| DESCRIPTION |
The Case Manager is responsible for collaborating with services internal
achieving desired outcomes for discharge, post hospital recovery and
health maintenance/wellness.
or external to the VA to manage the care of patients with needs of a
complexity level that exceeds the capability of the Primary Care Teamlet
to manage. The Case Manager is responsible for collaborating with
services external to the VA to facilitate care transition in order to
effectively meet the patients' needs, provides patient and family health
education with a focus on self-management, prevention, and wellness based
on the patients goals, and collaborates with patients to assess and
identify needs, issues, care goals, and resources in critical factors for
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