126.25 VA FTEE of currently vacant/recruiting positions 12.00 Fee/Contract FTEE 1.00

d. Program Manager disciplines (choose all that apply) (n=139) Count % 1. Social Work 108 78% 2. Nursing (RN, LVN/LPN) 26 19% 3. Psychology 1 1% 4. Mid-Level Provider (NP, PA, CNS) 5 4%



e. Program Managers Grade Level

(choose one) (n=139) Count %

GS 11 1 1% GS 12 90 64% GS 13 19 14% GS 14 1 1% Nurse 2 4 3% Nurse 3 24 17%

f. Program Manager primary program assignment

(n=139) Count % OEF/OIF/OND Case Manager 3 2% OEF/OIF/OND Program Manager 131 94% Social Work Case Manager 1 1% Other 4 3%

g. Do Program Managers have a secondary program assignment?

If yes, 13.g.1. Program Manager - secondary program assignment

(choose all that apply) (n=71) Count % OEF/OIF/OND Case Manager 30 42%

Outreach Coordinator 12 17% Polytrauma/Traumatic Brain Injury Case Manager 10 14% OEF/OIF/OND Program Manager 6 8% Mental Health Case Manager 3 4% Caregiver Support Coordinator 3 4% Registered Nurse Case Manager 3 4% VISN Point of Contact 3 4% Women Veterans Program Manager 2 3% VA Liaison for Healthcare 2 3% Amputee Case Manager 1 1% DoD Clinical Case Manager 1 1% DoD Non-Clinical Care Coordinator 1 1% Federal Recovery Coordinator 1 1% Social Work Case Manager 1 1% Other 34 48%

(n=139) Count % Yes 71 51% No 68 49%

“Other” secondary positions include VISN Lead Program Manager (4 facilities), Minority Veterans Program Coordinator (2), Social Work Supervisor (6), Mental Health Clinician (2), Outreach (1), Polytrauma Program Manager (3), Integrated Ethics Program Officer (2), Caregiver Support Program Manager (5), Post Deployment Coordinator (2), Federal Women’s Program Manager (1)



h. Overall what percentage of time do Program Managers spend completing the following tasks?

(n=139)

Direct Patient Interaction Care (virtual or face-to-face)

(i.e., initial screening, care/case assessment, treatment planning, ongoing case management, etc.)

Seriously Injured 9% Non-Seriously Injured 16%

Indirect Patient Care 20%


Outreach 13% (i.e., education, recruiting, enrollment, registering, etc.)

Administrative 42% (i.e., committee meetings, data entry, education, training, program development, supervisory duties, etc.)

i. Do Program Managers ‘case manage’ a panel of patients?

If yes, i.1. In the past year, how many cases did Program Managers case manage?

(n=77) Total Average National 6,515 85

13.i.1.a. Of these cases, how many are managed:

Total Average Daily (n=11) 43 4 Weekly (n=32) 245 8 Monthly (n=62) 1,291 21 Quarterly (n=70) 2,001 29 Semi-Annually (n=47) 716 15 Annually (n=36) 530 15 Other (n=11) 1,689 154

j. Do Program Managers handle complex cases?

(n=139) Count % Yes 120 86% No 19 14%

k. In addition to licensure, do Program Managers hold certification in case management?

(n=139) Count % Yes 20 14% No 119 86%

(n=139) Count % Yes 77 56% No 62 45%

Using CMTRA data from April, 2012, Case Managers manage an average of 112 cases per year, compared to Program Managers, who manage an average of 85 cases per year according to survey results.



If yes,

13.k.1. What organization(s) certifies OEF/OIF/OND Program Managers?

(choose all that apply) (n=20) Count %

Commission for Case Manager Certification (CCMC) 11 55% National Association of Social Workers (NASW) 9 45%

If no, 13.k.2. Are Program Managers in the process of obtaining certification?

(n=119) Count % Yes 21 18% No 98 82%

TRANSITION PATIENT ADVOCATE (TPA) 14. How many OEF/OIF/OND Transition Patient Advocates are currently employed at your facility/HCS?

