Case Management Referral Process

The Case Management Referral Process

Case management within Navy Medicine aims to support and develop the self-care capacity of beneficiaries with complex medical conditions and/or diverse support needs. An effective Case Management referral system aids in developing close relationships among all levels of the health system and helps to ensure patients receive the best possible care by the most appropriate service provider. A good case management referral system helps to ensure the following:

• Patients with complex care needs can access case management services in a timely manner.
• Case Management services are used optimally and cost-effectively.

What is the Case Management Referral Assessment Tool?

Utilizing the tool is easy. To get started:

• Download the Case Management Referral Assessment Tool from the link below and save to your computer desktop:
  Case Management Referral Assessment Tool


• Double click the file to open the tool.
• There are four blue tabs available to describe the patient’s current status. Select the blue tab that best describes the patient’s status based on the definition(s) provided:

Wounded, Ill, and Injured (WII)/Wounded Warrior Service Member:

• All eligible recovering service members undergoing medical treatment, recuperation, or therapy and are in an inpatient/outpatient status, who incurred or aggravated a deployment related injury or illness.

Seriously Injured/Ill (SI) or Very Seriously Injured/Ill (VSI):

• SI: The casualty status of a person whose illness/injury is classified by medical authorities to be of such severity that there is cause for immediate concern, but there is no imminent danger to life.
• VSI: The casualty status of a person whose illness/injury is classified by medical authorities to be of such severity that life is in imminent danger.

Warrior Program Enrollee:

• Any service member currently enrolled in/eligible for a branch of services’ Wounded Warrior Program and has been assigned or is eligible to be assigned to a wounded warrior program advocate.

Not applicable:

• The “Not Applicable” tab allows you to assess the patients according to the following categories:
  • General Medicine and Clinical Status
  • Health Care Access
  • Self-Care Ability
  • Basic Necessities and Life Skills
  • Mental Health/Psycho-Social Conditions
  • Substance and Alcohol Use/Misuse
  • Medication Adherence
  • Housing Circumstances
  • Benefits Procurement
  • Health Knowledge
  • Language and Cultural Barrier Occurrences
  • Military Related Concerns
• Select the down arrow next to each category to assess the current state. You must assess the patient in all 12 categories or the tool will not generate a score or provide EMR text.
• Select the grey “Generate EMR Text” tab.
• At this point the tool will provide a case management referral score and recommendation based on the information provided.
• Copy and paste the text directly entered into the Electronic Medical Record or referral as deemed appropriate.

Whom should I contact if I have questions?

• Your local Case Management Staff can answer questions about this tool or your MTF’s referral process.
• Care Management Program staff at the Bureau of Medicine and Surgery are also available to answer your questions regarding this tool and process

Case Management Referral Tool Workflow

1. Download the Tool

Download the Case Management Referral Tool to your computer

2. Navigate the Tool

• Open the Tool
• Does the patient meet one of the following categories:
  • Assess and score the patient accordingly in the following categories:
  • Seriously Injured, Ill (SI), or Very Seriously Injured/Ill (VSI)?
  • Enrolled in a Warrior Program?
• If “No” to all of the categories, select “Not Applicable”
  • Assess and score the patient accordingly in the following categories:
    • General Medicine and Clinical Status
    • Health Care Access
    • Self-Care Ability
    • Basic Necessities and Life Skills
    • Mental Health/Psycho-Social Conditions
    • Substance and Alcohol Use/Misuse
    • Medication Adherence
    • Housing Circumstances
    • Benefits Procurement
    • Health Knowledge
    • Language and Cultural Barrier
    • Occurrences
    • Military Related Concerns
  • Select the “Generate EMR” text box located at the bottom of the Case Management Referral Tool
  • Copy and paste the patient’s case management assessment score directly into the electronic medical record note and generate a case management referral, if necessary
• If “Yes” to any of the categories:
  • Select the tab that best identifies the patient’s current status
  • Select the “Generate EMR” text box located at the bottom of the Case Management Referral Tool
  • Copy and paste the patient’s case management assessment score directly into the electronic medical record note and generate a case management referral, if necessary