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TBI and the VA: A Patient Centered Care Approach

TBI and the VA: A Patient Centered Care Approach. Sandra Hall MSW/L, BSN/RN,HNB-BC Melissa Hall, LGSW/MSSW Terry Gee, MS, PT Hershel “Woody” Williams VA Medical Center. The History of the Polytrauma System of Care (PSC).

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TBI and the VA: A Patient Centered Care Approach

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  1. TBI and the VA:A Patient Centered Care Approach Sandra Hall MSW/L, BSN/RN,HNB-BC Melissa Hall, LGSW/MSSW Terry Gee, MS, PT Hershel “Woody” Williams VA Medical Center

  2. The History of the Polytrauma System of Care (PSC) • In 2005 the Veteran’s Administration (VA) began to require screening for Traumatic Brain Injuries for post deployment OEF/OIF veterans (post-9/11). • Between 2007 and Sept 2016, the VA screened over 1 million Veterans for TBI. • 83, 318 of those Veterans were diagnosed with a TBI (most were mild TBIs) • This program is very active and ongoing! In Fiscal Year 2019, Quarter 1: 94.83% (or 426,722) of OEF/OIF Veterans seen in the VA system were screened for TBI. 15,164 of those Veterans were referred on for a Level 2 Comprehensive TBI exam • 502 were in VISN 5 • Baltimore VA: 107 Referrals • Beckley VA: 23 Referrals • Clarksburg VA: 56 Referrals • Huntington VA: 32 Referrals • Martinsburg VA: 104 Referrals • Washington DC VA: 180 Referrals

  3. Population served by the PSc Eligible Veterans and Active Duty Service Members covered by Defense Health Agency Great Lakes (DHA-GL) or TRICARE authorization, who sustained polytrauma and TBI. This includes: • TBI (whether deployment related or not); • Blast and non-blast related traumatic injuries including (but not limited to) amputations, musculoskeletal injuries, open wounds; • Other acquired brain injuries including, but not limited to, stroke, brain tumors, infection, poisoning, hypoxia, ischemia, encephalopathy, or substance abuse, as appropriate for specific cases; • Physical, cognitive, emotional, and behavioral impairments related to the brain injury; • Impairments that are clinically and functionally significant, leading to activity and participation restrictions; and • Potential to benefit from the specialized rehabilitation services provided by the PCS.

  4. The VA’s Polytrauma System of Care • An integrated nationwide network of facilities • There are: • Five Polytrauma Rehabilitation Centers (PRC) /Polytrauma Residential Transitional Rehabilitation Programs (PTRP) that provide acute, intensive inpatient rehabilitation. These sites also house the Emerging Consciousness (EC) Programs and Assistive Technology (AT) Labs. • Twenty-three Polytrauma Network Sites (PNS) established regionally, which offer continued medical and rehabilitation services closer to home after discharge from a PRC. Also can be the entry point for rehabilitation services for mild-moderate TBI or polytraumatic injury. Provides both inpatient and outpatient services. • Eighty-seven Polytrauma Support Clinic Teams (PNSC) providing specialized outpatient care in coordination with the regional PNS. Can be the entry point for veterans who have experienced a mild-moderate TBI or polytraumatic injury. • And 39 Polytrauma Points of Contact (PPOC) who have no specialized rehabilitation teams, but offer case management and referrals throughout the system. PPOCs may provide a limited range of rehabilitation services.

  5. VHA Polytrauma/TBI System of Care

  6. Polytrauma Services-Inpatient (1) Polytrauma Rehab Centers (PRCs) are interdisciplinary, specialized brain injury programs that have: • Outcomes which are focused for persons with both traumatic and non-traumatic injuries • Multifaceted approach addressing the challenging medical, physical, cognitive, psychosocial, mental health, and recreational needs of each individual receiving treatment • Structured approach of rehabilitation and education • Patients must be able to participate in a minimum of 3 hours of physical, occupational, and/or speech therapy daily, along with specialized medical and nursing care, psychological services, recreation therapy, and vision rehabilitation. All PRCs are accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) using Brain Injury Specialty standards.

