VHA Polytrauma TBI System of Care

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• VHA Polytrauma / TBI System of Care
• American Academy of Physical Medicine and
  Rehabilitation
• September 29, 2007
• Barbara Sigford, M.D.
• VHA National Director
• Physical Medicine and Rehabilitation

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Objectives

• Describe background and principles underlying the
  VHA Polytrauma System of Care (PSC)
• Describe the components of the PSC

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To Care for Him Who Shall Have Borne the Battle
and for His Widow and His Orphan

• Abraham Lincoln

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Rebuilding Wounded Lives
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Rehabilitation for Multiple Impairments
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Who Do We Serve The Presidents Commission

• Number of deployments 2,200,000
• Service members deployed 1,500,000
• Air evacuated 37,851
• Wounded in action 28,000
• Treated and returned to duty
• within 72 hours 23,270
• Time in combat greater than
• any other time in military history

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Who Do We Serve The Presidents Commission

• Seriously injured (TSGLI recipients) 3,082
• Traumatic Brain Injuries
  2,726
• Amputations
  644
• Serious burns
  598
• Polytrauma
  391
• Spinal cord injuries
  94
• Blind
  48

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Common Sequelae of Blast Injury

• Brain Injury
• Amputation
• Fractures
• Wounds
• Psychological-PTSD
• Crush Injuries
• Burns
• Auditory/Vestibular

• Eye, Orbit, Face,
• Dental
• Renal
• Respiratory
• Cardiac and Vascular
• Gastrointestinal
• Pain
• Peripheral Nerve

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Cultural Transformation New Generation

• Military identity
• Connectivity
• Recognition of service
• Family stress
• Family configuration
• Family friendly environment
• Family inclusion and support

• Visiting hours
• Tech savy
• Combat stress
• Developmental stage and social role
• Sexuality
• Care Management
• Prolonged recovery

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Polytrauma / TBI Continuum of
CareAcute/Trauma Acute
Post Acute
Lifetime Care
Rehabilitation
Rehabilitation Community Care

• Family Support
• Case Management
• Benefits Management
• Information Management

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Are we ready to handle these patients?

• They require a closely integrated network of
  emergent, urgent, surgical, and rehabilitative
  care across the battlefield, MTF and VHA
  facilities.
• They require rapid transition through the system
  of care to optimize when and where treatment is
  received.

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Are we ready to handle these patients?

• This requires highly trained clinicians,
  significant infrastructure and administrative
  support, and a unified treatment and
  communication system.
• This requires comprehensive care management of
  each individual to make sure they are
  appropriately and expediently transitions through
  the systems of care.

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Developing the Polytrauma System of Care
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Polytrauma / TBI System of Care

• Polytrauma Rehabilitation Centers (PRC)
• Polytrauma Network Sites (PNS)
• Polytrauma Support Clinic Teams (PSCT)
• Polytrauma Point of Contact (PPOC)
• Care Management
• Family Support
• Integrated Communication System
• Community Care/Reintegration
• Long Term Follow-up

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The TBI/Polytrauma System of Care
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Lessons Learned at the PRCs

• Clinical Differences
• Higher medical acuity
• More severely injured
• Multiple co-morbidities
• PTSD and/or other mental health problems
• Pain
• Infection
• Increased length of stay

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Lessons Learned at the PRCs

• Family Care
• More intense and different quality involvement
• High expectations
• Heavy emotional impact
• Need
• Support / Therapy
• Education
• Resources

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Polytrauma Rehabilitation Centers
Tampa
Richmond
Palo Alto
Minneapolis
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PRC Acute Interdisciplinary Rehabilitation

• Patient centered
• Enhanced family support
• CARF accredited in TBI and comprehensive
  rehabilitation
• Integrated military supports
• Tertiary Care Facilities
• Specialized services for multiple impairments

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Provision of Comprehensive Rehabilitation Care
Brain Injury Program
Audiology Program
Polytrauma Rehabilitation Center
Hearing Loss
Head Injuries
Spinal Cord Injury Program
Cord injury
Pain Management
Pain
Amputations
Soft Tissue Trauma
Emotional Shock
Vision Loss
Amputee Program
Rehabilitation And Orthopedic Programs
PTSD Program
Blind Rehabilitation Program
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PRC Scope of Clinical Services

• Comprehensive Interdisciplinary Inpatient
  Evaluations
• Acute Comprehensive Inpatient Rehabilitation
• Manage Medical Instability
• Transitional Community Re-entry Program
• Emerging Consciousness Program
• Ongoing Follow-up and Care Management
• Consultation

