Case Management
Video / August 1, 2024
Transcript
Hello and welcome to the medical section of the My Transition Seminar dedicated to the Canadian Forces Health Services Case Management program. Thank you for attending.
The purpose of this presentation is to provide ill and injured members with insight into how the Canadian Forces Health Services Case Management Program provides guidance and clinical support through rehabilitation and return to duty or transition to civilian life via the medical release process. Over the course of this presentation, we will provide an overview of the Canadian Forces Health Services Case Management Program, discuss the role of Nurse Case Managers within the care delivery unit as part of the primary care team and the health system. We will provide information about the case management process, how and when a CAF member is referred to a Nurse Case Manager, and what to expect when engaging with a Nurse Case Manager. We will share with you the various health related program and services that case management partners can support members, keeping in mind that the goal is always to improve the overall health of a member. At the end of the presentation, you will find some helpful references and resources that support members in attaining their health goals.
The Case Management Program is a national standardized program with the Canadian Forces Health Services System, which is a nationally accredited system by Accreditation Canada. The Canadian Forces Health Services Case Management Program was first stood up in the year 2000 to help address gaps in transitioning of ill and injured members.
Some injuries may lead to permanent military employment limitations resulting in the inability to perform duties under the principle of universality of service and in some case the member may be rehabilitated back to duty. Nurse Case Managers are registered nurses with university degrees and with expertise in complex health and social needs planning. Nurse Case Managers complete a comprehensive physical, mental and social health assessment, that helps to guide a member throughout their rehabilitation and transition. Nurse case managers provide services tailored to the individual needs of a CAF member facing an illness or an injury by following national case management standards that are used by the health care system across Canada.
When facing health challenges, not every CAF member will need the assistance of a Nurse Case Manager. Typically, CAF members are referred to a Nurse Case Manager for complex health care needs such as serious accident or if there are multiple medical health conditions, including mental health issues. This also applies when a member is facing a complex return to duty or is medically releasing.
Additionally, there are specific points after an injury when a Nurse Case Manager may become involved. This includes during an administrative review of the permanent category. When a member is assigned a permanent category that will likely breach universality of service. When a member is assigned a third temporary category. These situations usually generate a referral to a Nurse Case Manager for all Regular Force members and most Reserve Force members.
Nurse Case Managers specialize in assisting members with medical conditions to transition smoothly to civilian life or return to work. They offer expert guidance in navigating the health care system, ensuring that members receive timely, and appropriate access to care. Nurse Case Managers aim to empower members to take an active role in their care by helping them understand their medical condition and treatment plans, enabling them to make better informed decisions. Nurse Case Managers can link members to appropriate benefits and services, ensuring they receive timely support during their recovery and or transition. The case management model of care is founded on understanding the interrelationship between health, family life and work life.
Healthcare professionals recognized the need for support in all these areas to ensure quality of life is maintained throughout the rehabilitation process. As health care providers, Nurse Case Managers play a crucial role in coordinating patient care, ensuring that patients receive the necessary services efficiently and effectively. CAF members referred to case management will receive supportive care and guidance as they navigate through the stages of their medical release or return to duty.
Those seen by a Nurse Case Manager can expect a partnership that includes the patient, their family and their support group. Members also receive individualized health assessments that encompasses all aspects of health and social well-being.
Nurse Case Managers provide patients education and information about individual health concerns, services and benefits that support a seamless transition. They also offer guidance in establishing personal goals related to specific health concerns which impact the quality of life and ability to work.
The case management program includes a series of encounters with a Nurse Case Manager initiated by a referral from a healthcare provider. The health care provider identifies when case management services will be of benefit to the CAF member. As mentioned earlier, not all CAF members will need this assistance. Usually, it is for those with complex healthcare needs or facing restrictive medical employment limitations likely to become permanent.
Once the referral is completed at the CDU level by the member’s healthcare provider such as a medical doctor, a nurse practitioner, physician assistant, the case management team is notified, and the member is contacted for an intake appointment. An intake appointment is then arranged by the case management office. The first encounter with a Nurse Case Manager typically starts with attending a small group information session followed by an individual appointment to discuss immediate needs. In some situations, the first appointment may be scheduled as one-on-one meeting.
