Name | Value |
---|---|
TEAM PURPOSE | CASE MANAGEMENT |
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 |