Transition Patient Advocates (n=100) Count Number of TPAs (Head Count) 121 VA FTEE of currently filled positions 108.78 VA FTEE of currently vacant/recruiting positions 4.00 Fee/Contract FTEE 7.00

d. What is the Grade Level for TPAs

(n=119) Count GS 9 4 GS 11 115

e. Overall what percentage of time do TPAs spend completing the following tasks?

Direct Patient Interaction Care (virtual or face-to-face)

(n=121) % Direct Patient Interaction Care (virtual or face-to-face)

(i.e., initial screening, care/case assessment, treatment planning, ongoing case management, etc.)

Seriously Injured 19% Non-Seriously Injured 23%

Indirect Patient Care 20%


Outreach 24% (i.e., education, recruiting, enrollment, registering, etc.)

Administrative 13% (i.e., committee meetings, data entry, education, training, program development, supervisory duties, etc.)

One hundred facilities account for a total of 121 TPAs. One facility, Central Texas HCS, has four TPAs, four facilities (Cleveland, Milwaukee, San Diego, and Minneapolis) have three TPAs, eight facilities have two TPAs, and the remaining 87 facilities have one TPA.



VISN LEAD PROGRAM MANAGER 15. Is your facility/HCS supported by the VISN Lead Program Manager?

(n=140) Count % Yes 111 79% No 29 21% If yes, a. How frequently are you in contact with your VISN Lead Program Manager?

(n=111) Count % Daily 6 5% Weekly 45 41% Monthly 51 46% Quarterly 6 5% Bi-annually 1 1% Yearly 0 0% Never 2 2%

b. How would you rate the support from your VISN Lead Program Manager?

(support is inclusive of responsiveness) (n=111) Count %

Very satisfied 82 74% Somewhat satisfied 17 15% Neither satisfied nor dissatisfied 8 7% Not very satisfied 3 3% Not at all satisfied 1 1%

c. Does your VISN Lead Program Manager have regular meetings with facility Program Managers?

(n=111) Count % Yes 95 86% No 15 14%

VISN POINT OF CONTACT (POC) 16. Is your facility/HCS supported by the VISN POC?

(n=140) Count % Yes 126 90% No 14 10%

If yes, a. How frequently are you in contact with your VISN POC?

(n=126) Count % Daily 5 4% Weekly 49 39% Monthly 57 45% Quarterly 8 6% Bi-annually 4 3% Yearly 1 1% Never 2 2%



b. How would you rate the support from your VISN POC?

(support is inclusive of responsiveness) (n=126) Count %

Very satisfied 81 64% Somewhat satisfied 23 18% Neither satisfied nor dissatisfied 13 10% Not very satisfied 7 6% Not at all satisfied 2 2%

c. Does your VISN POC have regular meetings with facility Program Managers?

(n=126) Count % Yes 107 85% No 19 15%

STAFF ORIENTATION

17. Does your facility/HCS provide an organized orientation program for new OEF/OIF/OND Care Management Team

members? (n=140) Count % Yes 104 74% No 36 26%

If yes, 17.a. Which of the following topics are included in the orientation?

(choose all that apply) (n=104) Count %

Staff Contact Information (i.e., OEF/OIF/OND Seamless Transition Team, SW&CBS, Psychiatry, MSW email group, appointment scheduling) 101 97%

VHA Handbook 1010.01 - Care Management of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans 100 96%

Resources: (i.e., VBA, VHA, Financial, Legal, Dental, Relationship, Housing, Employment, Education, Healthcare, Environmental Exposure, Suicide Prevention, Veterans Service, Offices)

100 96%

Case Management Tracking Application (CMTRA) 99 95% Performance Measures 99 95% Local Protocols/Procedures 98 94% Facility OEF/OIF/OND Brochures 98 94% Release of Information Procedures 97 93% National OEF/OIF/OND Websites 96 92% OEF/OIF/OND Clinical Reminders and TBI Reminder 96 92% Facility OEF/OIF/OND Website, SharePoint, IT Information 91 88% Case Management Initiative Requirements 88 85% Outreach (i.e., Veterans Outreach Reporting System (VORS), Case Management Log, etc.) 87 84%

Only 74 percent of facilities provide an organized orientation program for OEF/OIF/OND Care Management team members. Of those facilities that do provide an orientation, most relevant topics are covered, ranging from a low of 84 percent of facilities covering Outreach, to a high of 97 percent covering Staff Contact Information.



