Defense and Veterans Brain Injury Center

Transcription

1 Defense and Veterans Brain Injury Center Traumatic Brain Injury Recovery Support Program Donna Dennis, RN BSN Recovery Support Specialist (RSS)

2 Agenda Who We Are: MRMC> DCoE> DVBIC >RSP Severity Rating for TBI Why TBI Care Coordination? DVBIC s TBI Recovery Support Program Role of Recovery Support Specialists (RSSs) TBI-related resources Site-specific RSP and Regional Education Coordination (REC) Program information

3 Who We Are MRMC, DCoE and its Centers Army Medical Research and Materiel Command (MRMC) 2

4 DoD Numbers for TBI Worldwide - Totals

5 Severity Rating for TBI Traumatic Brain Injury Description Severity GCS AOC LOC PTA Imaging Mild hrs 0-30 min 24 hrs Neg Moderate 9-12 >24 hrs >30min <24 hrs >24hrs <7 days Pos or Neg Severe 3-8 >24hrs 24 hrs 7 days Pos GCS Glasgow Coma Score LOC Loss of consciousness AOC Alteration in consciousness PTA Post traumatic amnesia

6 Defense and Veterans Brain Injury Center DVBIC s military and veterans health care partners serve active duty military and veterans who have sustained a TBI through a nationwide, multi-center network DVBIC NATIONAL HEADQUARTERS MILITARY / DoD SITES VA SITES Fort Belvoir Fort Carson Walter Reed National Military Med Center San Antonio Military Medical Center Richmond VAMC Tampa VAMC Fort Bragg Naval Medical Center San Diego Palo Alto VAMC Camp Pendleton Fort Hood Minneapolis VAMC Camp Lejeune Landstuhl Regional Medical Center Boston VAMC Joint Base Elmendorf- Richardson

7 DVBIC TBI Recovery Support Program (formerly known as Care Coordination Program) Mission: To optimize successful engagement, treatment and recovery from TBI by providing TBI expertise, resources and support to the military and veterans communities and facilitating connections across the entire continuum of recovery and spectrum of care Eligibility: Service members (including National Guard/Reservists) or veterans who have sustained a TBI, family members or caregivers Services: Clients: Support, education, advocacy, and connection to TBI services and other resources for clients as they negotiate and transition through complex systems of care Providers and Care Managers: Information and access to TBI research, training and educational products

8 TBI Recovery Support Program History What happened? The Washington Post - Sunday, February 18, 2007 Soldiers Face Neglect, Frustration At Army's Top Medical Facility by Dana Priest and Anne Hull What followed? IRG, Rebuilding the Trust, Arlington, April 2007 President s Commission on Care for America s Returning Wounded Warriors, Serve, Support, July 2007

9 History Continued What were the findings? Complex war injuries Care for TBI not consistent and not coordinated Breakdown in transitions from DoD to VA Inadequate support for SM and family members What was recommended? Establish a network of recovery coordinators Expanded support and training for caregivers 9

10 Staying Connected: The Challenges of Multiple Transitions

11 What We Do Establish ongoing relationship with client to empower them with resources that advance their care and understanding of TBI Conduct regular follow-up interviews for 24 months Track symptoms and monitors treatment compliance and outcomes Identify local resources and programs Transition client to another RSS if client relocates RING Thanks for calling and listening I really appreciate all of your help.

12 Intake Follow-Up Closure Intake Establish relationship; identify current issues and discuss interventions develop baseline of support Subsequent FU Contact to check-in Review previous issues and symptoms; continue to track issues and monitor progress Make referrals for assistance as appropriate, send resources via Case Closed Completed 24 months Decline to participate Lost to Follow up Can continue with case if service members request continued assistance

13 Focus of Care Recovery Support Program Emphasis on seamless care/connection through transition points Collaborative relationships Systematic follow-up of prolonged duration Knowledge of DoD, VA and civilian TBI resources throughout geographic regions Case Management Emphasis on site-specific care and single point of transition, i.e. discharge plan Direct service role May have limited follow-up after discharge Knowledge of diverse injury resources in close proximity to site Nationwide network

14 How We Get Referrals Sources include: Self MTF VA Other health care providers Family, caregivers or friends Community organizations Contact us via at: Visit our website at:

15 DVBIC Sites and TBI RSP and REC Regions

16 RSP Partners

17 TBI RSP Client Brochure Addresses: What is the DVBIC TBI Recovery Support Program? Why would I need this program? How do I get into the program? What s the difference between a TBI recovery support specialist and a case manager? Available for download at:

18 Regional Education Coordinator Develops, implements, and extends outreach efforts to advance excellence in TBI awareness, education, and prevention in ongoing collaborations with active duty military, their beneficiaries, and veterans

19 Representative TBI-related Resources Traumatic Brain Injury: A Guide for Caregivers of Service Members and Veterans Signs and Symptoms Concussion/mTBI Progressive Return to Activity Following Acute Concussion/ Mild Traumatic Brain Injury Clinical Recommendations Clinical Support Tool Provider Training Slides Educational Brochure Back to School: Guide to Academic Success After Traumatic Brain Injury

20 Military TBI Case Management Quarterly Newsletter Representative TBI-related Resources Mild Traumatic Brain Injury Pocket Guide and Mobile Application Webinars/Online Education DCoE Resource Catalog TTWRL Telehealth and Technology Web Resource Locator for TBI Case Managers

21 Questions? Donna Dennis, RN BSN DVBIC Recovery Support Specialist Jordan Ramirez, MA DVBIC Regional Educational Coordinator