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Polytrauma System of CareSouth Texas Veterans Health Care SystemVETERANS HEALTH ADMINISTRATION

New Model of Care “Polytrauma” describes unique, complex patterns of injuries:– Complex, multiple injuries occurring as result of same event– Unpredictable patterns including: brain injury, amputation, hearing and visionimpairments, spinal cord injuries, psychological trauma, and musculoskeletalwounds Individuals with polytrauma require extraordinary level of integration andcoordination of medical, rehabilitation, and support services––––––Brain injury is primary injury that drives careUnique rehabilitation challenges with blast related injuriesHigher level of acuity due to severity of injuriesSimultaneous treatment of multiple injuriesSequence and integrate therapies to meet patient needCoordinate interdisciplinary team effort with expanded team of consultantsVETERANS HEALTH ADMINISTRATION2

MissionProvide a comprehensive, patient-centered, integrated system ofrehabilitation care for Veterans and Service Members with Polytraumaand Traumatic Brain InjuryVETERANS HEALTH ADMINISTRATION3

VHA Polytrauma / TBI System of Care Level 1: Polytrauma Rehabilitation Centers (5)– Regional referral centers for acute, comprehensive rehabilitation– Lead clinical care, research, education, program development– Tampa, Minneapolis, Richmond, Palo Alto, San Antonio Level 2: Polytrauma Network Sites (23)– Veteran Integrated Service Network referral sites for post-acute rehabilitation Level 3: Polytrauma Support Clinic Teams (87; 2-8 per VISN)– Interdisciplinary team follow-up and management of stable TBI/Polytraumasymptoms at local VA facilities Level 4: Polytrauma Points of Contact (41 VA medical centers)– Care coordination and referral to appropriate servicesVETERANS HEALTH ADMINISTRATION4

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Polytrauma System of Care Transitional ProcessVETERANS HEALTH ADMINISTRATION6

VHA Polytrauma Rehabilitation Center (PRC) SitesTampaRichmondMinneapolisPalo AltoVETERANS HEALTH ADMINISTRATIONSan Antonio7

PRC Overview Five Level 1 medical centers provide the highest echelon of comprehensivemedical and rehabilitative services (inpatient and outpatient) for the mostcomplex and severely injured:– 12-18 inpatient bed unit providing acute interdisciplinary evaluation, medical––––management, and rehabilitation10 inpatient bed residential Transitional Rehabilitation ProgramEmerging Consciousness ProgramAssistive Technology LabPolytrauma Telehealth Network National leaders in polytrauma, TBI, and blast-related injuries, providingconsultation, medical education, research, & program development for VHA Accredited by Commission on Accreditation of Rehabilitation Facilities (CARF)for inpatient TBI and general rehabilitation Collaborative partner sites with DVBIC and national TBI Model SystemsVETERANS HEALTH ADMINISTRATION8

PRC Inpatient Care(March 2003 through September 30, 2012)2,735 inpatients received PRC (inpatient) care1,532 Active Duty Service members 115 new AD patients in FY12 (through Q3)1,132 injured in foreign theatre 99 new patients in FY12 (through Q3)1,203 Veterans 125 new patients in FY12 (through Q3)166 with Disorder of ConsciousnessVETERANS HEALTH ADMINISTRATION

Current Utilization of the PRCs Occupancy rates fluctuate; 85% occupancy rate is preferredmaximum–June 2012 - Average inpatient occupancy rate 75% across all PRCs Average length of stay (LOS) in PRC: 46 days––More severely injured average 83 days LOSLess severely injured average 28 days LOS Discharge destinations vary; nearly two-thirds are discharged tohomeVETERANS HEALTH ADMINISTRATION10

Patient Referral Sources to PRCsForeign TheatreVETERANS HEALTH ADMINISTRATION11

PRC Rehabilitation Team PhysiatristRehabilitation NursingSpeech Language PathologistOccupational TherapistPhysical TherapistBlind Rehabilitation SpecialistTherapeutic Recreation SpecialistCounseling PsychologistNeuropsychologistFamily TherapistVETERANS HEALTH ADMINISTRATION Patient/Family EducatorNurse EducatorSocial Work / Care ManagerDriver TrainerProsthetist / OrthotistDoD Military LiaisonWound CareTeamNutritionistPet TherapyAssistive Technology Specialist12

PRC Specialty Consultants AnesthesiologyAudiologyChaplain ServicesDentistryGastroenterologyGeneral SurgeryInfectious DiseaseInternal TERANS HEALTH ADMINISTRATION OptometryOral and Maxillofacial SurgeryOrthopedicsOtolaryngologyPain ClinicPlastic SurgeryProstheticsPulmonologyRadiologyUrologyVBA Vocational Specialist13

Discharge Destination from PRCsForeign TheatreVETERANS HEALTH ADMINISTRATION14

South Texas Veterans Health Care SystemSan Antonio, TexasVETERANS HEALTH ADMINISTRATION15

