Justice For Vets Veterans Court Conference Traumatic Brain Injury and the VA Polytrauma System of Care

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1 Justice For Vets Veterans Court Conference Traumatic Brain Injury and the VA Polytrauma System of Care Lisa Perla, MSN, FNP, CNRN, CRRN National Polytrauma Coordinator Linda M. Picon, MCD, CCC-SLP Senior Consultant/VA-DoD Liaison for TBI Veterans Health Administration Office of Patient Care Rehabilitation and Prosthetic Services July 29, 2015

2 Disclaimer Contents do not necessarily represent the views of the U.S. Department of Veterans Affairs or the United States Government.

3 TBI Defined The Department of Defense (DoD) and the Department of Veterans Affairs (VA) have defined TBI as any traumatically induced injury and/or disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: Any period with loss of or decreased level of consciousness Any loss of memory for events immediately before or after the injury Any alteration in mental state at the time of the injury (e.g., confusion, disorientation, slowed thinking) Neurological deficits (e.g., weakness, balance disturbance, praxis, paresis/plegia, change in vision, other sensory alterations, aphasia) that may or may not be transient Intracranial lesion

4 TBI Classified Severity Index Mild TBI/Concussion Moderate TBI Severe TBI Neuroimaging Findings Normal structural imaging Normal or abnormal structural imaging Normal or abnormal structural imaging Initial GCS < 9 Loss of Consciousness (LOC) Length of Alteration of Consciousness (AOC) 0 30 min. A moment up to 24 hrs. > 30 min. and < 24 hrs. > 24 hrs. AOC > 24 hrs. (use other criteria) Length VETERANS of HEALTH ADMINISTRATION Posttraumatic 0 1 day > 1 and < 7 days > 7 days

5 Epidemiology ~ 1.7 million traumatic brain injuries occur each year in the United States of which more than 75% are classified as a mild TBI (or concussion). The most common causes of TBI in the United States are falls and motor vehicle related incidents. Over 300,000 service members suffered traumatic brain injuries between 2000 and Blast exposure has become well known as a frequent cause of combatrelated TBI in the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) cohort. Important to note - active duty service members and Veterans (ADSM/V) may sustain a TBI due to other causes both in deployment and in nondeployment settings

6 VA Polytrauma System of Care 110 specialized rehabilitation sites across VA: o 5 Polytrauma Rehabilitation Centers All inpatient, residential, outpatient and telehealth care o 23 Polytrauma Network Sites Outpatient TBI and telehealth care, inpatient rehabilitation o 87 Polytrauma Support Clinic Teams Outpatient TBI care 39 Polytrauma Points of Contact (2-3 per region) o o Primary Care services Polytrauma social worker to facilitate referrals Range of Specialty Programs across system

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8 Polytrauma System of Care VA-PSC locations matched geographic need of Veterans and Servicemembers with clinical expertise in VA. VA uses extensive Geo-ID mapping of all Veterans and SMs Most Veterans are from rural areas (>30 miles) surrounding of major cities Through MOU, VA may provide Servicemembers with services for TBI, SCI, Amputation and Burns. At some sites >80% patients are Active Duty SMs. Approximately 55% of eligible OEF/OIF/OND Veterans utilize VA services (compared with 45% of all Veterans).

9 Continuum of Special Programs Transitional Rehabilitation Program Emerging Consciousness Program Polytrauma Telehealth Network Advanced Technology Applications Drivers Training Programs (Simulator/Road) Amputation System of Care Blind Rehabilitation Mild TBI Screening and Evaluation Program

10 Complexity of Mild TBI Veterans completing a CTBIE report multiple current symptoms: Over 50% of Veterans endorse 21 of 22 symptoms on the Neurobehavioral Symptom Inventory (irritability, sleep disturbance, forgetfulness, anxiousness, headaches most commonly endorsed)* In FY12 OEF/OIF/OND Veterans utilizing VHA for healthcare: ~7% of OEF/OIF/OND Veterans utilizing VHA carry a TBI diagnosis 72% of those with a TBI diagnosis also carry a diagnosis of PTSD compared to only 26% of those without TBI diagnosis 54% of Veterans with a TBI diagnosis have both a PTSD and Pain diagnosis compared to only 12% without a TBI diagnosis** Highlights the need for coordinated, interdisciplinary care *Scholten et. al Brain Injury, September 2012; 26(10): **Polytrauma QUERI Utilization Report

