Transcript Background of soldiers served - Brain Injury Alliance of

SERVING THE RETURNING VETERAN:
THE POLYTRAUMA SYSTEM OF CARE
Andrea Karl, MD
Ellen Kessi, MSW LCSW
Katherine Noonan, Ph.D.
Katrell Rhinehart, PT
Kiersten Smith, MOTR/L
Tricia Strombom, RN BSN
AGENDA
Background on Veterans Served
TBI Primary Screen and Secondary Screening
Polytrauma System of Care
Therapies Available within Polytrauma Clinic
Additional Resources
POLYTRAUMA TEAM
Andrea Karl, MD- Director of Polytrauma Clinic
Katherine Noonan, Ph.D.- Polytrauma Psychologist
Ellen Kessi, LCSW- Social Work Case Manager
Katrell Rinehart, PT-Physical Therapist
Kiersten Smith, MOTR/L-Occupational Therapist
Tricia Strombom, RN BSN- Nurse Case Manager
BACKGROUND ON VETERANS SERVED
Tricia Strombom, RN BSN
Polytrauma OEF/OIF Nurse Case
Manager
PORTLAND CATCHMENT AREA
DEMOGRAPHICS OF OEF/OIF VETERANS
UTILIZING VA HEALTH CARE
Sex
Male
Female
88%
12%
Age
Under 20
20 to 29
30 to 39
Over 40
8%
50%
22%
20%
Analysis of Health Care Utilization
Among OEF and OIF Veterans
Branch
Air Force
Army
Marine
Navy
12%
64%
13%
12%
Unit Type
Active duty
Reserve/ Guard
52%
48%
Rank
Enlisted
Officer
92%
8%
MEDICAL DIAGNOSES AMONG OEF/OIF
VETERANS (N=400,304)
Diagnosis
Musculoskeletal
Mental Disorders
Ill Defined Conditions
Nervous System/Sense organs
Digestive System
Endocrine/Metabolic
Injury/Poisoning
Respiratory
ICD-9 Category
710-739
290-319
780-799
320-389
520-579
240-279
800-999
460-519
%
49.2%
44.6%
42%
36.6%
32.4%
23.2%
23%
20.9%
MEDICAL DIAGNOSES AMONG OEF/OIF
VETERANS (N=400,304)
Diagnosis
Musculoskeletal
Mental Disorders
Ill Defined Conditions
Nervous System/Sense organs
Digestive System
Endocrine/Metabolic
Injury/Poisoning
Respiratory
ICD-9 Category
710-739
290-319
780-799
320-389
520-579
240-279
800-999
460-519
%
49.2%
44.6%
42%
36.6%
32.4%
23.2%
23%
20.9%
MENTAL HEALTH DIAGNOSES AMONG
OEF/OIF VETERANS
Disease Category
PTSD
Depressive Disorders
Neurotic Disorders
Affective Psychoses
Nondependent Drug Abuse
Alcohol Dependence
Syndrome
Special Symptoms, NEC
Sexual Disorders
ICD Code
309.1
311
300
296
305
303
#GWOT Veterans
92,998
63,009
50,569
35,937
27,246
16,217
307
302
9,755
8,696
New Unique OEF/OIF Veterans by Year Enrolled at the Portland VAMC
Source: VSSC OEF/OIF Unique Users Station Level Report
6,000
5650
Current OEF/OIF Veterans
represent approximately
11% of all unique patients
of the PVAMC thru May
2009
5,000
4,000
3275
3,000
2366
1815
2,000
1238
1,000
564
152
207
0
2002
2002
2003
2004
2005
2006
2007
2008
2003
2004
2005
2006
2007
2008
Total Currently
Enrolled
OEF/OIF
Veterans
METHOD OF ACCESS OF SERVICES
• Demobilizations
• Enrollment Office
• OIF/OEF program staff
EXPANSION OF SERVICES
6000+ OEF/OIF veterans enrolled PVAMC
3500 ORNG returning from theater April 2010
Mandated to see veterans within 30 days of
enrollment
Mandated to complete TBI secondary within 30
days of positive initial screen
59% of active duty
52% of Army Reserves
65% of retired/separated service members
were exposed to an event or blast that caused
a jolt or blow to the head
Report of the President’s Commission on Care for America’s Returning
Wounded Warriors – July 30, 2007 (Bob Dole, Donna Shalala – Co-Chairs)
Blast Wave/Blast Wind
