Polytrauma Rehabilitation Center Design Guide May, 2008

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2 Table of Contents CONTENTS PAGE NUMBER PREFACE Table of Contents...i Foreword...vii Introduction...viii Glossary...ix Abbreviations...xii 1.0. NARRATIVE General Considerations General Trends in Polytrauma Rehabilitation Center Design Codes, Standards and Executive Orders Functional Concepts Operations: Services Operations: Concepts, Classification of Polytrauma Symptoms Space Planning and Design Functional Diagrams Functional Relationships Technical Considerations Architectural Structural Equipment Heating, Ventilation and Air Conditioning Plumbing Electrical Communications Waste Management Transportation INDEX OF FIGURES AND TABLES Figure No. Description Page No. Figure 1.1 Work Flow Variation # Figure 1.2 Work Flow Variation # Figure 1.3 Work Flow Variation # Figure 1.4 Work Flow Variation # Figure 1.5 Overall PRC Diagram Option Figure 1.6 Overall PRC Diagram Option Figure 1.7 Overall PRC Diagram Option Figure Functional Diagram: Inpatient Nursing Unit Central Nurse 1-12 Station Figure Functional Diagram: Decentralized Monitoring Stations 1-13 Figure Functional Diagram: Transitional Rehabilitation Unit 1-14 Figure Functional Diagram: Outpatient Services 1-15 i

3 INDEX OF FIGURES AND TABLES (con t) Table No. Description Page No. Table 1.1 Required* Core Dedicated Staffing Per Twelve Beds For 1-3 Each PRC Center Table 1.2 Dedicated Consultative Services Recommended At Each 1-4 Medical Center With A PRC Table 1.3 Blast-Related Injury Table 1-9 ii

4 Acknowledgements The following individuals are those whose guidance, insight, advice and expertise made this Polytrauma Rehabilitation Design Guide possible: Lloyd H. Siegel, FAIA Director, Strategic Management Office, 00CFM1 Kurt D. Knight, PE Chief, Facilities Quality Service, 00CFM1A Donald Myers, AIA, NCARB Senior Architect, 00CFM1A Orest Burdiak Principal Interior Designer, 00CFM1A Dan Colagrande Architect, Consulting Support Service, 00CFM3A Dennis Hancher, RA Architect, 00CFM1A Jim McCord Architect, Consulting Support Service, 00CFM3A Satish Sehgal General Engineer, 00CFM1A Dennis Sheils Project Planning & Development, 00CFM2C Julius Sztuk, AIA Architect, 00CFM1B N Frances C. Wells Technical Information Specialist, 00CFM1A PRC Design Advisory Group Veterans Health Administration Lucille B. Beck, PhD Chief Consultant, Rehabilitation Services, Director, Audiology & Speech Pathology Service iii

5 David W. Chandler, PhD Deputy Chief Consultant, Rehabilitation Services Barbara Sigford, MD, PhD National Program Director, Physical Medicine & Rehabilitation Gretchen Stephens, MPA TBI and Polytrauma Program Coordinator, Physical Medicine & Rehabilitation Service, National Program Office Richard Ames San Antonio VAMC Jack Avery Speech Pathologist, Minneapolis VAMC Richard Bauer, MD Chief Medical Officer, South Texas VHCS Mark Bender Richmond VAMC Ken Burris Chief Engineer, San Antonio VAMC Beverly Cheshire, PT Chief of Physical Therapy, Tampa VAMC Mark Chronis Richmond VAMC Jeffrey Denzler Richmond VAMC Bill Gregg Nurse Manager, Richmond VAMC Paul Koons Blind Rehabilitation Outpatient Specialist, Palo Alto VAMC Eric Lipton Palo Alto VAMC Daniela Lita Occupational Therapist, Palo Alto VAMC Richard Martinez Richmond VAMC iv

6 Paul Miller Tampa VAMC William Mullin, PT, M.S. Richmond VAMC Jason Neitupski Facility Planner, Palo Alto VAMC Nina Pagel, RN PRC Nurse Manager, Minneapolis VAMC Michelle D. Peterson Physical Therapist, Minneapolis VAMC Gail Powell-Cope Tampa VAMC Steven Scott, DO Director of Rehabilitation, Research & Development, Tampa VAMC Richard Smith Palo Alto VAMC Margaret Veneman, NM Tampa VAMC Deborah J. Voydetich Occupational Therapist, Minneapolis VAMC Andrew M. Welch Associate Director (001), South Texas VHCS Angela Whitener Tampa VAMC Ex Officio Donald Orndoff Director,, 00CFM Robert L. Neary Director, Service Delivery Office, 00CFM3 v

