Transition Of Integrated Care Coordination In Specialty Clinic

valles gutierrez

sahlee balajadia

lisa lobdell

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States. VHA provides care to over 9 million veterans in 1,255 healthcare facilities, including 170 VA Medical Centers and 1,074 outpatient sites of care of varying complexity (U.S. Department of Veterans Affairs, 2019).

Along with many other organizations within VHA, VA Long Beach Healthcare System (VALBHS) has begun the process of redefining the vision for care coordination and integrated case management, aligning with the Case Management Society of America’s transformation goals outlined in the 2019 white paper The Practice of Hospital Case Management by Mary McLaughlin Davis:

  • Redesigning scope of service
  • Establishing clear roles and responsibilities
  • Developing an entrepreneurial structure to support coordination goals
  • Positioning case management with a transformative executive sponsor
  • Realigning for greater effectiveness
  • Fine tuning work-flow
  • Separating professional transition responsibilities from associated logistics and
  • Resolving opposing view of case management

We will reflect on our journey of case management at the VALBHS from the 90s to the present. This article outlines the roadmap and vision of our newly developed, highly skilled, and integrated care coordination team. The initiative began in late 2017 with a small group of experienced case managers and nurse leaders performing a needs assessment for specialty care clinics.

Specialty care at the VALBHS is made up of many clinics which include but are not limited to the “ology’s”: neurology, cardiology, dermatology, endocrinology, gastroenterology, pulmonology, hematology-oncology and rheumatology. Next, we outline the findings of our initial needs assessment, our request for full-time employment (FTE), the development of our standardized orientation process to streamline reliable care coordination and work flow and the recent integration of the newly passed Mission Act. Finally, we share our challenges and successes as well as the current and future state.


Over the last 30 years, there have been varying levels of care coordination, care management and case management at VALBHS. In the 1990s the VALBHS began a pilot program for case management in the surgery clinics. At that time, patients were admitted to the hospital for their preop workup. The pilot was successful in transitioning this workup to an outpatient process. As a result, our experienced case manager spread this work to other areas including spinal cord injury, community living center, and the inpatient wards. Case managers existed until the late 1990s. Then, there was a push to bring these nurses back to the bedside. However, VALBHS also renewed its interest to establish a case management program in the outpatient setting.

The surgery clinics began to utilize their case managers to coordinate the care for a specific period. The episode began at the request for surgery and ended at the time of surgery. Through the decades they have successfully cleared thousands of veterans for surgery who had complex mental and physical issues. Currently, Transition Care Management (formerly known as OEF/OIF/OND), Housing and Urban Development VA Supportive Housing, and the Mental Health Intensive Case Management (MHICM) are all programs that VHLBHS has in place that utilize case managers. Patient Aligned Care Teams (PACT), also known as the Medical Home Model, began at VALBHS in 2010. The core team consisted of a primary care provider, registered nurse care manager, licensed vocational nurse and clerk. Other team members included social worker and pharmacist support.

VALBHS had five care coordinators in specialty care at the completion of the 2017 needs assessment. We have since grown to a team of fifteen nurse care coordinators. All new team members have utilized highly successful standardized orientation and standard of work. To better define the roles of care coordinator, care manager and case manager, we utilized VHA Directive 1110.04, The Integrated Case Management Standards of Practice, which came out in September of 2019, to help guide our efforts further.


Specialty care is an increasingly essential element of outpatient care coordination. As patients’ conditions become more complex, their care is often managed by multiple providers, increasing the likelihood of fragmented care, missed and unmet needs, duplicated tests, medication errors, patient confusion and dissatisfaction (Vimalananda, et al., 2019). Further studies suggest that greater use of specialty providers may also reduce the primary care provider’s ability to coordinate care effectively. Practices to improve care coordination using a unified vision across the facility and throughout specialty care services improve efficiency and effectiveness of care. Standardized care coordination in specialty clinics has been associated with more favorable patient experience and cost management (Mohr, et al., 2019). Additionally, compared to nonveterans, veterans have a greater number of comorbidities that need to be considered and coordinated when receiving healthcare (Greenstone, et al., 2019).

