2012 OEF OIF OND Final Report

Department of Veteran Affairs Veterans Health Administration Office of the Assistant Deputy Under Secretary for Health for
Policy and Planning
Womens Support Group
Substance Abuse Outreach SCI Vocational & Employment Services
TBI
Housing Programs
Suicide Prevention
2012 Care Management Survey of Operation Enduring Freedom (OEF) Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) Veterans in VHA
September 2012
Prologue
In order to assess Veterans Health Administrations (VHA) Care Management of Operation Enduring Freedom (OEF) / Operation Iraqi Freedom (OIF) / Operation New Dawn (OND) Veterans, the Healthcare Analysis and Information Group (HAIG) (a field office of the Assistant Deputy Under Secretary for Health for Policy and Planning), in collaboration with experts from the Office of Patient Care Services (PCS) and clinicians and coordinators from the field, developed a survey tool to collect data on Care Management of OEF/OIF/OND Veterans in VHA. This report provides quantitative and qualitative data regarding Care Management programs for OEF/OIF/OND Veterans, including information pertaining to services provided, organizational structure, staffing, policy, and practices. It provides staffing information on Case Managers, Program Managers, Transition Patient Advocates (TPAs), Veterans Integrated Service Network (VISN) Lead Program Managers, and VISN Points of Contact. The report also draws from the Care Management and Tracking Reporting Application (CMTRA) reports to supplement case load information for Case Managers. The data collected by this survey reflects the status of VHA Care Management of OEF/OIF/OND Veterans at the time of the survey. A unique response was collected from each of 140 facilities/Health Care Systems (HCS) and from each of 21 Network Points of Contact. The facility and network cooperation in completing this survey is appreciated.
Deborah Amdur, LCSW, ACSW Chief Consultant, Care Management and Social Work Service Office of Patient Care Services
Patricia Vandenberg, MHA, BSN Assistant Deputy Under Secretary for Health for Policy and Planning VA Central Office
Healthcare Analysis & Information Group (HAIG) A Field Unit of the Office of Strategic Planning & Analysis within the Office of the ADUSH for Policy and Planning
2012 Care Management of OEF/OIF/OND Veterans in VHA
Table of Contents
Prologue ..................................................................................................................................................................... 1 Introduction ................................................................................................................................................................. 3 Survey Methodology ................................................................................................................................................... 3 Key Findings and Recommendations ......................................................................................................................... 4 Survey Results with Select Analysis........................................................................................................................... 6 Services Provided ............................................................................................................................................... 7 Organizational Structure ...................................................................................................................................... 9 Space ................................................................................................................................................................. 10 Staffing ............................................................................................................................................................... 11 Case Manager ....................................................................................................................................... 12 Program Manager .................................................................................................................................. 14 Transition Patient Advocate (TPA) ........................................................................................................ 17 VISN Lead Program Manager ............................................................................................................... 18 VISN Point of Contact ............................................................................................................................ 18 Staff Orientation ..................................................................................................................................... 19 Policy and Practices ..................................................................................................................................... 21 Care Management Tracking .................................................................................................................. 21 VISN POC Survey Results .................................................................................................................................... 23 Participating Facilities .............................................................................................................................................. 26 Acknowledgements .................................................................................................................................................. 29
Introduction
The purpose of the Care Management Survey of OEF/OIF/OND Veterans in VHA was to: Assess strengths and weaknesses of the Care Management services for OEF/OIF/OND Veterans across VHA; Assist in measuring the effectiveness and efficiency of VHA Care Management services for OEF/OIF/OND Veterans; Assist in determining adequate resources to support the maintenance and growth of the care management services to this population of Veterans.
Survey Methodology
Data were collected using a self-administered online survey tool. A Technical Advisory Group (TAG) made up of national program office, VISN, and facility Care Management staff drafted the survey questions. The web-based survey administered by the Healthcare Analysis and Information Group (HAIG) was distributed via VISN offices to VISN Points of Contact (POCs) and to facility Directors for OEF/OIF/OND Program Managers to complete. Where obvious errors were apparent, data were validated with respondents. However, questions may be subject to individual interpretation by respondents and the scope of VHA services did not permit independent confirmation of all data. The survey was available to the field April through May, 2012. One-hundred forty VA Medical Centers and Health Care Systems (HCS) and all 21 VISNs responded to this survey. One facility (Manila, PI) does not have an OEF/OIF/OND program, and was excluded from the survey. Thus, the response rate was 100 percent for both facilities and VISN Offices.
2012 OEF/OIF/OND VHA Care Management Survey Instrument
2012 OEF/OIF/OND VISN POC Survey Instrument
Key Findings and Recommendations

