Warrior CarePreparing a Case for

TransitionOctober-November 2017

At the end of this module, participants will be able to

• Identify when and why a transition is required

• Facilitate the transition

• Describe the “warm hand-off” process

• Close-out a case

• Complete an LC checklist in DoD-CMS

Objectives

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Case Transition Defined1. Current Lead Coordinator transfers case to new

Lead Coordinator (LC)

2. Current Lead Coordinator closes a case or deems the case inactive

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Facilitating the TransitionYour responsibilities: • Letting go emotionally

• Helping the RSM/family through the transition

• Preparing the next LC for success

• Obtaining the Service member’s authorization to release protected health information prior to a warm hand-off to a non-covered entity

• Documenting the transition in DoD-CMS

Why would a case be transferred?

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Transfers may happen for a variety of reasons. The most common include:

• Change in location of either LC or Service member

• Service member/Family requests a different RCC/LC

• WWP determines that the RCC/LC can no longer provide the necessary services for the Service member/Family

• RCC/LC leaves the job

• Service member’s medical needs increase; transferred to medical case coordinator who serves as LC

• Service member transitioning from DoD to VA

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Release of Information – DD Form 2870

Prior to the transfer of a case it is essential that the Service Member or Caregiver complete and sign a release of information form, DD Form 2870 – Authorization For Disclosure of Medical Or Dental Information

While there is some flexibility in when each step occurs, generally, LCs should follow the order on the left:

Reminder: Steps in the Handoff of LC Role

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Need for LC transfer

determined

Referral made to next

level/site

Receiving CMT and sending CMT discuss

Receiving CMT determines new

LC

"Warm Handoff”

Receiving LC assumes LC

Role

Achieve Best

Possible Outcome

Reduce Anxiety

Prevent Delays

Reminder: The “Warm Handoff”

• Set up the new LC for success• Ensure care is provided during a critical transition

point• Include Face-to-Face, Email, and Telephone

communication as well as Secure transmission of documents

• Include a referral packet to the VA Liaison for Healthcare (or to the TCM Program Manager in the absence of a VA Liaison)

It is vitally important that the transfer of duties between the current LC and the receiving LC be as smooth and efficient as possible. A “warm handoff” will:

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Cases may be closed or given inactive status for a variety of reasons. The most common include:

• Achievement of agreed upon, documented outcomes or maximum benefit reached (goals)

• Service member/Family requests discontinuation of services

• Service member expires or other conditions make care coordination unnecessary

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Why would a case be closed or deemed inactive?

For some cases, there may be a strong feeling of loss during or after the transition – for either or both the RCC/LC and the Service member/Family.

Do not ignore the need for self-care, grief counseling, and resilience support.

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The Human Component

Common problem: RCCs fail to close-out cases after transition. Document, document, document! ….or it didn’t happen. • Timely documentation of a transitioned case is important and required

• Make sure the name and details associated with the new LC are included in the final case note

• Document whether the Service member/Family was informed and acknowledged the transition

Sample Case Note: “Service member is ready and willing to transition to the VA. He has been informed that he has been assigned to XXXXXXX, at XXX-XXX-XXXX and has acknowledged the transition. Completed warm handoff and provided LC checklist to the new LC. Service member will continue to use TRICARE. He and family will stay in the local area with possible use of the VAMC as well.”

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Documenting the Transition

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Exercise -- LC Checklist Handoff You are now in the role of transferring a case to a new RCC/LC. • Complete an LC Checklist for SGT Wind (see next slide or Tab 7) in

preparation for the transfer.*

• When you are done, compare and review your Checklist with the person sitting next to you. Do your respective checklists include the same information?

• Discuss the exercise with the class.

*See Tab 9 for a paper version of the LC Checklist if DoD-CMS is unavailable. To complete the checklist, use information about SGT Wind from the scenario (Tab 7), from DoD-CMS, and/or from your own notes.

Case #1: SGT WindCase History:• Suffered amputations of the left leg below the knee, the right

leg above the knee and the right arm as a result of IED• Received 100% disability rating last month• Now in the process of transitioning off active duty• Continues to have pain management issues• Suffers from night terrors• Owns numerous weapons

Background:• Having marital problems with wife Jaime and discussing divorce• Considering selling their house• Have an autistic son who is being harassed at school; SGT Wind has complained to the

school’s Principal• Jaime is primary caregiver to both son and husband; has not worked since son was born• Having financial issues• After transitioning, SGT Wind intends to relocate his family from CA to NC

Questions?

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