11 TBI and PTSD Co-Morbidities (Stein & McAllister, 2009) 10

12 TBI Screening, Evaluation, and Rehab in VA All Veterans with a separation date after 9/11/01 have a TBI screen activated in CPRS Four question screen regarding trauma, immediate symptoms, and current symptoms. If all answers are positive then a Comprehensive TBI Evaluation (CTBIE) is triggered A CTBIE must be completed by a TBI specialist (physiatrist, neurologist, or neuropsychiatrist) 2008 NDAA legislation mandates that all Veterans with TBI receiving ongoing rehabilitation have an Individualized Rehabilitation and Community Reintegration (IRCR) Plan of Care* *VHA Directive , VHA Handbook

13 VA Screening for Mild Traumatic Brain Injury for OEF/OIF/OND Veterans From April 2007 to September 30, 2014: 883,883 have been screened for possible mild TBI 166,049 screened positive and consented to follow-up comprehensive evaluation 124,751 completed comprehensive evaluation 73,469 received confirmed diagnosis of mild TBI

14 Integration of Comprehensive Rehabilitation Care Audiology Program VA + DOD Care management Hearing Loss Coordinate Support Amputations Trauma Polytrauma Case Management Patient & Caregiver IRCR Care Plan Vision Loss Mental Health Head Injuries Pain Brain Injury Program Pain Management Amputee Program Rehabilitation And Orthopedic Programs Blind Rehabilitation Program PTSD Program

15 Polytrauma Case Management All patients receiving rehabilitation services within the Polytrauma System of Care are assigned a Polytrauma Case Manager (PCM) PCMs caseloads: o 1 PCM for every 6 PRC inpatients - provide 24/7 coverage 1 PCM for every 10 inpatients at the PTRPs o PCM for patients at PNSs and PSCTs, based on case mix and geographic region Specialty case management includes: o Coordination of services o Ongoing evaluation of rehabilitation, psychosocial needs o Family education and support services o IDT lead in development of IRCR care plan o Partnership with other VA and DoD case managers to assure continuity in care management from battlefield to home

16 Virtual Care Standardized TBI evaluation protocol for Telehealth TBI Subject Matter Expert panel developed consensus TBI evaluation protocol 40 pilot sites trained and virtual training modules now available online TBI Telehealth Team funded at Washington DC VA to provide TBI care for rural Veterans in Maryland and Georgia in FY15 Secure Messaging All VAMCs have rehabilitation messaging triage teams E-consults Specialist consultation may reduce need for additional patient visit 15

17 Virtual Care: Mobile Technology Concussion Coach is a mobile phone application for Veterans and Service members who experience symptoms that may be related to brain injury It can be used as a stand-alone education and symptom management tool, or to augment face-to-face care with a healthcare professional Available for mobile Apple devices: Downloaded > 4000 times in 62 countries

18 Continuity of Care: From Battlefield to VA TBI/Polytrauma System of Care Landstuhl Regional Medical Center Palo Alto PRC Minneapolis PRC San Antonio Military Medical Center San Antonio PRC Walter Reed National Military Medical Center at Bethesda Tampa PRC Richmond PRC Iraq Balad, Iraq Afghanistan Bn Aid Station

19 Staying Connected: The Challenges of Multiple Transitions

20 Transition Assistance Program Pre- Deployment and Post-Deployment Yellow Ribbon Events Information about DoD/VA programs and services addressing a variety of issues, from financial matters, to benefit concerns, to emotional support. The redesigned TAP provides training, known as, GPS (goals, plans, success) to build skills for transitioning service members to meet career readiness standards established by DOD. The Disabled Transition Assistance Program (DTAP) another component of TAP involves intervention on behalf of Soldiers who may be released because of a disability qualifying them for the Department of Veterans Affairs' (VA) Vocational Rehabilitation and Employment Program (VR&E). Finding a TAP office:

21 One Mission One Policy One Plan IC3 and the Lead Coordinator Role Over the past years, there have been a myriad of programs developed to help wounded warriors. Creates a structured VA and DoD care delivery and transition approach which includes a common mission, language, and processes to improve warrior care coordination Facilitates synchronized care, service delivery and information for Service members / Veterans (SM/V) and their families and caregivers Minimizes patient, family and caregiver confusion with the number of VA and DoD staff who manage and coordinate the delivery of care and benefits Prevent Delays Reduce Anxiety Achieve Best Possible Outcome INTERAGENCY CARE COORDINATION COMMITTEE IC3

22 One Mission One Policy One Plan Lead Coordinator (LC) Role LC functions are formalized responsibilities conducted by an existing care manager Provides a primary point of contact for recovering Service Members, Veterans and their families and caregivers at each stage of their recovery, rehabilitation, and transition Assumes responsibility for coordinating and overseeing execution of the care plan Is not responsible for the actual delivery of care beyond their scope of practice Ensures each eligible SM/V gets a warm hand off as they transition from AD to veteran status INTERAGENCY CARE COORDINATION COMMITTEE IC3