Findings 1. Ninety-five percent of facilities offer Womens Support Group/Clinic specifically to OEF/OIF/OND Veterans. 2. Benefits information is provided by both VHA Care Management staff on site (89%) and by referral to VBA (69%). 3. Caregiver support groups targeted toward OEF/OIF/OND Veterans are provided either on site or referred at 89 percent of facilities. 4. As of the time of survey (May 2012) 78 percent of VA facilities provide an on-site caregiver support group and 34 percent of facilities refer caregivers to the community, thus maintaining partnerships with communities. 5. Child care is provided at four sites (two of which were identified pilot sites in 2011) in VHA. Fifty-four percent of facilities refer child care to community resources. 6. Program availability to families of OEF/OIF/OND Veterans is limited. 7. Non-traditional appointments are available to varying degrees from a high of 83 percent of facilities for Outpatient Behavioral Health to a low of 9 percent of facilities for Rehabilitation Services, such as Physical Therapy/Occupational Therapy. 8. Ninety-one percent of facilities have designated space for the OEF/OIF/OND Program. 9. Nearly 1/3 (30%) of Case Managers have a secondary program assignment. Most secondary assignments are Polytrauma/Traumatic Brain Injury Case Managers or Program Managers. 10. Case Managers spend 80 percent of their time on patient care activities. The rest is devoted to outreach or administrative tasks. (See Q12h. on Page 18 for definitions of activities.) 11. More than half (51%) of OEF/OIF/OND Program Managers have a secondary position, 42 percent of whom act as OEF/OIF/OND Case Managers. 12. Seventy-four percent of facilities provide an organized orientation program for new OEF/OIF/OND Care Management team members. 13. Orientation materials for OEF/OIF/OND Program Managers are perceived by staff as lowest quality, when compared to TPA and Case Manager orientation materials. 14. Twelve percent of VHA Case Managers and one (5%) of 21 VISN POCs are certified Case Managers. 15. Seventy-one percent of OEF/OIF/OND Teams participate in regular meetings with facility executive leadership.
Healthcare Analysis & Information Group (HAIG) A Field Unit of the Office of Strategic Planning & Analysis within the Office of the ADUSH for Policy and Planning 4
Strengths / Recommendations Identify facilities not offering womens support group/clinics and encourage the OEF/OIF/OND staff to coordinate with Womens Health staff for this population. Continue to encourage closer collaboration between OEF/OIF/OND Care Management and VBA via monthly conference calls, joint training and identifications of both VHA and VBA Case Managers in the record, etc.
Share findings with Caregiver Support Program Office.
Review pilot results and coordinate with Womens Health staff to identify the need for this type of service for OEF/OIF/OND Veterans. Encourage facilities to explore other creative alternatives to provide these services. VHA Care Management Program Office to study further and enhance services accordingly. Share these results with VHA Operations and Management. Strength. No recommendations. Share findings with Rehabilitation Program Office.
Strength. No recommendations. Collaborate and consult with 10N regarding Program Managers having collateral duties; careful consideration is recommended that collateral responsibilities are kept to a minimum. Develop an orientation manual for the OEF/OIF/OND Care Management Program. Provide comprehensive education on the use of the manual. Tracking of training will occur upon completion of training. VA Central Office (VACO) provided study material to requesting facilities in FY 2012. Continue to encourage and track case manager certification. VACO to develop guidance in the OEF/OIF/OND orientation manual on what to report to facility executive leadership on a regular basis.
Findings 16. Ninety-six percent of facilities use CMTRA data to assist in managing the OEF/OIF/OND program.
Strengths / Recommendations Provide training via monthly conference calls regarding how to use CMTRA data in managing and demonstrating efficacy of the OEF/OIF/OND Care Management Program. Continue to require referrals to the OEF/OIF/OND Care Management Team via a warm handoff versus other methods and follow-up with referring parties to reinforce warm handoffs. (VHA Handbook 1010.01 p.9, Section 11.h.1 and 11.i.) Recommend that the Care Management Leadership Council review the warm handoff process. Include warm handoff protocol and examples in the orientation manual. Strength. Recommend that facilities appropriately transfer these Veterans to a PACT or other appropriate case management venue upon completion of the care management plan. Further analyze case load by breakdown of intensity level and by facility to determine appropriate staffing ratios. Overall, average staffing levels do increase by facility complexity level, as demonstrated in Figure 1 on Page 16. Develop a case management ratio report in CMTRA so VA Medical Centers can monitor ratios on an ongoing basis.
17. Eighty-five percent of facilities report that case management referrals are received via warm handoff (phone, face-to-face, or team meetings).
18. Ninety-four percent of facilities case manage OEF/OIF/OND Veterans after the 5-year combat eligibility deadline has passed.
19. Case Managers manage an average of 112 cases, while Program Managers manage an average of 85 cases.
20. All VISN POCs collect, maintain, and forward reports and data prepared by the OEF/OIF/OND Care Management team and submitted by facility senior management to the appropriate VHA requesting office and serve as a liaison between the VA Central Office (VACO), the VISN, VISN Lead, and facility OEF/OIF/OND Program Manager and other agencies and organizations. 21. All VISN POCs brief executive network leadership on the OEF/OIF/OND Program. 22. One-third of VISN POCs attended a formal orientation to their position. 23. Seventy-one percent of VISN POCs were satisfied with the support provided by VACO.