7 Prime Consultant HDR Architecture, Inc. James R. Langlois, AIA Senior Project Manager April McKinley, RN Healthcare Programmer Natalie Sutto, RN Nursing and Operations Planner Steve Tozer, AIA, LEED AP Healthcare Architect Jeff Getty, AIA, LEED AP Healthcare Planner Julian Jones, AIA Healthcare Architect David Gebel, AIA, LEED AP Healthcare Architect Anne Sullivan Medical Equipment Planner John Pate, AIA Healthcare Architect vi

8 Foreword The material contained in the Polytrauma Rehabilitation Center Design Guide is the culmination of a partnering effort within the Department of Veterans Affairs by the Veterans Health Administration and the. The goal of this Design Guide is to facilitate the design process and to ensure the quality of VA facilities, while controlling construction and operating costs. This document is intended to be used as a guide and to supplement VA Space Planning Criteria, other technical criteria, and related VA programs and policies for Polytrauma Rehabilitation. Use of this Design Guide does not preclude the need for a functional and physical design program for each specific project. It is the responsibility of the Project Architect and the Project Engineer to develop a complete and accurate project design that best meets the users' needs, applicable standards, and code requirements. Lloyd H. Siegel, FAIA Director Strategic Management Office vii

9 Introduction The Polytrauma Rehabilitation Center Design Guide is intended to be a graphic consolidation of new and existing Department of Veterans Affairs standards and criteria. It contains data from the following sources: 1. Standards and Criteria Sources a. Master Construction Specifications PG-18-1 b. Construction Standards H-18-3 c. Standard Details PG-18-4 d. Equipment Guide List PG-7610 e. List of Equipment symbols PG-18-6 f. Space Planning Criteria PG-7610 g. Barrier-Free Design Handbook H h. Room Finish and Door Hardware Schedule i. PG j. Various Technical Criteria (Design Manuals)pertaining to Architectural, HVAC, Plumbing, and Electrical k. Consensus information from various VA medical centers The Design Guide refers to the above mentioned sources when data is either too detailed or too broad to be included in this guide. The Design Guide for Polytrauma Rehabilitation Center was developed as a design tool to assist the medical center staff and the contracting officers in better understanding the choices that designers ask them to make, and to help designers understand the functional requirements necessary for proper operation of Inpatient, Outpatient, and Transitional Polytrauma Rehabilitation. The Guide Plates contained in the Polytrauma Rehabilitation Center Design guide are intended as illustrations of VA's furniture, equipment and personnel space needs. They are not meant to limit design opportunities. This Design Guide is not intended to be project specific. While it does contain the vast majority of department / program specific spaces required in a Polytrauma Rehabilitation Center, it is not possible to foresee all future requirements. Additionally, the Design Guide does not include every room listed in the Space Planning Criteria (PG-7610). The project-specific space program is the basis for an individual project design. It is important to note that the guide plates are a generic graphic representation only. Equipment manufacturers should be consulted at time of design to ensure specific dimensions and utility requirements. Use of this Design Guide does not supersede the project architect's and engineers' responsibilities to develop a complete and accurate design that meets the user's needs and the appropriate code requirements. viii

10 Glossary Adjacency Matrix: Americans with Disabilities Act (ADA) Assignable Space: Bay: Case Mix: Certificate of Need (CON) Circulation Area: Correlated Color Temperature (CCT): Departmental Gross Square Feet Footprint: Gross Square Feet (GSF): Indoor Air Quality (IAQ): A diagram illustrating the relative proximity of each workspace to other workspaces Legislates access for disabled persons in most privately owned buildings or businesses that serve the public A measurement of space attributable to a distinct function or service including support areas and intradepartmental circulation. Defines Net Square Feet The space in a building generally bounded by four columns. Case Mix categorizes patients into statistically and clinically homogenous groups based on the collections of clinical and administrative data. Adjusting for patients of different levels of acuity forms the basis for healthcare organization comparisons and case mix adjusted resource utilization Certificate of Need (CON) is a formal statement that a health care facility, medical equipment purchase, or new medical or expanded service is needed, or that a reduction or termination in service will not have an adverse affect on health care access. Entrances, vestibules, (interdepartmental) corridors, passages, elevators, escalators, stairs, etc; included in gross areas and excluded in net areas. Describes the degree to which a color appears warm (reddish), neutral or cool (bluish) and is measured in Kelvin (K). The sum gross spaces in a department. Describes the actual floor area for a function or activity; it does not include circulation space. Also refers to the building floor plate. Total building gross areas measured from exterior faces of exterior walls. Refers to the quantitative level of contaminations in the air as well as the qualitative level of satisfaction of those exposed to the air. Standards for acceptable IAQ have been developed by the U.S. Environmental Protection Agency. ix