PRC – San Antonio5th PRCOpening Ceremony October 2011 66 Million Project3 levels - 12 Bed UnitIncludes inpatient andoutpatient programs Inpatient Referrals from San Antonio Military Medical Center, Walter ReedNational Military Medical Center, community hospitals, Other VAs Service veterans and active duty with polytrauma injuries including TBI,Amputations, SCI, burns, limb salvage, multiple fractures, etc. VETERANS HEALTH ADMINISTRATION16

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PRC – San AntonioDec 2010- presentPolytrauma-115Active Duty- 75Rehab-146Veteran- 186261 TotalPatientsAverage Age- 45.3VETERANS HEALTH ADMINISTRATIONTotal average LOS- 26.0 daysPolytrauma LOS- 38.7 days18

Polytrauma Transitional Rehabilitation Program (PTRP) PTRP - Residential Rehabilitation–––––One at each PRC site10-20 beds for extended stay rehabilitation (1-6 months)Focus on community reintegration and vocational rehabilitationLinked in with local and regional military treatment facilitiesFocus of care is on independent living with less family interactionVETERANS HEALTH ADMINISTRATION19

PTRP ExperienceFY08-FY12Average Length of StayAverage Age66.9 days32.8415 UniquePatientsOEF/OIFFemale23.4%5.1%VETERANS HEALTH ADMINISTRATION20

Discharge Destination from PTRPsVETERANS HEALTH ADMINISTRATION21

Transitional Rehabilitation Program Vocational OutcomesOther, 2.8% Retired,1.4%Student, 5.6%Unemployed,23.6%Employed, 66.7%VETERANS HEALTH ADMINISTRATION22

PTRP – San AntonioVETERANS HEALTH ADMINISTRATION23

PTRP - San AntonioApril 2013- presentAverage Length of Stay62.1 daysAverage Age34.621 UniquePatientsActive Duty- 10Veterans- 11VETERANS HEALTH ADMINISTRATIONPolytrauma- 15Rehab- 624

All PRCs/ PTRPsOctober 2012 – September 2013All Patients(1N) POLYTRAUMA REHABUNITUniquePatients(82) PM&R TRANSITIONALREHABILITATIONAverage AverageUniqueDailyLength h ofStayRichmond, VA597.044.16714.984.8Tampa, FL11814.845.5357.179.9San Antonio, TX505.438.7152.162.1Palo Alto, CA466.247.4325.057.5Minneapolis, MN697.334.7375.152.7VETERANS HEALTH ADMINISTRATION25

Polytrauma Network Sites (PNS) 23 regional (Level 2) medical centers providing full range of comprehensivefollow-on medical and rehabilitative services (inpatient and outpatient) forpatients recovering from polytrauma and TBI (1 per VISN, and San Juan):– Develop and support patient’s rehabilitation plan through comprehensiveinterdisciplinary, specialized team– Serve as resource and coordinate services for TBI and polytrauma across VISN(VHA, DOD, private sector) VISN leader for polytrauma/TBI consultation, education, monitoringoutcomes, and program development for system Accredited by CARF for inpatient general rehabilitationVETERANS HEALTH ADMINISTRATION26

Screening for Mild Traumatic Brain Injury forOEF/OIF/OND Veterans VHA (April 2007 – August 31, 2013)– 768,744 have been screened for possible mild TBI– 144,787 screened positive and consented to follow-up 108,807 have completed comprehensive evaluation so far 62,545 received confirmed diagnosis of mild TBIVETERANS HEALTH ADMINISTRATION27

TBI Outpatient 0FY1130,000FY1220,00010,0000Total TBI Uniques All ClinicsVETERANS HEALTH ADMINISTRATIONSources:Uniques with prior TBI – VSSC ad hoc query

PNS - San Antonio Outpatient Clinic dedicated to TBI (mild to severe) and other polytraumainjuries Interdisciplinary Team that includes PM&R physicians, clinic nurse, socialwork, psychology, neuropsychology, physical therapy, occupationaltherapy, speech therapy, blind rehab Consults received as a result of positive TBI screening Currently 3rd nationally in number of uniques Treat symptoms related to TBI and other injuries including headaches,dizziness, vision deficits, hearing loss, concentration/ memory deficits,mental health issues (including PTSD), sleep issues Goal of community reintegrationVETERANS HEALTH ADMINISTRATION29

PNS - San AntonioPOLYTRAUMA/TRAUMATIC POLYTRAUMA/TRAUMATICBRAIN INJURY (TBI)BRAIN INJURY (TBI)INDIVIDUALGROUPAll Facility50,516173,131UniquePatients2,784San Antonio, TX1,0736,61080Unique Patients EncountersVETERANS HEALTH ADMINISTRATIONEncounters12,01516130

