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Overton Brooks VA Medical Center


OBVAMC Transition Care Management

Kay Sanders, BSN/RN, simulates an appointment with a Veteran using Telehealth.

Kay Sanders, BSN/RN, simulates an appointment with a Veteran using Telehealth.

By Shannon Arledge, Public Affairs Officer
Thursday, August 16, 2018

OBVAMC Transition Care Management: Leveraging Technology, Improving Access

Transition Care Management (TCM) traces its roots to 2007. TCM, once known as OEF/OIF/OND, was created to assist and support Iraq and Afghanistan combat Veterans transition from military service, after Sept. 11, 2001. The name was changed to TCM in 2015 when services expanded to all Veterans who separated from military service after Sept. 11.

TCM provides Veterans enrollment assistance and guidance navigating VA health care. The TCM Team consists of six staff who are clinical counselors and a registered nurse. OBVAMC serves a Veteran population of over 37,000 throughout parts of Louisiana, Arkansas, and Texas (ArkLaTex). There are approximately 12,000 Post 9/11 Veterans residing throughout this area. More than half of these Veterans actively use the OBVAMC health care system, and on average TCM sees 115 new Veterans per month, therefore, increasing case management and patient aligned care.

“The TCM team is fundamental to the VA system because we are at the forefront of improving the Veterans experience within the VA,” said Ryan Jacobsen, TCM Program Director. “The TCM provides case management services for those Veterans who may need one-on-one support by creating Veteran-centered goals and plans to achieve those goals.” Jacobsen added, “The TCM team provides the information needed for Veterans to make decisions, understand what services are available to them, access those services, assist them when concerns arise and support these heroes to live healthy and satisfying lives.”

A Growing Population

As the Post 9/11 Veteran population increases, the need to expand health care options and access are more important. The ArkLaTex Post 9/11 Veteran population covers a vast geographic region, and the TCM Team is located at the central facility in Shreveport, Louisiana. The geographic region, Veterans in rural communities and distance, and professional schedules make it difficult for Post 9/11 Veterans to make appointments requiring travel to the City of Shreveport continually.

Three years ago, as the Veterans Health Administration (VHA) offered more Telehealth options, Jacobsen and the OBVAMC TCM Team took notice. TCM now cares for 70 percent more Veterans in lesser time. According to Shea Wilkes, TCM Social Work Case Manager, “before Telehealth we were able to assist about 20 percent of Veterans from the community regions because we would have them drive to us in Shreveport; that can be up to three hours of driving one way. Now we serve about 300 more Veterans per year, a 90 percent increase using Telehealth.”

Decreased Need for Travel

In 2018 the Telehealth project limited a Veterans need to travel. Over the three years of offering Telehealth TCM has completed 700 assessments, reduced the Veterans drive time, and is respectful of professional and personal schedules. The decreased need for travel directly affects Veterans living in rural locations affording those Veterans consistent case management care.

Telehealth requires coordination and technology. As more Post 9/11 Veterans enroll with OBVAMC, the TCM Team continually coordinates with its VA Clinics in Longview, Texas; Texarkana, Arkansas; and Monroe, Louisiana, to assess their current health care treatment plan, answer questions, and serve as the Veterans advocate. Health care and Telehealth staff at each clinic arrange the appointment and connection. This arrangement allows TCM staff to assist with appointments and to get the Veteran to the right person for the right care.

Suicide Prevention & The Virtual Face-to-Face Difference

Communication consists of both verbal and non-verbal messages. When Telehealth was not an option and communication consisted of telephone conversations, because face-to-face was not available, the TCM Team was unable to identify certain expressions or warning signs.

Recently Telehealth resulted in saving a Veterans life because the TCM provider identified interpretive signs that something was not natural during a routine assessment via a VA Clinics’ video system.

“…because we could see [the Veteran] it provided the opportunity to ask serious questions,” said Jacobsen. “So, we asked, and he was having a hard time, and the Veteran felt no one cared. We kept talking with him while notifying the clinic’s mental health staff for assistance.  We ended our conversation with him when the provider came to the room and took over. We spoke to [the Veteran] later, and he said, ‘thanks for asking because I wanted someone to ask, someone to save me.’”

Wilkes adds suicide is a real problem. “Everyone should be confident to ask the tough questions and pick up on those potential indicators that may suggest there’s a problem, and the use of Telehealth provides that last piece for us.” 

Make the Connection

Transition Care Management provides ArkLaTex Veterans with valuable information, support, and resources to live successful, healthier lives, through guidance and navigating a large VA system. The OBVAMC TCM Team understands Veterans have busy schedules and Veterans have questions unanswered because they have been unable to communicate face-to-face with TCM personnel. The use of Telehealth has made a difference for TCM by leveraging technology that allows personal contact. TCM will take the time to get things moving in the right direction, minimize confusion, and help to achieve the best outcome for the Veteran and their family.

Veterans separated from military service after Sept. 11, 2001, should contact the Overton Brooks VA Medical Center’s Transition Care Management team to ensure they are connected and enrolled. Veterans may call 318-990-5012 or connect via secure message at MyHealtheVet. Veterans may also visit the office, no appointment needed, to meet the staff. TCM is located in rooms 1E86-88. Moreover, of course, the TCM Team can arrange a connection using Telehealth technology from nearby VA clinics.


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