18. Please rate the quality of orientation materials for the following positions:

a. Program Manager

b. Transition Patient Advocate (TPA)

c. Case Manager

19. Does an OEF/OIF/OND Care Management Team representative participate in regular meetings with facility/HCS executive leadership? (n=140) Count % Yes 99 71% No 41 29%

If yes,

a. How frequently? (n=99) Count %

Daily 14 14% Weekly 18 18% Monthly 43 43% Quarterly 16 16% Other 8 8%

b. How often do you brief your facility/HCS leadership?

(n=99) Count % Annually 3 3% Quarterly 25 25% Monthly 48 48% Weekly 17 17% Daily 5 5% Never 1 1%

(n=140) Count % Excellent 25 18% Good 51 36% Fair 30 21% Poor 6 4% No orientation materials 28 20%

(n=140) Count % Excellent 23 16% Good 46 33% Fair 22 16% Poor 4 3% No role in TPA orientation 45 32%

(n=140) Count % Excellent 35 25% Good 73 52% Fair 14 10% Poor 6 4% No orientation materials 12 9%

The quality of orientation materials are perceived as best for Case Managers, TPAs, then Program Managers respectively when comparing the ratio of Excellent/Good responses to Fair/Poor responses for each position (as follows).

Program Managers: 76/36 = 2.1 TPAs: 69/26 = 2.7 Case Managers: 108/20 = 5.4

Seventy-one percent of Care Management Teams participate in regular meetings with facility executive leadership. Most briefings occur monthly, with smaller percentages occurring weekly, quarterly, and daily.



POLICY AND PRACTICES

Care Management Tracking

20. Does your facility/HCS use any of the following data in managing the OEF/OIF/OND program? (choose all that apply) (n=140) Count % CMTRA data 135 96% Iraq/Afghanistan clinical reminder data 131 94% Monthly Outliers 125 89% Screening Reports 121 86% New OEF/OIF/OND Veterans report data 114 81% Unique patients seen 113 81% Outreach reporting data 110 79% OEF/OIF/OND PTSD Program Monitors 81 58% No show rates 69 49% Caseload ratios 67 48% Consultation completion rates 57 41% Caregiver stipend data 56 40% Other 17 12% TBI performance measures 122 87%

If TBI: (n=122) Count % Initial Clinical Reminder for Screen 120 98% Scheduling within 14 days of initial appointment 108 89% Evaluation completed within 30 days 106 87%

21. What source/report is your facility/HCS using to obtain data for the monthly case management screening report? (choose all that apply) (n=140) Count % Health Factors – CPRS 50 36% VistA/Fileman Reports 82 59% Independent Tracking (i.e., Microsoft Excel) 68 49% Post-deployment Monitor 36 26% Event/Encounter Capture 32 23% CMTRA 57 41% Veterans Service Support Center (VSSC) 51 36% Other 25 18%

Many of the “other” responses were sub-sets of the existing choices. These responses included: referrals (phone, electronic, or in-person), VISN reports or databases, clinical reminder, specific progress note titles in CPRS, enrollment data, DSS, and appointments in OEF/OIF/OND clinic.



22. At your facility/HCS, who completes the initial case management screening for OEF/OIF/OND Veterans? (choose all that apply) (n=140) Count % OEF/OIF/OND Care Management Team 137 98% Post-deployment Clinic 36 26% Patient Aligned Care Team (PACT) 28 20% If PACT, Primary Care 24 17% Does PACT case manage/refer/both? Ambulatory Care 8 6% (n=28) Count % Polytrauma/TBI Team 24 17% Refer 17 61% Mental Health 16 11% Both Case Manage/Refer 10 36% Emergency Department 6 4% Case Manage 1 4% Spinal Cord Injury 7 5%

Enrollment/Registration 5 4%

*Other 15 11%

If not “OEF/OIF/OND Care Management Team,”

l. How often are OEF/OIF/OND Case Managers receiving internal referrals for case management?

m. How are OEF/OIF/OND Veteran referrals communicated to the case management team?

