Warrior CareContinuum of Care

August 20, 20183:10 p.m.

Image Source: Warrior Care staff. (c. 2013) WCP Logo RGB [JPEG file].

2

Presenters(s)/Moderator

Sandra Mason, MSWDirector, Recovery Coordination Program

Clinical Support (J3)Defense Health Agency

Arlington, VA

Jonathan Morris, BS, LPN Director, Information Technology

Clinical Support (J3) Defense Health Agency

Arlington, VA

3

Disclosures• Presenter(s) have no relevant financial or non-financial relationships to disclose relating to the

content of this activity; or presenter(s) must disclose the type of affiliation/financial interest (e.g. employee, speaker, consultant, principal investigator, grant recipient) with company name(s) included.

• The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, not the U.S. Government.

• This continuing education activity is managed and accredited by the Defense Health Agency J7 Continuing Education Program Office (DHA J7 CEPO) in collaboration with the Professional Education Services Group/AffinityCE (PESG/ACE), DHA J& CEPO and PESG/ACE as well as all accrediting organizations do not support or endorse any product or service mentioned in this activity.

• DHA J7 CEPO and PESG staff, as well as activity planners and reviewers have no relevant financial or non-financial interest to disclose.

• Commercial support was not received for this activity.

4

Learning ObjectivesAfter completing this briefing, you should be able to do the following:• Define care coordination• Select tools applicable to the care coordination process• Explain the three phases of the Continuum of Care: Recovery,

Rehabilitation and Reintegration • Analyze the typical needs and concerns of Service members and

families/caregivers in each phase, including benefits and entitlements• Describe the recovery care plan process• Outline how to assess and provide support for wounded, ill and injured

Service members and their families/caregivers• Compare and contrast privacy and confidentiality

5

What is Care Coordination?• Care Coordination involves the

following: − Integrating the episodes of

care that occur during a Service member’s rehabilitation process

− Ensuring a synchronous flow of information among participants responsible for delivering different aspects of care at different times

− Decreasing confusion throughout the process

• Care Coordination is not just healthcare, but all services and benefits that are a part of Service member/Veteran rehabilitation pathway after injury or illness. This includes: − Disability benefits − Education and training − Employment support − Housing− Transportation.

6

People, Tools and TechnologyRecovery Care Coordinator (RCC)

• Jointly trained by Department of Defense (DoD) and Wounded Warrior Programs (WWP)

• Assigned/supervised by WWPs• Works with Recovery Team to ensure non-medical needs are met

Interagency Comprehensive Plan (ICP)

Lead Coordinator (LC) Checklist

Central IT solution to manage Care Plans: DoD Case Management System (DoD-CMS)

Image Source: Powerpoint (Office 2010) [Computer Software]. 1390787932_toolbox .[PNG file]. Redmond, WA: Microsoft

7

The Plan

THE PLAN

ICP

CRP

CP

IEP

ISP

CTP1

2

3

4

5

6

1. Interagency Care Plan (ICP)

2. Comprehensive Recovery Plan (CRP)

3. Comprehensive Plan or Care Plan (CP)

4. Individual Education (IEP)

5. Individual Service Plan (ISP)

6. Comprehensive Transition Plan (CTP)

8

Coordinate

MedicalPersonnel

MedicalPersonnel

MedicalPersonnel

MedicalPersonnel

PEBLOS & Military Service

Coordinators

Family Support

Programs

MilitaryLiaisons

OEF/OIFLiaisons

Image Source: Department of Defense and Warrior Care staff.(c. 2015) Recovery Coordination Program graphic. [JPEG file].

9

Continuum of Care

The Three Phases

Phase 1

Recovery

Phase 2

RehabilitationPhase 3

Reintegration

10

Continuum of Care Model

Service

Service member serves in Active,

Reserve, or National Guard

component

Identification

Service member becomes wounded, ill or injured and is

enrolled in care programs

…and Fitness / Disability Evaluation

Service member develops recovery plan, participates in rehabilitation

activities, and may be enrolled in the Disability Evaluation System to be

determined fit or unfit for duty

…and Transition

Service member returns to Service or transitions to

civilian life

Sustainment

Veteran and family/caregiver receive ongoing

benefits and support

Event

Service member receives treatment, services and benefits

Phase

C O N T I N U U M OF C A R E

RECOVERY REHABILITATION REINTEGRATION

11

Recovery Care Plan Process

Inputs• Enrollment Form• Medical Records

• Personnel

Collect Information from Files

Inputs• Service Member• Family/Caregiver

• Non-Medical Case Manager (NMCM)

• Medical Care Case Manager (MCCM)

• Command• Multidisciplinary

Team• Family Services

• Chaplain

Gather Information

from Participants

• Admin.Needs

• Assistive Devices & Tech.

• Awards• Benefits &

Comp.• Education &

Training• Employment• Family

Support• Finances• Gender

Specific• Housing

• Medical Evaluation Board orPhysical Evaluation Board (MEB/PEB)

• Medical Care• Psychological

Health• Post-

Traumatic Stress (PTS)

• Suicide• Homicide• Spiritual• Transportation• Legal

Needs

Review Needs

Create Goals with Service Member and

Family/Caregiver

YES

NeedsIdentified?