TRAUMATIC BRAIN INJURY:
SCREENING OVERVIEW
Katherine Noonan, PhD
Polytrauma OEF/OIF Psychologist
VA TASK FORCE ON TBI ESTABLISHED
DEC 2006
Addressed need to assess for TBI in returning
OEF/OIF (Operation Enduring Freedom/Operation
Iraqi Freedom)
Representatives from various fields:
Physical Medicine and Rehabilitation
Neurology
Psychiatry
Psychology
Primary Care
Prevention
Medical Informatics
OUTCOMES OF TASK FORCE
Reviewed
Limited available research on TBI screening
Results from VA’s and Military Treatment Facilities
that initiated screening locally
Clinical presentation and natural history of TBI
Consult with Defense and Veterans Brain Injury
(DVBIC)
There are currently no validated instruments for TBI
screening
VHA Directive 2007-013
TBI CLINICAL REMINDER
Screening occurs upon entry into a VA Health
Care System
The first step of the reminder is to identify possible
Operation Enduring Freedom (OEF)/Operation
Iraqi Freedom (OIF) participants based on
whether date of separation from military duty or
Active Duty status occurred after September 11,
2001.
Screening is done once, for those who confirm
OEF/OIF deployment and no prior diagnosis of
concussion/mTBI
VHA Directive 2007-013
PRIMARY TBI SCREENING-CLINICAL
REMINDER
Positive replies in all four sections constitute a
positive screen
1.
2.
3.
4.
Events that may increase the risk of TBI
Immediate symptoms following the event
New or worsening symptoms following the event
Current symptoms
VHA Directive 2007-013
INITIAL SCREENING IDENTIFIES POSSIBLE TBI
Not all patients with positive initial screen will have
TBI
Other diagnoses possible. Examples:
PTSD
Cervico-cranial injury with headache
Positive screens need further evaluation
TBI Secondary Screen
Consultative
− Referrals from anywhere in medical center following
positive primary screen
Multidisciplinary team approach
Render opinion about cause of symptoms
Close collaboration with other specialties
Case load shared between Post-Deployment
Clinic and Polytrauma Clinic
NSI (NeuroBehavioral Symptom
Inventory)
Completed during the TBI secondary level
evaluations
Outlines common complaints of those individuals
who have mTBI and PCS
22 items-5 point scale
Validated for mTBI
Guides the treatment process
OVERVIEW OF VETERANS SCREENED
(PVAMC APRILS 2007-DECEMBER 2009)
3,911-
OIF/OEF veterans screened for possible
TBI
1,022-
TBI screen positive (26.1%)
971-
Those who screened positive who
agreed to second level evaluation
(95%)
677-
Comprehensive Second Level
Evaluation Completed (69.7%)
517-
Confirmed TBI diagnosis (76.4%)
OEF/OIF New PCP Requests All Clinics Jan09-Jan10
200
177
180
160
158
155
140
148
131
120
112
97
100
98
101
92
75
80
73
60
50
40
20
0
1
2
3
4
5
6
7
Month
8
9
10
11
12
13
Positive TBI Consults
40
35
34
30
29
28
25
25
25
25
22
22
20
20
27
20
17
15
10
5
0
jan
feb
march
april
may
june
july
aug
Total TBI Consults Per Month 2009
sept
oct
nov
dec
POLYTRAUMA SYSTEM OF CARE:
OVERVIEW
Andrea Karl, MD
Polytrauma Program Director
POLYTRAUMA CLINIC
“Polytrauma is defined as injury to the brain in
addition to other body parts or systems resulting in
physical, cognitive and functional disability. Injury
to the brain is the impairment which guides the
course of rehabilitation.”
