Patient Care Services

Care Management and Social Work

The Department of Veterans Affairs (VA) Care Management and Social Work (CMSW) is leading VA's transformation to a Veteran-Centric organization that places Veterans and their families first. CMSW programs provide a vast array clinical services, which address the needs of wounded, injured and ill Servicemembers, Veterans, their family members and family caregivers, with care and compassion throughout the Veteran's Health Administration. 

Care Management and Social Work Services(CMSWS)
   - Social Work
   - Survivors Assistance and Memorial Support (SAMS) Program
   - Fisher House Program
   - Intimate Partner Violence Assistance Program (IPVAP)
   - National Advance Care Planning via Group Program
   - Post-9/11 Transition and Case Management 
   - VHA Liaisons to Health Care
   - VA Liaisons for Health Care with Military Treatment Facilities

• Partner Violence (DV/IPV) Assistance Program: The VA Intimate Partner Violence Program addresses the identification of IPV and access to services for Veterans with the aim of maintaining or establishing the physical, emotional and psychological safety and well-being of Veterans and their families. Program implementation across VHA expands, screening, prevention, and intervention services to Veterans and strengthens collaboration with community partners.  The focus is on developing a culture of safety and adopting a holistic, trauma-informed, Veteran-centered approach to services and support for those Veterans using and experiencing intimate partner violence.

• Fisher House & Family Hospitality Program: This highly acclaimed program provides national oversight for the Temporary Lodging and Fisher House Programs. The Temporary Lodging program (generally referred to as “Hoptel”) provides temporary lodging for Veterans receiving outpatient VA medical care or Compensation and Pension (C&P) examinations. Veterans may be accompanied by family members or Caregivers to provide additional support during the course of treatment.  Temporary accommodations may be provided in non-utilized beds and rooms at a VA health care facility, or lodging facilities in the community such as hotels or motels. The VA Fisher House Program provides temporary accommodations for the family and Caregivers of hospitalized Veterans and Active Duty Servicemembers.  Fisher House Foundation builds and donates a comfortable “home away from home” to VA Medical Centers that enables families to be together during a loved one’s extended treatment for serious illness or lengthy rehabilitation.  Fisher Houses are built on the premise that “a family’s love is good medicine,” and when a loved one is ill or injured, the Fisher House unites families and relieves the financial and emotional strain of being away from home. Fisher Houses provide a warm and compassionate environment where families and Caregivers find support and encouragement from others in similar circumstances.  There is no charge for guests to stay at a VA Fisher House. Link to Fisher House information.

• Social Work: Social workers are an integral part of the Veterans Health. Social workers support and advance the mission by providing high quality psychosocial services to Veterans, their families, and /caregivers.  Social workers are Licensed Independent Practitioners and are highly valued as interdisciplinary team members. Social work services are a key component in the continuum of clinical services provided to Veterans in VHA facilities.  Social workers assist Veterans by helping them cope with and solve issues in their everyday lives.  They connect Veterans with services and programs to meet their emergent needs. The Social Work Program provides policy development for the professional practice of social work for VA’s social work programs nationwide. VA is the largest employer of social workers in the Nation with over 12,000 Master’s prepared social workers. VA trains more social work graduate students than any other single agency. The social work allied health trainee program in collaboration with the Office of Academic Affiliations offers approximately 1,000 stipends per year and helps meet succession planning for social work. Link to Social Work Site.

• Military2VA Case Management Program: VA provides comprehensive transition assistance and case management for wounded, ill and injured Post-9/11 Veterans. Since 2007, each VA Medical Center has had a program dedicated to serving Post-9/11 Service members and Veterans, now known as the Post-9/11 Military2VA Case Management (M2VA CM) Program. M2VA CM teams are highly experienced and specially trained in the needs of returning (combat and noncombat) Servicemembers and new Veterans. These teams coordinate patient care activities and ensure that Service members and Veterans are receiving patient-centered, integrated care and benefits. M2VA CM clinical case managers screen all new Veterans for the need for case management services to identify those who may be at risk, ensuring that VAs intervenes early to provide assistance before a Veteran is in crisis. In addition to prevalent medical and mental health issues related to deployment, this screening includes the risk factors for psychosocial issues such as homelessness/ housing insecurity, unemployment, and substance abuse. Severely ill and/or injured Service members and Veterans are provided a case manager and other Post-9/11 Service members and Veterans are assigned a case manager as indicated by a positive screening assessment or upon request. Post-9/11 Veterans may request case management services at any time during the continuum of care and can receive case management as long as needed. Accessing Post-9/11 M2VA CM teams for assistance with care coordination and case management ensures early engagement, a plan of care and follow up to promote wellness and a seamless reintegration back into the community. Post-9/11 Transition and Case Management Home (va.gov).
  
  
• Survivors Assistance and Memorial Support (SAMS) Program: Every Veteran and survivor deserves the highest caliber of care as a Veteran transitions through end of life. For this reason, VHA is establishing a Survivors Assistance and Memorial Support (SAMS) Program to provide personalized, supportive services to families, caregivers, and survivors at the end of a Veteran's life and ensure Veterans without identified family receive dignified burials to honor their service. VHA convened an Integrated Project Team (IPT) in January 2023 to begin establishing a new program for standardizing processes and executing an engagement strategy. Comprised of America’s best health care professionals working together with Veterans Benefits Administration and National Cemetery Administration the IPT will produce a new SAMS policy, processes, tools, and products incorporating best business and clinical practices. We are committed to providing exceptional care to families, caregivers, and survivors during an extraordinarily challenging time of their lives - the loss of a loved one.

• VA Liaison for Healthcare Program: VA has 43 VA Liaisons for Healthcare stationed at 21 of the major MTFs with high concentrations of recovering Servicemembers returning from theaters of combat. These VA Liaisons, who are either social workers or nurses, facilitate the transfer of wounded, injured and ill Servicemembers and Veterans from the MTF to a VA health care facility closest to their home or most appropriate for the specialized services their medical condition requires. VA Liaisons collaborate with the MTF treatment team to ensure that VA services are accessed for a Servicemember as early as appropriate for their clinical condition.  VA Liaisons are co-located with DoD Case Managers at MTFs and provide onsite consultation and collaboration regarding VA resources and treatment options.  VA Liaisons contact treatment teams, including specialty services, from VA facilities nationwide to engage with patients prior to separating from active duty. VA Liaisons meet with Servicemembers directly to provide education about VA healthcare benefits and services as well as discuss the individual’s healthcare needs and the VA system of care. They identify and communicate healthcare needs to the VA healthcare facility closest to the Servicemember’s home or most appropriate location for the specialized services the medical condition requires.

return to top