23 One Mission One Policy One Plan Lead Coordinator Role Who will assume the role of Lead Coordinator? Any existing member of the Care Management Team Normally either a medical or non-medical case manager Who is eligible to have an LC assigned? Servicemembers or Veterans with permanent, severely disabling wounds, illnesses, injuries, disorders or diseases that make it highly unlikely that the SM will return to active duty INTERAGENCY CARE COORDINATION COMMITTEE IC3

24 One Mission One Policy One Plan Lead Coordinator When should a wounded/recovering warrior be assigned a LC? Anytime the care team feels it would be beneficial to have a primary point of contact for coordination and oversight of the SM/V s care plan When the decision is made that the AD member will be separating from the military When should you implement the Lead Coordinator Program at your facility/command? As soon as Lead Coordinator Training is complete INTERAGENCY CARE COORDINATION COMMITTEE IC3

25 One Mission One Policy One Plan Standardized Tools Co-Lab Fact Sheet Lead Coordinator Script Shared, secure website accessible only to DoD and VA care coordinators, for staff to share information, exchange ideas, search personnel directories and coordinate a SM/V s care plan INTERAGENCY CARE COORDINATION COMMITTEE IC3

26 One Mission One Policy One Plan Standardized Tools LC Checklist Interagency Comprehensive Plan (ICP) A SM/V-centered plan with identified goals to facilitate care, recovery, rehabilitation, transition and community reintegration Three-page document that includes a list of Tasks that should occur when the Service member/caregiver transitions between LCs Common care-benefitsservices categories that should be considered throughout recovery, rehabilitation, reintegration, and ongoing care coordination. INTERAGENCY CARE COORDINATION COMMITTEE IC3

27 Traumatic Brain Injury Clinical presentation and practice

28 TBI in the news Dementia Pugilistica NFL - Sport concussions Return to Play Law across all 50 states Signature wound

29 How TBI occurs

30 Some unique causes of assault-related brain trauma Gang-related Some of the specific causes of assault-related TBI among prisoners are unique. For example, in the Minnesota project, some of the reported head injuries among incarcerated gang members were the result of a gang initiation procedure called "pumpkinhead" in which new gang members are beaten until their heads swell "like pumpkins." Domestic violence In a 2007 study of TBI among federal prison inmates at the University of Texas, Houston, a high percentage of women reported a history of TBI, especially multiple concussions, often totaling 10 or more, and these were usually associated with interpersonal violence. One subject in this study estimated that she had been hit in the head and often knocked unconscious by her boyfriend nearly every weekend during a three year period prior to entering prison. (Pamela Diamond, PhD, University of Texas-Houston, October 2007) Source: brainline.org

31 Blast-related TBI One event, multiple potential sources of injury 1. Wall of air Primary blast 2. Overpressure 3. Displacement 4. Flying debris and crashing buildings 5. Others a. Burns b. Toxins and chemicals

32 Understanding TBI External force does not mean the head must come in contact with something Shaken baby, whip lash, blast exposure There does not have to be a complete loss of consciousness Altered consciousness, dazed or confused There does not have to be a change on neuroimaging Normal CT scan and MRI

33 Moderate and Severe TBI Results in cognitive, medical social, emotional, and behavioral problems, including aggressive behavior NIH Consensus Conference, 1998 Some have accompanying and life-long physical deficits. Many live in the community without visible, physical disability

34 Mild TBI = CONCUSSION Most symptoms go away within 3 months of injury BUT.NOT ALWAYS Physical External appearance is normal Headache, dizziness, fatigue, noise/light intolerance, insomnia Cognitive Memory complaints, poor concentration Emotional Depression, anxiety, irritability, worry

35 Co-existing conditions Mental Health Conditions Pain PTSD, depression Headaches Sleep Insomnia

36 Symptoms of Mild TBI and PTSD TBI Difficulty concentrating Problems remembering Problems thinking and making decisions Anxiety and stress Irritability HEADACHES DIZZINESS PTSD Difficulty concentrating Problems remembering Problems thinking and making decisions Anxiety and stress Irritability AVOIDANCE RE-EXPERIENCING

37 Functional impairments - Physical Decreased or rigid muscle tone Paralysis of one or more limbs Weakness in one or more limbs Balance problems Coordination problems Decreased endurance American Academy for the Certification of Brain Injury Specialists

38 Functional Impairments - Thinking Attention deficits may make it difficult for the prisoner with TBI to focus on a required task or respond to directions given by a correctional officer. Either situation may be misinterpreted, thus leading to an impression of deliberate defiance on the part of the prisoner Memory deficits can make it difficult to understand or remember rules or directions, which can lead to disciplinary actions by jail or prison staff Poor problem solving skills can make it difficult to sequence instructions or steps to a task Slowed speed of information processing make it difficult to think and respond or react quickly