VHA 2005-24 Directive definition
POLYTRAUMATIC INJURIES
Traumatic Brain Injury (TBI)
Hearing Loss
Amputations
Fractures
Burns
Visual Impairment
REHABILITATION FOR MULTIPLE IMPAIRMENTS
POLYTRAUMA REHABILITATION’S ROLE
To care for patients with these diverse and serious
injuries requiring more than one type of therapy
(physical/occupational/speech)
Interdisciplinary care approach with ongoing
follow up
POLYTRAUMA CONTINUUM OF CARE
Acute/Trauma
Care
Inpatient
Rehabilitation
Inpatient
Surgical
care
Medical
care
Outpatient
Rehabilitation
Outpatient
Acute
Specialized
Intensive
Interdisciplinary
Rehabilitation
Rehabilitation
Family Support
Case Management
Benefits Management
Lifetime
Community Care
Outpatient followup with Rehabilitation
team
--Supported Living
--Vocational support
--Educational
support
--Support Groups
--Skilled Nursing
--Total Care
GEOGRAPHIC ORGANIZATION
Polytrauma Rehabilitation Centers
Polytrauma Network Sites
Polytrauma Support Team Clinics
Polytrauma Points of Contact
POLYTRAUMA NETWORK SITES
• Our closest:
VA Puget Sound- Seattle/Tacoma
POLYTRAUMA REHABILITATION CENTERS
Richmond
Palo Alto
Tampa
Minneapolis
POLYTRAUMA SERVICES
POLYTRAUMA REHAB CENTERS
SCOPE OF CLINICAL SERVICES
• Comprehensive Interdisciplinary Inpatient
Evaluations
• Manage Medical Instability
• Acute Comprehensive Inpatient
Rehabilitation
• Ongoing Follow-up and Care Management
Consultation
• Specialized interdisciplinary post-acute
rehabilitation services; inpatient and outpatient
• Manage new patients from inpatient services
• Identify local resources for VA and non-VA
care
• Provide proactive clinical and psychosocial
case management; continued support for
families
• Provide regular follow-up care, check-ups
• Coordinate services between VHA, military,
private sector
POLYTRAUMA SUPPORT CLINIC TEAMS
*Our Site in Portland/Vancouver
POLYTRAUMA SUPPORT
CLINIC TEAMS
• Outpatient rehabilitation services closer to homewide distribution across US
• Able to care for lifelong impairments with ongoing
follow up and family support
• Multidisciplinary rehabilitation team approach
POLYTRAUMA POINT OF
CONTACT (PPOC)
• Point of contact at every VA facility not
otherwise designated
• Knowledgeable about Polytrauma System
of Care
• Responsible for Triage and referral to a
Polytrauma site
REHABILITATING FROM COMBAT INJURY
REHABILITATION THERAPIES
Occupational Therapy
Physical Therapy
Speech Therapy
PHYSICAL THERAPIST
Diagnose and treat conditions to restore function
and prevent disability
Treat conditions such as head injuries, dizziness,
sports injuries, stroke patients, amputees, postsurgical patients, and burn patients among others.
PHYSICAL THERAPISTS EVALUATE:
Sensation
Range of Motion
Posture
Strength
Coordination
Balance
Flexibility
Gait/mobility
Need for braces/prosthesis
Need for assistive devices:
− Cane, walker, crutches, wheelchairs
PHYSICAL THERAPY
AND
TRAUMATIC BRAIN INJURY
Common impairments include:
− Dizziness
− Poor balance
− Other injuries sustained with head injury
OCCUPATIONAL THERAPY
Rehabilitative therapy that provides education and
training to assist individuals with disabilities to
achieve maximal independence in day to day
activities that are personally relevant
EXAMPLE AREAS OF INTERVENTION
Activities of daily living (dressing, bathing, hygiene,
etc.)
Money mgmt and banking skills
Cooking and kitchen safety
Managing your home
Cognitive planning for daily task
Functional performance
Visual perception
Strength and range of motion
EXAMPLE OF AREAS OF INTERVENTION:
Driving and/or ability to use public transportation
Hand function after injury
Sports after injury
WHO WOULD BENEFIT FROM OT?
Individuals with:
Brain Injury
Visually Impaired
Stroke/ CVA
Serious Mental Illness
Hand or upper extremity Injuries
Debilitating Illness (cardiac, respiratory)
Children with developmental disabilities
OCCUPATIONAL THERAPIST EVALUATE:
Ability to perform ADLs and life skills
Functional cognition for making decisions and
safety
Visual perception
Ability to mange demands of living independently
Upper extremity strength, range of motion and
coordination
Sensation and sensory loss
Need for adaptive equipment and/or
modifications
Need for splinting and/or orthotics
OCCUPATIONAL THERAPY AND
TRAUMATIC BRAIN INJURY
Each individual with a brain injury has different
needs and personal goals. There is no usual
impairment or routine treatment plan that can
be followed. The role of the occupational
therapist is to evaluate the individuals needs
through assessment and focus the treatment
on goals that are personally relevant to that
individual. OT bridges the gap between
cognitive function and actual functional
performance.