  7. Polytrauma Services-Inpatient (2) Polytrauma Transitional Rehabilitation Programs (PTRPs) provide: • Inpatient rehabilitation services in a residential type environment for individuals that will benefit from physical, cognitive, communicative, behavioral, and psychosocial therapies to facilitate their return to home, school, work, or military service after a significant injury or illness. • Therapy is interdisciplinary and uses a combination of group and individual formats. • Services include a broad range of vocation, leisure, and spiritual needs with a focus on community reintegration goals. • Families and caregivers are encouraged to participate in all phases of the rehabilitation process whenever appropriate and practical. CARF accredited for residential rehabilitation with brain injury specialty programming.

  8. Polytrauma Services-inpatient (3) Emerging Consciousness (EC) Programs • VA developed in collaboration with experts from the academic community and private sector. • Highly specialized protocol for the rehabilitation of Veterans and Service Members who are slow to recover consciousness after severe injuries • Provides a balance of medical and therapeutic interventions to: • Improve responsiveness • Return to consciousness • Minimize complications, and • Facilitate progress towards the next level of rehabilitation care • Programs are housed at the PRCs

  9. Polytrauma Services-inpatient (4) Assistive Technology (AT) Labs • Provide services directly to Veterans and Service Members • Serve as expert resources to support the application of AT throughout the Veteran’s Health Administration • Responsible for evaluation, development, and implementation of appropriate AT services, strategies, devices, and/or practices to improve the functional challenges faced by Veterans & Services Members in daily life. • Services may include: adaptive automotive equipment, adapted sports and recreational equipment, aids for daily living, wheelchairs, and communication aids. • AT specialists (including rehabilitation engineers and rehabilitation providers) have the skills and equipment to modify or design devices that serve specific needs of Veterans • AT Labs are housed at the PRCs

  10. Polytrauma Services-Outpatient (1) Polytrauma Network Sites focus on outpatient services, but do have some inpatient beds available to address post-acute and chronic complications. Inpatient beds at PNS are CARF accredited for Comprehensive Integrated Inpatient Rehabilitation. • Maintain a full complement of rehabilitation professionals on staff to address complex TBI and Polytrauma related symptoms and their functional deficits. • Provide clinical oversite of the PSC sites within their VISN, including: • Care coordination • Managing referrals and consultations • Advising on the collection and reporting of data

  11. Polytrauma Services-Outpatient (2) • Polytrauma Clinical Support Team (PSCT) • Provides individualized rehabilitation services including comprehensive evaluations and development of Interdisciplinary Rehabilitation and Community Reintegration (IRCR) Care Plan. • Polytrauma Point of Contact (PPOC) sites • Deliver a limited range of outpatient rehabilitation services for TBI and Polytrauma related problems. • Works closely with PNS for clinical cases that exceed local expertise.

  12. Polytrauma Services-Outpatient (3) A spectrum of treatment options based on the VA/Department of Defense Clinical Practice Guidelines are available for Veterans with TBI in all Polytrauma System of Care programs, including but not limited to: • Health Care Services • Individual and Group Therapy • Education and Counseling • Vocational and Employment Services • Social and Independent Living Skills • Healthy Living Recommendations, and • Telerehabilitation • Services are provided based on the individual Veteran’s preference and needs

  13. VISN 5: What’s LOCAL?

  14. VISN 5 Polytrauma Network • PNS • Washington, DC • PSCT • Baltimore • Martinsburg • Huntington • PPOC • Clarksburg • Beckley

  15. Polytrauma Services in VISN 5

  16. Polytrauma Services in VISN 5, Cont.

  17. Specialty Treatment:Vestibular Rehabilitation (1) • A Physical Therapy approach used by an advanced trained therapist in the treatment of dizziness and imbalance caused by vertigo and balance disorders. • Some disorders, such as Benign Paroxysmal Positional Vertigo (BPPV), are treated effectively in one visit. • Who can benefit from Vestibular Rehabilitation? • Those suffering from the following: • Vertigo (central vs. peripheral/vestibular vs. non-vestibular causes) • BPPV • Balance/Neuromuscular Disorders • Labyrinthitis/Neuronitis • Concussion • Cervical Vertigo

  18. Specialty Treatment:Vestibular Rehabilitation (2) • Vestibular Treatment may include: • Canalith Repositioning Maneuvers • To treat BPPV • Vestibular Ocular Reflex (VOR) retraining exercises • Stabilize gaze which leads to improved visual acuity • decreases vertigo-like sensations during head movement • Reduces loss of balance episodes • Exam assists in the prescription of specific vestibular exercises for the individual • Balance and Proprioceptive exercise • Emphasize reducing fall risk • Improves coordination and balance reactions • Huntington VAMC utilizes Computerized Dynamic Posturography and Computerized Dynamic Vision assessment and treatment that enhance the quality of intervention implementation.