Strength. Evaluate impact of consolidating / downsizing VISN staff.
Strength. No recommendations. Recommend OEF/OIF/OND Care Management Education Committee develop a formal orientation for VISN POCs. Recommend VACO Care Management staff seek input from the Care Management Leadership Council and VISN POCs for feedback on how to better meet their needs.
Survey Results with Select Analysis
Services Provided 1. What types of Post Deployment Clinic services does your facility/Healthcare System (HCS) utilize for OEF/OIF/OND Veterans? (choose all that apply) (n=140) Consultative Model Post Deployment Clinical Model Cohort Model Other Count 76 61 34 13 % 54% 44% 24% 9% Post Deployment Clinics are provided through a variety of models. The majority (54%) of facilities use the consultative model, in which OEF/OIF/OND Veterans are assigned to all Primary Care Providers. Medical/Mental Health/Social Work staff with specialized knowledge and skills is identified to assist in a consultative role.
2. Are the following services available for OEF/OIF/OND Veterans at your facility/HCS? (choose all that apply) Available Referred to Referred Referred to Referred to Service not (n=140) at VA Another VA to VBA Vet Center Community Available 138 7 1 76 33 1 Group Therapy 99% 5% 1% 54% 24% 1% 85 2 50 33 20 Peer-to-Peer Support Groups 61% 1% 36% 24% 14% 137 4 2 85 40 Individual Counseling 98% 3% 1% 61% 29% 140 21 22 41 Substance Abuse 100% 15% 16% 29% 127 7 34 23 7 Women's Support Group/Clinic 91% 5% 24% 16% 5% 140 4 3 8 58 Housing (Homeless Services) 100% 3% 2% 6% 41% 99 4 29 13 98 1 Financial Hardship Resources 71% 3% 21% 9% 70% 1% 75 1 2 6 104 4 Legal Issue Services 54% 1% 1% 4% 74% 3% 128 6 57 15 64 Vocational/Employment 91% 4% 41% 11% 46% 117 3 92 54 3 Couples Counseling 84% 2% 66% 39% 2% 22 1 20 101 22 Parenting Classes 16% 1% 14% 72% 16% 72 1 47 68 19 Family Psychosocial 51% 1% 34% 49% 14% Educational Classes 109 2 6 47 16 Caregiver Support Groups 78% 1% 4% 34% 11% 125 3 96 20 26 VA Benefits Information 89% 2% 69% 14% 19% 107 3 1 19 85 8 Recreational 76% 2% 1% 14% 61% 6% Activities/Opportunities 125 4 1 4 83 4 Transportation 89% 3% 1% 3% 59% 3% 4 2 75 65 Childcare* 3% 1% 54% 46% * Onsite childcare was provided on a pilot basis at three VA facilities (Northport, NY, Tacoma, WA, and Buffalo, NY) by Public Law 111-163 in 2011. Tacoma did not indicate in this survey that it offers onsite childcare, while New Jersey HCS and Washington D.C. VAMC did respond that they offer onsite childcare.
3. What kind of programs are available for families of OEF/OIF/OND Veterans? (choose all that apply) (n=140) Family support groups Family workshops Individual counseling Other Count 74 37 95 52 % 53% 26% 68% 37% Frequently cited Other responses included: Couples counseling (11), caregiver support/counseling (10), and refer to Vet Center (7).
4. Does your facility/HCS have appointments available outside the traditional business hours of Monday-Friday, 8:00 am5:00 pm for OEF/OIF/OND Veterans? (n=140) Yes No Count 90 50 % 64% 36%
If yes, a. Please indicate the non-traditional hours your facility/HCS has appointments available outside of the traditional business hours for the following programs: (choose all that apply) Evenings None for Weekends Holidays after 5:00 pm this Service (n=90) Total Count % Count % Count % Count % PACT (formerly Primary Care) Behavioral Health (Outpatient) OEF/OIF/OND Care Management Post Deployment Clinic Rehabilitation Services (i.e., PT, OT, etc.) Polytrauma/ Traumatic Brain Injury Care 30 75 45 23 8 13 33% 83% 50% 26% 9% 14% 10 6 8 6 2 3 11% 7% 9% 7% 2% 3% 1 0 3 0 0 1 1% 0% 3% 0% 0% 1% 54 15 45 65 81 77 60% 17% 50% 72% 90% 86% 95 96 101 94 91 94
If weekend or evening hours, b. When evening or weekend hours are offered, are these appointments slots being utilized by OEF/OIF/OND Veterans? (n=90) Count % Yes 85 94% No 5 6% If yes, 4.b.1. On average, what percentage of these appointment slots is being booked for OEF/OIF/OND Veterans? (n=85) Count % 0 25% 40 47% 26 50% 15 18% 51 75% 12 14% 76 100% 18 21% 4.b.2. On average, what percentage of appointments are no-shows for OEF/OIF/OND Veterans? (n=85) Count % None 0 0% Less than 10% 36 43% 11 20% 33 39% 21 50% 13 15% More than 50% 2 2% Note: May not total 100% due to rounding
4.b.3. Are these no-show percentages similar to regular daytime appointment no-shows for OEF/OIF/OND Veterans? (n=85) Count % Yes 58 69% No 26 31%
ORGANIZATIONAL STRUCTURE 5. Where is Care Management aligned within your facility/HCS or network's organizational chart? (n=140) Count % Social Work Service Chief of Staff Ambulatory/Primary Care Mental Health Medical Center Director Nursing Associate Director for Patient Care Physical Medicine and Rehabilitation Associate Director VISN Care Line (Product Line) Other 50 24 15 15 9 4 8 2 2 0 11 36% 17% 11% 11% 6% 3% 6% 1% 1% 0% 8%
6. Which of the following VA services do OEF/OIF/OND Case Managers/Care Management Team members collaborate with? (choose all that apply) Womens Health Caregiver Support Mental Health Traumatic Brain Injury VBA Staff PACT/Primary Care VA Liaison Polytrauma Rehabilitation Services Spinal Cord Injury DoD Liaison Visual Impairment Services Federal Recovery Coordinator Amputee Clinic Fee Basis Providers Other (n=140) Count 140 140 140 138 137 136 135 134 131 129 127 124 119 106 106 52 % 100% 100% 100% 99% 98% 97% 96% 96% 94% 92% 91% 89% 85% 76% 76% 37% Notable frequent Other responses include: Veteran Service Officers, HUD VASH / Homeless Programs, and Vet Centers
