Article Content

The mission of Veterans Affairs (VA) is "to care for him who shall have borne the battle" (Lincoln, 1865, p. 2). Nowadays, the VA upholds this mission as the largest federal health care system in the United States, providing health care services to veterans and active-duty service members in the U.S. Army, Navy, Air Force, National Guard, and Military Reserves (National Center for Veterans Analysis and Statistics, 2017; U.S. Department of Veterans Affairs, 2019).

 

Following the wars in Iraq and Afghanistan, the number of veterans cared for in VA facilities approached 10 million (Huang et al., 2017). By 2019, the number of veterans receiving services in the VA was about 5 million annually (National Center for Veterans Analysis and Statistics, 2019). Concurrently, the ability of VA leadership and staff to provide coordinated access to health care services was questioned, threatening the long-standing mission of the VA (Greenstone et al., 2019).

 

U.S. government reports of VA health care services revealed deficits in access to timely care and coordinated services for veterans. Solutions to these reported shortfalls included legislative and fiscal support for case management programs and services (National Defense Authorization Act, 2008; U.S. Department of Veterans Affairs, 2018; U.S. Government Accountability Office, 2012; Veterans Access to Care Act, 2014,2017; Veterans Affairs MISSION Act, 2018; Veterans Affairs Office of Inspector General Report, 2014; Veterans Affairs Testimony, 2019). Despite the addition of numerous case management services, programs, and resources, veterans continued to report dissatisfaction with the VA (Survey of Healthcare Experience of Patients, 2018). According to 2018 survey responses, the top two complaints of more than 50% of veterans about the VA were a lack of timely access to health care and coordination of health care services.

 

Purpose and Objectives

Care coordination in the VA is a unique challenge for veterans with more complex care needs than nonveterans. In addition, the critical work of VA case managers is to assist and advocate for veterans navigating the VA and civilian health care systems, aligning services, developing integrated care plans, and supporting team-based care (Hunt & Burgo-Black, 2011). To better understand the current role of VA case managers, this article first provides a brief review of the history of VA case management. A systematic review of the VA case management literature is then assessed using a leadership conceptual framework.

 

VA Case Management: Background

A substantial shift in the practice of nursing and case management occurred in the mid-1980s when private sector insurers developed managed care programs intended to contain costs incurred by catastrophically ill and injured persons (Keeling et al., 2018). Similarly, VA case management programs focused on severely ill and injured patients during the Iraq and Afghanistan wars from 2003 through 2014. This focus resulted in a gap in care for veterans with invisible, but devastating, war wounds including mild traumatic brain injury, posttraumatic stress disorder, and chronic pain (Lew et al., 2009). Congressionally mandated programs were developed to address these gaps in care coordination.

 

VA case managers are required to manage and lead in a constantly evolving government organization but are not necessarily provided academic leadership training (Choy-Brown et al., 2020; Major, 2019). It remains unclear to what extent the role of VA registered nurse (RN) and social work (SW) case managers has been evaluated for leadership elements and the influence on implementation of congressionally mandated programs.

 

Leadership Conceptual Framework and the VA Case Management Model

To determine how best to evaluate leadership in the VA case management and All Employees Survey (AES) literature, 22 leadership theories and principles applicable to case managers were considered (Antonakis & Day, 2017; Callahan & Grunberg, 2019; Grunberg, Barry, Callahan, et al., 2018; Nohria & Khurana, 2010; Northouse, 2019; see Table 1). The Leader-Follower Conceptual Framework (LF2) was chosen as most appropriate to evaluate the literature based on its clarity and comprehensive inclusion of essential leadership elements (Callahan & Grunberg, 2019; Grunberg, Barry, Callahan, et al., 2018). The LF2 draws upon many leadership models to identify, educate, and train adaptive and effective health care leaders and is used at the Uniformed Services University of the Health Sciences School of Medicine and Graduate School of Nursing, comparable settings to the VA federal health care system (see Figure 1).

  

TABLE 1 Leadership Models, Principles, and Theories

 

FIGURE 1. Leader-Follower Conceptual Framework (LF2)(

According to the LF2, leadership is defined as "influence on individuals and groups by enhancing behaviors (actions), cognitions (perceptions, thoughts, and beliefs), and motivations (why people act and think as they do) to achieve goals that benefit individuals and groups" (Barry, Grunberg, Kleber, McManigle, et al., 2018, p. 99). The delivery of case management services in the VA requires leadership skills and can be complicated by evolving demographics, unique diagnoses, socioeconomics, and aging vulnerabilities of veterans. The standards of practice for VA case managers dictate that services are provided to satisfy health care needs while promoting the highest standards of resource utilization, crisis intervention, and veteran outcomes, across a variety of environments (VHA Handbook 1110.04, 2021). Case managers are patient advocates who navigate the health care system to guide veterans' health care plans. Clear and frequent communication among members of an interdisciplinary team, veterans, and their caregivers is essential for successful case management outcome.

