Ensuring our Veterans receive the best possible healthcare often requires seamless coordination between the Department of Veterans Affairs (VA) and community-based providers. This collaborative approach is vital for delivering timely, high-quality care that addresses the unique needs of each Veteran. The VA has established a robust care coordination model, a Veteran-centered, team-based strategy designed to streamline this process and empower community providers. This model operates through five key steps, supported by essential digital tools that enhance communication, efficiency, and ultimately, Veteran well-being. Understanding and utilizing these tools is critical for community providers dedicated to serving our nation’s heroes and embodying the spirit of Community Cares Drug Tool – a commitment to providing the necessary instruments and support for comprehensive Veteran care within the community.
Navigating the 5-Step VA Care Coordination Model
The VA’s care coordination process is meticulously structured to ensure Veterans receive the right care, at the right time, in the most appropriate setting, whether within the VA system or through community providers. Here’s a breakdown of the five crucial steps:
1. Receiving Community Care Requests: The Starting Point
The journey begins with a request for community care. These requests can originate from various points, ensuring that Veterans’ needs are identified and addressed promptly. Common triggers for community care requests include:
- New Veteran Clinical Appointments: During initial or follow-up VA appointments, a need for specialized care outside the VA system may be identified.
- Hospital Notifications: VA facilities are alerted when a Veteran is admitted to a community hospital, signaling a potential need for coordinated care upon discharge.
- Referrals from VA or Community Providers: Both VA and community-based healthcare professionals can initiate referrals for specialized services or care that can be best delivered in the community.
- Inpatient Admissions or Emergency Department Visits: Following inpatient stays or emergency department visits, Veterans may require ongoing care coordination to manage their health and recovery.
Upon receiving these requests, the VA facility’s community care team takes immediate ownership. Their responsibilities include assigning dedicated staff to manage each request, verifying Veteran eligibility for community care programs, and authorizing the necessary services as outlined in the consultation. The HealthShare Referral Manager (HSRM) system plays a central role in this step, efficiently managing referrals and authorizations for community care. More information on HSRM and its benefits is detailed below.
2. Assessing Veteran Needs: Tailoring Care Coordination
Not all Veterans require the same level of care coordination. To ensure resources are allocated effectively and Veterans receive personalized support, the VA community care team conducts a thorough assessment of each Veteran’s needs. This assessment process leverages the Screening Triage Tool, a standardized instrument designed to evaluate the complexity of a Veteran’s healthcare requirements. Combined with the clinical judgment of experienced VA professionals, this tool helps determine the most appropriate level of care coordination for each individual Veteran. This step is crucial for efficient resource allocation and personalized care planning.
3. Developing a Care Coordination Plan: A Collaborative Blueprint
The development of a comprehensive care coordination plan is a collaborative effort between community providers and the VA facility’s integrated community care team. This individualized plan serves as a roadmap for the Veteran’s care journey and includes essential elements such as:
- Scheduling: Coordinating appointments with community providers and within the VA system to ensure seamless transitions and avoid gaps in care.
- Navigation: Providing Veterans with clear guidance and support to navigate the community care system, including understanding appointments, referrals, and available resources.
- Follow-up Activities: Establishing clear protocols for communication and follow-up to monitor the Veteran’s progress, address any emerging needs, and ensure a smooth transition back to VA care when appropriate.
This planning phase emphasizes determining the complexity of the Veteran’s care needs and strategically coordinating the delivery of care within the community, always with an eye toward eventual reintegration back into VA care if desired and appropriate.
4. Implementing the Care Coordination Plan: Putting the Plan into Action
Effective implementation hinges on fostering strong, collaborative relationships among all stakeholders. The VA facility’s integrated community care team acts as a central hub, facilitating seamless information exchange and communication between Veterans, VA providers, community providers, and the VA community care team itself. This collaborative approach streamlines the entire care coordination process, ensuring everyone is informed and working in unison to support the Veteran’s health goals. Regular communication and proactive problem-solving are key components of this implementation phase.