7. Does your facility/HCS have a written formal process/procedure/policy in place for transfer of services for all OEF/OIF/OND Veterans? Less than half (44%) of VHA facilities have a (n=140) Count % procedure for transfer of services for all Yes 61 44% OEF/OIF/OND Veterans. Of those that do, No 79 56% nearly all transfer to a VA Facility within their If yes, a. Are these transfers: (choose all that apply) (n=61) To a VA Facility within VISN To a VA Facility outside of VISN To Community Transfer to DoD SPACE 8. Does your facility/HCS have designated space for the OEF/OIF/OND Program? (n=140) Count % Yes 128 91% No 12 9% If yes, a. Is this a shared space with another office or clinic? (n=128) Count % Yes 54 42% No 74 58% b. Does this space include a private/confidential office? (n=128) Count % Yes 110 86% No 18 14% c. Do OEF/OIF/OND Case/Program Managers share an office with more than one person? (n=128) Count % Yes 31 24% No 97 76% If yes, 8.c.1. Do Case/Program Managers need to leave the office for privacy of the Veteran and/or family member? (n=31) Count % Yes 27 87% No 5 16% VISN, but also provide for transfer to other types of facilities.
Count 60 53 45 34
% 98% 87% 74% 56%
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9. Does your facility/HCS have any space specifically designated for OEF/OIF/OND Veterans for the following services? (choose all that apply) Post-deployment Clinic Private Meeting Space Conference Room V-Tel (Videoconference) Access OEF/OIF/OND Waiting Rooms OEF/OIF/OND Family Play Space (n=140) Count 71 77 36 45 49 27 % 51% 55% 26% 32% 35% 19% Three facilities did not offer any of the services listed (Ann Arbor, Saginaw, Iron Mountain) specifically designated for OEF/OIF/OND Veterans.
10. Is your facility/HCS currently renovating space for the OEF/OIF/OND Care Management program? (n=140) Yes No Count 25 115 % 18% 82%
If no, a. Does your facility/HCS have future plans to renovate space to be dedicated to the OEF/OIF/OND Care Management program? (n=115) Yes No STAFFING 11. Please indicate whether the following barriers to recruitment/retention exist in your facility/HCS for OEF/OIF/OND Program staff: (choose all that apply) No barriers Stress Patient acuity (nature of the job) Difficult hiring process (USA Jobs, HR, etc.) Inadequate backup (other personnel to work with) Perceived internal support Medical Center concurrence with hiring Number of working hours required Inadequate salary Geography/Location Benefits issues Other (n=140) Count 53 52 35 35 30 32 27 19 12 11 0 19 % 38% 37% 25% 25% 21% 23% 19% 14% 9% 8% 0% 14% The top three barriers to staff recruitment and retention were: stress, patient acuity (nature of the job), and a difficult hiring process. Count 27 88 % 23% 77%
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CASE MANAGER 12. How many Case Managers (Head Count) are currently assigned to the OEF/OIF/OND Program at your facility/HCS? Average CASE MANAGERS (n=140) Total *406 Number of Case Managers (Head Count) 2.90 VA FTEE of currently filled positions (not acting) 372.4 2.66 VA FTEE of currently vacant/recruiting positions 50.5 0.36 Fee/Contract FTEE 4.55 0.03 *V6 Asheville, NC (637) and V19 Sheridan, WY (666) Did not have any Case Managers at time of survey. Figure 1. Avg. Case Manager FTEE per Facility by Complexity Level Facility Complexity Level Excl 3 2 1c 1b 1a 0 1 2 3 1.67 1.61 2.45 2.92 2.84 3.64 4 Generally, as facility complexity levels increase, so too does the average number of Case Manager FTEE per facility, as demonstrated in Figure 1. Level 1a facilities are the most complex, and level 3 are the least complex. Texas Valley Coastal HCS and James Lovell FHCC are excluded from the 2011 Facility complexity model, and display in the Excl portion of Figure 1.
Average FTEE per Facility d. Case Manager disciplines (choose all that apply) Social Work Nursing (RN, LVN/LPN) Mid-Level Provider (NP, PA, CNS) **Other **Mental Health Specialist e. Grade Level for Case Managers (n=404) GS 9 GS 11 GS 12 GS 13 Nurse 1 Nurse 2 Nurse 3 Count 8 199 85 1 7 64 40 % 2% 49% 21% 0% 2% 16% 10% (n=406*) Count 285 121 1 1 % 70% 30% 0% 0%
*Although vacant at the time of the survey, Sheridan and Asheville indicated the clinical disciplines of the positions. These site responses for questions 12 e-i were removed from survey responses. Therefore, the number of Case Managers decreases to 404.
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f. Case Manager primary program assignment (n=404) OEF/OIF/OND Case Manager Polytrauma/Traumatic Brain Injury Case Manager OEF/OIF/OND Program Manager Mental Health Case Manager Social Work Case Manager Registered Nurse Case Manager Spinal Cord Injury Case Manager Outreach Coordinator Blind/Visual Impairment Team Coordinator Other
Count 331 28 13 10 5 3 3 2 1 8
% 82% 7% 3% 2% 1% 1% 1% 0% 0% 2%
g. Do Case Managers have a secondary program assignment? (n=404) Yes No Count 120 284 % 30% 70%
If yes, 12.g.1. Case Manager secondary program assignment (choose all that apply) (n=120) Polytrauma/Traumatic Brain Injury Case Manager OEF/OIF/OND Case Manager Social Work Case Manager Registered Nurse Case Manager Caregiver Support Coordinator Mental Health Case Manager OEF/OIF/OND Program Manager Spinal Cord Injury Case Manager Amputee Case Manager Outreach Coordinator Blind/Visual Impairment Team Coordinator DoD Clinical Case Manager Women Veterans Program Manager Other
Count 40 23 12 7 6 6 5 4 3 2 1 1 1 40
% 33% 19% 10% 6% 5% 5% 4% 3% 3% 2% 2% 1% 1% 33%
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h. Overall what percentage of time do Case Managers spend completing the following tasks? Range of (n=404) Total % responses Direct Patient Interaction (i.e., initial screening, care/case assessment, Care (virtual or face-to-face) treatment planning, ongoing case management, etc.) Seriously Injured 9,324 23% 0 90% Non-Seriously Injured Indirect Patient Care Outreach Administrative 15,744 7,496 3,095 4,727 39% 19% 8% 12% 0 100% 0 92% (i.e., activities which support direct patient care, such as follow-up with other community agencies or stakeholders, research, referrals/care coordination, identifying and making resource contacts, etc.) (i.e., education, recruiting, enrollment, registering, etc.) (i.e., committee meetings, data entry, education, training, program development, supervisory duties, etc.)
0 60% 0 50%