  19. Specialty Treatment:Vestibular Rehabilitation (3)

  20. Veteran Centered Treatment • In addition to standardized treatment options, the VA has implemented a Whole Health approach to care, which is shifting the focus to “what matters most” to the Veteran. • A Holistic approach looking at work, environment, relationships, diet, sleep patterns, and more. • This model allows the Veteran and Health Care Provider to have a conversation about the Veteran’s needs and goals, and design a personal health plan to help them achieve those goals.

  21. Complementary & Integrative Health (1)

  22. Complementary & Integrative Health (2) CIH Directive List 1 Must be made available to Veterans across the system Acupuncture Meditation Yoga Tia Chi/Qi Gong Biofeedback Clinical Hypnosis Guided Imagery Massage CIH Directive List 2 “Generally Considered Safe” –Optional to Provide Healing Touch Acupressure Alexander Technique Reflexology Reiki Therapeutic Touch Emotional Freedom Technique (EFT) Aromatherapy Biofield Therapies Rolfing Somatic Experiencing Zero Balancing

  23. Technology-Bridging the GapTelehealth (1) • In 2017, the VA identified the need for increased rehabilitation services, as well as a lack of rehabilitation providers, in rural areas • The Hub and Spoke Model was developed in 2018, allowing expertise from the “Hub” to be delivered via technology to the “Spoke” sites. 4 Hub and 7 Spoke sites began clinical telerehab protocols, education, and outreach. • By June 2018, the VA amended its medical regulations and standardized the delivery of care by VA health care providers through telehealth with the “Anywhere to Anywhere” regulation. • Ensures that VA health care providers can offer the same level of care to all beneficiaries, irrespective of the State or location in a State of the VA health care provider or the beneficiary. • Achieves important Federal interests by increasing the availability of mental health, specialty, and general clinical care for all beneficiaries

  24. Technology-Bridging the GapTelehealth (2) In 2018, Telerehabilitation Programs had a total of 77,199 total encounters in the VA System. Of those, 46,997 were unique. These visits included clinics in: Audiology Blind Rehab Physical Medicine and Rehabilitation Polytrauma/TBI Amputation Assistive Technology Kinesiotherapy Occupational Therapy Physical Therapy Recreational Therapy, and Speech Therapy

  25. Technology-Bridging the GapTelehealth (3)

  26. Technology-Bridging the GapVA Video Connect (VVC) • The VA is striving to deliver care to Veteran’s in their preferred locations, including their homes when clinically appropriate. • VA Video Connect (VVC) enables a Veteran to have an outpatient telehealth visit with their provider using their smartphone, tablet, or desktop computer (must have video/camera capability). • Provider and veteran set an appointment time and connect via an email generated link, allowing face to face video chat.

  27. Technology-Bridging the GapThe App Store • Download apps to your tablet or phone from https://mobile.va.gov/appstore/veterans • Free for anyone (not just veterans!) • Available apps include: Online Scheduling, VA Video Connect, Anger and Irritability Management Skills, Concussion Coach, and a Mindfulness Coach • Sample: Concussion Coach • Designed for Veterans, Service Members, and others who are experiencing physical, cognitive, and emotional symptoms that may be related to mild or moderate TBI • Provides information about concussion, a self-assessment instrument for symptoms and their severity, tools to help build resilience and manage symptoms, and community-based support and resource recommendations

  28. Polytrauma-Case Management (1)

  29. Polytrauma-Case Management (2)

  30. Questions and Comments?

  31. Contact Us Sandra Hall, MSW/L, BSN/RN, HNC-BC Polytrauma/TBI/Amputee Case Manager 304-429-6741 x 2772 Melissa Hall, LGSW/MSSW Polytrauma/TBI/Amputee Social Work Case Manager 304-429-6741 x 2848 Terry Gee, MS, PT Polytrauma/TBI Vestibular Therapist 304-429-6741 x 3782

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