Veterans and TBI- Collaboration is the Key May 1, 2014 Sheree Gordon, BSN, MS, Polytrauma Nurse Case Manager Elsie Moore, MSW, LICSW, PolytraumaSocial Work Case Manager TBI/Polytrauma Program Washington DC VA Medical Center TBI from Global War on Terror 7-12% of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans (OEF/OIF/OND) who received medical care in the VA have confirmed Traumatic Brain Injury (TBI) o 60,000 total (of 750,000 screened) 95% mild 5% moderate-severe (2,500-3,000) 73% of Veterans with symptomatic mild TBI also have mental health diagnosis, most commonly Posttraumatic Stress Disorder (PTSD) > 90% also have either PTSD or chronic pain disorder Source: www.queri.research.va.gov/ptbri/docs/vha-tbi-screening-eval.pdf VA Polytrauma System of Care 110 specialized rehabilitation sites across VA: 5 Polytrauma Rehabilitation Centers 23 Polytrauma Network Sites [1-2 per Veterans Integrated Service Network (VISN)] 87 Polytrauma Support Clinic Teams (2-8 per VISN) 39 Polytrauma Points of Contact DoD/VA Memorandum of Agreement that VA may provide rehabilitation services for Service Members with TBI, Spinal Cord Injury (SCI), Polytrauma, and Amputation Polytrauma System of Care (PSC) locations matched geographic distribution of Veterans and Service Members with VA locations of clinical expertise o Most are from rural areas (>30 miles) surrounding major cities 1
VA Polytrauma System of Care OEF/OIF/OND Service Members are eligible for care within VA for 5 years after service ( 55% of eligible OEF/OIF/OND Veterans utilize VA services compared to 45% of all other Veteran groups) In Fiscal Year 2013: o 50,516 unique Veterans were served in PSC (outpatient) clinics. o 1,381 unique patients were treated in PSC inpatient units, of which as many as 67% were Service Members. 23 regional Level 2 medical centers providing full range of comprehensive follow-on medical and rehabilitative services (inpatient and outpatient) for patients recovering from polytrauma and TBI (1-2 per VISN): odevelop and support patient s rehabilitation plan through comprehensive interdisciplinary, specialized team oserve as resource and coordinate services for TBI and polytrauma across VISN (VHA, DOD, private sector) VISN leader for polytrauma/tbi consultation, education, monitoring outcomes, and program development for system of care Accredited by CARF for inpatient general rehabilitation (300+ inpatient beds available) http://www.polytrauma.va.gov/ Polytrauma Network Sites Interdisciplinary Team Physiatry(Rehab Medicine) Neurology Psychology/Neuropsychology Case Manager, CRRN Occupational Therapy Physical Therapy Speech-Language Pathology Orthotist Prosthetist Blind Rehabilitation Outpatient Specialist Social Worker Liaison with DOD and PRC s Recreation Therapy Drivers Rehabilitation Psychiatry Optometry Vocational Rehab 2
Assessment Impairments Activity Limitations Participation Restrictions Environmental Factors Family Needs Individualized Rehabilitation and Reintegration Plan of Care (IRCR) Rehabilitation Goals Access to Care Treatments IRCR Reviews Responsible Person Adjustment to Life Post-TBI Life with chronic disability Common reactions Grief, denial, depression, anxiety, perplexity, frustration, embarrassment, catastrophic reaction, Post-Traumatic Stress Disorder (PTSD), personal reformation (Judd, 1999) Changes in role functioning Changes in family, employment, and financial status Perceived stigma Vulnerability to exploitation Accessibility and accommodations Awareness of deficits, assessment guides treatment 3
Medical Family Disability Reintegration Veteran community Work or School Social 31 year old, served in Iraq and Afghanistan, 3 combat deployments Exposed to multiple blasts; 1 significant for mild TBI Diagnosed with TBI, PTSD, headaches, tinnitus, sleep problems and back/neck pain Referred to PolytraumaProgram at the Polytrauma Network Site for therapy/services Patient Goals: To reintegrate into family and community activities To obtain employment To attend school 4
Treatment Plan: TBI doctor Case management Mental health Cognitive Rehabilitation therapy Physical therapy Recreation therapy Interests and activities in the community Local volunteer opportunities Education about community organizations Referred to Brain Injury Services References Department of Veterans Affairs (2010). Veterans Health Initiative: Traumatic Brain Injury Study Course. Accessed on 11/11/13 http://www.publichealth.va.gov/docs/vhi/traumatic-brain-injury-vhi.pdf Judd, T. (1999). Neuropsychotherapyand community reintegration: Brain illness, emotions, and behavior. New York: Kluwer Academic/Plenum Publishers UNC Charlotte Posttraumatic Growth Research Group www.ptgi.uncc.edu 5
Resources Department of Veterans Affairs http://www.va.gov/ Veterans Affairs Polytrauma Program http://www.polytrauma.va.gov/ Brain Injury Association of America http://www.biausa.org/ National Center for PTSD http://www.ptsd.va.gov/ Veterans Crisis Line http://veteranscrisisline.net/ Veterans Justice Outreach Program http://www.va.gov/homeless/vjo.asp Defense and Veterans Brain Injury Center http://dvbic.dcoe.mil/ Defense Center of Excellence for Psychological Health and Traumatic Brain Injury http://www.dcoe.mil/ Veterans Benefits Administrationhttp://benefits.va.gov/benefits/ Referral to the Brain Injury Services What s Next? Joyce Cohen, RN,LCSW(CA),CBIS, Adult Case Manager, Brain Injury Services Tomoko Rose, MA,CRC,CBIS,CVA, Volunteer Placement Program Specialist Brain Injury Services What s next? Receive referral from VA Polytrauma Services Assign CM to geographic location (BIS Springfield or Fredericksburg office) Proceed with Intake process Awareness of polytrauma framework and need for multiple agency appointments 6
