Interdisciplinary Teamwork Using Care Coordination and Integrated Case Management (CCICM): The Key to Breaking Traditional Health Care Silos
BY , MSW, LCSW, CCM AND BINA STITT, MPA, MSN, RN, CCM
Back in 2016, two major VA offices— Offices of Nursing Services (ONS) and Care Management and Social Work (CMSW)—teamed up for something big: the Integrated Case Management Initiative. The goal was to take a hard look at how we handle case management across the Veteran’s Health Administration (VHA) and find a better way to weave it all together.
By looking at what works best in both the private sector and our own clinics, the team built a nationwide framework called Care Coordination & Integrated Case Management (CCICM).
WHY IT MATTERS
Think of CCICM as the new roadmap for how we work together. It’s not just about paperwork; it’s about making sure we’re all speaking the same language. Here is what this framework brings to the table:
- Better Collaboration: It breaks down silos, making it easier for different healthcare professionals to work as a unified team.
- A Focus on the Whole Veteran: By addressing social needs along with complex medical needs, we’re helping Veterans improve their day-to-day quality of life.
- Efficiency: It cuts out the “red tape” by reducing fragmented services and avoiding double-work.
- Staff Support: It provides clear standards so staff aren’t left guessing, allowing them to focus on what they do best—caring for patients.
Ultimately, this initiative is about making sure our Veterans get safe, cost-effective care that is easy to access. It’s about keeping pace with new improvements in healthcare while ensuring every clinician has the tools they need to succeed.
CCICM AT VA NORTH TEXAS HEALTH CARE SYSTEM
Care Coordination & Integrated Case Management hit the ground running at VA North Texas Health Care System. We kicked things off with a pilot program at the Polk Street facility on January 7, 2019. We chose that site because it had the highest hospital readmission rates—we knew we could make a real impact there. Just a few months later, in May 2019, we expanded to the Bonham site. Here is how that rollout looked:
- Initial Launch: We started small, working with just three Patient Aligned Care Teams (PACT).
- Early Success: During that initial phase, we screened 39 patients and found 10 who were the perfect fit for the service.
By March 2020, the Bonham initiative was ready for prime time. We went live across all Primary Care teams known as PACT at our facility, which led to screening another 40 Veterans and successfully getting 21 of them the CCICM services they needed.
It’s been a great journey so far, and we’re excited to keep this momentum going!
The secret sauce? Assigning a Lead Coordinator. This person is the go-to contact, flagging potential issues, tackling risks head-on, and making sure everyone on the clinical team stays in the loop. By keeping communication simple and direct, the Lead Coordinator cuts down on service mix-ups and ensures a smooth experience for the Veteran.
Since full implementation of the CCICM practice change, we’ve enrolled 406 Veterans in the CCICM program.
WHAT HAPPENS WHEN A VETERAN ENROLLS?
When a Veteran joins CCICM, we make sure their care team is clear to everyone. We note it right in their medical record and key electronic documents. This visibility helps the Lead Coordinator keep information flowing smoothly across all services.
THE LEAD COORDINATOR’S TOOLKIT
Lead Coordinators are vital for keeping care collaborative, comprehensive, and patient-centered. They use a few key strategies to make this happen:
- Interdisciplinary Case Reviews: They bring everyone to the table—primary care, mental health, pharmacy, social work, and specialty teams. Together, they create a care plan specifically designed for that Veteran.
- Real-Time Collaboration: Think of it as seamless info sharing. Using the Electronic Medical Record, Microsoft Teams, and talking directly with providers, Lead Coordinators actively work to connect the dots and stop care from feeling fragmented.
- Smooth Care Transitions: The whole team works together to ensure moving between inpatient, outpatient, and community care goes off without a hitch, so no services get missed.
CMSA PROJECT: INTERDISCIPLINARY TEAMWORK: THE KEY TO BREAKING TRADITIONAL HEALTH CARE SILOS
We created a poster presentation for consideration for the Case Management Society of America (CMSA) Annual Conference. This retrospective review examined high-risk Veterans enrolled in the Care Coordination and Integrated Case Management (CCICM) model at the VA North Texas Health Care System (VANTHCS). The study, covering the period from January 2023 to March 2024, utilized purposive sampling to identify frequent emergency department (ED) users.
Participants were selected based on the following inclusion criteria:
- High Emergency Department Utilization: A minimum of four ED visits within a 12-month period.
- Housing Instability: Currently experiencing or at high risk of homelessness.
- Acute Behavioral Health Risk: Identified as having a high risk for suicide attempts.
