TRO North/Health Net Federal Services
Warrior Care Support Program
In the North Region, Health Net’s Warrior Care Support (WCS) Program has allowed Health Net to meet the needs of more than 1,100 wounded, ill, or injured (WII) Service members since its inception in August 2007. The WCS Program is designed to provide assistance when case management responsibility is retained by the military treatment facility (MTF) or, when requested by the MTF, to take full case management control. Once MTF has determined that care for a WII Service member will be delivered within the civilian health care sector, the WCS Program either coordinates care plans with the MTF Case Management person of contact (POC), or it directly connects the WII to a single Health Net POC for total health care support. WCS leaves the navigation of health care services to the Health Net Health Care Coordination (HCC) Team and allows Warriors and their families to focus their time and energy on healing and recovery.
Following a Warrior’s transfer of care, the HCC serves as the Warrior’s single point of contact, personally providing guidance through the civilian care continuum to facilitate best-in-quality health care and to improve the Warrior’s quality of life. The coordinator will work with MTF and Veterans Affairs (VA) physicians, physical therapists, the Federal Recovery Coordinators, and other health care providers to coordinate care; empower Warriors with knowledge about their health care choices as they make decisions about their care; and assist with referrals and authorizations care.
Health Net’s HCC Team includes handpicked professionals with experience in utilization management, transitional care, case management, social services, and behavioral health services. In addition, Health Net’s team of physicians works closely with Health Net care coordinators to provide support and counsel.
The TRICARE Regional Office Clinical Operations Division and the TRO VA Liaison are also actively engaged in ensuring the needs of our WII Service members are met.
Traumatic Brain Injury (TBI)–Coordination of Benefits
Nursing Home Care (Nonnetwork)
Situation: A medically retired Marine Corporal who suffered a blast injury in Iraq during March 2004 was diagnosed with TBI along with several other physical injuries.
He received the majority of his medical care at the Washington, District of Columbia (DC) VA Medical Center (VAMC). However, he was also enrolled as a retiree to TRICARE Prime at Walter Reed Army Medical Center. Due to his many physical problems, he received multiple referrals to several civilian medical providers. There was a significant amount of confusion for the Marine and his family as to who was referring the care and how the care should be authorized and paid for.
Response: Health Net Federal Services and the TRO-North VA Liaison worked together on the Marine’s behalf to provide case management/care coordination, and to ensure proper referral and authorization was provided by the appropriate referring agency
(VHA or Department of Defense (DoD)).
Behavioral Health–Coordination of Benefits
Situation: An active duty Service member (ADSM) from the Erie, PA area had completed his acute rehabilitation at the Minneapolis Polytrauma Center. His condition did not warrant his return home, and he was in need of nursing home placement. The standard practice when a community based nursing home is identified as the next level of care has been for the local VA to contract with the community nursing home. TRICARE provides a preauthorization and the ADSM gets the necessary care without delays. In this case the family selected a VA contract home, hoping that the patient would receive a Service Connected rating and remain there under VA contract for the long term. The facility did not have a TRICARE contract.
Response: After discussions between the TRO-North VA Liaison and Health Net Federal Services, the facility was contacted and they agreed to provide care to the ADSM with reimbursement through TRICARE.
Severe Multiple Physical Trauma Motorcycle Accident
Situation: An active duty Army soldier required mental health services and primary care at the Albany VAMC while on convalescent leave. The care had not been coordinated in advance by the enrolled MTF. The Albany VAMC was notified by the Service member’s mother of the required care. Due to the specific type of medical care needed by the Service member, a referral written by a physician was required. The Albany case manager had trouble making contact with the appropriate MTF POC to request a referral and authorization for mental health services and primary care.
Response: The TRO-North VA Liaison and Health Net Federal Services combined efforts to assure the MTF POC was contacted and an appropriate referral was written. The Service member received the required care.
TBI Motor Vehicle Accident
Situation: ADSM sustained severe trauma with extensive multiple fractures to the upper and lower extremities from a motorcycle accident. The injuries required multiple surgeries and constant wound care. Health Net coordinated transfer to a skilled nursing facility until an additional series of surgeries were needed, and ADSM was moved back to an acute care facility. Once stable and in full recovery, ADSM was transferred home, and outpatient physical and occupational therapy was arranged.
Response: Health Net worked in tandem with MTF and directly with ADSM to provide seamless transitions throughout multiple transfers to various facilities and periods of out-patient care, ensuring all needs were being met and quality care services were provided. This ADSM continues working with a dedicated Care Coordinator through Health Net’s Warrior Care Support (WCS) Program and will do so until medically boarded out of the Service. When that occurs, Health Net’s WCS program ensures ADSM a smooth transition into the next care contingency, which might include the VA or civilian care.