11 Glossary Layout: Leadership in Energy and Environmental Design (LEED ) A floor plan showing the specific placement of walls, doors, furniture, and equipment. LEED includes a rating system for building design as well as professional accreditation for people working in the design and building industry. Mechanical Area National Fire Protection Association (NFPA): Net Area: Net-to-Gross: Nurses Station: Off-gassing: Resident Bed Room: Residential Model: Responsible Design: Site: Main boiler room and other mechanical and electrical areas: included in gross areas and excluded in net areas. Produces a code used in many jurisdictions to define fire protection requirements of building codes. The area of rooms or spaces as measured from inside wall to inside wall and assigned to functional use by occupants. A measure of the ration of assignable space to total space in a building: typically expressed as a percentage. Location at which nursing staff traditionally performs charting and related activities throughout the day. The release of chemicals from non-metallic substances used in construction or furnishing. Off-gassing compromises indoor air quality (IA). Common sources of off-gassing included interior-grade pressed wood materials and synthetic furnishing such as carpeting. A room in the facility licensed for one or more patient beds. Design philosophy based on incorporating home like elements while minimizing institutional aspects. Architecture that respects the natural environment and integrates it into building design, addresses the health of individuals and community, and is sensitive to the cultural context of the site. The land parcel on which the building(s) sits or will be built. It includes the grounds, driveways, and walkways associated with the building(s). x

12 Glossary Uninterruptible Power Supply (UPS): United States Green Building Council (USGBC) Veterans Integrated Service Network (VISN): Generators, batteries, and/or associated equipment that provide continuous electrical power, preventing power loss to critical functions that rely on absolute continuity of service. The United States Green Building Council is a national coalition of leaders in the building industry that developed the LEED system. The VA healthcare system consists of 21 integrated networks across the US and Puerto Rico that are focused on pooling and aligning resources to better meet local health care needs and provide greater access to care. xi

13 Abbreviations A ABA AC/HR ADA ADAAG AHJ AIA ANSI AR BOMA CAD CARES CFM CFM CON DAG EPA FC FTEE GRECC GSF GSM HIPAA HP HPD HVAC IAQ IBC JCAHO LB Amps Architectural Barriers Act Air Changes per Hour Americans with Disability Act ADA Accessibility Guidelines Authority Having Jurisdiction American Institute of Architects American National Standards Institute As Required Building Owners and Management Association Computer Assisted Design Capital Asset Realignment for Enhanced Services Cubic Feet per Minute Certificate of Need Design Advisory Group Environmental Protection Agency Foot Candle Full Time Equivalent Employee Geriatric Research, Education and Clinical Center Gross Square Feet Gross Square Meters Healthcare Insurance Portability and Accountability Act Horsepower Hours per Day Heating, Ventilating and Air Conditioning Indoor Air Quality International Building Code Joint Commission on Accreditation of Healthcare Organizations Pound, Pounds xii

14 Abbreviations (cont d) LEED Leadership in Energy and Environmental Design LUX Lumen Per Square Meter MDS Minimum Data Set NFPA National Fire Protection Association NSF Net Square Feet NSM Net Square Meters NTS Not to Scale OBRA Omnibus Budget Reconciliation Act (of 1987) OSHA Occupational Safety and Health Administration OT Occupational Therapy PG Program Guide PRC Polytrauma Rehabilitation Center PT Physical Therapy RUG Resource Utilization Group RH Relative Humidity RT Recreation Therapy SF Square Feet, Square Foot SVH State Veterans Home SqM Square Meters TV Television UBC Uniform Building Code UFAS Uniform Federal Accessibility Standards UPS Uninterruptible Power Supply USGBC United States Green Building Council V Volts VA Department of Veterans Affairs VACO Veterans Affairs Central Office xiii