During these sessions, information is provided on available health services and potential benefits. The main concerns and needs of the members regarding recovery or transitions are also discussed. Following an intake, the CAF member will meet with their Nurse Case Manager for a comprehensive health assessment. This assessment includes questions related to overall physical and mental health, as well as social well-being and work life balance. It helps identify unique needs related health care coordinator, formulate goals to help meet those needs, and develop an individualized patient action plan.
With the consent of the member, the Nurse Case Manager facilitates timely requests to appropriate partners for programs or services pertinent to each individual situation. Example goals may include: to ensure continuity of care throughout the continuum of services, to address barriers to improvement which impact on health stability, to understand the medication plan, to understand medication side effects, to recognize and report medication adverse effects, to be informed about the medical administration process, to understand my medical employment limitations or to understand how my medical employment limitations are reflective of my current conditions.
Follow up appointments are set up according to the level of assessed need by the Nurse Case Manager. After each appointment, the member will receive a patient action plan which summarizes the plan with goals that were discussed during the appointment. Periodically there may be a need to attend appointments to reassess patient's goals and realign the patient action plan according to the health needs and/or change to those needs.
Reassessment is a follow up appointment meant to ensure that coordination of the care plan is maintained or adjusted as required. This is done with members input in consultation with the health care team and partners as needed. Reassessments are completed regularly until the member returns to duty or transitions to civilian life. During these appointments, a patient action plan is developed, discussed and adjusted collaboratively between the member, their family and the Nurse Case Manager.
When the medical release becomes clear, the Nurse Case Manager completes a complexity assessment and if there are complex needs, a request will be sent to the Transition Centre to set up a meeting to establish an Integrated Transition Plan. More to follow on this process in the next slide.
Care coordination with a Veterans Affairs Case Manager also takes place for members who are medically releasing and have complex care needs. Upon member's consent, the Nurse Case Manager will discuss the medical concerns with a VAC Case Manager to support transition of the medical treatment plan.
Transition is the last appointment which occurs once the member is deemed fit to return to duty, is releasing or when there is mutual agreement that there is no longer a requirement for case management services. All members assessed by a Nurse case Manager for a medical release will have a complexity assessment completed. The complexity assessment is an internationally validated clinical tool that provides objective criteria for determining barriers to care and the level of support that is required for by a member. The complexity assessment determines the degree of care and support required related to the overall healthcare of a patient. It takes into consideration the physical, psychological, social, and health system factors such as the determinants of health like support network, financial stability, housing, work/life satisfaction.
Based on this assessment, the medical team evaluates the member's health history, current state, and prognosis to determine a complex score. The score indicates the level of care and support needed as the member returns to duty or transition to civilian life. If a member is deemed complex by the medical team, the Nurse Case Manager, with the member’s consent, will send a request to the Transition Centre and other external partners such as Veterans Affairs Canada and Manulife, who will assist with the formal development of an integrated transition plan.
This plan requires that each service partner presents recommendations for a member’s transition plan based on the member’s needs and the partners program. The member is an active participant in this process and will be invited to attend the ITP meeting. If a member is deemed to have non-complex needs by the medical team, the eligibility to the various support services from the different service partners such as the Transition Centre, Veterans Affairs and Manulife are still available.
The main difference for members deemed non-complex is that the medical and or vocational transition plan is to respect the standard transition time allocated by DMCA, usually six months. Taking into consideration the career transition support policy, the Nurse Case Manager will ensure that the member is referred to the appropriate service support representative so that the plan is developed. The goal here is to ensure that a smooth medical and vocational transition takes place. The CANFORGEN 183-11 provides more details on career transition supports.
When the focus is on the transition to civilian life, the Nurse Case Manager guides and assists the member to ensure an integrated medical and vocational transition plan is established. This could include activities such as ensuring timely referrals or follow up appointments with specialists, referrals to Base/Wing Personnel Selection Officers for education upgrading, vocational transition planning, career workshops or recommending applications to various benefit programs to VAC or Manulife, for example. The Nurse Case Manager will help the member access medical care through the provincial health care system. This includes things like providing information on how and when to transfer your most current medical and treatment prescriptions to civilian services, how and when to obtain a copy of the key medical documents for the new or future civilian healthcare provider, and how to register to public service health and dental care plan.
