Veterans with complex health conditions navigate a bewildering array of providers and supportive services. Those Veterans who live in rural areas often face additional challenges in getting the right care at the right time because providers may be geographically dispersed or unavailable in their neighborhood. Social-work case- management (SWCM) addresses the need for better access, coordination, and community support. A licensed social worker, acting as part of a primary-care team, connects the Veteran, their families and caregivers with a support network in their community. Case management is distinct from other forms of social work assistance in its emphasis on comprehensive assessment of the Veteran?s needs followed by intervention, evaluation, and documentation, which continue until treatment goals are met. In response to a shortage of social workers needed to complement its primary-care Patient Aligned Care Teams (PACTs) in rural areas, the Veterans Health Administration (VHA) has implemented a program to place additional social work case managers at rural PACT sites. Little is known, however, about the impact of adding social workers to primary-care teams or the effectiveness of the case-management model. We propose a rigorous evaluation of this initiative. The long-term goal of this partnered evaluation is to improve the implementation of the Rural PACT SWCM Initiative in order to deliver patient-centered, timely, and appropriate care to Veterans. As a necessary step toward that goal, the objective of our partnered evaluation is to assess the Rural PACT SWCM Program?s success an achieving its goals and improve its implementation. Our central hypothesis is that social-work case- managers connect Veterans to services and resources, such as personal care services, better-coordinated primary care, care planning, and mental health services, that ultimately will reduce unplanned health-care use that impose stress on Veterans and costs on the health system. This assessment will be used to create a tailored intervention, designed in cooperation with the operations partners, to improve implementation of Rural PACT SWCM by helping social workers to identify high-risk Veterans who need supportive services and provide case- management assessment and services. The knowledge gained from this evaluation will not only enhance implementation of Rural PACT SWCM Initiative, but also demonstrate the value of SWCM as a key component of primary care in the VHA. That evidence will provide the basis for medical centers to invest in sustaining SWCM for the long term. To do so, the evaluation team will pursue the following aims: (1) Assess the implementation of SWCM and barriers and facilitators of implementation of the case-management model and targeting of high-risk Veterans. (2) Evaluate the effect of social worker placement on Veterans? access to services and health outcomes. (3) Design and pilot-test a case-management-improvement bundle to help program social workers increase their use of case management tools and identify Veterans in need of SWCM. The product of this QUERI evaluation will be an in-depth appraisal of the Rural PACT SWCM Initiative. The project touches the VA?s highest priorities: connecting Veterans to their choice of providers and community resources, taking advantage of electronic health records to modernize targeting of SWCM resources, improving timeliness of care by addressing barriers to access in rural areas, and connecting high-risk Veterans with needed supportive services, community providers, and mental health resources.
The proposed evaluation is relevant to the Veterans Administration (VA) priorities because it aligns with the VA goals for access, timely and integrated care, and modernization. Case management supports greater choice for Veterans by coordinating access to community resources that align preferences with care and help elderly Veterans remain in the community and avoid transitions to nursing homes. The case-management- improvement bundle that we propose will modernize systems by leveraging electronic health records to help social workers target their services more efficiently. Social-work case-management can improve timeliness of services by helping Veterans to surmount barriers to access that are particularly acute in remote areas. Finally, social workers are providing case management are positioned to assess psychosocial issues, build trust between patients and their care team, and make referrals to mental health providers, thereby improving access to needed mental health services.