TBI, Newly Blind Combat Related
Situation: As the result of a motor vehicle accident, ADSM sustained traumatic brain injuries (TBI) causing subarachnoid hemorrhage and limited movement in the limbs due to spasticity. ADSM lives with his grandmother, his primary care giver, who has found herself overwhelmed with his needs.
Response: Health Net’s role has been to communicate with all parties, educate on the processes in place and the steps needed to arrange services, recommend alternative resources, and to encourage and support caregivers. In this case, Health Net offered the following actions:
- Worked with MTF case manager to identify a home care agency and obtained Primary Care Manager (PCM) orders for home health services and follow-up visits to specialists;
- Facilitated a line of communication between the grandmother and occupational therapist to determine the appropriate chair to assist the ADSM with transfers in and out of bed;
- Provided the caregiver access to a TRICARE medical supplies network provider to mitigate costly weekly purchases at a nearby store; and
- Collaborated and shared information and ideas on alternative resources with the MTF case manager, VA social worker/case manager, the Navy/Marine Relief Nursing Corps, and other military community resources for the grandmother, which resulted in her receiving a stipend for the care of her grandson and a new home with wheelchair accessibility.
TBI, Post Traumatic Stress Disorder (PTSD) Combat Related
Situation: ADSM incurred a combat-related TBI and blindness. When ADSM was sent home after receiving care from an inpatient rehabilitation facility, his mother, who is also a nurse, was identified as the primary caregiver. Though capable, the mother expressed difficulty understanding the Military Health System (MHS) process. A civilian family physician and a neurologist in their local area were identified and are providing ongoing care until this ADSM’s medical board, retirement, and military discharge are complete.
Response: Health Net provided the beneficiary and his mother education on civilian caregivers and local medical resources to meet their specific medical needs, as well as keeping the case manager at the MTF informed of ADSM’s progress in outpatient therapies. Health Net’s Health Care Coordinator ensured that the primary caregiver, ADSM’s mother, had a clear understanding of MHS process, as well as reassurance and support of how she was caring for her son. Constant, concise, and clear communication was the key to successfully ensuring quality care for this Service member.
PTSD, Multiple Physical Health Problems Combat Related
Situation: A TRICARE Prime Remote (TPR) ADSM sustained combat related TBI and PTSD, which resulted in persistent headaches, night terrors, anxiety attacks, tremors, inability to focus, and feeling that he was not able to adequately function as a recruiter. He received care at a local civilian provider and, following a series of exams and tests, was not confident that the provider understood his injuries or symptoms.
Response: Health Net enrolled ADSM into our WCS Program, immediately researched the nearest VA hospital, and once it was determined that they treat TBI and PTSD, obtained a referral through TRICARE for him to be treated by VA.
ADSM excitedly reported back to the HCC that upon his first appointment at VA, he was assigned an escort to guide him through appointments. He was also evaluated and treated for TBI and later, PTSD. ADSM relayed that he was satisfied with his care at VA. He will continue to receive care via VA system and will remain enrolled in Health Net’s WCS program to track and be available to coordinate quality care.
Situation: Army Staff Sergeant who served for 21 years (11 years reserve and 10 years active duty) has been deployed on 2 tours of duty to Iraq and is a Bronze Star recipient. During his service, ADSM had been exposed to numerous improvised explosive device (IED) explosions and now suffers from tinnitus, hearing loss, migraine headaches, memory loss, inability to express himself clearly, and multiple other physical health problems.
In July 2007, the Staff Sergeant was referred for neuropsychological testing but was not aware that he had to make his own appointment, and thus wasn’t seen. Two months later, he was referred for PTSD and then enrolled into the Health Net WCS program.
Response: A HCC, who serves on the WCS team, who served on the WCS team, worked with the Staff Sergeant for several months, provided encouragement, and suggested therapy for spousal and family matters. HCC provided continual updates to the Warrior Transition Unit (WTU) case manager on the Sergeant’s status and needs to ensure quality, and that needed care was being provided.
Currently, the Staff Sergeant uses a wheelchair but can walk with a cane, uses a Transcutaneous electrical nerve stimulation unit for back pain, and uses braces for the severe arthritis in his knee. To manage it all, he takes over 22 pills a day.
In March 2008, the Sergeant retired with 60 percent permanent medical retirement and 100 percent VA disability. He is participating in the Vocational Rehabilitation Center, a first of its kind facility created through a unique public-private partnership of Paralyzed Veterans of America (PVA), VA, and Health Net to learn skills to enter back into the work force, and in turn be a better father. He now assists other members in the WTU and is helping those who are experiencing difficulty in navigating through the system. The Staff Sergeant states that he will keep his Health Net Warrior Care Support card, with his coordinator’s number on it, in his wallet, as a permanent reminder of the individualized care and assistance that he received.