Ensuring Continuity of Care for Veterans with Comprehensive Case Management Tools

November 12, 2024

After serving, many veterans have serious care needs. For example, 1.1 million veterans who served our country’s military in the post-9/11 era receive care from a friend or family member at home. Issues that veterans experience returning to America are complex, with multi-faceted care needed to address the issues. Additionally, these are not one-and-done problems. Many veterans experience trauma that they will need care for indefinitely.

These individuals need continuity of care, which for veterans is the consistent delivery of healthcare services over time, coordinated between multiple parties, guaranteeing that they have uninterrupted, quality care. This applies even during transitions between different healthcare providers or settings. Veterans often have complex, long-term care needs, so these services are critical to maintaining health and a higher quality of life.

Case managers work tirelessly to ensure veterans get all the services they need. However, with disjointed systems, complicated issues, and miscommunication, it’s easy for a case to slip through the cracks. In this article, we’ll explore different comprehensive care solutions, support services for veterans in need, and how to use veteran case coordination tools to provide the best continuity of care.

Comprehensive Care Solutions for Veterans

Comprehensive care solutions for veterans’ health and wellness cover services and programs to address their physical, mental, and social needs. These issues do not appear in a vacuum; all three affect one another. That’s why health professionals stress comprehensive care as the best healthcare approach, with “attention to context, community linkages, continuity, and coordination appears to be responsible for better outcomes over the long term.”

For veterans, comprehensive care typically covers the following services:

Primary and specialty care: The Department of Veterans Affairs provides quality services, including primary, women’s care, dentistry, and more.
Urgent and emergency care: The Department of Veterans Affairs also offers emergency care through their network’s urgent care facilities and other providers.
Community care: Veterans can receive services through community partners if they live too far away from a VA facility.
Mental health care: Veterans suffer from many mental health challenges, such as anxiety, depression, and substance abuse. Robust mental health care from professionals, including medication management, therapy, and other innovative practices, is often required for holistic veteran care.
Amputation care: Veterans experiencing limb loss or facing an upcoming surgery need additional support to walk through the transition and readjust to daily life afterward.
Homelessness care: Veterans need resources to transition skills learned in the military into civilian jobs. To remain housed, many need to be connected to immediate housing, job skills training, and financial support.
LGBTQ and minority care: The VA offers specialized services to address specific issues in both groups.

Veteran Support Services

If you’re a veteran experiencing homelessness or a case manager who works directly with veterans, please review PlanStreet’s guide to VA programs for homeless veterans. If a client needs immediate assistance, call the National Call Center for Homeless Veterans at 1-877-4AID VET (877-424-3838). The hotline is open 24/7, and every conversation is confidential.

Other veteran social services support includes:

The VA also provides services to caregivers who work day in and day out in veteran well-being support systems. The Department of Veteran Affairs (VA) Caregiver Support Program (CSP) provides caregivers with services needed to remain healthy. Additionally, caregivers can utilize the VA Program of General Caregiver Support Services (PGCSS), which provides supportive programs such as peer mentoring, skills training, and more.

If a caregiver is interested in these programs, they can contact the Caregiver Support Line at 1-855-260-3274, free of charge.

Veteran Case Management Tools

While all of these fantastic programs are available to veterans, it’s the job of a case manager to provide veterans with access to these services and connect them to the ones that address their specific issues.

Clunky, outdated systems can cause service delays, and these can be rampant in VA facilities. Some of the most common issues that delay services for veterans include:

Inefficient clinic operating procedures
Last-minute appointment cancellations, with a 21% cancellation rate for mental health appointments. This is incredibly damaging for veterans, who have suicide rates twice as high as the rest of the US population.
Long delays for specialty appointments

While issues in the VA cannot change overnight, case management software for veterans offers a solution to streamline some of these common issues. It’s one of the most important emerging tools to address these issues and streamline veteran care. Consider software such as PlanStreet, specializing in veteran case management to help case managers provide a robust continuum of care services. Some of their critical tools for veteran case management include:

A central data hub, so you can understand all the services currently given to a client, and you can make adjustments as needed.
Behavioral health assessments, so that the case manager can design the ideal program for their client.
Outcome tracking, so you can work toward long-term solutions for your client that follow their needs for a continuum of care.
Needs assessments, so you can gain a better understanding of demographics, skills, interests, and current needs.

Efficient Case Management for Veterans

Case management software such as PlanStreet facilitates efficient case management for veterans. It creates a single place for data, services, case notes, and assessments related to a client. Any case manager or stakeholder can be given access, creating barrier-free communication across providers.

Let’s discuss how comprehensive case management software tools can help case managers guide veterans to the best services possible.

Focus on Comprehensive Care

Case management software allows your team to take a holistic approach, connecting every service area. Software like PlanStreet offers robust case boards, so case managers can see at a glance information such as:

Support services
Mental health assistance
Disability services
Personal growth

Each category can be tailored to the client’s needs, tracking assigned services, their roadmap to health, and more. By seeing all of this in one place, case managers can make quick decisions on behalf of their clients, helping them gain faster access to the services needed.

Data-Driven Veteran Care Solutions

According to Google, organizations that use data to drive decision-making are three times as likely to see improvement. This same idea can be applied to service planning and care coordination for veterans. Implementing data tracking to improve decision-making can lead to better long-term care for veterans. PlanStreet’s software offers Microsoft Power BI to create tailored reports.

Apply specific filters to hone in on critical data points, such as clients or activities. You can schedule report updates to see changes over time and make adjustments accordingly. Automating reporting schedules takes the mental work away from caseworkers so they can instead focus on using the reports to improve client outcomes.

Revitalize Processes

Automated veteran case management software offers built-in tools to simplify time-consuming administrative processes for case managers. Client intake can be tedious, especially if forms are outdated and don’t reflect all the information needed. Excessive back and forth between the client and the case manager can delay critical services.

Document automation tools like PlanStreet’s form builder allow them to tailor forms to collect the exact data needed in the intake process. Case managers can change fields easily depending on the needs of the client, so they aren’t overwhelmed by providing information that isn’t even relevant to them.

Additionally, PlanStreet provides robust screening tools to help case managers build a foundation for their case plans. PlanStreet is HIPAA-compliant and offers robust behavioral assessments, skills assessments, and more, helping case managers gain a deeper understanding of the variety of needs a veteran may have.

Improve Communication

Communication is key when providing services for the long haul. A case manager needs to develop a relationship with their clients. GPD (grant and per diem)-funded case managers with the VA must maintain a monthly caseload of at least 16 veterans. With this many clients, case managers need improved tools to ease communication.

One of the best ways is through a client portal. This creates a space for clients to review information and find answers to their questions. If they can’t, they can message providers with questions and concerns. With PlanStreet, our client portal offers robust scheduling, collaboration, and accessibility tools to streamline services and improve outcomes faster.

PlanStreet’s Case Management Software for Veterans

Veterans face long-term health challenges. Case managers come alongside them to provide coordinated and continuous comprehensive care. Combat fragmented systems and administrative errors with PlanStreet’s comprehensive veteran case management solution.

Our software creates an integrated case management system for every piece of important data, facilitating real-time communication between relevant parties, robust reporting features for improved data-driven decision-making, and better outcome tracking. Case managers can address veterans’ needs, improve their quality of life, and guarantee that no case falls through the cracks. Schedule a demo to learn how our tools can help your case managers create streamlined veteran care processes today.