15 Abbreviations (cont d) VAMC VHA VISN VSO W Veterans Affairs Medical Center Veterans Health Administration Veterans Integrated Service Network Veterans Service Organizations Watts xiv

16 Polytrauma Rehabilitation Center Design May, NARRATIVE 1.1. General Considerations The Polytrauma Patient The polytrauma (PT) patient has sustained multiple life-threatening injuries and disability at the same time requiring specialized intensive rehabilitation and coordination of medical care. Injuries are sustained during active duty service as the result of Improvised Explosive Device (IED) explosions and blasts. Traumatic Brain Injury (TBI) is a key component of the polytrauma injury and results in brain injury (mild, moderate, and severe), PTSD, pain, fractures, hearing loss, spinal cord injury, loss of vision, and burns. Due to the symptoms of the blast injuries, coordinated interdisciplinary care in provided to address cognitive, emotional and physical rehabilitation. The varied pattern of severe and disabling injuries include, but are not limited to traumatic brain injury (TBI), amputation, visual and hearing impairment, spinal cord injury (SCI), musculoskeletal injuries, wounds and psychological trauma. In addition to a team of physiatrists or physicians who specialize in physical medicine and rehabilitation, specialists in surgery, neurosurgery, internal medicine, psychiatry, infectious disease, prosthetics, orthotics, and spinal cord injury as part of the day-to-day planning and patient care. Physiatrists lead an interdisciplinary rehabilitation team consisting of physical therapists, occupational therapists, speech therapists, rehabilitation nurses, kinesiotherapists, vocational therapists, social workers, neurophysiologists, psychologists, advance nurse practitioners, wound care nurses, respiratory therapists, recreational therapists, rehabilitation counselors, military liaisons, chaplains, blind occupational therapy case managers, physical therapy amputee case managers, social worker case managers, education specialist and veteran benefit specialist. Each one of these medical specialties and health care disciplines has specialized expertise in caring for the polytrauma patient and family and are essential to ensuring the comprehensive care results in optimal outcomes. Due to the nature of the injuries sustained and the length of time required for rehabilitation, the polytrauma patient has extended hospital stays. Treatment is provided in the acute inpatient, outpatient, and transitional setting. Patients can be expected to access the polytrauma network of care in an outpatient setting for many years post injury. The Polytrauma Patient s Family When patients sustain Polytrauma, the entire family is affected. The family experiences multiple stressors including often being away from home and support systems, caring for children and/or elderly parents and possible job loss or financial strain due to the length of time away. The need for adequate family space within the inpatient room and on the inpatient floor is supported by the extensive role the family plays in recovery and longterm care of the patient. 1-1

17 Polytrauma Rehabilitation Center Design May, 2008 Unlike a typical med-surg patient, the polytrauma patient will typically require long-term assistance from family members for activities of daily living (ADL). The family member acts as an extension of the medical staff by assisting with ADLs as they participate in the patient s care. Oftentimes the family will spend much of the day (and night) in the inpatient room for fear of leaving the patient alone. Research also indicates the need for decompression areas that allow the family to leave the patient room, yet remain on the unit. These areas can also be utilized for family counseling as the family dynamics are drastically changed when family member suffers a brain injury. The Polytrauma Interdisciplinary (Medical) Team The Polytrauma Rehabilitation of Care system is comprised of the Polytrauma Rehabilitation Center (PRC). A PRC provides comprehensive interdisciplinary rehabilitation and coordinates complex medical, surgical, and mental health care, as well as long-term follow-up. The individual with overall responsibility and authority in the care of patients identified within the medical system with Polytrauma is the PRC Medical Director. The PRC Medical Director is a board-certified or board-eligible Physical Medicine and Rehabilitation (PM&R) physician or a board-certified or board-eligible physician in another medical specialty with at least two years of experience in rehabilitation of brain injury, amputation and other complex impairments. An essential component to the PRC system of care is the Admission and Follow-up Clinical Case Management. The clinical case managers provide clinical case management of referrals and follow-up for the ongoing rehabilitation plan of care after discharge. Individuals assigned to this function require knowledge and clinical reasoning skills necessary to review the medical status of the patient, identify all of the current medical problems, evaluate the acuity level, assess factors surrounding readiness for inpatient rehabilitation, and monitor patient status until transfer is completed. The clinical case manager makes recommendations for alternative care settings when appropriate. The clinical case manager organizes the rehabilitation health care services that promote optimal outcomes for patients. This includes assessing patients strengths, challenges, prognosis, functional status, goals, and needs for specific services and resources, and developing a plan that identifies short- and long-term goals. Additional responsibilities may include coordinating resources to implement the plan and evaluation of the effectiveness and appropriateness of the services provided throughout the entire spectrum of care. Polytrauma injuries and care create a dramatic change in the lifestyle and family interactions of the patients. For this reason, a strong component of the program is Social Work Case Management. In collaboration with the clinical case management, the PRCs provide social work case management services for all patients and their families. VHA Directive , Social Work Case Management in Polytrauma Centers, provides additional guidance on the provision of these case management services. Social work case management differs from clinical case management in that the social worker case manager addresses the psychosocial needs of the patient, advocates for the patient and family, provides supportive services for the family and caregivers, and addresses home 1-2

