Maximizing Effectiveness of Case Management in Primary Care for Rural Veterans

健康状况复杂的退伍军人在一系列令人眼花缭乱的提供者和支持性服务中导航。 那些生活在农村地区的退伍军人往往面临着在正确的时间获得正确的护理的额外挑战 因为供应商可能在地理上分散，或者在他们的社区内不可用。社会工作案例- 管理(SWCM)解决了对更好的访问、协调和社区支持的需求。有执照的人 作为初级保健团队的一部分，社会工作者将退伍军人、他们的家人和照顾者与 在他们的社区中支持网络。个案管理在以下方面有别于其他形式的社会工作援助 它强调对退伍军人的需求进行全面评估，然后进行干预、评估和 文件，这将一直持续到达到治疗目标。应对所需社会工作者短缺的问题 为了补充其在农村地区的初级保健与患者挂钩的护理团队(PACTS)，退伍军人健康 行政当局(VHA)实施了一项计划，在农村协会安排更多的社会工作案件经理 网站。然而，关于增加社会工作者到初级保健团队或 病例管理模式的有效性。我们建议对这一倡议进行严格评估。 这项合作评价的长期目标是改善《农村公约》的执行情况。 主动行动，为退伍军人提供以患者为中心的、及时和适当的护理。作为必要的一步 为了实现这一目标，我们合作评估的目标是评估农村公约SWCM计划的 成功就是实现其目标并改进其执行。我们的中心假设是社会工作案例- 管理人员将退伍军人与个人护理服务等服务和资源联系起来，更好地协调 初级保健、护理规划和精神卫生服务，最终将减少计划外的卫生保健使用 这给退伍军人带来了压力，也给医疗体系带来了成本。此评估将用于创建量身定制的 与业务伙伴合作设计的干预措施，以改善《农村公约》的执行 通过帮助社会工作者识别需要支持性服务的高危退伍军人，并提供案例- 管理评估和服务。从这次评估中获得的知识不仅将增强 实施《农村公约》主权财富管理倡议，但也展示了主权财富管理作为关键组成部分的价值 在VHA的初级保健方面。这些证据将为医疗中心投资于持续的SWCM提供基础 从长远来看。为此，评价小组将追求以下目标： (1)评估小岛屿发展中国家管理的实施情况以及实施个案管理的障碍和促进者 高危退伍军人的模型和目标。 (2)评估社会工作者安置对退伍军人获得服务的机会和健康结果的影响。 (3)设计并试行个案管理改善捆绑计划，以协助计划社工增加其 使用案例管理工具并确定需要SWCM的退伍军人。 这次QUERI评估的结果将是对农村公约SWCM倡议的深入评估。这个 该项目触及退伍军人管理局的最高优先事项：将退伍军人与他们选择的提供者和社区联系起来 资源，利用电子健康档案，使SWCM资源的目标现代化，改善 及时提供护理，解决农村地区的障碍，并将高危退伍军人与有需要的人联系起来 支持性服务、社区提供者和心理健康资源。

Veterans with complex health conditions navigate a bewildering array of providers and supportive services. Those Veterans who live in rural areas often face additional challenges in getting the right care at the right time because providers may be geographically dispersed or unavailable in their neighborhood. Social-work case- management (SWCM) addresses the need for better access, coordination, and community support. A licensed social worker, acting as part of a primary-care team, connects the Veteran, their families and caregivers with a support network in their community. Case management is distinct from other forms of social work assistance in its emphasis on comprehensive assessment of the Veteran’s needs followed by intervention, evaluation, and documentation, which continue until treatment goals are met. In response to a shortage of social workers needed to complement its primary-care Patient Aligned Care Teams (PACTs) in rural areas, the Veterans Health Administration (VHA) has implemented a program to place additional social work case managers at rural PACT sites. Little is known, however, about the impact of adding social workers to primary-care teams or the effectiveness of the case-management model. We propose a rigorous evaluation of this initiative. The long-term goal of this partnered evaluation is to improve the implementation of the Rural PACT SWCM Initiative in order to deliver patient-centered, timely, and appropriate care to Veterans. As a necessary step toward that goal, the objective of our partnered evaluation is to assess the Rural PACT SWCM Program’s success an achieving its goals and improve its implementation. Our central hypothesis is that social-work case- managers connect Veterans to services and resources, such as personal care services, better-coordinated primary care, care planning, and mental health services, that ultimately will reduce unplanned health-care use that impose stress on Veterans and costs on the health system. This assessment will be used to create a tailored intervention, designed in cooperation with the operations partners, to improve implementation of Rural PACT SWCM by helping social workers to identify high-risk Veterans who need supportive services and provide case- management assessment and services. The knowledge gained from this evaluation will not only enhance implementation of Rural PACT SWCM Initiative, but also demonstrate the value of SWCM as a key component of primary care in the VHA. That evidence will provide the basis for medical centers to invest in sustaining SWCM for the long term. To do so, the evaluation team will pursue the following aims: (1) Assess the implementation of SWCM and barriers and facilitators of implementation of the case-management model and targeting of high-risk Veterans. (2) Evaluate the effect of social worker placement on Veterans’ access to services and health outcomes. (3) Design and pilot-test a case-management-improvement bundle to help program social workers increase their use of case management tools and identify Veterans in need of SWCM. The product of this QUERI evaluation will be an in-depth appraisal of the Rural PACT SWCM Initiative. The project touches the VA’s highest priorities: connecting Veterans to their choice of providers and community resources, taking advantage of electronic health records to modernize targeting of SWCM resources, improving timeliness of care by addressing barriers to access in rural areas, and connecting high-risk Veterans with needed supportive services, community providers, and mental health resources.