 

The practice requirements of VA case managers are represented in the LF2 four "C" leadership domains: Character, Competence, Context, and Communication. Character refers to who the leader is and all aspects of the individual, including attributes, personality, attitudes, values, charisma, and physical characteristics. Competence refers to what the leader knows and does, including role-specific and transcendent knowledge and skills (e.g., problem-solving skills, decision-making, emotional intelligence, conflict resolution). Context refers to when and where leadership occurs and includes physical, psychosocial, and cultural environments. Communication refers to how the leader interacts with others, including sending and receiving verbal and nonverbal information.

 

The LF2 operates at four psychosocial levels (PITO): Personal aspects of the individual, including self-awareness; Interpersonal interactions between people; Team interactions; and Organizational aspects of large groups, institutions, and systems. The LF2 also applies to followers (or team members) because without followers, there cannot be leaders or teams (Barry & Grunberg, 2020; Callahan & Grunberg, 2019; Grunberg, Barry, Kleber, et al., 2018).

 

To address each veteran's physical and psychosocial needs, a close collaboration between RN and SW case managers provides the most comprehensive approach to care coordination. This interprofessional case management model supports veterans as they maneuver across health care settings, ensuring the provision of safe, high-quality, and cost-effective services (VHA Handbook 1110.04, 2021). Therefore, RN and SW case managers operate within the four "C" leadership domains and across the four psychosocial levels of the LF2 that overlap and interact (Jackson et al., 2010; Price, 2004; U.S. Air Force Academy, 2017).

 

Literature Review: Methods

The terms "case management," "care coordination," "outcome measures," and "leadership" were used to perform a literature search of publications from 2008 to 2021 via PubMed and CINAHL search engines. This search generated 605 separate articles, but less than 5% of these articles related to case management leadership and patient health care outcomes. Therefore, the search was repeated adding the words "veterans" and "Veterans Affairs" and removing the terms "outcome" and "measure." The second search yielded 25 articles.

 

Publications regarding the VA AES also were reviewed for relevance to VA case managers, care coordination, organizational change, and leadership, because the VA AES assesses workforce satisfaction with VA organizational health and culture (National Center for Organizational Development, 2016; Osatuke et al., 2012). Of the AES publications, 20 were relevant to leadership and case management and were included in the literature review.

 

Case Management and AES: Literature Review

Articles addressing VA case management and the AES were reviewed according to study design and methods; overall strengths, weaknesses, or gaps in findings; central theme of the article; and the presence or absence of leadership elements. Themes that emerged from the case management review included organizational change/redesign assessment; case management and care coordination model assessment; clinical program assessment; nursing and case management competency assessment; team program assessment; and veteran experience (see Table 2). Themes from the AES literature included organizational change; employee satisfaction; interpersonal engagement; and teamwork (see Table 3). Of the 45 articles reviewed, six identified all eight LF2 leadership elements; two identified seven; 12 identified six; 10 identified five; nine identified four; two identified three; and four identified two of the eight LF2 leadership elements.

  

TABLE 2 VA Case Management and Leadership Literature Review

 

TABLE 3 VA All Employee Survey Literature Review

The VA case management literature incorporated elements from the LF2, but the discussion of leadership elements relevant to case managers was vague and mostly addressed program evaluation and implementation. The three articles describing unsuccessful program implementation reported a lack of adaptability of staff, a lack of staff resources and training, a lack of leadership involvement, and a fear of reprisal related to unmet predetermined metrics (Ball et al., 2017; Chinman et al., 2017; Kertesz et al., 2015). Although all eight LF2 elements were identified in these three articles, the findings reveal the need for specific and clear case management leadership evaluation to influence future program implementation success and sustainment.

 

The two articles addressing transitions in care between the Department of Defense and the VA are clearer with regard to leadership and case management. A description is offered about the lead coordinator (LC) initiative and the assignment of a lead case manager as a single point of contact for each veteran (Perla et al., 2013). The role of the LC is described as a specifically chosen case manager with knowledge of the veteran's health care plan, relaying vital information between health care providers and the veteran. The LC is described in a manner that is consistent with the leadership elements of the LF2. According to Greenstone et al. (2019), the Care Coordination and Integrated Case Management (CC&ICM) initiative evolved the LC role and case management approach. The case managers described in both the LC and CC&ICM publications are described as invested in a common goal (Callahan & Grunberg, 2019).

 

The use of organizational change theories to analyze adaptability and resistance of staff to change occurred in five of the AES publications. One study included all eight LF2 elements and described a program designed to improve civility in workgroups, termed CREW, representing Civility, Respect, and Engagement in the Workplace (Osatuke et al., 2013). The theme of employee engagement was noted in five of 20 (25%) AES publications, with civility and respect influencing employee satisfaction. Although an evaluation of case managers per se was not evident, all eight leadership elements were identified within the five articles.

