Community Care

Strong care coordination between VA and community providers ensures Veterans receive timely and high-quality care. VA’s care coordination model is a Veteran-centered, team-based approach involving five steps:

1. Receive request for community care: Several events can trigger the receipt of a request for community care, such as:
   • A new Veteran clinical appointment
   • A hospital notification
   • Referral from VA or community provider
   • An inpatient admission or emergency department visit.

It is the responsibility of the VA facility community care team to receive these requests, assign staff to manage them, and to confirm eligibility and authorize services indicated in the consult. Referrals and authorizations for community care are managed through the HealthShare Referral Manager (HSRM) system. See below for more information.

2. Assess Veteran needs: The VA facility community care staff determines the appropriate level of care coordination for each Veteran through the use of the Screening Triage Tool combined with clinical judgment.
3. Develop care coordination plan: Community providers and VA facility community care integrated team will develop an individualized care coordination plan to include: scheduling, navigation and other follow-up activities. Care coordination involves determining the complexity of care needs of Veterans who receive community care followed by coordination of care delivery and transition back to VA.
4. Implement care coordination plan: VA facility community care integrated team will facilitate a collaborative relationship regarding all aspects of the care coordination process. This helps streamline the flow of information between Veterans, VA community care integrated teams, VA providers, and the community provider.
5. Follow-up and complete episode: VA facility community care team will follow-up with the Veteran to ensure all services were performed appropriately, perform any necessary handoff and close the consult. Throughout the episode of care, facility community care staff should be monitoring and tracking the Veteran.

Facility Contact Numbers for Care Coordination
Use this list of VA medical facility contacts to locate and contact the nearest VA medical facility community care office in order to coordinate care for a Veteran.

Care Coordination Tools

VA has several tools available for community providers that help support the continuity of care Veterans receive, including HealthShare Referral Manager and Azure RMS.

• Request for Service
• HealthShare Referral Manager
• Azure Rights Management Services
• Veterans Health Information Exchange

Request for Service (RFS) Requirements

Community Care Provider-Request for Service (RFS), VA Form 10-10172, is used to request additional services or continued care from VA. The requested care may be performed within VA or in the community based on a Veterans eligibility.

The signed RFS is required to facilitate care review and authorization. All supporting medical documentation, such as provider progress notes and procedures, laboratory and radiology reports must accompany the completed form. If more supporting medical documentation is needed, the community provider has three business days to provide the necessary documentation, or the request will be denied.

Community Care Provider-Request for Service (RFS), VA Form 10-10172

VA processes requests for care within three business days. The community provider will be notified of the outcome via their preferred communication method. The notification will show if the care is to be provided within VA or in the community. If the care is denied, community providers must contact the Veteran to discuss alternative treatment plans.

A recorded training session on the RFS form, Community Care Referrals (Enduring), is available on VHA Training Finder Real-time Affiliate Integrated Network (TRAIN).

Community Care Referrals (Enduring), VHA TRAIN recorded training

HealthShare Referral Manager

Benefits

• Facilitates Health Information Exchange (HIE) between community providers and VA via one unified platform
• Gives the flexibility to easily refer Veterans for other specialized care
• Allows community providers to submit Requests for Services (RFS)
• Generates reports to inform decision-making and track workflow
• Provides clinical summary of Veterans' medical history, including details like diagnoses, prior medical procedures and medications, via the Clinical Viewer module

To receive HSRM updates, please sign up for VHA Office of Integrated Veteran Care (VHA IVC) Provider Advisor newsletter.

How to Access HSRM

If you are interested in using HSRM, first confirm your facility has an active Community Care Network (CCN) agreement with TriWest or Optum, or a Veterans Care Agreement (VCA) with VA. Next, follow the steps below to obtain access to HSRM. Resources mentioned in the following steps are available in the HSRM Training and HSRM Resources sections below.

Figure 1: HSRM Registration Steps for Community Providers

1. Attend the live training webinar or access the eLearning course on the Veterans Health Administration (VHA) Training Finder Real-time Affiliate Integrated Network (TRAIN) website to learn how to use HSRM.

NOTE: The Community Care Referral & Authorization (CCRA) Team strongly encourages community providers to attend the live training webinar hosted on VHA TRAIN prior to obtaining access to HSRM. The training webinars include an overview of HSRM, an in-depth walkthrough of the system, registration guidance and additional time for questions.

2. All users sign up for an ID.me account and verify their identity using the steps outlined in the HSRM Account Creation and Single Sign-On External (SSOE) Quick Reference Guide.
3. One point of contact from your organization fills out the End User Tracker (EUT) with information for staff requiring HSRM access, then submits the EUT to HSRMSupport@va.gov.

NOTE: Please ensure the email addresses entered in the EUT match those used for each respective user’s ID.me account.

4. The HSRM Help Desk provides the point of contact with confirmation that staff access has been granted.
5. All end users access HSRM via the CCRA website at https://ccracommunity.va.gov.

NOTE: If your HSRM account becomes deactivated, email hsrmsupport@va.gov, requesting reactivation.

Once these steps are complete, contact the VA medical centers you partner with to let them know you have access to HSRM and to discuss your transition to using HSRM.

HSRM System Training

For interested community providers, HSRM trainings are offered multiple times each week through the VHA TRAIN website. The HSRM trainings provide an in-depth walkthrough of the system's functionality. Please check VHA TRAIN for available dates and to register in advance. A free account in VHA TRAIN is required to register for the webinar.

A two-part extended HSRM training event is also being offered weekly for community providers. This event will be slower paced, have more time for system demonstrations, and allow participants to speak directly with the trainers. Please check VHA TRAIN for available dates and to register in advance. A free account in VHA TRAIN is required to register for the webinar.

HSRM Registration Information Session

For interested community providers, HSRM registration information sessions are offered weekly through the VHA TRAIN website. The HSRM registration information sessions walk community providers through the process of obtaining access to HSRM (i.e. creating an ID.me account and completing the End User Tracker). Please check VHA TRAIN for available dates and to register in advance. A free account in VHA TRAIN to register for the webinar.

HSRM eLearning

Community providers can also learn about HSRM system functionality through self-paced eLearning, available 24/7 through VHA TRAIN. A free account in VHA TRAIN is required to access the eLearning.

Frequently Asked Questions about HSRM

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Azure Rights Management Services (Azure RMS)

As of August 24, 2019, VA has transitioned from Virtru Pro to Azure RMS for encrypted email. Azure RMS allows VA to securely exchange information with community providers using encrypted email. With Azure RMS, community providers no longer have to wait for a Veteran’s information via fax or mail. Azure RMS enables safe communication about Veterans’ health information through email.

How Azure RMS Works

When a community provider receives an email from VA encrypted through Azure RMS, they will be able to seamlessly read and respond to the email through the existing email provider or open the email in a web browser and read and respond securely.

Access to Azure RMS

To access Azure RMS, you do not need to install any software to receive and reply to secure messages from VA. Azure RMS is accessed directly through email in the same way you receive other emails.

If you, as a provider, want to reply to an older message that was encrypted with Virtru Pro (the previous encryption software), you will continue to have the ability to do so. On the VA side, VA users will still get notice of the email response and can open the email in the Virtru Pro Secure Reader via a web browser.

Frequently Asked Questions about Azure RMS

Veterans Health Information Exchange (VHIE)

Please note: If you are trying to view a referral submitted by VA, please utilize HealthShare Referral Manager (HSRM).

VA Exchange Onboarding Flyer 2022