(choose all that apply) (n= 75) Count % Warm handoff (phone/face-to-face/team meetings) 64 85% Co-signature 61 81% E-mail 54 72% Consult 47 63% Other 17 23%

23. Are OEF/OIF/OND Veterans followed by the OEF/OIF/OND Team after 5 years of combat eligibility has expired?

(n=140) Count % Yes 131 94% No 9 6%

(n= 75) Count % Daily 39 52% Weekly 29 39% Monthly 7 9%

Social Workers accounted for nine of the 15 “other” responses, responsible for completing the initial case management screening for OEF/OIF/OND Veterans.

If a facility provided case management of OEF/OIF/OND Veterans by any providers outside the OEF/OIF/OND Care Management Team, they were asked to indicate who completes the initial case management screening.



2012 Survey of Care Management of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans in VHA

VISN POC

1. How often do you make the following types of contact with the facility/HCS OEF/OIF/OND Program Managers in

your VISN? (choose all that apply)

Facility VISN POC Daily 4% 38% Weekly 39% 57% Monthly 45% 5% Quarterly 6% Bi-annually 3% Yearly 1% Never 1%

2. What is your primary discipline?

(n=21) Count % Social Work 9 43% Nursing (RN, LVN/LPN) 5 24% Psychology 1 5% Mid-Level Provider (NP,PA, CNS) 1 5% Physician 1 5% Blind Rehabilitation Specialist (VIST) 0 0% Other 5 24%

3. Are you certified in case management?

One (5%) VISN POC is certified in case management by the Commission for Case Manager Certification (CCMC).

(n=21) Daily Weekly Monthly Quarterly Semi-Annually Annually

Phone Calls 3 13 5 0 0 0 14% 62% 24% 0% 0% 0%

E-mail 8 12 1 0 0 0 38% 57% 5% 0% 0% 0%

Site Visits 0 0 1 4 5 11 0% 0% 5% 19% 24% 52%

Totals 11 25 7 4 5 11

VISN POCs email the facility Program Managers most frequently (95% daily/weekly), compared to phone calls (76% daily/weekly) and site visits.

“Other” VISN POC disciplines included: administrative specialists, masters-prepared professionals, and a Registered Dietitian.

The VISN POC response to “How often do you make the following types of contact with the facility/HCS OEF/OIF/OND Program Managers in your VISN?” was compared with the fields' response to "How frequently are you in contact with your VISN POC?" Differences in perception may account for the dramatic difference. Email is one-way communication, and may not be perceived as "contact" by facility staff. However, some staff may view phone or in-person contact to be considered "contact" with the VISN POC. Of note, two facilities reported never being in contact with their VISN POC.



4. Which of the following functions do you perform?

(choose all that apply) (N=21) Count %

Collect, maintain, and forward reports and data prepared by the OEF/OIF/OND Care Management team and submitted by facility senior management to the appropriate VHA requesting office

21 100%

Serve as a liaison between the VA Central Office (VACO), the VISN, VISN Lead, and facility OEF/OIF/OND Program Manager and other agencies and organizations

21 100%

Attend monthly conference calls by Care and Social Work at VA Central Office 20 95%

Provide briefings and presentations to VA staff and non-VA organizations/audiences about OEF/OIF/OND VA health care 19 90%

Standardization of the OEF-OIF-OND Care Management Program and the VISN 18 86%

Coordinate with Lead OEF-OIF-OND Program Manager for periodic VISN Level face-to-face meetings and conference calls with the OEF/OIF/OND Care Management team

17 81%

Assure OEF/OIF/OND Care Management team has the necessary resources to achieve program goals 16 76%

Moderate monthly conference calls with all facility OEF/OIF/OND Program Managers within the VISN 16 76%

Update Care Management and Social Work on changes in facility OEF/OIF/OND Program Managers/Case Managers/TPAs 15 71%

Coordinate and participate in review panels for the selection of new TPAs 12 57%

Outreach Coordination 12 57%

5. Do you have supervisory authority over Care Management Staff in your VISN?

(n=21) Count % Yes 1 5% No 20 95%

If yes, 5.a. What type of staff do you supervise?

