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Follow-up and complete episode: VA facility community care team will follow-up with the Veteran to ensure all services were performed appropriately, perform any necessary handoff and close the consult.

This helps streamline the flow of information between Veterans, VA community care integrated teams, VA providers, and the community provider.

Implement care coordination plan: VA facility community care integrated team will facilitate a collaborative relationship regarding all aspects of the care coordination process.

Care coordination involves determining the complexity of care needs of Veterans who receive community care followed by coordination of care delivery and transition back to VA.

Develop care coordination plan: Community providers and VA facility community care integrated team will develop an individualized care coordination plan to include: scheduling, navigation and other follow-up activities.

Assess Veteran needs: The VA facility community care staff determines the appropriate level of care coordination for each Veteran through the use of the Screening Triage Tool combined with clinical judgment.

Referrals and authorizations for community care are managed through the HealthShare Referral Manager (HSRM) system. It is the responsibility of the VA facility community care team to receive these requests, assign staff to manage them, and to confirm eligibility and authorize services indicated in the consult.

An inpatient admission or emergency department visit.

Several events can trigger the receipt of a request for community care, such as: VA’s care coordination model is a Veteran-centered, team-based approach involving five steps:

Strong care coordination between VA and community providers ensures Veterans receive timely and high-quality care. VA Software Documentation Library (VDL).Clinical Trainees (Academic Affiliations).War Related Illness & Injury Study Center.Average Administrative Cost for Prescriptions.Durable Medical Equipment/ Pharmacy Requirements.– Veterans Health Information Exchange Program.Spina Bifida Health Care Benefits Program.– Indian Health Service/Tribal Health/Urban Indian.

CHAMPVA In-house Treatment Initiative (CITI).Indian Health Service/Tribal Health Program.

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