JUNE 10-14, 2019   •  Las Vegas, NV
Navigating the Full Spectrum of Case Management • Mirage Convention Center

PP211 – Organizational Change through Partnerships and Pilot Sites: A National Care Coordination and Case Management Initiative

Jun 12 2019
12:30 pm - 2:30 pm

PP211 – Organizational Change through Partnerships and Pilot Sites: A National Care Coordination and Case Management Initiative

The Veterans Health Administration (VHA) offers a vast array of health and social services delivered in outpatient and inpatient settings to a diverse population of Veterans. To support Veterans’ optimal experience and health outcomes, care coordination (CC) and case management (CM) services are woven into the fabrics of the VHA. With a growing number of enrolled Veterans also seeking care in the community, it is vital that CC and CM services and resources are strengthened and integrated. To accomplish this goal, VHA created a framework that fosters enhanced coordination of these services, considering different program-specific policies and a diverse network of VA facilities.

VHA includes multiple program offices, each with a critical but focused view of the system and divided into Veterans Integrated Service Networks that are in urban, rural and highly rural communities. In such a complex system, effecting organizational change requires a high degree of collaboration. Offices of Nursing and Care Management and Social Work engaged key partners and invited them to participate in the redesign effort through informal consultation, membership and a structured governance council. Twelve VA facilities volunteered to pilot new CC and CM tools and processes to determine their effectiveness. A collaborative forum was used to provide training and encourage idea sharing. The application of tools and processes was captured through a lessons learned repository. Information was analyzed to establish standards in many areas, including complex patient identification.  Partnerships and pilot sites allowed VHA to make breakthroughs in how CC and CM is delivered across a care continuum. These elements led VHA to redefine care coordination, amend case management policy and develop infrastructure for a care coordination system with integrated case management. These changes improved how VHA tailors CC and CM interventions to at-risk Veterans and helped the organization meet its mission.


1. Describe the path to care coordination and case management innovation and how it is driving an organization to improve how it identifies and serves patients with complex needs

2. Discuss collaborative strategies that were used to sustain a successful care coordination and case management initiative and the impact on outcomes

3. Describe key lessons learned from pilot testing and subsequent breakthroughs in care coordination and case management