As mentioned earlier with members consent, the Nurse Case Manager will also collaborate with the VAC Case Manager to coordinate the healthcare benefits that are part of the transition plan. This could involve timely referrals to VAC to discuss what programs or services the member or family may be eligible for, or discussion in advance of the needs and services to initiate or continue so that there is no disruption in the medical treatment plan and overall transition.
Nurse Case Managers will also advise members to go to their local CFHS Health Records department to request a copy of their most current and relevant medical documents.
In some locations, access to a family doctor remains a challenge. The Nurse Case Manager will facilitate bringing to a community physician in the intended place of residence. Overall, the Nurse Case Manager will direct the member to partners and/or resources when additional assistance is required to facilitate this process.
As identified in a Surgeon General Integrated Health strategy, one of the most important components of integration is what is referred to as the triad of responsibility between the Canadian Forces Health Services group and members chain of command and the CAF member and their families.
Without question, CAF members and their families must be fully engaged as a partner in their health, preventing further illness and injury and actively participating in their treatment and recovery so they can improve their quality of life, long term well-being and resilience, as well as their operational readiness.
Partnership means that there is a shared accountability for health between the patient and their family, the chain of command and the care providers and the team. The Nurse Case Manager works closely with internal and external resources like the Chain of Command, the Transition Group and the Transition Centre, Base/Wing Personnel Selection Officers, Veterans Affairs Canada and others as required to ensure timely and appropriate administrative services and support throughout the whole process of rehabilitation, reintegration and transition.
We know that health is not merely the absence of illness and that there are many factors that influence the members overall health such as lifestyle, education, social supports and employment. CAF members and their family are integral in maintaining and improving their overall health. With this in mind, Nurse Case Managers treat members with dignity and respect while providing compassionate care and sharing with them the responsibility for their health. Nurse Case Managers understand that empowering the member is also key towards successful training through education and motivation. Leaders at all levels with the chain of command are ultimately responsible for the health of those under their command and have a significant impact on their health and well-being.
The CAF Health Services Group does not function in isolation and therefore it must also be effectively integrated with the chain of command, the federal, provincial and territorial health care systems, the families and other programs and services within the CAF.
Along with the triad of responsibility, Nurse Case Managers work in collaboration and partnership with internal and external resources such as the Transition Group, Transition Centre, Transition PSO, Manulife, VAC, Soldier On, Military Family Resource Centre, Family Liaison Officer and the National Peer Support programs. The attending healthcare team works together in partnership with patients to ensure comprehensive, coordinated care. This approach reinforces timely communication and fosters informed decision making. As part of the team, Nurse Case Managers work to coordinate healthcare and related medical administrative processes.
The Nurse Case Managers will work in collaboration with the military and civilian health care services to establish a joint care plan while the member is still serving, but also when transitioning to civilian life.
Personal health information is information in any form that identifies you and that relates to your health and healthcare, including health history, healthcare programs and services, healthcare providers, substitute decision makers. Your personal health information must be safeguarded and care is taken to only share this with your healthcare provider.
Healthcare professionals need your consent to share your personal information. Consent requires justifications, purpose, and the benefit of sharing personal health information. In other words, the consent must specify what is shared, to whom and the reason it needs to be shared. For example, the treatment plan may be shared between the Nurse Case Manager and the healthcare team, between the Nurse Case Manager and the VAC Case Manager once the member has applied for VAC benefits, or the Nurse Case Manager and his civilian specialist.
Your medical employment limitations are not considered part of your PHI and this is the only information that is shared with the chain of command, including the Transition Centre, the Personnel Selection Officer, the Family Resource Centre and other support services.
In summary, Nurse Case Managers will assess and guide members and their family in navigating the military and civilian healthcare system. They will provide specific health information, education and resources relevant to members health condition, for example, the medical administrative process and access to health promotion programs through Force Health Protection. They will assist members with application processes for benefits and services when required. In partnership with members and their family, they will collaborate to develop and coordinate the patient action plan, facilitate appropriate transfer of health care to the province or territory, and refer and collaborate with the VAC Case Manager to develop a joint medical transition plan.
Here are some of the references with associated links. Don't hesitate to speak with your health care provider if you feel you need a case management referral. Thank you for listening.