As I was walking down the hall of the Community Living Center to speak with the medical director from the Geriatric Primary Care Clinic, Mr. Anderson (one of the Community Living Center residents) shouted to me, "Goddess Stir It Up" to which I replied, "Hello, Mr. Anderson. Good to see you today." The medical director who overheard this exchange laughed and said, "What did he call you, 'Goddess Stir It Up'? What an appropriate title for you."
I am not sure why I received this title. Mr. Anderson has named many of the female staff with the title "Goddess" followed by something else. But for me, as a case manager, I think I do have the reputation of stirring things up. I have the honor and privilege of being a case manager at the Hunter Holmes McGuire Veterans Administration (VAMC) hospital in Richmond, VA. In the Spring of 2015, I was working as a Transitional Care and Home Based Primary Care RN when a new position was posted to USA Jobs titled "Geriatrics and Extended Care (GEC) RN Navigator." I decided to apply, went through the interview process, and was offered the position. I officially became the first GEC RN Navigator in June 2016.
This role requires the following: expertise in case management for veterans with complex chronic illness; service as a subject-matter expert and consultant for Home and Community Based Services (HCBS) within GEC working closely with the interprofessional team; and to support implementation of appropriate and timely HCBS as part of a comprehensive veteran-centered plan of care for veterans and their caregivers.
Initially, I provided education to primary care providers (PCPs) and their care managers on GEC and HCBS and programs as well as assisting with identification and transition of appropriate senior veterans to these programs. This was an enormous assignment! I started at the beginning because educational material on these services did not exist. Often, consults were not pursued because of many reasons (e.g., missing information, incomplete forms, unmet eligibility requirements).
With more than 22 years of case management experience, I accepted the challenge and rolled up my sleeves. I invited myself to all four PCP clinics' monthly meetings. I supported program staff to develop educational materials for staff, senior veterans, and family caregivers. I designed a reference chart highlighting each service (or program) with its respective requirements (e.g., documentation, forms). I also designed a consultation path chart as an easy reference for PCPs to order the right consult for the right service. These documents are shared with every new PCP as part of their welcome to the VAMC. Each message includes my name and direct contact information as well as an invitation to reach out to me with any question pertaining to GEC services or programs. Today, each of our programs has an information sheet as well. I utilized the VA website (http://www.va.gov/Geriatrics) during the design and documentation process. This site contains a plethora of valuable resource for anyone seeking information pertaining to geriatric veteran-related services.
Upon returning from a VA-wide geriatrics meeting, one of our PCPs provided me with Shared Decision Making material. I enhanced this material, which is now part of the information packet distributed to veterans, families, caregivers, and staff at our facility. This is an excellent tool used to determine what services are needed, explore available options, and involve appropriate care team members in action planning. This packet provides veterans with information that empowers them and supports informed decision-making. It provides cues which they may use as a starting off point to ask for what they feel is needed rather than what we think they need. It gives the entire care team a starting off point from the patient's perspective.
Other resources now in place include a shared drive folder with program information and educational materials and a monthly newsletter for the primary care staff. I invite the GEC program staff to join me at primary care staff meetings, having them introduce themselves, and provide program information to the clinic staff. To top it all off, we held an inaugural Annual Senior Resource Spring Fling.
As the result of these efforts, I receive a continuous flow of calls and messages from providers requesting outreach to veterans to discuss our services and available care options. The word is out in the hospital that GEC has an RN Navigator. In addition to Primary Care, calls have come in from Vision Rehab, Amputee Clinic, Physical Medicine & Rehabilitation, Spinal Cord Clinic, and Renal Clinic. The program opened up a Pandora's box of needs and, thankfully, it is a thriving example of how we support our senior veterans.
As case managers, we do stir things up. That should never be considered a bad thing when the end result is for higher quality care coordination and improved outcomes. We help our patients (in my case, U.S. veterans) receive the right care, in the right place, at the right time, in an efficient fashion. The path we take to establish these programs is neither smooth nor straight but if we keep stirring things up, we ultimately find our inner Goddess.
Editorial note: Please be aware that the patient's privacy has been protected; his real name was not used in this editorial.