5. Follow-up and Episode Completion: Ensuring Quality and Closure
The final step involves diligent follow-up by the VA facility community care team. This includes contacting the Veteran to confirm that all services were delivered appropriately and to their satisfaction. The team also ensures any necessary handoffs between providers are executed smoothly and formally closes the consultation episode once care is complete. Throughout the entire episode of care, continuous monitoring and tracking of the Veteran’s progress are essential responsibilities of the facility community care staff, ensuring accountability and proactive intervention if needed.
Contact your nearest VA medical facility to coordinate care for a Veteran.
Essential Care Coordination Tools: Empowering Community Providers
To effectively support community providers in delivering coordinated care to Veterans, the VA offers a suite of powerful tools. These resources are designed to enhance communication, streamline processes, and ensure continuity of care. These tools embody the essence of “community cares drug tool” by providing the instruments necessary for community providers to actively participate in and improve Veteran healthcare.
Request for Service (RFS) – VA Form 10-10172: A Key Communication Tool
The Community Care Provider-Request for Service (RFS), officially VA Form 10-10172, is a vital form used by community providers to request additional services or continued care for Veterans from the VA. This form is essential for both requesting care within the VA system and in the community, depending on the Veteran’s eligibility and needs.
The signed RFS form is mandatory to facilitate thorough care review and authorization by the VA. To ensure timely processing, the completed form must be accompanied by all relevant supporting medical documentation, such as provider progress notes, procedure details, and laboratory and radiology reports. Community providers are given three business days to furnish any additional medical documentation requested by the VA; failure to do so may result in the denial of the request.
A blank RFS form is included in all referral packets provided to community providers and is also readily accessible online. To complete the form, providers must fill out all required fields accurately and clearly specify the type of service being requested.
Important Note: A separate RFS form is required for each distinct service requested, ensuring clarity and proper authorization for each aspect of care.
Access VA Form 10-10172, Community Care Provider-Request for Service (RFS).
The VA is committed to efficiency, processing RFS requests within three business days. Community providers are promptly notified of the decision via their preferred communication method, indicating whether the requested care will be provided within the VA or authorized in the community. If a request is denied, community providers are expected to contact the Veteran to discuss alternative treatment options and ensure continuity of care.
For comprehensive guidance on completing the RFS form, the VA offers a recorded training session titled Community Care Referrals (Enduring), accessible through the VHA Training Finder Real-time Affiliate Integrated Network (TRAIN). This training is a valuable resource for community providers seeking to master the RFS process.
Access the Community Care Referrals (Enduring) training on VHA TRAIN.
HealthShare Referral Manager (HSRM): Streamlining Referrals and Authorizations
HealthShare Referral Manager (HSRM) is a secure, web-based system at the heart of VA’s community care coordination efforts. This platform is specifically designed to facilitate the generation and submission of referrals and authorizations to community providers. HSRM empowers both community providers and the VA to more effectively manage community care for Veterans, leading to significant improvements in efficiency and communication. The system’s robust functionalities translate to reduced turnaround times for processing referrals, delivering timely care, submitting claims efficiently, and receiving prompt payment. Crucially, registration, comprehensive training, and ongoing technical support for HSRM are provided to community providers at no cost, underscoring the VA’s commitment to accessible and user-friendly tools.
Figure 1: HSRM Registration Steps for Community Providers
Key Benefits of HSRM:
- Facilitates Health Information Exchange (HIE): HSRM serves as a unified platform for seamless Health Information Exchange (HIE) between community providers and the VA, fostering better-informed care decisions.
- Flexibility for Specialized Referrals: The system provides the flexibility to easily refer Veterans for a wide range of specialized care services within the community.
- Streamlined Request for Services (RFS) Submissions: Community providers can efficiently submit Requests for Services (RFS) directly through the HSRM platform, simplifying the authorization process.
- Data-Driven Decision Making: HSRM generates valuable reports that inform decision-making, allowing for better tracking of workflow and identification of areas for process improvement.
