Canadian Forces Health Services Case Management

This presentation is an overview of the Canadian Forces Health Services (CFHS) Case Management and will cover:

• An Overview of Case Management;
• CAF members being referred to Case Management;
• Case Management process;
• The various health-related programs and services that Case Management partners with to improve the overall health of the member; and
• Helpful references. 

The CFHS Case Management provides standardized services to CAF members who are facing an illness or injury.
In many cases, these injuries are likely to lead to permanent military employment limitations, resulting in the inability to perform duties under the principle of Universality of Service.
Nurse Case Managers are Registered Nurses who have a university degree and expertise in complex health and social needs planning.
Nurse Case Managers work closely within the Care Delivery Unit (CDU) with other clinicians and promote the achievement of optimal health and wellness of CAF members.
Nurse Case managers build an ongoing relationship with the member and their family to help effectively navigate through the military and civilian health care systems.
Nurse Case Managers work with the health care team, as well as key partners such as, JPSU, PSO, VAC and SISIP.  This ensures that CAF members receive continued support and access to benefits as they Return to Duty or transition to civilian life.  

CAF members who are referred to Case Management will receive supportive care and guidance as they navigate through the stages of their medical release or return to duty.  Members who are seen by a Nurse Case Manager can expect the following: 

•  A partnership with the Patient and Family;
• Individualized health assessments, which include all aspects of health and social well being;
• Education and information about individual health concerns, services and benefits that support a seamless transition; and
• Guidance in establishing personal goals related to specific health issues that impact the quality of life and ability to work.

Case Management Services are designed to help CAF members:

• Navigate the health care system to ensure they receive the care they need, when they need it;
• Empower them to be an active participant in their care, by helping the members to understand their medical condition and care plan; and
• Access appropriate benefits and services so they can receive timely support in their recovery and transition.

When facing health challenges, not every CAF Member will need
the assistance of a Nurse Case Manager.
Most of the time, CAF members in the following situations will be
referred to a Nurse Case Manager:

1. When a patient has complex health care needs, such as a serious accident, or multiple medical health conditions including mental health; and
2. When a member is facing a complex Return To Duty or is medically releasing.

Additionally, there are specific points after a member is injured that Nurse Case Managers may become involved, such as:

1. When an Administrative Review of the Permanent Category is taking place;
2. At the time of being assigned a Permanent Category that will likely breach Universality of Service; or
3. When assigned a third Temporary Category.

The above situations would normally generate a referral to a Nurse Case Manager for all Regular Force Members and most Reserve Force Members. 

The Case Management process consists of the following steps:
The Referral, Intake, Assessment, Reassessment, and Transition.
Referral. is completed at the CDU level by the health care practitioner (for example, Medical Doctor, Nurse Practitioner, Physician Assistant).  This person 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 health care needs or facing restrictive medical employment limitations likely to become permanent.
Intake.  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.  In some situations, the first appointment may be scheduled as a one on one appointment. Information is provided on some of the CAF health services and potential benefits available.  The main concerns and needs of the member regarding recovery or transition are also discussed.
Initial Assessment.  Following an Intake, the CAF member will meet with the assigned Nurse Case Manager for a full case management assessment. This includes questions related to your overall health and social wellbeing.  This assessment helps identify the member’s needs related health care coordination, and develop an individualized care plan. It also facilitates, with the consent of the member, timely referrals by the Nurse Case Manager to the appropriate partners for programs or services pertinent to each individual situation. 

Reassessment is a follow-up appointment meant to ensure that the coordination of the care plan is maintained or adjusted as required. This is done with member’s input and in consultation with the health care team and partners as needed. The reassessment is an on-going phase until the member returns to duty or transitions to civilian life. During these appointments, an action plan is developed, discussed and adjusted collaboratively between the member and the Nurse Case Manager.
Transition. This last type of appointment happens 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.

A Complexity Assessment examines how complex the overall health care needs of a patient are. It takes into consideration the physical, psychological, social and health system factors. Each factor is scored by the medical team who considers a member’s health history, current state and prognosis.
If a member is deemed complex by the medical team, the Nurse Case manager, with the member’s consent, will make a referral to the Integrated Personnel Support Centre (IPSC) and other external partners like VAC and SISIP, who will assist with the formal development of an Integrated Transition Plan (ITP).  This plan requires that each service partner present recommendations for a member’s transition plan, based on their programs and the member’s need.  The member is an active participant in this process by being consulted regularly.
For a member deemed by the medical team to have non-complex needs, the eligibility to the various support services from the different service partners like IPSC, VAC and SISIP is still available. The main difference for members deemed non-complex is the medical and/or vocational transition plan must respect the standard transition time allocated by DMCA (usually 6 months). 
Taking into consideration the career transition support policy (CANFORGEN 183/11), the Nurse Case Manager will ensure that the member is referred to the appropriate service support representative so that a plan is developed. The goal here is to ensure that a smooth medical and vocational transition takes place.
CANFORGEN 183/11 provides more details on Career Transition Support, and specifically states:
‘’THE POLICY INCORPORATES BEST-PRACTICE CONCEPTS OF INDIVIDUALIZED ASSESSMENT, EARLY INTERVENTION, INTERDISCIPLINARY CARE, PLANNING AND VALIDATED ASSESSMENT TOOLS. IT ALSO BUILDS ON THE EXISTING FOUNDATION OF CAF CASE MANAGEMENT, THE JPSU/IPSC NETWORK AND THE CLOSE PARTNERSHIPS WITH SISIP FS AND VAC’’ .

When the focus is on transitioning 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 the Base/Wing Personnel Selection Officer for education upgrading, vocational transition planning, or career workshops, or recommending applications to various benefit programs to VAC or SISIP 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 to transfer your most current medication and treatment prescriptions to civilian services;
• How to obtain a copy of the key medical documents for the new or future civilian health care practitioner; and
• How to register to Public Service Health and Dental Care Plans, for example.

The Nurse Case manager will also collaborate with the VAC Case Manager to coordinate the health care 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, or
• Discussions in advance of the needs and services to initiate or continue so that there is minimal 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. Overall, the Nurse Case manager will direct the member to partners and/or resources when additional assistance is required to facilitate this process. 
In some places, access to a family doctor is still difficult. The Nurse Case Manager can facilitate this process by directing the member to appropriate partners or resources when it needs additional assistance.

As identified in the Surgeon General Integrated Health Strategy (2017), 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, a member’s 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 wellbeing and resilience, as well as their operational readiness.

Partnership means there is a shared accountability for health between the patient and their family, the Chain of Command, and the care provider and team.
The Nurse Case manager works closely with internal and external resources like the Chain of Command, JPSU, PSO, VAC, 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 member’s 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 Member’s 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 transition (through education and motivation).

Leaders at all levels within the Chain of Command are ultimately responsible for the health of those under their command and have a significant impact on their health and wellbeing.
The CF 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; our 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: JPSU/IPSC, PSO, SISIP-Long Term Disability, VAC, Soldier On, Military Family Resource Center/Family Liaison Officer, and the National Peer Support Programs.

The attending health care 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 health care and related medical adminstrative 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.

To recap, Nurse Case Managers will:

• Guide Members and their families in navigating the military and civilian healthcare systems;
• Provide education and resources relevant to members’ illness or disability, medical administrative process, and access to health promotion;
• Assist members with application processes for benefits and services, when required;
• Develop and Coordinate a care plan in partnership with members;
• Facilitate appropriate transfer of health care to the province or territory; and
• Refer and collaborate with the VAC Case Manager for a joint medical transition plan.

Here are some of the references with associated links.