Care Coordination

In response to growing concern surrounding unrecognized TBI, the United States Congress has mandated that military and Veterans Affairs hospitals screen all service members returning from combat assignment.

This helps to ensure early treatment but also presents a challenge to medical doctors and other healthcare professionals who are now faced with evaluating every war fighter for concussion as well as addressing any TBI-related impairments which may be identified during the post-deployment health screening. Meeting these needs for such a large group of service members and veterans who may be eligible for care under the many different clinical programs available throughout the country requires a new approach to TBI management and care coordination.

The Defense and Veterans Brain Injury Center (DVBIC) is working in partnership with military and Veterans Affairs medical centers throughout the country to unify these systems of care — from point of injury to stateside treatment facilities.

While TBI may result in physical impairment, often the more problematic consequences involve an individual's cognition, emotional functioning, and behavior. These can impact all aspects of life including the development and maintenance of interpersonal relationships and the ability to function in social settings. Community re-integration efforts are therefore aimed at maximizing individual strengths and creating supportive environments that will allow for a return to work and family.

Early identification and treatment efforts are the first steps in ensuring optimal recovery. Following the initial TBI and the immediate medical intervention, a wide variety of clinical and rehabilitative resources are available to service members and veterans. The particular resources used will depend upon the severity of the injury, the clinical presentation of the individual with TBI, and the extent of their recovery during the initial intervention and stabilization.

Individuals with TBI and their families benefit from the close partnerships formed between clinicians and other TBI health professionals who work together over distance and within multiple systems of care. DVBIC, in conjunction with numerous other agencies, is working continuously to improve clinical services and strengthen the channels which support medical transitions for service members and veterans with TBI.

UNDERSTANDING ENVIRONMENTS OF CARE

Different settings and populations provide unique challenges

• Non-combat related TBI that occurs in CONUS (i.e., stateside motor vehicle crashes or training accident)
• Those injuries that are initially detected during post-deployment screening
• And those who come home via the Air Evacuation (AE) system because of identified injuries

The wounded warriors who come home in the AE system can be further sub-divided into 1) those individuals with a primary diagnosis of TBI and 2) those individuals who are medically evacuated because of other physical injuries, but also have a mild TBI (mTBI)/ concussion that may not be identified until they are screened at a Level IV facility such as Landstuhl Regional Medical Center in Germany.

PATIENT AND FAMILY NEEDS

Following medical evacuation from theater and during stabilization at a stateside military treatment facility, the treatment team will determine the medical plan of care that best meets recovery goals.

In addition to medical management, TBI care also requires that logistical issues surrounding the care of an individual with TBI and the needs of his or her family are addressed. Depending on the severity of the TBI, the individual may or may not be able to participate in discussions and decisions regarding their treatment plan and recovery expectations.

Helping family members adjust to the changes evidenced in an individual with TBI can range from learning to assist him or her with slight memory problems, to caring for a bed-bound or minimally responsive individual. In many cases, if a service member or veteran is unable to completely return to their prior level of functioning, families undergo a complex process of adapting, coping and grieving. By providing emotional support and assisting with positive coping mechanisms, the treatment team can foster healthy re-integration of the individual and family.

EDUCATION WITHIN THE MILITARY & VA MEDICAL SYSTEMS

Early educational efforts focus on the immediate aspects of TBI including current medical status, treatment plan and expected recovery course.

As transitions become imminent, family education must shift to include details of the rehabilitation process, logistics of military TBI care, and in some cases, the procedures for securing service discharge and disability. Open communication among medical providers, families and other care givers will help ensure that all available resources within the DoD and VA healthcare systems are identified for each individual with TBI.

Service members with moderate or severe TBI often need to access acute inpatient rehabilitation at a VA Polytrauma Rehabilitation Center (PRC) while still on active duty, and the most severely impaired service members with TBIs will often stay within the VA healthcare system for the remainder of their time in the military and beyond. While an active duty service member with TBI is receiving care at a VA Medical Center (VAMC), coordination must occur between the VAMC, the military case manager, the DVBIC care coordinator and the MTF treatment team.

In addition, arrangements for family members to remain at the VAMC with the injured service member involve many logistical concerns that need to be addressed such as Non-Medical Attendant Orders from the military, lodging and transportation arrangements, etc. Those service members with TBIs who then return to an MTF or who did not need inpatient acute TBI rehab are transitioned to long term management of their TBI at local MTFs or VA medical facilities. Much attention has been paid to these processes in an effort to improve transitions across two large systems of care (the Military Health System and Veterans Health Affairs).

DVBIC NATIONAL CARE COORDINATION NETWORK

To better support service members and veterans with TBI, DVBIC created a network of Regional Care Coordinators (RCC) who are able to follow individuals within a specific region. The goal of this network is to improve service delivery by allowing professionals (nurses/social workers/counselors) specializing in TBI to guide TBI specific treatment and services.

Each DVBIC Care Coordinator is assigned to a specific geographical region of the country and tasked with monitoring service members and veterans with TBIs in that region as well as maintaining knowledge of the TBI treatment and support assets of the region (military, veteran and civilian).

Among their core responsibilities, care coordinators serve as points-of-contact to assess TBI resources in communities where individuals reside, facilitate access to those services, and ensure that individual plans of care are appropriate and therapeutic in the short-term and long-term.

DVBIC Regional Care Coordinators work to ensure optimal care and recovery for service members and veterans with TBIs whose rehabilitation and return to community does not always follow a strict linear path, or whose injury may result in cognitive, social, behavioral or physical deficits which prevent them from accessing available systems of care. RCCs also follow service members and veterans with TBIs longitudinally to help avert poor outcomes and to improve our understanding of the many factors related to outcome following TBI.

The implementation of the DVBIC Regional Care Coordination system ensures that service members and veterans with TBIs have access to appropriate medical care, support, and available resources throughout the recovery process.

The DVBIC National Office of Care Coordination is responsible for the management and growth of DVBIC's care coordination network which serves hundreds of service members and veterans with TBIs who require any amount of support. An RCC operating from each of DVBIC's core sites is responsible for a catchment area that may include both urban and rural populations, service members and veterans, and other diverse communities. Their goal is to facilitate access to the full scope of resources available to service members and veterans with TBIs, and their families, in whatever area they live.

View our Interactive Map with listings for each DVBIC RCC.