i. In addition to licensure, do Case Managers hold certification in case management? (n=404) Count % Yes 50 12% No 354 86% If yes, 12.i.1. What organization(s) certifies OEF/OIF/OND Case Managers? (choose all that apply) (n=50) Commission for Case Manager Certification (CCMC) American Nursing Credentialing Center (ANCC) American Case Management Association (ACMA) National Association of Social Workers (NASW) City University of New York, Hunter College Brookdale Center on Aging If no, 12.i.2. Case Managers in the process of obtaining certification? (n=354) Yes No PROGRAM MANAGER 13. How many OEF/OIF/OND Program Managers are currently employed in your facility/HCS? Two facilities have a vacant position with no acting Program Manager. PROGRAM MANAGERS Number of Program Managers (Head Count) VA FTEE of currently filled positions (not acting) VA FTEE of currently vacant/recruiting positions Fee/Contract FTEE d. Program Manager disciplines (choose all that apply) (n=139) 1. Social Work 2. Nursing (RN, LVN/LPN) 3. Psychology 4. Mid-Level Provider (NP, PA, CNS) Count 108 26 1 5 Count 56 298 % 16% 84%
Count 27 6 12 13 1
% 35% 1% 3% 3% 1%
139 126.25 12.00 1.00 % 78% 19% 1% 4%
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e. Program Managers Grade Level (choose one) (n=139) Count % GS 11 GS 12 GS 13 GS 14 Nurse 2 Nurse 3 1 90 19 1 4 24 1% 64% 14% 1% 3% 17%
f. Program Manager primary program assignment (n=139) Count OEF/OIF/OND Case Manager OEF/OIF/OND Program Manager Social Work Case Manager Other 3 131 1 4
% 2% 94% 1% 3%
g. Do Program Managers have a secondary program assignment? (n=139) Yes No Count 71 68 % 51% 49%
If yes, 13.g.1. Program Manager - secondary program assignment (choose all that apply) OEF/OIF/OND Case Manager Outreach Coordinator Polytrauma/Traumatic Brain Injury Case Manager OEF/OIF/OND Program Manager Mental Health Case Manager Caregiver Support Coordinator Registered Nurse Case Manager VISN Point of Contact Women Veterans Program Manager VA Liaison for Healthcare Amputee Case Manager DoD Clinical Case Manager DoD Non-Clinical Care Coordinator Federal Recovery Coordinator Social Work Case Manager Other (n=71) Count 30 12 10 6 3 3 3 3 2 2 1 1 1 1 1 34 % 42% 17% 14% 8% 4% 4% 4% 4% 3% 3% 1% 1% 1% 1% 1% 48%
Other secondary positions include VISN Lead Program Manager (4 facilities), Minority Veterans Program Coordinator (2), Social Work Supervisor (6), Mental Health Clinician (2), Outreach (1), Polytrauma Program Manager (3), Integrated Ethics Program Officer (2), Caregiver Support Program Manager (5), Post Deployment Coordinator (2), Federal Womens Program Manager (1)
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h. Overall what percentage of time do Program Managers spend completing the following tasks? (n=139) Direct Patient Interaction Care (virtual or face-to-face) Seriously Injured Non-Seriously Injured Indirect Patient Care Outreach Administrative (i.e., initial screening, care/case assessment, treatment planning, ongoing case management, etc.) 9% 16% 20% 13% 42% (i.e., activities which support direct patient care, such as follow-up with other community agencies or stakeholders, research, referrals/care coordination, identifying and making resource contacts, etc.) (i.e., education, recruiting, enrollment, registering, etc.) (i.e., committee meetings, data entry, education, training, program development, supervisory duties, etc.)
i. Do Program Managers case manage a panel of patients? (n=139) Count % Yes No 77 62 56% 45%
If yes, i.1. In the past year, how many cases did Program Managers case manage? (n=77) National Total 6,515 Average 85 Using CMTRA data from April, 2012, Case Managers manage an average of 112 cases per year, compared to Program Managers, who manage an average of 85 cases per year according to survey results.
13.i.1.a. Of these cases, how many are managed: Total Daily Weekly Monthly Quarterly Semi-Annually Annually Other (n=11) (n=32) (n=62) (n=70) (n=47) (n=36) (n=11) 43 245 1,291 2,001 716 530 1,689 Average 4 8 21 29 15 15 154
j. Do Program Managers handle complex cases? (n=139) Yes No k. Count 120 19 % 86% 14%
In addition to licensure, do Program Managers hold certification in case management? (n=139) Yes No Count 20 119 % 14% 86%
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If yes, 13.k.1. What organization(s) certifies OEF/OIF/OND Program Managers? (choose all that apply) (n=20) Count 11 9 % 55% 45%
Commission for Case Manager Certification (CCMC) National Association of Social Workers (NASW)
If no, 13.k.2. Are Program Managers in the process of obtaining certification? (n=119) Count % Yes No 21 98 18% 82%
TRANSITION PATIENT ADVOCATE (TPA) 14. How many OEF/OIF/OND Transition Patient Advocates are currently employed at your facility/HCS? Transition Patient Advocates (n=100) Number of TPAs (Head Count) VA FTEE of currently filled positions VA FTEE of currently vacant/recruiting positions Fee/Contract FTEE d. What is the Grade Level for TPAs (n=119) GS 9 GS 11 Count 4 115 Count 121 108.78 4.00 7.00 One hundred facilities account for a total of 121 TPAs. One facility, Central Texas HCS, has four TPAs, four facilities (Cleveland, Milwaukee, San Diego, and Minneapolis) have three TPAs, eight facilities have two TPAs, and the remaining 87 facilities have one TPA.
e. Overall what percentage of time do TPAs spend completing the following tasks? Direct Patient Interaction Care (virtual or face-to-face) (n=121) Direct Patient Interaction Care (virtual or face-to-face) Seriously Injured Non-Seriously Injured Indirect Patient Care Outreach Administrative % (i.e., initial screening, care/case assessment, treatment planning, ongoing case management, etc.) 19% 23% 20% 24% 13% (i.e., activities which support direct patient care, such as followup with other community agencies or stakeholders, research, referrals/care coordination, identifying and making resource contacts, etc.) (i.e., education, recruiting, enrollment, registering, etc.) (i.e., committee meetings, data entry, education, training, program development, supervisory duties, etc.)