OCCUPATIONAL THERAPY SERVICES
PROVIDED AT THE VA
Outpatient Rehabilitation
Outpatient Hand Therapy
Outpatient Driving Rehabilitation
Outpatient Polytrauma
Inpatient Acute
Inpatient Rehabilitation
Inpatient Community Living Center (skilled
nursing, palliative, hospice)
SPEECH-LANGUAGE THERAPY
Collaborates with patient, family, and
multidisciplinary rehab team to restore
cognitive and communication abilities.
SPEECH-LANGUAGE THERAPISTS
EVALUATE AND TREAT:
Attention/Concentration
Executive Functioning
− Initiation, organizing, planning, sequencing, and timing of behavior; selfevaluation and insight.
Reasoning and Problem Solving
Memory
− Encoding, storing, retrieving information
Language
− Auditory comprehension; reading comprehension; verbal expression;
writing
Social Communication and Behavior
− Interacting appropriately with others
Voice and Speech Impairment
Swallowing Impairments
SPEECH-LANGUAGE THERAPY
AND TRAUMATIC BRAIN INJURY
Examples of Cognitive Rehabilitation:
− Training in the use of environmental modifications (e.g., file
systems, organizing tools; identifying and minimizing external
distractions) to compensate for attention difficulties.
− Treatment designed to directly improve the processes
underlying attention.
− Training in use of compensatory memory management
techniques and external devices (e.g., PDA/Smartphones,
alarm watches, voice recorders).
− Training in the use of task-specific routines, including time
management.
− Study skills/Back to School Group.
− Social skills/social communication training.
SPEECH THERAPY SERVICES
PROVIDED AT THE VA
Acute Rehabilitation – Portland VA Medical
Center
Inpatient Rehabilitation – Comprehensive
Rehabilitation Unit (CRU)
Subacute Rehabilitation – Skilled Nursing Unit,
Palliative Care, Hospice Care, Community
Living Center.
Outpatient Rehabilitation: Portland VA Medical
Center and Vancouver Campus.
ADDITIONAL RESOURCES
Ellen Kessi, MSW LCSW
Polytrauma Social Work Case Manager
CASE MANAGEMENT
Social Work Case Management
Nursing Case Management
Levels of Care-Case Management
RESOURCES AVAILABLE AT PVAMC
Post Deployment Health Care
OEF/OIF Program Point of Contact
Veteran’s Health Care Administration
Outreach
Yellow Ribbon Events
PDHRA (30, 60 and 90 days Post Deployment)
Reintegration Team Events
Inform about community resources
Care Management
Mental Health
Cognitive Skills Training
SATP
PTSD
Counseling
Vet Centers
Weekly OEF/OIF & Family support groups
Veteran's Benefits Administration –
Compensation and Pension
Home Loan Guarantee Program
Vocational Rehabilitation Program
Education Benefits
Survivor and Dependent Compensation
National Cemeteries Administration
Transportation
MyHeatheVet
Homemaker Home Health Aide Program
HISA Grants
Homeless Programs
Contract Nursing Home
“[L]et
us strive on to finish the work we are in, to bind up the
nation’s wounds, to care for him who shall have borne the
battle and for his widow and his orphan…”
President Abraham Lincoln
2nd Inaugural Address
POLYTRAUMA TEAM
Andrea Karl, MD- Director of Polytrauma Clinic
Katherine Noonan, Ph.D.- Polytrauma Psychologist
Ellen Kessi, LCSW- Social Work Case Manager
Katrell Rinehart, PT-Physical Therapist
Kiersten Smith, MOTR/L-Occupational Therapist
Tricia Strombom, RN BSN- Nurse Case Manager
CONTACT INFORMATION
For Referrals Please Contact:
The Polytrauma Case Management Team
(800) 949-1004 ext. 34029
(503) 220-8262 ext. 34029
[email protected]
[email protected]