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Interdisciplinary Rehabilitation Team
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Team of Specialized Consultants

• Anesthesiology
• Audiology
• Chaplin Services
• Dentistry
• Driver Rehabilitation
• Gastroenterology
• General Surgery
• Infectious Disease
• Medicine
• Neurology
• Neuro-ophthalmology
• Neurosurgery

• Nutritionist
• Optometry
• Oral and Maxillofacial Surgery
• Orthopedics
• Otolaryngology
• Pharmacy
• Plastic Surgery
• Prosthetics
• Pulmonology
• Radiology
• Urology
• VBA Vocational Specialist

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Polytrauma Network Sites
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Polytrauma Network Sites

• Twenty one sites
• Geographically distributed
• CARF accredited comprehensive rehabilitation
• Designated military liaison

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PNS Scope of Clinical Services

• Provide specialized interdisciplinary post-acute
  rehabilitation services inpatient and outpatient
• Manage new polytrauma patients in consultation
  with PRC
• Identify resources for VA and non-VA care across
  the VISN
• Provide proactive clinical and psychosocial case
  management continued support for families
• Provide regular follow-up care, check-ups
• Coordinate services between VHA, VBA, DOD,
  private sector (fee-basis)

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Experience to Date
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Injured in Theatre
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Branch of Service
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Demographics
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AGE AT ADMISSION

• lt 20 3.4
• 20-30 66.3
• 31-40 21.3
• 41-50 7.5
• gt50 1.5

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Referral Sources
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Discharge Destination
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Polytrauma Support Clinic Teams
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Polytrauma Support Clinic Teams

• Provide specialized rehabilitation services
  closer to home
• Sequelae are life long/require special expertise
• Support successful integration back into the home
  community
• Evaluate new patients identified locally (TBI)
• Are widely distributed across the country (76 and
  counting)

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PSCT Role in the Community

• Collaborate with other federal and state agencies
  (VRE, state voc rehab)
• Collaborate with private sector (local
  rehabilitation programs or providers)
• Know community resources (local BIA, or ACA,
  local educational institutions)

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Polytrauma Point of Contact(PPOC)

• Point of contact at every VA facility not
  otherwise designated
• Knowledgeable about capabilities of each
  component in the polytrauma system of care
• Responsibility for triage and referral to most
  appropriate facility for expertise and location.

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VA TBI/Polytrauma Life Time Care Management

• Clinical Care Management- Certified
  Rehabilitation RN
• Psychosocial Care Management- Licensed Clinical
  Social Worker
• Monitor the implementation of the care plan
• Assess for new emerging issues
• Identify VA and non-VA resources
• Provide ongoing patient and family support
• Educate patient and family
• Assist with military to VA transition

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Patient and Family Centered Care
Volunteer Services
Social Workers
Military Liaisons
Logistics Special Needs
Military Issues
Case Management
Family Program
VA Liaisons
Transition Issues
Spiritual
Chaplain
Counseling Coping
Care Environment
Education Care Involvement
Psychologist
Leadership
IDT
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Community Re-integration

• Care for those who cant return home
• Supportive services in the home
• Support for the care giver
• Day activity
• Vocational Rehabilitation
• Return to school
• Compensated work therapy
• Collaboration with civilian section for episodic
  care for subsection of veterans
• Transitional Rehabilitation
• Outpatient Rehabilitation

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Long Term Follow-Up

• Sequelae are life long/require special expertise
• Emerging complications
• Changes in developmental stage
• Changes in social situation
• New treatments or technology
• Support and connectivity
• Aging with disability
• Scheduled and as needed (patients and families
  may not always be proactive)

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TBI Screening

• Initiated at all VHA facilities 4/2/07
• Identifies veterans with possible mild
  symptomatic TBI
• Requires consult for full evaluation and treatment

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Common Health Problems of OIF/OEF Veterans

• Diseases of Musculoskeletal System/Connective
  System 1

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Polytrauma Network Sites

• Boston-West Roxbury
• Syracuse
• Bronx
• Philadelphia
• Washington DC
• Richmond
• Augusta
• Tampa
• Lexington
• Houston
• Dallas

• Cleveland
• Indianapolis
• Hines (Chicago)
• St. Louis
• Minneapolis
• Tucson
• Denver
• Seattle
• Palo Alto
• West Los Angeles

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VHA Internet Address

• http//www.polytrauma.va.gov/

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Thank you