18 Polytrauma Rehabilitation Center Design May, 2008 and community environment issues. A social worker case manager conducts a comprehensive psychosocial assessment, which includes review of cultural issues, patient support systems, family and caregiver support systems, financial and vocational status, and the living situation. In partnership with the clinical case manager, patient, and family, the social worker case manager develops treatment and discharge plans and provides ongoing case management services including post-discharge. The social worker case manager may provide clinical services, such as individual and family counseling and grief counseling. The social worker case manager contacts the patient or family prior to transfer to answer questions they may have and to assist with the transition. Social worker case management services continue through the rehabilitation process and postdischarge, providing assistance with transitions to the referring military treatment facility (MTF) or other VHA facility, or to the home and community. PERSONNEL DESCRIPTION Full-time Equivalent (FTE) Rehabilitation Physician 1 Nurse Manager 1 Registered Nurse (2.0 must be Certified Rehabilitation Registered Nurse 11 (CRRN) Licensed Practical Nurse and/or Certified Nursing Assistant 8 Nurse Educator 1 Clinical Nurse Leader (CNL)** 1 Admission and Follow-up Nurse Case Manager 1 Social Worker 3 Speech-Language Pathologist 3.0 Physical Therapist 3.5 Occupational Therapist 3.5 Recreation Therapist 2 Neuropsychologist 1 Counseling Psychologist 1 Family Therapist 1 Neuropsychologist 1 Blind Rehabilitation Outpatient Specialist 1 Certified Prosthetist 1 Certified Driver Trainer 1 Program Administrator 1 Program Assistant 1 Table 1.1 REQUIRED* CORE DEDICATED STAFFING PER TWELVE BEDS FOR EACH POLYTRAUMA REHABILITATION CENTER 1-3

19 Polytrauma Rehabilitation Center Design May, 2008 * Variances from the staffing model will have to be approved by the Physical Medicine and Rehabilitation Service Program Office. ** The CNL is a mandated position for all patient care settings in all VAMCs by 2016 and the rapid implementation of this role in the polytrauma network is a high priority. Office of Nursing Service will assist sites as needed with the implementation. Audiology Clinical Nutrition Clinical Chaplain Clinical Pharmacy Dentistry and/or Oral and Maxillofacial Surgery Driver Training Ear, Nose, and Throat (ENT) Gastroenterology General Medicine General Surgery Infectious Disease Neurology Neuroophthalmology Neurosurgery Optometry Orthopedic Surgery Plastic Surgery Psychiatry Post-traumatic Stress Disorder (PTSD) Clinic Team Pulmonary Radiology Urology Vocational Rehabilitation Table 1.2 DEDICATED CONSULTATIVE SERVICES RECOMMENDED AT EACH MEDICAL CENTER WITH A POLYTRAUMA REHABILITATION CENTER The Polytrauma Interdisciplinary (Medical) Team consists of the medical team devoted to the care and rehabilitation of the Polytrauma patient. The Each Medical Center Director is responsible for ensuring all polytrauma patients are initially referred to the VA Polytrauma Center or SCI Center in their respective referral region. The respective medical center Director at each of the four facilities with a PRC is responsible for facilitating transfers of care between MTFs and the PRC; ensuring that 1-4