- Clinical Viewer Module: Provides access to a clinical summary of Veterans’ medical history, including essential details such as diagnoses, prior medical procedures, and current medications, empowering community providers with crucial patient information.
To stay informed about the latest HSRM updates and enhancements, community providers are encouraged to subscribe to the VHA Office of Integrated Veteran Care (VHA IVC) Provider Advisor newsletter.
Sign up for VHA IVC Provider Advisor newsletter to receive HSRM updates.
Accessing HSRM: A Step-by-Step Guide
To gain access to HSRM and begin leveraging its benefits, community providers should first verify that their facility has an active Community Care Network (CCN) agreement with either TriWest or Optum, or a Veterans Care Agreement (VCA) directly with the VA. Once this is confirmed, follow these straightforward steps:
- Complete HSRM Training: Attend a live training webinar or complete the eLearning course available on the Veterans Health Administration (VHA) Training Finder Real-time Affiliate Integrated Network (TRAIN) website. These training resources provide comprehensive instruction on effectively using HSRM. Note: The VA strongly recommends attending a live training webinar for an interactive learning experience.
- Create and Verify ID.*me* Account: All HSRM users are required to sign up for an ID.*me* account and verify their identity. Detailed instructions are provided in the HSRM Account Creation and Single Sign-On External (SSOE) Quick Reference Guide.
- Submit End User Tracker (EUT): A designated point of contact from your organization must complete the End User Tracker (EUT), providing information for all staff members who require HSRM access. The completed EUT should be submitted to [email protected]. Note: Ensure that the email addresses entered in the EUT precisely match those used for each user’s ID.*me* account.
- Access Confirmation: The HSRM Help Desk will notify the point of contact to confirm when staff access to HSRM has been granted.
- HSRM Login: Once access is confirmed, all authorized users can access HSRM via the CCRA website at https://ccracommunity.va.gov. Note: For account reactivation requests due to deactivation, email [email protected].
After completing these steps and gaining HSRM access, it’s recommended to inform your partnering VA medical centers to facilitate a smooth transition to using HSRM for all Veteran care coordination activities.
HSRM Training and Resources:
The VA provides extensive training and resources to support community providers in utilizing HSRM effectively:
- HSRM System Training Webinars: Offered multiple times weekly through VHA TRAIN, these webinars provide in-depth walkthroughs of HSRM functionalities. Advance registration through a free VHA TRAIN account is required. Register for a virtual Community Provider HSRM Training Session.
- Extended HSRM Training Events: Two-part extended training sessions are offered weekly, providing a slower pace, more system demonstrations, and direct interaction with trainers. Registration via a free VHA TRAIN account is required. Register for the two-part extended virtual Community Provider HSRM Training.
- HSRM Registration Information Sessions: Weekly sessions via VHA TRAIN guide community providers through the HSRM access process, including ID.*me* account creation and EUT completion. Free VHA TRAIN account registration is necessary. Register for a virtual Community Provider HSRM Registration Information Session.
- HSRM eLearning: Self-paced eLearning modules are available 24/7 through VHA TRAIN, allowing providers to learn about HSRM at their convenience. A free VHA TRAIN account is required for access. Access all Community Provider HSRM eLearning courses.
HSRM FAQs:
- Staying Updated on HSRM: Subscribe to the VHA IVC Provider Advisor newsletter for the latest HSRM updates. Sign up for VHA IVC Provider Advisor newsletter.
- HSRM Usage Costs: HSRM is provided to community providers at no cost. It requires only internet access and a web browser.
- CCN Requirement for HSRM: HSRM is not exclusive to Community Care Network (CCN) providers. Providers with Veterans Care Agreements (VCA) are also encouraged to use HSRM. The VA encourages all community providers receiving Veteran referrals to utilize HSRM for all care episodes.
- Referrals to Non-HSRM Providers: VA medical centers can still refer Veterans to community providers not using HSRM, provided they are in the VA Provider Profile Management System (PPMS). In such cases, VA generates an “Offline Referral Form” in HSRM and sends it via traditional methods (fax, email) along with relevant medical documents.