39 Functional impairments - Communication Slowed responses Excessive use of pauses Inefficient filtering or not holding back Poor topic maintenance, irrelevant topic drifting, tangentiality, repeating Excessive talking or not explaining enough Reduced fluency Use of peculiar phraseology Overreliance on expressions

40 Functional Impairments Emotional and Behavioral American Academy for the Certification of Brain Injury Specialists Apathy or unresponsiveness to requests Aggression Decreased sensitivity to others Property destruction Self-injurious behavior Decreased frustration tolerance Paranoia Yelling and angry outbursts Inappropriate sexual behavior Hyperactivity Impulsivity Immature self-focused behavior Emotional swings

41 Changes in activity participation after mtbi Disruptions in Social interactions Leisure activities Independence Work status Research indicates Fewer social encounters Fewer friends Moore, Terryberry-Spohr & Hope (2006)

42 Screening Identifying a TBI No objective mild TBI test There must be a potentially concussive event CT and MRI for moderate to severe + evaluation Screening for mild TBI + evaluation as needed 1. Were you exposed to a trauma or blast (while in OEF/OIF)? 2. As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)? 3. Did you develop problems with headache, insomnia, dizziness, thinking or behavior immediately to soon after the trauma or blast? 4. Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

43 Evaluation and Rehabilitation Identifying the physiological and functional changes that occur after a brain injury Identifying environmental factors that influence behavior Restoring functions that can be improved Promoting alternative skills and adaptive behaviors to facilitate increased independence and return to the highest possible level of function

44 Outcomes Who tends to do better? Better outcomes Milder injuries Completed recommended treatments Good psychosocial support Family, employed, no substances, supportive environments Worse outcomes Increased severity of injury Multiple/Repeated TBIs Non-compliant with treatments Poor psychosocial status or support systems Unemployment, substance abuse, lack of support

45 Treatment for TBI-related deficits Interdisciplinary Rehabilitation teams Rehabilitation Physician (Physiatry) other Medical disciplines as needed Nursing PT OT Speech Psychology Community re-entry Recreation Vocational Family/Caregiver support

46 Treating related conditions Mental Health Conditions PTSD Depression Anxiety Pain Headaches Sleep Insomnia Apnea (breathing/snoring) Medical concerns Epilepsy Neuroendocrine dysfunction

47 What about mild TBI? In the community Most concussions go unreported and untreated 2.2 million are treated and released from an emergency department (CDC) typically discharged to home with little or no follow up In the military system Mild TBIs may go unreported Soldiers don t want to delay going home Soldiers don t want to leave their peers

48 How can we help someone with TBI? First, be aware o Information overload o Long or multi-step instructions o Fast paced communication o Distractions o Unexpected and quickly changing conditions o Challenging and stressful situations o Not remembering o Excessive fatigue Break up information into manageable pieces Demonstrate Slow down when giving instructions Ensure understanding Don t assume recall Respect personal space Allow breaks

49 VA Healthcare for Re-entry The Health Care for Re-entry Veterans (HCRV) Program Services include: Outreach and pre-release assessments services Referrals and linkages to medical, psychiatric, and social services, including employment services upon release Short term case management assistance upon release Provides information to Veterans while they are incarcerated so they may plan for re-entry State-specific resource guides identify steps that Veterans can take prior to their release

50 SUMMARY: Recognize a concussion cdc.org

51 When someone has a concussion Some things to do Get plenty of rest and sleep. Return to normal activities GRADUALLY Carry and use a notebook Establish a regular daily routine to structure activities. Do only one thing at a time if you are easily distracted turn off the TV or radio while you work. Some things to avoid Avoid activities that could lead to another brain injury examples include contact sports Avoid alcohol Avoid caffeine or energyenhancing products

52 Injury Prevention and Control

53 References Polytrauma QUERI Utilization Report available at Concussion App available for mobile Apple devices: Finding a TAP office:

54 References Traumatic Brain Injury legislation: CDC Report to Congress on TBI: a.pdf Healthcare Re-entry for Veterans Program: Real Warriors Campaign: Moore et,al., Mild traumatic brain injury and anxiety sequelae: a review of the literature. Brain Injury 2006 Feb;20(2): Ragnarsson, Kristjan T. "Traumatic brain injury research since the 1998 NIH Consensus Conference: accomplishments and unmet goals." The Journal of head trauma rehabilitation 21.5 (2006): Silver, JM., McAllister, TW. And Yudosfky, SC., Textbook of Traumatic Brain Injury. American Psychiatric Pub,

55 Thank you! Questions? Rebuilding Injured Lives