CASE MANAGEMENT (11)    TEAM PURPOSE (403.47)

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