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VISN LEAD PROGRAM MANAGER 15. Is your facility/HCS supported by the VISN Lead Program Manager? (n=140) Count % Yes 111 79% No 29 21% If yes, a. How frequently are you in contact with your VISN Lead Program Manager? (n=111) Count % Daily 6 5% Weekly 45 41% Monthly 51 46% Quarterly 6 5% Bi-annually 1 1% Yearly 0 0% Never 2 2% b. How would you rate the support from your VISN Lead Program Manager? (support is inclusive of responsiveness) (n=111) Count % Very satisfied 82 74% Somewhat satisfied 17 15% Neither satisfied nor dissatisfied 8 7% Not very satisfied 3 3% Not at all satisfied 1 1% c. Does your VISN Lead Program Manager have regular meetings with facility Program Managers? (n=111) Count % Yes 95 86% No 15 14% VISN POINT OF CONTACT (POC) 16. Is your facility/HCS supported by the VISN POC? (n=140) Count % Yes 126 90% No 14 10% If yes, a. How frequently are you in contact with your VISN POC? (n=126) Count % Daily 5 4% Weekly 49 39% Monthly 57 45% Quarterly 8 6% Bi-annually 4 3% Yearly 1 1% Never 2 2%
Healthcare Analysis & Information Group (HAIG) A Field Unit of the Office of Strategic Planning & Analysis within the Office of the ADUSH for Policy and Planning 18 2012 Care Management of OEF/OIF/OND Veterans in VHA
b. How would you rate the support from your VISN POC? (support is inclusive of responsiveness) (n=126) Count % Very satisfied 81 64% Somewhat satisfied 23 18% Neither satisfied nor dissatisfied 13 10% Not very satisfied 7 6% Not at all satisfied 2 2% c. Does your VISN POC have regular meetings with facility Program Managers? (n=126) Count % Yes 107 85% No 19 15%
STAFF ORIENTATION 17. Does your facility/HCS provide an organized orientation program for new OEF/OIF/OND Care Management Team members? Only 74 percent of facilities provide an organized orientation program for (n=140) Count % OEF/OIF/OND Care Management team members. Of those facilities that do Yes 104 74% provide an orientation, most relevant topics are covered, ranging from a low No 36 26% of 84 percent of facilities covering Outreach, to a high of 97 percent covering Staff Contact Information. If yes, 17.a. Which of the following topics are included in the orientation? (choose all that apply)
(n=104)
Count 101 100 100 99 99 98 98 97 96 96 91 88 87
% 97% 96% 96% 95% 95% 94% 94% 93% 92% 92% 88% 85% 84%
Staff Contact Information (i.e., OEF/OIF/OND Seamless Transition Team, SW&CBS, Psychiatry, MSW email group, appointment scheduling) VHA Handbook 1010.01 - Care Management of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans Resources: (i.e., VBA, VHA, Financial, Legal, Dental, Relationship, Housing, Employment, Education, Healthcare, Environmental Exposure, Suicide Prevention, Veterans Service, Offices) Case Management Tracking Application (CMTRA) Performance Measures Local Protocols/Procedures Facility OEF/OIF/OND Brochures Release of Information Procedures National OEF/OIF/OND Websites OEF/OIF/OND Clinical Reminders and TBI Reminder Facility OEF/OIF/OND Website, SharePoint, IT Information Case Management Initiative Requirements Outreach (i.e., Veterans Outreach Reporting System (VORS), Case Management Log, etc.)
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18. Please rate the quality of orientation materials for the following positions: a. Program Manager (n=140) Excellent Good Fair Poor No orientation materials b. Transition Patient Advocate (TPA) (n=140) Excellent Good Fair Poor No role in TPA orientation c. Case Manager (n=140) Excellent Good Fair Poor No orientation materials Count 35 73 14 6 12 % 25% 52% 10% 4% 9% Count 23 46 22 4 45 % 16% 33% 16% 3% 32% Count 25 51 30 6 28 % 18% 36% 21% 4% 20% The quality of orientation materials are perceived as best for Case Managers, TPAs, then Program Managers respectively when comparing the ratio of Excellent/Good responses to Fair/Poor responses for each position (as follows). Program Managers: 76/36 = 2.1 TPAs: 69/26 = 2.7 Case Managers: 108/20 = 5.4
19. Does an OEF/OIF/OND Care Management Team representative participate in regular meetings with facility/HCS executive leadership? (n=140) Yes No Count 99 41 % 71% 29% Seventy-one percent of Care Management Teams participate in regular meetings with facility executive leadership. Most briefings occur monthly, with smaller percentages occurring weekly, quarterly, and daily. % 14% 18% 43% 16% 8%
If yes, a. How frequently? (n=99) Count Daily 14 Weekly 18 Monthly 43 Quarterly 16 Other 8
b. How often do you brief your facility/HCS leadership? (n=99) Count % Annually 3 3% Quarterly 25 25% Monthly 48 48% Weekly 17 17% Daily 5 5% Never 1 1%
Healthcare Analysis & Information Group (HAIG) A Field Unit of the Office of Strategic Planning & Analysis within the Office of the ADUSH for Policy and Planning 20 2012 Care Management of OEF/OIF/OND Veterans in VHA
POLICY AND PRACTICES Care Management Tracking 20. Does your facility/HCS use any of the following data in managing the OEF/OIF/OND program? (choose all that apply) (n=140) CMTRA data Iraq/Afghanistan clinical reminder data Monthly Outliers Screening Reports New OEF/OIF/OND Veterans report data Unique patients seen Outreach reporting data OEF/OIF/OND PTSD Program Monitors No show rates Caseload ratios Consultation completion rates Caregiver stipend data Other TBI performance measures Count 135 131 125 121 114 113 110 81 69 67 57 56 17 122 % 96% 94% 89% 86% 81% 81% 79% 58% 49% 48% 41% 40% 12% 87% Count 120 108 106 % 98% 89% 87%
If TBI: (n=122) Initial Clinical Reminder for Screen Scheduling within 14 days of initial appointment Evaluation completed within 30 days
21. What source/report is your facility/HCS using to obtain data for the monthly case management screening report? (choose all that apply) (n=140) Health Factors CPRS VistA/Fileman Reports Independent Tracking (i.e., Microsoft Excel) Post-deployment Monitor Event/Encounter Capture CMTRA Veterans Service Support Center (VSSC) Other Count 50 82 68 36 32 57 51 25 % 36% 59% 49% 26% 23% 41% 36% 18% Many of the other responses were sub-sets of the existing choices. These responses included: referrals (phone, electronic, or inperson), VISN reports or databases, clinical reminder, specific progress note titles in CPRS, enrollment data, DSS, and appointments in OEF/OIF/OND clinic.