(choose all that apply) Count % Transition Patient Advocate 1 100% Program Managers 0 0% Case Managers 1 100% VISN Lead Program Managers 0 0% Other 0 0%

6. Do you brief your VISN leadership on the OEF/OIF/OND Program?

(n=21) Count % Yes 21 100% No 0 0%



If yes,

6.a. How often do you brief your VISN leadership?

(n=21) Count % Annually 1 5% Quarterly 9 43% Monthly 7 33% Weekly 4 19% Daily 0 0%

7. Did you attend a formal orientation program?

(n=21) Count % Yes 7 33% No 14 67%

If yes,

7.a. Please rate the quality of VISN POC orientation materials.

Count %

Excellent 3 43% Good 4 57% Fair 0 0% Poor 0 0%

If no, 7.b. Did you receive any orientation materials?

Count %

Yes 4 29% No 10 71%

8. Overall, how satisfied are you with the support for VISN POCs by VA Central Office?

(support is inclusive of responsiveness)

(n=21) Count % Very satisfied 15 71% Somewhat satisfied 1 5% Neither satisfied nor dissatisfied 3 14% Not very satisfied 2 10% Not at all satisfied 0 0%



PARTICIPATING FACILITIES



VISN Facility Name from Survey VISN Facility Name from Survey

1 Bedford, MA - 518 7 Augusta, GA - 509 Boston HCS - 523 Birmingham, AL - 521 Connecticut HCS - 689 Central Alabama HCS - 619 Manchester, NH - 608 Charleston, SC - 534 Northampton, MA - 631 Columbia, SC - 544 Providence, RI - 650 Decatur, GA - 508 Togus, ME - 402 Dublin, GA - 557 White River Junction, VT - 405 Tuscaloosa, AL - 679 2 Albany, NY - 528A8 8 Bay Pines HCS - 516 Bath, NY - 528A6 Caribbean HCS-San Juan - 672 Canandaigua, NY - 528A5 Miami HCS - 546 Syracuse, NY - 528A7 North Florida-South Georgia HCS - 573 Western New York HCS - 528 Orlando, FL - 675 Tampa, FL - 673 3 Bronx, NY - 526 West Palm Beach, FL - 548 Hudson Valley HCS - 620 New Jersey HCS - 561 9 Huntington, WV - 581 New York Harbor HCS - 630 Lexington, KY - 596A4 Northport, NY - 632 Louisville, KY - 603 Memphis, TN - 614 4 Altoona, PA - 503 Mountain Home, TN - 621 Butler, PA - 529 Tennessee Valley HCS - 626 Clarksburg, WV - 540 Coatesville, PA - 542 10 Chillicothe, OH - 538 Erie, PA - 562 Cincinnati, OH - 539 Lebanon, PA - 595 Cleveland, OH - 541 Philadelphia, PA - 642 Columbus, OH - 757 Pittsburgh HCS - 646 Dayton, OH - 552 Wilkes-Barre, PA - 693 Wilmington, DE - 460 11 Ann Arbor HCS - 506 Battle Creek, MI - 515 5 Martinsburg, WV - 613 Detroit, MI - 553 Maryland HCS - 512 Illiana HCS - 550 Washington, DC - 688 Indianapolis, IN - 583 Northern Indiana HCS - 610 6 Asheville, NC - 637 Saginaw, MI - 655 Beckley, WV - 517 Durham, NC - 558 Fayetteville, NC - 565 Hampton, VA - 590 Richmond, VA - 652 Salem, VA - 658 Salisbury, NC - 659