HSRM Resources and Contacts:
| Category | Resource |
|---|---|
| Information | HSRM Resources |
| Registration | HSRM Registration |
| Education | HSRM System Training |
| Help Desk | Phone: 844-293-2272 | Email: [email protected] |
| HSRM Team | [email protected] |
| Support List | HSRM Support–Contact List |
External Websites:
Azure Rights Management Services (Azure RMS): Secure Email Communication
Since August 24, 2019, the VA has utilized Azure Rights Management Services (Azure RMS) for encrypted email communication, replacing Virtru Pro. Azure RMS facilitates secure information exchange with community providers via encrypted email, eliminating the delays associated with fax or mail. This system ensures safe communication of Veterans’ protected health information (PHI) through email, promoting timely and efficient collaboration.
How Azure RMS Works for Community Providers:
When a community provider receives an email from the VA encrypted with Azure RMS, they can seamlessly read and respond directly through their existing email provider. Alternatively, they can open the email in a web browser for secure reading and replying. No special software installation is required to access Azure RMS.
Accessing Azure RMS:
Azure RMS is accessed directly through email, just like regular emails. No additional software installation is needed to receive and reply to secure messages from the VA. Providers can also reply to older messages encrypted with Virtru Pro, with VA users able to open these responses via the Virtru Pro Secure Reader in a web browser.
Azure RMS FAQs:
- Prescription Transmission via Azure RMS: Currently, Azure RMS should not be used to submit prescriptions to pharmacies.
- Initiating Secure Emails to VA: Community providers cannot initiate secure emails to the VA using Azure RMS. They can only securely reply to VA-initiated emails and include attachments. Sending unsolicited secure emails to the VA may require additional software and licenses. For Azure RMS questions, contact the Azure RMS Project Team. [email protected].
- Further Information on Opening Encrypted Emails: Contact the VA Azure RMS Project Team for assistance or refer to Microsoft Support for information on protected messages. VA Azure RMS Project Team. Microsoft Support: Information on protected messages. Note: This Microsoft website is external to the VA network.
Azure RMS Resources and Contacts:
| Category | Resource |
|---|---|
| Support | [email protected] (for technical questions) |
| VA Locator | VA Facility Locator |
Veterans Health Information Exchange (VHIE): Enhancing Information Sharing
Many Veterans receive care from both VA providers and community providers. Veterans Health Information Exchange (VHIE) addresses the challenge of fragmented medical records by enabling the electronic sharing of Veteran health information between the VA and participating community providers. This bi-directional exchange, conducted over a secure network, includes critical medical history, allergies, medications, immunizations, and problem lists. VHIE significantly improves care coordination and the overall quality of healthcare for Veterans by ensuring providers have access to a comprehensive view of their patients’ medical history.
VA Exchange: Connecting VA and Community Providers
VA Exchange facilitates the crucial exchange of Veteran health information between the VA and community providers. Key features include:
- Secure Network Exchange: Health information is exchanged securely through your Electronic Medical Record (EMR) system over a protected network.
- Broad Partner Network: VA Exchange connects the VA with various partners, including other federal agencies, healthcare organizations, and health information exchange networks, expanding the reach of information sharing.
Important Note: For viewing referrals submitted by the VA, please utilize HealthShare Referral Manager (HSRM), which is specifically designed for referral management.
Download the VA Exchange Onboarding Flyer 2022
Conclusion: Strengthening Community Care for Veterans
Effective care coordination is paramount to ensuring Veterans receive the comprehensive and timely healthcare they deserve. The VA’s five-step care coordination model, supported by tools like HSRM, Azure RMS, and VHIE, provides a robust framework for collaboration between VA and community providers. By understanding and utilizing these resources, community providers can actively contribute to a seamless and Veteran-centered healthcare experience. Embracing these tools and processes is a testament to the community cares drug tool ethos – providing the essential instruments and collaborative spirit needed to empower community-based care and profoundly impact the well-being of our Veteran population.