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22. At your facility/HCS, who completes the initial case management screening for OEF/OIF/OND Veterans? (choose all that apply) Post-deployment Clinic Patient Aligned Care Team (PACT) Primary Care Ambulatory Care Polytrauma/TBI Team Mental Health Emergency Department Spinal Cord Injury Enrollment/Registration *Other (n=140) Count 137 36 28 24 8 24 16 6 7 5 15 % 98% 26% 20% 17% 6% 17% 11% 4% 5% 4% 11% Social Workers accounted for nine of the 15 other responses, responsible for completing the initial case management screening for OEF/OIF/OND Veterans. Refer Both Case Manage/Refer Case Manage If PACT, Does PACT case manage/refer/both? (n=28) Count 17 10 1 % 61% 36% 4%
OEF/OIF/OND Care Management Team
If not OEF/OIF/OND Care Management Team, l. How often are OEF/OIF/OND Case Managers receiving internal referrals for case management? (n= 75) Count % If a facility provided case management of OEF/OIF/OND Daily 39 52% Veterans by any providers outside the OEF/OIF/OND Care Weekly 29 39% Management Team, they were asked to indicate who completes the initial case management screening. Monthly 7 9% m. How are OEF/OIF/OND Veteran referrals communicated to the case management team? (choose all that apply) Co-signature E-mail Consult Other (n= 75) Count 64 61 54 47 17 % 85% 81% 72% 63% 23% Warm handoff (phone/face-to-face/team meetings)
23. Are OEF/OIF/OND Veterans followed by the OEF/OIF/OND Team after 5 years of combat eligibility has expired? (n=140) Count % Yes 131 94% No 9 6%
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2012 Survey of Care Management of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans in VHA VISN POC 1. How often do you make the following types of contact with the facility/HCS OEF/OIF/OND Program Managers in your VISN? (choose all that apply) (n=21) Daily Weekly Monthly Quarterly Semi-Annually Annually 3 13 5 0 0 0 Phone Calls 14% 62% 24% 0% 0% 0% 8 12 1 0 0 0 E-mail 38% 57% 5% 0% 0% 0% 0 0 1 4 5 11 Site Visits 0% 0% 5% 19% 24% 52% Totals 11 25 7 4 5 11 VISN POCs email the facility Program Managers most frequently (95% daily/weekly), compared to phone calls (76% daily/weekly) and site visits. Facility The VISN POC response to How often do you make the following types of contact with the facility/HCS OEF/OIF/OND Program Managers in your VISN? was compared with the fields' response to "How frequently are you in contact with your VISN POC?" Differences in perception may account for the dramatic difference. Email is one-way communication, and may not be perceived as "contact" by facility staff. However, some staff may view phone or in-person contact to be considered "contact" with the VISN POC. Of note, two facilities reported never being in contact with their VISN POC. 2. What is your primary discipline? (n=21) Social Work Nursing (RN, LVN/LPN) Psychology Mid-Level Provider (NP,PA, CNS) Physician Blind Rehabilitation Specialist (VIST) Other 3. Are you certified in case management? One (5%) VISN POC is certified in case management by the Commission for Case Manager Certification (CCMC). Count 9 5 1 1 1 0 5 % 43% 24% 5% 5% 5% 0% 24% Other VISN POC disciplines included: administrative specialists, mastersprepared professionals, and a Registered Dietitian. Daily Weekly Monthly Quarterly Bi-annually Yearly Never 4% 39% 45% 6% 3% 1% 1% VISN POC 38% 57% 5%
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4. Which of the following functions do you perform? (choose all that apply) (N=21) Collect, maintain, and forward reports and data prepared by the OEF/OIF/OND Care Management team and submitted by facility senior management to the appropriate VHA requesting office Serve as a liaison between the VA Central Office (VACO), the VISN, VISN Lead, and facility OEF/OIF/OND Program Manager and other agencies and organizations Attend monthly conference calls by Care and Social Work at VA Central Office Provide briefings and presentations to VA staff and non-VA organizations/audiences about OEF/OIF/OND VA health care Standardization of the OEF-OIF-OND Care Management Program and the VISN Coordinate with Lead OEF-OIF-OND Program Manager for periodic VISN Level face-to-face meetings and conference calls with the OEF/OIF/OND Care Management team Assure OEF/OIF/OND Care Management team has the necessary resources to achieve program goals Moderate monthly conference calls with all facility OEF/OIF/OND Program Managers within the VISN Update Care Management and Social Work on changes in facility OEF/OIF/OND Program Managers/Case Managers/TPAs Coordinate and participate in review panels for the selection of new TPAs Outreach Coordination 5. Do you have supervisory authority over Care Management Staff in your VISN? (n=21) Yes No Count 1 20 % 5% 95% Count 21 % 100%
21 20 19 18 17 16 16 15 12 12
100% 95% 90% 86% 81% 76% 76% 71% 57% 57%
If yes, 5.a. What type of staff do you supervise? Count (choose all that apply) Transition Patient Advocate 1 Program Managers 0 Case Managers 1 VISN Lead Program Managers 0 Other 0
% 100% 0% 100% 0% 0%
6. Do you brief your VISN leadership on the OEF/OIF/OND Program? (n=21) Yes No Count 21 0 % 100% 0%
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If yes, 6.a. How often do you brief your VISN leadership? (n=21) Annually Quarterly Monthly Weekly Daily Count 1 9 7 4 0 % 5% 43% 33% 19% 0%
7. Did you attend a formal orientation program? (n=21) Yes No Count 7 14 % 33% 67%
If yes, 7.a. Please rate the quality of VISN POC orientation materials. Excellent Good Fair Poor Count 3 4 0 0 % 43% 57% 0% 0%
If no, 7.b. Did you receive any orientation materials? Yes No Count 4 10 % 29% 71%
8. Overall, how satisfied are you with the support for VISN POCs by VA Central Office? (support is inclusive of responsiveness) (n=21) Very satisfied Somewhat satisfied Neither satisfied nor dissatisfied Not very satisfied Not at all satisfied Count 15 1 3 2 0 % 71% 5% 14% 10% 0%
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PARTICIPATING FACILITIES
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VISN
1
