Care coordination
Strong care coordination between VA and community providers is essential to ensuring Veterans receive timely, high-quality care. As a community provider, you play a vital role in this process. VA uses a Veteran-centered, team-based approach to care coordination, which includes 5 key steps. This model is designed to support you and your team in delivering seamless care in partnership with VA.
1. Receive request for community care
Several events can trigger the receipt of a request for community care, such as:
- A new Veteran clinical appointment
- A hospital notification
- Referral from VA or community provider
- An inpatient admission or emergency department visit.
The VA facility community care team receive requests, assign staff, confirm eligibility, and authorize services. Referrals and authorizations are managed through the HealthShare Referral Manager (HSRM) system.
2. Assess Veteran needs
VA facility community care staff use the Screening Triage Tool combined with clinical judgment to determine the appropriate level of care coordination for each Veteran.
3. Develop care coordination plan
Once the Veteran’s needs are assessed, the VA team works with you to develop a personalized care coordination plan. This plan may include:
- Communication protocols and follow-up activities
- Scheduling and appointment logistics
- Navigation support for the Veteran
4. Implement care coordination plan
The VA care team facilitate a collaborative relationship among Veterans, community providers, and VA providers. This helps streamline communication and information sharing across all parties.
5. Follow-up and complete episode of care
VA community care staff follow up with the Veteran to confirm services were provided, complete any necessary handoffs, and close the consult. Staff continue to monitor and track the Veteran throughout the episode of care.
Use this list of VA medical facility contacts to locate and connect with the nearest community care office for help coordinating a Veteran’s care.