The VA is the primary coordinator of health care for veterans, whether that care is delivered at a VA medical center or through a community provider. Gaps in care, or poor coordination of care, can result in devastating health outcomes, especially for veterans with particularly complex conditions.

The House Committee on Veterans’ Affairs took up the topic of care coordination at a June 13 hearing of its health subcommittee to learn more about VA practices for meeting and improving veterans’ health outcomes.

“Veterans who get their care in multiple settings are at greatest risk for lapses in care, especially when their medical records are either not returned to the VA or the VA does not correctly input vital medical data,” Rep. Mariannette Miller-Meeks (R-Iowa), the subcommittee’s chair, stated in her opening remarks. “Communication between the VA and community providers could be greatly enhanced if coordinators were empowered to work across clinical and arbitrary bureaucratic lines.”

Officials from the Veterans Health Administration (VHA) acknowledged the need to improve care coordination. The department is developing a long-term strategy and integrated case management framework that will ensure care is delivered consistently across the system. The initiative aims to decrease navigational barriers and fragmented care by proactively identifying veterans with complex care coordination needs and aligning them with the right resources and support services.

The VHA started deploying the new initiative in December and expects to begin seeing system improvements soon after full deployment in September.

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Dr. Julie Kroviak, principal deputy assistant in the VA’s Office of the Inspector General (OIG), highlighted several issues care providers and patients face in navigating the complexities of care coordination — the transition from the DoD to VA care, barriers to care coordination within the VA, and the breakdowns that can occur when engaging with community care providers.

“Almost every report published by the OIG Office of Healthcare Inspections details aspects of care coordination, whether it is a hotline inspection detailing missteps or failures in that care coordination, or the cyclical reviews that provide VHA leaders with risk assessment of their medical facilities’ current practices,” Kroviak said. “These reports recognize that VHA personnel often have to overcome inefficient and ineffective processes or system limitations to ensure safe transitions and quality care both within VHA and with outside care providers.”

Advocates Recommend Reforms

Witnesses from the Quality of Life Foundation (QoLF), Paralyzed Veterans of America (PVA), and Wounded Warrior Project (WWP) shared similar examples and concerns about current VHA care coordination practices and processes.

QoLF is one of the few organizations working exclusively within the VHA to help veterans and caregivers apply for and navigate the Program of Comprehensive Assistance for Family Caregivers, along with other clinical support programs.

“In our experience, we see many veterans with care managers — people who usually manage one clinical support or disease specific program — but no overall case manager,” QoLF Advocacy Director Andrea Sawyer told members. “Many of the veterans QoLF serves have complex needs. With no higher oversight on the part of individual case managers, veterans and caregivers have multiple plans to try to navigate and multiple points of contact individual to each disease, injury, or intervention.”

Sawyer urged the committee to consider the following recommendations to improve VA care coordination by:

• Establishing a cadre of specially trained case managers like the federal recovery care coordination program to take on the most difficult cases.
  
  
• Establishing a case management and social work lead in the VHA regional networks to coordinate training and standardization of services, and to serve as a point of contact when challenges arise.
  
  
• Making the process easier for veterans to obtain a case manager. Many veterans have been unaware of case management programs and services available at their VA medical facility.
  
  
• Reviewing the current process for entering medical records from outside providers into a veteran’s medical record and how it impacts the ability to provide appropriate care and care management.
  
  
• Reviewing the actual caseloads of the different care management and social work teams across VHA to ensure proper staffing and allow for incentives to fill vacancies.

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Roscoe Butler, the PVA’s senior health policy adviser, told the committee that veterans with complex health care conditions like spinal cord injury or disorder (SCI/D) receive care from primary care physicians, a wide range of specialists, visiting nurses, and caregivers — care provided through several service points.

“VA has an excellent model for SCI/D veterans and knows how to care for them,” Butler said. “Civilian facilities are simply not equipped or properly staffed to handle SCI/D patients’ acute and long-term care needs, so most won’t accept them.”

He stressed the need for more SCI/D medical centers and for VHA to expand access to home and community-based services to meet the growing demand and needs for aging and disabled veterans. Butler also urged Congress to pass the MOAA-backed H.R. 542, the Elizabeth Dole Home and Community Based Services for Veterans and Caregivers Act.

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WWP delivers a series of programs to help post-9/11 wounded, ill, and injured veterans interact with the VA health system, and also so they can live more independently with a better quality of life.

“VHA has several pilot programs exploring how to improve integrated case management,” Matt Brady, WWP’s director of complex case management, told the lawmakers. “However, veterans need consistent coordination of care now, especially veterans with complex needs who get care from a variety of points of service.”

MOAA is grateful for the committee making care coordination a top priority. Like the committee, we agree no veteran should be in the dark about their ongoing medical care or its coordination.

We look forward to working with Congress and the VA in addressing these challenges so veterans, caregivers, and family members can more easily navigate and access the care they earned and deserve.