Facility Name from Survey Bedford, MA - 518 Boston HCS - 523 Connecticut HCS - 689 Manchester, NH - 608 Northampton, MA - 631 Providence, RI - 650 Togus, ME - 402 White River Junction, VT - 405 Albany, NY - 528A8 Bath, NY - 528A6 Canandaigua, NY - 528A5 Syracuse, NY - 528A7 Western New York HCS - 528 Bronx, NY - 526 Hudson Valley HCS - 620 New Jersey HCS - 561 New York Harbor HCS - 630 Northport, NY - 632 Altoona, PA - 503 Butler, PA - 529 Clarksburg, WV - 540 Coatesville, PA - 542 Erie, PA - 562 Lebanon, PA - 595 Philadelphia, PA - 642 Pittsburgh HCS - 646 Wilkes-Barre, PA - 693 Wilmington, DE - 460 Martinsburg, WV - 613 Maryland HCS - 512 Washington, DC - 688 Asheville, NC - 637 Beckley, WV - 517 Durham, NC - 558 Fayetteville, NC - 565 Hampton, VA - 590 Richmond, VA - 652 Salem, VA - 658 Salisbury, NC - 659
VISN
7
Facility Name from Survey Augusta, GA - 509 Birmingham, AL - 521 Central Alabama HCS - 619 Charleston, SC - 534 Columbia, SC - 544 Decatur, GA - 508 Dublin, GA - 557 Tuscaloosa, AL - 679 Bay Pines HCS - 516 Caribbean HCS-San Juan - 672 Miami HCS - 546 North Florida-South Georgia HCS - 573 Orlando, FL - 675 Tampa, FL - 673 West Palm Beach, FL - 548 Huntington, WV - 581 Lexington, KY - 596A4 Louisville, KY - 603 Memphis, TN - 614 Mountain Home, TN - 621 Tennessee Valley HCS - 626 Chillicothe, OH - 538 Cincinnati, OH - 539 Cleveland, OH - 541 Columbus, OH - 757 Dayton, OH - 552 Ann Arbor HCS - 506 Battle Creek, MI - 515 Detroit, MI - 553 Illiana HCS - 550 Indianapolis, IN - 583 Northern Indiana HCS - 610 Saginaw, MI - 655
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VISN
12
Facility Name from Survey Chicago HCS - 537 Hines - 578 Iron Mountain 585 Madison 607 Milwaukee 695 North Chicago 556 Tomah - 676 Columbia, MO - 589A4 Eastern Kansas HCS - 589A5 Kansas City, MO - 589 Marion, IL - 657A5 Poplar Bluff, MO - 657A4 St. Louis, MO - 657 Wichita, KS - 589A7 Alexandria, LA - 502 Central Arkansas HCS - 598 Fayetteville, AR - 564 Gulf Coast HCS - 520 Houston, TX - 580 Jackson, MS - 586 Muskogee, OK - 623 Oklahoma City, OK - 635 Shreveport, LA - 667 Southeast Louisiana HCS - 629 Central Texas HCS - 674 North Texas HCS - 549 South Texas HCS - 671 Texas Valley Coastal Bend HCS-Harligen - 740 Amarillo HCS - 504 El Paso HCS - 756 New Mexico HCS - 501 Northern Arizona HCS - 649 Phoenix, AZ - 644 Southern Arizona HCS - 678 West Texas HCS - 519
VISN
19
Facility Name from Survey Cheyenne, WY - 442 Eastern Colorado HCS - 554 Grand Junction, CO - 575 Montana HCS - 436 Salt Lake City HCS - 660 Sheridan, WY - 666 Alaska HCS - 463 Boise, ID - 531 Portland, OR - 648 Puget Sound HCS - 663 Roseburg HCS - 653 Spokane, WA - 668 Walla Walla, WA - 687 White City, OR - 692 Central California HCS - 570 Northern California HCS - 612 Pacific Islands HCS - 459 Palo Alto HCS - 640 San Francisco, CA - 662 Sierra Nevada HCS - 654 Greater Los Angeles HCS - 691 Loma Linda HCS - 605 Long Beach HCS - 600 San Diego HCS - 664 Southern Nevada HCS - 593 Black Hills HCS - 568 Central Iowa HCS - 636A6 Fargo VA HCS - 437 Iowa City, IA - 636A8 Minneapolis VA HCS - 618 Nebraska-Western Iowa HCS - 636 Sioux Falls, SD - 438 St. Cloud, MN - 656
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ACKNOWLEDGEMENTS
29
2012 VHA Survey of OEF/OIF/OND Care Management Technical Advisory Group (TAG)
Deborah Amdur
Chief Consultant Department of Veterans Affairs VA Central Office Washington, DC
Peggy Kennedy
OEF/OIF/OND Case Management Program Manager Department of Veterans Affairs VA Central Office Washington, DC
Janet Belisle
Health System Specialist Department of Veterans Affairs Washington, DC
Sarah Nowitzke
Clinical Social Worker Department of Veterans Affairs Ann Arbor, MI
Betty Dameron
RN Department of Veterans Affairs St Petersburg, FL
Carrie Bancroft
Social Work Service Department of Veterans Affairs San Francisco, CA
June Callasan
RN, OEF/OIF/OND Program Manager Department of Veterans Affairs Long Beach, CA
Lauren Love-Dubeau
OEF/OIF/OND Program Manager, VISN 2 POC Department of Veterans Affairs Syracuse, NY
Victoria Koehler
OEF/OIF Program Manager Department of Veterans Affairs Portland, OR 97239-2999
Christopher Petrone
OEF/OIF Program Manager VA Southern Oregon Rehabilitation Center & Clinics White City, OR
Crystal Woodard
Social Worker Department of Veterans Affairs Louisville, KY
Jennifer Perez
National VA Liaison Program Manager Department of Veterans Affairs Washington, DC
Kerry Traviss
OEF/OIF Program Manager Department of Veterans Affairs Atlanta, GA
Susan Watkins
Social Worker Department of Veterans Affairs Durham, NC
Kathleen Dinegar
VA Liaison for Health Care Department of Veterans Affairs Washington, DC
Healthcare Analysis & Information Group (HAIG) Tanya Kotar, Program Analyst Denise Ott, Management Analyst
30

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Department of Veteran Affairs Veterans Health Administration Office of the Assistant Deputy Under Secretary for Health for

Policy and Planning

Womens Support Group

Substance Abuse Outreach SCI Vocational & Employment Services

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 OEF/OIF/OND VHA Care Management Survey Instrument

2012 OEF/OIF/OND VISN POC Survey Instrument

2012 Care Management of OEF/OIF/OND Veterans in VHA

Key Findings and Recommendations

Share findings with Caregiver Support Program Office.

Strength. Evaluate impact of consolidating / downsizing VISN staff.

2012 Care Management of OEF/OIF/OND Veterans in VHA

Survey Results with Select Analysis

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

% 98% 87% 74% 56%

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

% 33% 19% 10% 6% 5% 5% 4% 3% 3% 2% 2% 1% 1% 33%

2012 Care Management of OEF/OIF/OND Veterans in VHA

139 126.25 12.00 1.00 % 78% 19% 1% 4%

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

Count 101 100 100 99 99 98 98 97 96 96 91 88 87

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

OEF/OIF/OND Care Management Team

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

2012 Care Management of OEF/OIF/OND Veterans in VHA

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