Leaders’ VisionOne Mission – One Policy – One Plan Secretary Shinseki and Secretary Panetta met three times to discuss the issue, setthe tone, and establish their expectations: Common, interagency guidance driven by an overarching formal interagencygovernance structure in support of the wounded, ill and injured & their families Integrated interagency community of practice comprised of professionals thatcoordinate and manage care, benefits, and services .with shared measures of successto include utilization, quality, and satisfaction Single comprehensive, interagency plan developed and shared by both Departmentsthat produces a common operational picture, visible to patient, family, and carerecovery team will drive effectiveness/efficiencies for the recovery process in supportof both recovering service member and recovery team Sustainable model that transcends current conflicts and is scalable to meet bothpeacetime and wartime support requirements The first step is to designate a Lead Coordinator for Service Members and Veterans ateach stage of their recovery31VETERANS HEALTH ADMINISTRATIONReference: IC3 Overview Briefing

Transitioning from DoD to VA VA & DoD partnership began in August 2003 Social Workers and Nurses embedded at Military TreatmentFacilities (MTFs) Care Management begins at the MTF Smooth transition to VA provides the Service member or Veteranand their family a sense of security that VA can meet their needsVETERANS HEALTH ADMINISTRATION32

Referrals from OEF/OIF/OND Program to PolytraumaSystem of CareVA Liaison initial contact is made through a DoD CM referralprocess when medically ready to be discharged from the military.The next step is to coordinate with the VA OEF/OIF programSeamless Transition of careNew OEF/OIF/OND Veteranpresents to OEF/OIF/OND Office.OEF/OIF/OND Veteran presentsto OEF/OIF/OND Office.New OEF/OIF/OND Veteran completesscreening questionnaire per 1010.01Handbook.OEF/OIF/OND Veteran completesscreening questionnaire per 1010.01Handbook.New OEF/OIF/OND Veteran meets with Transition Patient Advocate(TPA) who assists with enrollment and education on the OEF/OIF/ONDProgram and VA Healthcare.OEF/OIF/OND Case Manager meets with OEF/OIF/OND Veteranand completes psychosocial assessment and clinical reminders.VETERANS HEALTH ADMINISTRATION33

Referrals from OEF/OIF/OND Program to PolytraumaSystem of Care (continued)If the TBI clinical reminder is positive, OEF/OIF/OND CaseManager submits a consult to Polytrauma for further assessment.Seamless Transition of careOEF/OIF/OND Veteran contacted by Polytrauma and scheduled.OEF/OIF/OND Veteran evaluated by Polytrauma and assigned a level ofcare of one, two, or three. All level three OEF/OIF/OND Veterans arecase managed by the outpatient Polytrauma Case Manager.Outpatient Polytrauma Case Manager and Polytrauma Social WorkSupervisor attend the OEF/OIF/OND Care Management Review Teammeeting biweekly to complete a warm handoff on OEF/OIF/ONDVeterans that will be case managed by Polytrauma.VETERANS HEALTH ADMINISTRATION34

VA Liaisons for HealthcareWhy VA Liaisons?Coordinate VAhealthcare for Servicemembers (SM)transitioning fromDoD to VACollaborate andcoordinate with MTFtreatment team andOEF/OIF/ONDProgram Managerthroughout the referralprocessSM has appointmentsat the VAMC prior toleaving the MTFSMs who are severelyinjured are connectedwith the StateDepartment ofVeterans AffairsService Members and families/caregivers Are educated aboutVA Healthcare andresourcesDiscuss individualizedVA treatment optionsand resources with VALiaisonsVETERANS HEALTH ADMINISTRATIONEasily access VALiaisons who are colocated onsite withMilitary CaseManagersMay meet with VAtreatment teamsvia videoteleconference atMTF35

Lead Coordinator Overview The Lead Coordinator (LC) serves as the primary point-of-contact withina DoD or VA Care Management Team (CMT) for a Service member /Veteran (SM/V) and their families/caregivers during their recovery,rehabilitation, and transition By assigning a primary point-of-contact on the CMT, it reduces confusionand eliminates complexities for SMs/Vs and their families/caregivers Ensures a warm hand-off at the time of transition between DoD/VAfacilities, including transfer of documentation and the checklistVETERANS HEALTH ADMINISTRATION36

Best Practices for Seamless Transfer at South Texas Case management hand-offs Lead Coordinator V-tel communication with MTF’s and other VA’s to ensure acomprehensive handoff is completed Family meetings with care team Family tour of the PSC facilities Reintegration plans of care completed prior to discharge and shared forefficient continuation of care Liaison involvement from admission to dischargeVETERANS HEALTH ADMINISTRATION37

Best Practices for Transitioning Families at South TexasPTRP – San Antonio hosts a family conference day with each family onFridays that include: Family conference focusing on plan of care Safety and awareness in the community Caregiver TBI education group Family support & reintegration group Meeting with the lead therapistVETERANS HEALTH ADMINISTRATION38

Rebuilding Injured LivesVETERANS HEALTH ADMINISTRATION39

Polytrauma Transitional Rehabilitation Program (PTRP) 19 PTRP - Residential Rehabilitation – One at each PRC site – 10-20 beds for extended stay rehabilitation (1-6 months) – Focus on community reintegration and vocational rehabilitation – Linked