# Maximizing Effectiveness of Case Management in Primary Care for Rural Veterans

> **NIH VA I50** · PROVIDENCE VA  MEDICAL CENTER · 2021 · —

## Abstract

Veterans with complex health conditions navigate a bewildering array of providers and supportive services.
Those Veterans who live in rural areas often face additional challenges in getting the right care at the right time
because providers may be geographically dispersed or unavailable in their neighborhood. Social-work case-
management (SWCM) addresses the need for better access, coordination, and community support. A licensed
social worker, acting as part of a primary-care team, connects the Veteran, their families and caregivers with a
support network in their community. Case management is distinct from other forms of social work assistance in
its emphasis on comprehensive assessment of the Veteran’s needs followed by intervention, evaluation, and
documentation, which continue until treatment goals are met. In response to a shortage of social workers needed
to complement its primary-care Patient Aligned Care Teams (PACTs) in rural areas, the Veterans Health
Administration (VHA) has implemented a program to place additional social work case managers at rural PACT
sites. Little is known, however, about the impact of adding social workers to primary-care teams or the
effectiveness of the case-management model. We propose a rigorous evaluation of this initiative.
The long-term goal of this partnered evaluation is to improve the implementation of the Rural PACT SWCM
Initiative in order to deliver patient-centered, timely, and appropriate care to Veterans. As a necessary step
toward that goal, the objective of our partnered evaluation is to assess the Rural PACT SWCM Program’s
success an achieving its goals and improve its implementation. Our central hypothesis is that social-work case-
managers connect Veterans to services and resources, such as personal care services, better-coordinated
primary care, care planning, and mental health services, that ultimately will reduce unplanned health-care use
that impose stress on Veterans and costs on the health system. This assessment will be used to create a tailored
intervention, designed in cooperation with the operations partners, to improve implementation of Rural PACT
SWCM by helping social workers to identify high-risk Veterans who need supportive services and provide case-
management assessment and services. The knowledge gained from this evaluation will not only enhance
implementation of Rural PACT SWCM Initiative, but also demonstrate the value of SWCM as a key component
of primary care in the VHA. That evidence will provide the basis for medical centers to invest in sustaining SWCM
for the long term. To do so, the evaluation team will pursue the following aims:
(1) Assess the implementation of SWCM and barriers and facilitators of implementation of the case-management
model and targeting of high-risk Veterans.
(2) Evaluate the effect of social worker placement on Veterans’ access to services and health outcomes.
(3) Design and pilot-test a case-management-improvement bundle to help program social ...

## Key facts

- **NIH application ID:** 10021440
- **Project number:** 5I50HX002647-02
- **Recipient organization:** PROVIDENCE VA  MEDICAL CENTER
- **Principal Investigator:** Portia Yvonne Cornell
- **Activity code:** I50 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2021
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2019-10-01 → 2022-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10021440

## Citation

> US National Institutes of Health, RePORTER application 10021440, Maximizing Effectiveness of Case Management in Primary Care for Rural Veterans (5I50HX002647-02). Retrieved via AI Analytics 2026-05-25 from https://api.ai-analytics.org/grant/nih/10021440. Licensed CC0.

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