NO

Document that Needs Were Not Identified

Identify Action Steps to Meet Goals

Identify Point-of-Contact for Action Steps

Identify Services and Resources for Service

Member andFamily/

Caregiver

NO

All Needs

Addressed forService Member

and Family/Caregiver?

YES

ReviewPlan

Execute the Plan

Sign Plan

Image Source: : Warrior Care staff.(c. 2015) Recovery Care Plan Process graphic. [BMP files].

12

Privacy and Confidentiality

• The Privacy Act of 1974, Public Law 93-579, was created in response to concerns about how the use of computerized databases impacts individuals’ privacy rights.

• Each wounded warrior program requires the use of Privacy Act Statements.

Image: Powerpoint (Office 2007) [Computer Software]..Privacy_Confidentiality_PartII .[PNG file]. Redmond, WA: Microsoft

13

Privacy and Confidentiality (cont.)

When collecting information from the Service member, include the following on the collection form or on a separate form that can be retained by the individual (also referred to as the Privacy Act Statement):

• The authority who authorizes the solicitation of the information

• Whether disclosure of such information is mandatory or voluntary

• The principal purpose or purposes for which the information is intended to be used

• The routine uses that may be made of the information

• The effects on the individual, if any, of not providing all or any part of the requested information

14

Health Insurance Portability and Accountability Act

• The Health Insurance Portability and Accountability Act (HIPAA) Rules provide federal protections for patient health information and gives patients an array of rights with respect to that information.

• This suite of regulations includes the following:− The Privacy Rule, which protects the privacy

of individually identifiable health information

− The Security Rule, which sets national standards for the security of electronic Protected Health Information (ePHI)

− The Breach Notification Rule, which requires notification following a breach of unsecured Protected Health Information (PHI)

Image Source: Powerpoint (Office 2010) [Computer Software]. B4038532941C8305769_lockedfiles. [PNG file]. Redmond, WA: Microsoft.

15

The Privacy Rule• The Privacy Rule of HIPAA protects most individually identifiable health

information – in any form or media – whether electronic, paper, or oral. The Privacy Rule calls this information “protected health information” or “PHI.”

• Individually identifiable health information is information, including demographic information, that relates to:− The individual’s past, present, or future physical or mental health or

condition− The provision of health care to the individual− The past, present, or future payment for the

provision of health care to the individual• Examples of protected information:

− Medical records− Laboratory reports− Hospital bills

Improper disclosure of

personal information carries

both civil and criminal

penalties.

16

Key TakeawaysThe following are examples of important or key “take-away” messages:

• Care coordination decreases confusion throughout the recovery process.

• The Plan, which may have a variety of names, is key to effective care.

• The three phases in the Continuum of Care include recovery, rehabilitation, and reintegration.

• The Recovery Care Plan Process involves gathering information, identifying needs, creating goals, identifying services and resources, and executing the plan.

• RCCs must comply with the Privacy Act and HIPAA in maintaining the confidentiality of the Service members/families to which they are assigned.

17

ReferencesDepartment of Defense Instruction. (2009). DoDI 1300.24 Recovery Care Coordination. Retrieved from

: http://warriorcare.dodlive.mil/files/2016/03/DoDI-Recovery-Care-Coordination_1300.24.pdf

Department of Veterans Affairs (VA) and the Department of Defense (DoD) (2016). Memorandum of

Understanding (MOU) between VA and DoD : Interagency Complex Care Coordination

Requirements for Service Members and Veterans. Retrieved from:

http://warriorcare.dodlive.mil/files/2016/04/MOU-for-VA_DoD-IC3-Processes.pdf

H.R. 4986 – 110th Congress. (2008). National Defense Authorization Act (NDAA) for Fiscal Year 2008.

Retrieved from: https://www.gpo.gov/fdsys/pkg/CRPT-110hrpt477/pdf/CRPT-110hrpt477.pdf

18

References (continued)Department of Justice. (2015). Overview of the Privacy Act of 1974 (2015 edition). Retrieved from:

http://warriorcare.dodlive.mil/files/2016/03/DoDI-Recovery-Care-Coordination_1300.24.pdf

Department of Health and Human Services. (1996). Summary of the Health Insurance Portability Act

Security Rule of 1996 (HIPAA) . Retrieved from: https://www.hhs.gov/hipaa/for-

professionals/security/laws-regulations/index.html

Hussein M. Tahan PhD, RN & Teresa M. Treiger RN-BC, MA, CHCQM-CM/TOC. (2016). CMSA Core

Curriculum for Case Management, 3rd Edition. Retrieved from:

http://www.lww.com/Product/9781451194302

19

How to Obtain CE Credit• After the activity, go to URL https://dhaj7.cds.pesgce.com

• Select the activity titled Recovery Care Coordinator Course.

• You will be taken to the login page. Enter your e-mail address and password. If this is your first time visiting the site, enter a password you would like to use to create your account. Select continue.

• Verify, correct, or add your information, including your profession(s).

• Proceed and complete the activity evaluation. You may be required to pass a posttest.

• Upon completing the evaluation, you may view, download, or print your certificate and/or statement of participation. Your CE record will also be stored here for later retrieval.

• The Web site is open for completing your evaluation for 14 days.

• After the Web site has closed, you can come back to the site at any time to print your certificate, but you will not be able to add any evaluations.