Good Assessment Good Client Centered Goals Prior to Intake Military cultural competence, respect Collect BI documentation and history Decrease need for vet to reverbalize Initial joint intake set up with VA? VA has majority of documentation and medical hx w/ multidisciplinary team Ask about joint intake ease of transition Good Assessment Good Client Centered Goals Intake Ask what they want at the start Thread in service explanation Bring co-worker if need specific Flexibility (yours is added to multiple VA appts.) Activities, work, school VA asked about volunteer opportunities bring relevant staff What other activities? Good Assessment Good Client Centered Goals Prior to or at Intake Additional available provider diagnostic, clinical assessments Consumer profile VA probably able to provide BIS 7
BIS Assessment Tool Options Tool Consumer Profile Content Demographics, injury, agency hx, guardianship, meds, professionals, hospitalizations & treatments, health issues, health questions, MH hx., MH issues, Subs abuse, arrest/convictions, living situation, funding, transport, educ. Job hx, employment, prod focus, agency hx, CM hx. BIS Assessment Tool Options BIS Assessment Tool Options Patience/Flexibility Visual goal worksheet Additional considerations: Content 90 days to develop goal plan Developing a flow/art form Possible tool to ensure goals are theirs, not yours Transportation, funding, support, health Visual Tool Option Clinical Treatment Primary Care Self Care Alternative/ Complementary Meaning/ Purpose www.pwrsinc.org 8
Vocational goal: I want to volunteer. Client Sample Goal Plan Refer to BIS Volunteer Placement Program Meet with staff of program to discuss my interests If I agree, work with staff to find volunteer site matching my interest If I do not agree, have my CM help look for other activity options Target Dates 2 weeks out 1-2 months out 6 months out 6 months out Civilian resources to consider In General Volunteer Programs Mental Health Service partners with VA Faith based services DARS ( State Dept. of Aging and Rehabilitation Services) Clubhouses with military liaison Activity organizations in community to begin to engage veterans: adaptive sport programs, fishing and hunting licenses, discounts through County Park & Recreation programs BIS Volunteer Placement Program Clubhouse? DARS ( Dept. of Aging and Rehabilitation Services) Organizations in his community serving veterans &run by vets VA Vocational Dept. VITAL Campus assist program? Identifying Client s Genuine, Productive Focus Goals I would like to volunteer in the community What does your client really want to tell you and accomplish? Is volunteering the best way to accomplish the goal? ---Often, the initial stated goal differs greatly from what the client truly desires and can accomplish successfully. ---Our role is to tease out and help clients to articulate their dreams and match them with realistic resources in the community. 9
Understanding The Client s Vision Why interested in volunteering? What is their dream volunteer job? Narrow it down. Sample Questions: What aspects of being in the Army did you like and made you satisfied? List three places where you DO and DO NOT enjoy being or volunteering? And why? What is your favorite thing to do with your free time? What are/were your hobbies? Reality Check Understanding the value system of the client -- it could impact on the client s success in the placement (i.e., what environment is important for the client?) Knowing the tasks that the client is capable of as well as potential challenges that may arise Knowledge of their specific brain injury Knowing that they don t know what they don t know Brain injury education to the volunteer site (carry any materials with you) Universities Local Government Creating an Unique Opportunity Using Your Network Military Base Museums Rotary Club Retirement Nonprofit Agencies Volunteer Action Centers Local Hospitals Recreation Centers Faith Groups Independent Living Center Local Chambers of Commerce Senior Centers 10
In Summary Life after combat and Traumatic Brain Injury Is there an answer to help them adjust? A quality life? The answer is yes. How? Collaboration between military & civilian agencies Based Intervention Veteran Supports for adjustment to civilian life Resources matching specific veteran need Client centered assessment Additional Resources www.braininjurysvcs.org www.braininjuryclubhouses.net www.vadrs.org Volunteer Resources www.pointsoflight.org http://www.volunteermatch.org/ http://www.idealist.org/ 11
Contact Information Elsie Moore, MSW, LICSW Polytrauma Case Manager Dept. of Veterans Affairs (202)745-8000 x 55747 Elsie.moore@va.gov Joyce Cohen, RN, LCSW (CA), CBIS Adult Case Manager Brain Injury Services (703)451-8881 x231 jcohen@braininjurysvcs.org Sheree Gordon, RN, BSN, MS, CCM, CRRN Polytrauma Case Manager Dept. of Veterans Affairs (202) 745-8000 x55496 Sheree.gordon@va.gov Tomoko Rose, MA, CRC, CBIS, CVA Volunteer Placement Program Specialist Brain Injury Services (703)451-8881 x234 ttaguchi@braininjurysvcs.org Special acknowledgement for consultation by Markita Gilbert, MSW, CBIS and Rebecca Miller,BS, MPA, CBIS 12