VISN Facility Name from Survey VISN Facility Name from Survey

12 Chicago HCS - 537 19 Cheyenne, WY - 442 Hines - 578 Eastern Colorado HCS - 554 Iron Mountain – 585 Grand Junction, CO - 575 Madison – 607 Montana HCS - 436 Milwaukee – 695 Salt Lake City HCS - 660 North Chicago – 556 Sheridan, WY - 666 Tomah - 676 20 Alaska HCS - 463

15 Columbia, MO - 589A4 Boise, ID - 531 Eastern Kansas HCS - 589A5 Portland, OR - 648 Kansas City, MO - 589 Puget Sound HCS - 663 Marion, IL - 657A5 Roseburg HCS - 653 Poplar Bluff, MO - 657A4 Spokane, WA - 668 St. Louis, MO - 657 Walla Walla, WA - 687 Wichita, KS - 589A7 White City, OR - 692

16 Alexandria, LA - 502 21 Central California HCS - 570 Central Arkansas HCS - 598 Northern California HCS - 612 Fayetteville, AR - 564 Pacific Islands HCS - 459 Gulf Coast HCS - 520 Palo Alto HCS - 640 Houston, TX - 580 San Francisco, CA - 662 Jackson, MS - 586 Sierra Nevada HCS - 654 Muskogee, OK - 623 Oklahoma City, OK - 635 22 Greater Los Angeles HCS - 691 Shreveport, LA - 667 Loma Linda HCS - 605 Southeast Louisiana HCS - 629 Long Beach HCS - 600 San Diego HCS - 664

17 Central Texas HCS - 674 Southern Nevada HCS - 593 North Texas HCS - 549 South Texas HCS - 671 23 Black Hills HCS - 568 Texas Valley Coastal Bend HCS-Harligen - 740 Central Iowa HCS - 636A6 Fargo VA HCS - 437

18 Amarillo HCS - 504 Iowa City, IA - 636A8 El Paso HCS - 756 Minneapolis VA HCS - 618 New Mexico HCS - 501 Nebraska-Western Iowa HCS - 636 Northern Arizona HCS - 649 Sioux Falls, SD - 438 Phoenix, AZ - 644 St. Cloud, MN - 656 Southern Arizona HCS - 678 West Texas HCS - 519



ACKNOWLEDGEMENTS



2012 VHA Survey of OEF/OIF/OND Care Management

Technical Advisory Group (TAG)

Deborah Amdur Peggy Kennedy Chief Consultant OEF/OIF/OND Case Management Program Manager Department of Veterans Affairs Department of Veterans Affairs VA Central Office VA Central Office Washington, DC Washington, DC

Janet Belisle Sarah Nowitzke

Health System Specialist Clinical Social Worker Department of Veterans Affairs Department of Veterans Affairs Washington, DC Ann Arbor, MI

Betty Dameron Carrie Bancroft

RN Social Work Service Department of Veterans Affairs Department of Veterans Affairs St Petersburg, FL San Francisco, CA

June Callasan Lauren Love-Dubeau

RN, OEF/OIF/OND Program Manager OEF/OIF/OND Program Manager, VISN 2 POC Department of Veterans Affairs Department of Veterans Affairs Long Beach, CA Syracuse, NY

Victoria Koehler Christopher Petrone

OEF/OIF Program Manager OEF/OIF Program Manager Department of Veterans Affairs VA Southern Oregon Rehabilitation Center & Clinics Portland, OR 97239-2999 White City, OR

Crystal Woodard Jennifer Perez

Social Worker National VA Liaison Program Manager Department of Veterans Affairs Department of Veterans Affairs Louisville, KY Washington, DC

Kerry Traviss Susan Watkins

OEF/OIF Program Manager Social Worker Department of Veterans Affairs Department of Veterans Affairs Atlanta, GA Durham, NC

Kathleen Dinegar VA Liaison for Health Care Department of Veterans Affairs Washington, DC

Healthcare Analysis & Information Group (HAIG)

Tanya Kotar, Program Analyst Denise Ott, Management Analyst



Documents

2012 OEF OIF OND Final Report