After performing an initial complex needs assessment for the specialty clinic, our care coordination team and nursing leadership worked to establish a standardized specialty care coordination (CC) practice approach. Limited care coordination resources were identified as well as the need for coordination of highly complex veterans. In the areas with limited or no coordination, the following was observed:

  • High no-show rate;
  • Incomplete lab and study completion essential for critical decision making to drive patients care to ensure meaningful appointments
  • Decreased veteran satisfaction and confusion of their treatment plan of care
  • Decreased access
  • Delayed new veteran visits

After review of the assessment, we developed a new integrated practice approach that included a standardized care coordination orientation for staff development, ongoing mentorship and coaching from experienced and certified case managers, and utilization of a systematic method of documentation and tracking veterans throughout the entire episode of care. Our team has also created standards of work for each specialty for continuity of care. To ensure a unified facility vision, this care coordination approach can be adopted facility-wide with the aim of preventing gaps in care transition across our healthcare system.

Our team has meticulously focused on the veterans presenting to the “ology” clinics requiring specialty care and treatment. Patients in the specialty care clinics are a subset of high-risk, complex and critically ill patients with multiple comorbidities, including mental health and/or psychosocial issues. Care coordinators practicing in these clinics recognize the progression of diseases and must anticipate the needs of these high-risk veterans. Specialty care coordinators are a key member of the interdisciplinary team, often driving the care and coordinating the veteran’s care for the continuum of their illness. The specialty care coordinator is poised in a perfect position to interact with Primary Aligned Care Teams, mental health, social work, rehabilitative medicine and pharmacy, to ensure the veteran has one primary, clearly identifiable and accessible point of contact to ensure the care is coordinated across all healthcare settings.

At the same time, one of our nurse care coordinators embarked on the Care Coordination Quality Improvement Project. Our objective was to reduce the clinic’s “no-show appointment” rate in outpatient specialty clinics. This work commenced on January 2018 with a rate of 14.1%, and by December 2018 our rate was 7.7%. The definition of no-show is “veterans who fail to attend their scheduled specialty clinic appointments.” The rationale of monitoring these rates was that a reduction in clinic no-show would improve clinical outcomes, improve quality of care, increase patient satisfaction and continuity of care. This would also increase our access of appointments for other veterans who were waiting for an appointment. The care coordinator began collecting and posting data in the clinics monthly to show the rates for all the clinics to ensure transparency and to educate veterans on the importance of calling to cancel and reschedule appointment at least 24 hours in advance. We met our goal of less than 10%. However, we are currently working with our system redesign in a project called Rapid Improvement Event to do a deeper dive into the barriers of no show appointments.

After the successful implementation of care coordination in the specialty clinics and showcasing measurable outcome improvements, our team met with the executive leadership team (ELT) to obtain buy in to expand our concepts and centralized care coordination services facility-wide. As part of our facility’s unified vision, nursing leadership and ELT began the task of creating a centralized reporting structure, and continued dissemination and utilization of standardized terminology to define and drive the roles of care coordinator, care manager and case manager. Additionally, we are working to define interdisciplinary roles and responsibilities for utilization management and social work.


It was important to have clear understanding of the VHA Care Coordination/Integrated Case Management (CC/ICM) transition journey as we worked to shift our culture to adopt a uniform vision that clearly defined our goal. Our vision embraced a cohesive care team dedicated to delivering safe, cost-effective, quality patient-centric care that optimizes self-care and well-being.

VHA began its journey into integrated case management in April of 2016. While case management service had become more narrowly focused within certain populations to ensure access, fragmentation in case management can create inefficiencies and reduce the full capability of case management services (Rubin, Vogel, Weede, & Aaron, 2017). To overcome these challenges, the Offices of Nursing Services (ONS) and Care Management & Social Work (CMSW), supported by the Office of Strategic Integration, co-sponsored the Integrated Case Management (ICM) Initiative. The ICM identified an absence of standardization and operating procedures while also noting high-quality existing practices. Their ICM Initiative resulted in the National Care Coordination & Integrated Case Management Initiative Toolkit (VA Directive 1110.04, 2019).