CCICM PERFORMANCE OUTCOMES
The 89 Veterans enrolled in our retrospective review were primarily between ages 45 and 64, lived mostly in urban areas, and had significant medical or behavioral health comorbidities. After CCICM intervention, the team observed clear improvements, including fewer emergency department visits, fewer hospitalizations, and meaningful reductions in no-show and patient-canceled appointments. Veterans also reported greater satisfaction once communication strengthened and they had a consistent contact person. These results highlight what many case managers already know: case management is most effective when delivered through collaborative teamwork.
CMSA ANNUAL CONFERENCE REFLECTIONS—EXPERIENCES AS FIRST-TIME PRESENTERS
We were delighted to learn that our 2025 CMSA poster presentation submission was selected for presentation at the national CMSA conference in Dallas, Texas. This marked both my colleague’s and my first time presenting a poster and our first time attending a CMSA Conference. While we weren’t quite sure what to expect, we were pleasantly surprised by how openly and positively we were welcomed by both staffers and attendees.
Upon arrival, we were greeted with light-up blue cowboy hats, which was a fun and memorable nod to Texas culture that immediately set a welcoming tone. What started as a lighthearted moment at the conference has since become a meaningful symbol for our team. We have continued to wear our blue hats during interdisciplinary meetings at our facility, using them as a conversational starter and a reminder of the collaborative spirit and energy we brought back from CMSA.
We attended the keynote address, which was nothing short of phenomenal. The speaker inspired us, made us laugh, and even brought us to tears. It was the perfect way to start an incredible day. Throughout the conference, we attended several sessions and heard from experts from around the country who shared their best practices and innovative approaches to case management. We learned about a wide array of services and resources designed to support geriatric patient populations. One highlight was participating in think tank sessions, where we were grouped together with other government agencies to discuss challenges and opportunities unique to our sector.
These sessions fostered meaningful dialogue, idea sharing, and connections that extended well beyond the conference itself. We also attended an outstanding presentation by Danielle Caviness from Indiana University Health, who discussed her facility’s Integrated Care Management program. Many aspects of her program mirrored what we have implemented at our VA site, and it was incredibly validating to hear about similar processes and positive outcomes. That experience further strengthened our confidence and excitement about showcasing our own work.
During our poster session, many attendees stopped by to learn more about CCICM initiative and how it has been implemented at our facility. The conversations were engaging, and attendees asked thoughtful, insightful questions. We had the opportunity to speak at length with Ms. Caviness from Indiana University Health, exchanging ideas and contact information to continue collaboration in the future.
FUTURE PLANS FOR CCIM EXPANSION, SUSTAINABILITY, AND IMPROVEMENTS
We left the conference with not only valuable insights from the sessions we attended, but also actionable ideas to enhance our CCICM processes. As a result, we are planning to implement CCICM competency standards and education pathways to increase awareness of CCICM practice changes among clinical staff at our site. Additionally, we intend to develop a care plan quality audit tool to ensure CCICM Lead Coordinators are consistently delivering high quality care.
Overall, the conference was a meaningful and energizing experience, and we look forward to attending again in the future.
REFERENCES
Care Coordination and Integrated Case Management (CCICM) Implementation Guide (v. 9 -2023). Available at Care Coordination and Integrated Case Management Clinical Integration Guide
The Veterans Community Care Program: Background and Early Effects. Retrieved from www.cbo.gov/publications/57257
VHA Directive 1110.04 (2019). Case Management Standards of Practice. Available at https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8489
Angela Simmons, MSW, LCSW, CCM, is a Licensed Clinical Social Worker with over 18 years’ experience at the Department of Veteran Affairs with extensive experience working within the Health Care for Homeless Veterans program. Her current role as the Social Work Co-Coordinator for Care Coordination and Integrated Case Management (CCICM) focuses on ensuring care coordination, collaboration and integrated case management for high risk Veteran populations to reduce care fragmentation and siloed care.
, MPA, MSN, RN, CCM, is a registered nurse with 12 years’ experience at the Department of Veteran Affairs in North Texas. She is a board-certified Case Manager. Her current work lies in identification of high-risk Veteran populations, intensive case management, and hospital utilization rates. Currently, she is the Care Coordination and Integrated Case Management (“CCICM”) RN Co-Coordinator at VA North Texas Healthcare System. In this role, she serves as a vital link between executive leadership, work groups, and frontline staff to ensure seamless integration and rigorously apply care coordination and case management principles to facility priorities.
