VHA Office of Rural Health
Enterprise-Wide Initiative (EWI) - Care Coordination
Care Coordination and Integrated Case Management
Background
The Veterans Health Administration (VHA) provides health care for millions of Veterans, including many who live in rural or very rural areas. Many rural Veterans have trouble getting care because there are fewer local services, they often must travel long distances to VA facilities, and their internet may not be strong enough for video visits (telehealth).
To help, the VHA Office of Rural Health (ORH) started the Care Coordination and Integrated Case Management (CCICM) Enterprise‑Wide Initiative (EWI) in 2025. This program helps VA health care teams and community providers work together so Veterans get complete, Veteran‑centered care that fits their unique needs and goals.
CCICM creates clear structures and standards so different health professionals can work as a team across all parts of the health care system. It also focuses on social needs that affect health, such as housing, transportation, food, and support, to improve Veterans’ wellness, daily functioning, and quality of life.
Goals and Objectives
The main goal of CCICM is to make sure care is connected and coordinated across the whole health care system, from clinics to hospitals to community providers. The program aims to provide care that is safe, efficient, and cost‑effective for Veterans wherever they receive services.
Goals
By better integrating care, CCICM:
- Improves access to care for Veterans.
- Reduces repeated or overlapping services.
- Decreases “fragmentation,” where care is broken up and not well coordinated.
- Helps staff follow professional standards and best practices.
- Supports the staff who coordinate care for Veterans within VHA.
Objectives
- Count how many rural and highly rural Veterans live in each VA site’s service area.
- Review facility data to see which services use the most resources.
- Find rural Veterans who use a lot of VA and non‑VA (community) services.
- Define the main group of Veterans the program will serve by looking at their characteristics and their social drivers of health (SDOH), such as income, housing, and transportation needs.
Methodology
Clinical Resource Hubs (CRHs) use a hybrid care model that combines telehealth, care across multiple VA sites, and in‑person visits. This model helps the VA expand its capacity so more Veterans can receive timely, high‑quality care, even if they live far from a VA medical center. In this program, a Registered Nurse (RN) and a Social Worker (SW) work together as a team. They support rural Veterans who have moderate to complex medical and/or behavioral (mental) health needs and help them use VA and community services in a consistent and appropriate way. The CCICM ORH EWI focuses on fixing “fragmented” care, where Veterans may see many providers who do not always communicate or coordinate. It supports rural Veterans who have complex conditions and need strong care coordination and case management by:
1. Finding rural Veterans with complex needs. Using tools like risk scores and predictive analytics (data that helps predict who might need more help) to identify Veterans with complex medical and/or behavioral health needs.
2. Reviewing what level of support each Veteran needs. Completing a Complexity Assessment Review (CAR) to understand each Veteran’s care coordination, care management, and case management needs.
3. Holding a Care Coordination Review Team (CCRT) meeting. Bringing together a Care Coordination Review Team (CCRT) to choose the best person to be the Veteran’s Lead Coordinator (LC). The CCRT includes:
- Staff from different professions (multidisciplinary teams).
- Staff from different programs and services.
- Key partners from the VA Medical Center (VAMC).
- Provides clinical oversight – Acts as a clear, main point of contact who helps the Veteran and their family navigate the VA system and community providers.
- Reduces duplication of efforts – Helps prevent situations where several case managers or providers are doing the same work, especially when Veterans receive both VA and community care.
- Removes inconsistency of practice – Encourages shared standards so care is more consistent across VA and community providers.
- Meets educational and competency needs – Supports health education for Veterans by giving clear, consistent information and instructions, which reduces confusion when different providers give different messages.
The CCICM Evaluation Team studies how well these core functions are built into everyday care. They look at what helps or blocks integration and track outcomes of the program. Working with the VA Central Office CCICM Team, they use both qualitative (stories, interviews, feedback) and quantitative (numbers, data) methods at the same time. What they learn is used to improve program structure, processes, care delivery, and workforce support on an ongoing basis.
Impact on Rural Veteran Health
To date, 133 Veterans have an assigned Lead Coordinator and receive individualized care coordination, care management, and case management for their complex medical and/or behavioral health needs. In the first 90 days of the EWI, CCICM made a difference for rural Veterans in these ways:
Potential impacts for rural Veterans include:
- 155 rural and highly rural Veterans were reviewed to see what level of care coordination, care management, or case management they needed.
- Seven Veterans who had support from a Lead Coordinator gained enough skills to manage their health conditions on their own; they were considered to have reached “self‑management” and no longer needed an LC.
- Nine Veterans had fewer hospital readmissions, which can improve Veteran satisfaction, build self‑management skills, and show better health outcomes
These early results suggest that CCICM can help reduce hospital use and support Veterans in managing their own care more confidently.
Key Takeaways
VA Medical Centers (VAMCs) with a dedicated CCICM RN and SW team are better able to follow national standards for case management. They do this by:
- Integrating CCICM into everyday clinical practice and teaching RNs, SWs, and case managers about care coordination, care management, and case management based on research and evidence.
- Creating structures and processes that support collaboration across the full continuum of care and make good use of health care resources.
- Identifying rural and highly rural Veterans who have complex medical and/or behavioral health needs and require strong care coordination or case management.
The CCICM team works with many types of staff to decide who is best suited to care for each Veteran. A Lead Coordinator is then assigned to provide evidence‑based case management and to help Veterans build self‑management skills so they can better manage their own health over time.
Download the Printable PDF for Healthcare Providers and Researchers.
Contact
- Francesca Bryan Couch, EWI Program Manager / Care Coordination and Integrated Case Management (CCICM) Field Advisor, VA Central Office, Washington, DC. Francesca.Bryan-Couch@va.gov
- Funding Acknowledgement: Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD #PRFY‑00643.
- Suggested Citation: Bryan‑Couch, F. & Melillo, C. (2025). Care Coordination and Integrated Case Management (CCICM). Department of Veterans Affairs, Veterans Health Administration. Washington, DC: Office of Rural Health.
Rural Health - Navigation
- Office of Rural Health Home page:
https://www.ruralhealth.va.gov/index.asp - Enterprise-Wide Initiatives (EWI) page:
https://www.ruralhealth.va.gov/Enterprise-Wide-Initiatives-EWI.asp - Veterans Rural Health Resource Centers (VRHRC) page:
https://www.ruralhealth.va.gov/Veterans-Rural-Health-Resource-Center-VRHRC.asp
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