VALBHS was one of the twelve pilot sites for CC&ICM, and we had the opportunity to help spearhead this initiative. The CC&ICM Initiative Strategic Communication Plan is being completed as well as many other efforts in order to roll this out to all VA Medical Centers.


Over the last decade, the VA has made great strides expanding veterans’ access to care in non-VA settings, progressing from the Fee Basis Program to Non-VA Medical Care to the Veterans Choice Program (VCP) of 2014. The VCP allowed eligible veterans to receive healthcare from a community provider rather than waiting for a VA appointment or traveling to a VA facility. There were eligibility requirements (appointment wait times and travel distance) for receiving this care.

The VA recently initiated the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act). This federal regulation became law in June 2018, establishing a permanent community care program for veterans that increases the options veterans have for where and when they receive their health care.

The VA Mission Act is designed to improve upon the previous programs. A key improvement should focus on enhancing the communication between VA-referring providers and the community-based providers who will care for our veterans. The lack of coordination between VCP providers and VA providers was identified as a challenge in qualitative studies investigating veterans’ experiences with the VCP. Data suggested that veterans could benefit from additional resources to help them coordinate care across systems such as dedicated case managers (Stroupe, et al., 2019). The MISSION Act will strengthen VA’s ability to deliver trusted, easy to access, high quality care at VA facilities, virtually through telehealth, and in the community (Mission Act Strengthens VA Care, 2019).


As the largest healthcare system in the United States, the VA is well equipped to care for our nation’s finest. Many of the individuals we serve have increased medical and mental health risks because of their military experiences and socioeconomic status (Rubin, Vogel, Weede, & Aaron, 2017). For many VA staff, they too have served and understand this. For others, they have a family member who has served, and for others it is a calling.

“A veteran is someone who, at one point in their life wrote a blank check made payable to ‘the United States of America,’ for an amount up to and including their life.” — Unknown

After this initial article describing the unified vision for VALBHS and our journey to date, we will continue this with a series of articles that further define and clarify the goals of our care coordination team in specialty areas of practice one “ology” at a time.

Please don’t forget to partner with your nurse care coordinators in the ology’s…

Linda Valles-Gutierrez DNP, FNP-BCChief, Patient Care Services, Outpatient Medicine HCG

Sahlee Balajadia, MSN-PH, RN-BC, WCCNurse Manager Specialty Clinics, Outpatient Medicine HCG

Lisa Lobdell, MSN, RN, CCMLead Case Manager Specialty Clinics, Outpatient Medicine HCG

Special Acknowledgment to Liza Castillo, BSN, RNEndocrinology Care Coordinator for the work on the Care Coordination Quality Improvement Project.


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(2019). Integrated Case Management Standards of Practice. Veterans Health Administration. Washington, DC: Department of Veterans Affairs. Retrieved 2019

McLaughlin-Davis, M. (2019). The Practice of Hospital Case Management: A White Paper. Professional Case Management, 24(6), 280-296.

Mission Act Strengthens VA Care. (2019, September 30). Retrieved from U.S. Department of Veterans Affairs:

Mohr, D. C., Benzer, J. K., Vimalananda, V. G., Singer, S. J., Meterko, M., McIntosh, N., … Charns, M. P. (2019, May 16). Organizational coordination and patient experiences of specialty care integration. Journal of General Internal Medicine, 34, 30-36. Retrieved from

Rubin, M., Vogel, D., Weede, A., & Aaron, J. (2017). Integrating VA case management to promote access. VA Integrated Case Management. Veterans Administration.

Stroupe, K. T., Martinez, R., Hogan, T. P., Gordon, E. J., Gonzalez, B., Kale, I., … Hynes, D. M. (2019, October). Experiences with the Veteran’s Choice program. Journal of General Internal Medicine, 34(10), 2141 — 2149.

U.S. Department of Veterans Affairs. (2019, July 14). Retrieved October 22, 2019, from About VHA:

Vimalananda, V. G., Meterko, M., Waring, M. E., Quan, S., Solch, A., Wormwood, J. B., & Fincke, B. G. (2019, August 6). Tools to improve referrals from primary care to specialty care. The American Journal of Managed Care, 25(8), 237-242. Retrieved from


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