 

The AES publications related to VA case managers and care coordination included the themes of teamwork and managerial self-awareness-leadership elements explicitly described in the LF2. Benzer et al. (2011) indicated that relational climates in diabetic and primary care clinics increased the likelihood of patient compliance. A positive relational climate is often critical to whether veterans keep their appointments and adhere to medication regimens and is vital to a therapeutic relationship in general. A review of Gittell and Hajjar (2019) further supported the use of the LF2 to analyze the levels of interaction applicable for successful relational climates in the VA.

 

Additional topics germane to case managers included the AES publications addressing managerial self-awareness, the impact of burnout (Hernandez et al., 2015), and Freedman's theory on organizational change (Osatuke et al., 2014). According to the LF2, good leaders are aware of their contextual setting and the impact of their personal and interpersonal interactions (Callahan & Grunberg, 2019). The self-awareness of case managers is essential to improve veteran satisfaction and for the self-actualization of competent nurses and social workers. According to Freedman's theory on organizational change, the experience of change might be better managed by both seeking and offering support throughout the change process. Support through change is typically offered from leader to subordinate. According to the LF2, the leader can offer support to the follower who may become a newly empowered leader, who then supports other followers who, in turn, become empowered leaders (Barry & Grunberg, 2020). Accordingly, VA case managers fluctuate between leader and follower roles in their organization, on teams, in dyads, and on an autonomous personal level.

 

Major Findings

The literature review revealed a modest amount of literature on VA case management and leadership elements. In addition, scarce literature about case managers and leadership was identified in the VA AES publications. Throughout the VA case management and AES literature, several publications pointed to problems with program implementation, but few provided solutions and fewer provided insight into leadership elements that are present, need bolstering, or are absent among case managers. The literature also indicated a repeated theme between unsuccessful program implementation and an associated lack of staff adaptability, a lack of necessary resources, a lack of ongoing involvement of senior leaders, and a fear of reprisal (Ball et al., 2017; Chinman et al., 2017; Kertesz et al., 2015).

 

Several publications suggested that VA case managers lead as well as manage without indicating the extent to which they function as leaders (Benzer et al., 2014; Chinman et al., 2017; Perla et al., 2013; Richmond, 2017). The findings indicated that the LF2 is an applicable framework to identify leadership elements in publications, with at least two leadership elements identified in the 45 articles reviewed.

 

Application of Findings

Those case managers who have leadership skills, such as teaming, self-awareness, problem-solving, consensus building, patient advocacy, collaboration, and decision-making capability, are more effective and more satisfied in the work they do (Korner et al., 2015; Schutt et al., 2010). Case managers must have these skills and the authority to act on behalf of patients (Case Management Society of America, 2016).

 

The literature review on VA case management, the VA AES, and on leadership conceptual models points to the need for a systematic assessment of VA case management and leadership. In addition, implementation science could be used to evaluate the success or failure of new VA programs as well as case management staff satisfaction and leadership qualities (Kilbourne et al., 2018).

 

Implications for Case Management Practice

The 2018 MISSION Act permits veterans to seek health care services in the community. This unprecedented change resulted in increased case management demand and further complicated the existing care coordination system (Greenstone et. al., 2019). It is crucial to retain case managers with leadership skills as the VA navigates these complex and unique challenges. An understanding of the leadership elements influencing successful care coordination is vital to promote veteran satisfaction with safe, high-quality health care services.

 

Further research is needed to assess the annual VA AES and the responses of RNs, social workers, and case managers utilizing a leadership conceptual framework. Attention to leadership development among case managers would likely improve morale, retention, and performance.

 

Limitations

The lack of publications related to case managers limits firm conclusions regarding associations about leadership elements and case manager performance.

 

Future Directions

The number of veterans seeking services in the community is expected to increase the workload for VA case managers attempting to coordinate VA services as well as private sector resources. A review of the VA case management and AES literature indicates that an understanding of the leadership elements influencing case managers is lacking. As veterans now seek health care services in the private sector, a lack of care coordination may, in part, be a result of the lack of the leadership skills or knowledge of VA case managers. The present literature review indicates that leadership qualities of case managers merit further evaluation. Future research should apply a conceptual leadership framework to assess leadership elements of VA case managers on the annual VA employee survey and compare leadership elements among nurse and SW case managers.

 

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Yanchus N. J., Periard D., Moore S. C., Carle A. C., Osatuke K. (2015). Predictors of job satisfaction and turnover intention in VHA mental health employees: A comparison between psychiatrists, psychologists, social workers, and mental health nurses. The Human Service Organizations: Management, Leadership, & Governance, 39(3), 219-244.

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For more than 52 additional continuing education articles related to Case Management topics, go to http://NursingCenter.com/CE.

case management; leadership; registered nurse; social worker; Veterans Affairs