20 Polytrauma Rehabilitation Center Design May, 2008 medical center leadership is a visible participant in the admission and hospital stay, recognizing the importance of the service these individuals have provided to their country; meeting environmental and staffing requirements for the PRC; provision is made for patients with polytrauma to have basic medical and primary care, and emergent medical and surgical care; and facilitating access to the next appropriate level of care, e.g., transition of care back to the MTF, or transition of care to the VHA facility closest to the service member s home with the capability of meeting care needs. The Chief of Staff (COS) at each of the Four Facilities with a PRC at each of the Four Facilities with a PRC is responsible for ensuring availability of a PM&RS staff physician 24 hours a day, 7 days a week; establishing local policy to ensure that a multidisciplinary assessment is performed immediately upon admission and an interdisciplinary treatment plan is documented. Medical and surgical specialty services (e.g., physical medicine and rehabilitation, surgery, psychiatry, medicine, orthopedics, infectious disease, etc.) are essential and to be involved in the pre-admission assessment of patients with polytrauma. The Chief Nurse Executive (CNE) at each of the Four Facilities with a PRC is responsible for ensuring availability of nursing and other assigned program services 24 hours a day, 7 days a week. Collaborating with the COS to ensure that results and recommendations of multidisciplinary evaluations and interdisciplinary treatment are documented in the patient s medical record is crucial to the interdisciplinary nature of care provided to Polytrauma patients General Trends in Polytrauma Rehabilitation Center Design The specialized Polytrauma Rehabilitation Center (PRC) is designed to provide the full range of care for patients who have sustained polytraumatic injuries requiring a comprehensive interdisciplinary rehabilitation, medical care and coordination of emotional, cognitive and emotional care. The purpose of the PRC is to concentrate the specialty trained staff and resources required in an environment dedicated to the unique needs of the polytrauma patient. Polytrauma patient care goals include the initial rehabilitation, additional outpatient rehabilitation, proactive case management, telehealth, and long term follow-up. This care occurs in three phases and the PRC designs provided for the differing needs. 1. Admission criteria (ref. VHA Handbook ) include: a. The individual with polytrauma is an eligible veteran or an active duty military service member; and b. The individual has sustained multiple physical, cognitive, and/or emotional impairments secondary to trauma; and c. The individual has the potential to benefit from inpatient rehabilitation; or d. The individual ahs the potential to benefit form a transitional community re-entry program; or e. The individual requires an initial comprehensive rehabilitation evaluation and care plan. 2. Inpatient Care 1-5

21 Polytrauma Rehabilitation Center Design May, 2008 Due to the medical complexity of the patients the inpatient care provided to the PRC patient is a 24 hours per day program coordinated by a multidisciplinary team. This team identifies and addresses medical and rehabilitation needs associated with the initial blast injury of the patient. Average length of stay for a PRC Inpatient is currently 48 hours. The physical design of the inpatient program is patient and family centered. The units are designed to increases staff efficiency and create a safe, supervised and structured environment. The goal is to closely monitor patients for safety, while still allowing them access around the unit. Inpatient units have therapy gyms, as well as smaller, less stimulating therapeutic areas, including activity rooms, and "Quiet rooms" in which individual therapy or co-treatments (more than one therapeutic discipline providing treatment simultaneously) can be provided without distraction. The goal is to provide the least restrictive and most home-like environment possible. 3. Transitional Care The Polytrauma Transitional Rehabilitation Program (PTRP) provides comprehensive, post-acute cognitive retraining and community re-entry rehabilitation to TBI patients. The program lasts an average range of 3 to 6 months, but continues as long as the patient is making significant progress. Most rehabilitation treatment takes place in a group setting; however, all patients receive one-on-one therapy as needed. As the patient prepares to leave the Program, vocational rehabilitation services, work preparation, or school activities are supported by the staff and other members of the rehabilitation team. Care Coordinators work closely with their assigned patients throughout the rehabilitation process to ensure they are getting every treatment necessary to make the fullest recovery possible. These Coordinators conduct follow-up assessments for patients after their discharge for a minimum of one year to support a seamless transition to home, work, school, or a return to active duty. 4. Outpatient Care Outpatient treatment maintains the continuum of care from the inpatient stay and is the point of entry into the system for patients with delayed onset of TBI symptoms. The outpatient care component of the PRC is a separate level of care than Transitional Care and is utilized by individuals living and working in their communities. The physical facilities required for the delivery of outpatient care are minimal, in support of utilizing PM&R resources within the hospital. The Outpatient Program is a combination of multiple individual patient programs, not a prescribed day treatment model. It is a process of improvement, often of adjustment, uniquely designed and delivered for each patient based on individual medical, functional and clinical needs. Outpatients commute from home and typically attend visits with family members. The overall goal is multidisciplinary outpatient treatment coordination in support of patient independence in the community. 1-6

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