“To Care for Him Who Shall Have Borne the Battle and for His Widow and His Orphan” (Abraham Lincoln): The Department of Veterans Affairs Polytrauma System of Care

Article Outline

• Abstract
• Recognizing the Need for Change
• A New Model of Care
• Developing the System of Care
• Entering and Traversing the PSC
• Conclusions
• References
• Copyright

Abstract 

Sigford BJ. “To care for him who shall have borne the battle and for his widow and his orphan” (Abraham Lincoln): the Department of Veterans Affairs Polytrauma System of Care.

The initiation of combat in Iraq and Afghanistan has resulted in a new cohort of active-duty service members and veterans seeking rehabilitation care through the U.S. Department of Veterans Affairs (VA). Service members injured in combat most often sustain multiple injuries (polytrauma) and require a unique service delivery model to meet their needs. The VA recognized this need and responded with the development of the Polytrauma System of Care (PSC). This national system of care balances access and expertise to provide specialized life-long care to the combat injured. The PSC is comprised of: 4 specialized regional rehabilitation centers that are accredited in brain injury by the Commission on Accreditation of Rehabilitation Facilities; 21 specialized outpatient and subacute rehabilitation programs; designated polytrauma teams at smaller, more remote VA facilities; and a point of contact at all other VA facilities. In addition, the PSC has developed a proactive case-management model, a specialized telehealth network, guidelines for long-term follow-up, and services for those individuals who are unable to return home. The following commentary and articles provide additional detail on this new and unique system of care.

Key Words: Brain injuries, traumatic, Injuries, multiple, Rehabilitation, Veterans

THE FIRST COMBAT-INJURED “polytrauma” patient was admitted into a U.S. Department of Veterans Affairs (VA) rehabilitation unit in January 2002. This began a remarkable change in the provision and delivery of rehabilitation services to the combat injured. The commitment of the VA to Abraham Lincoln’s famous statement “to care for him who shall have borne the battle and for his widow and his orphan” is nowhere more evident than in the current Polytrauma System of Care (PSC).

This commentary describes the development of this system of care, setting the stage for future discussion and research.

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Recognizing the Need for Change 

Although few combat-injured active-duty service members were transferred to VA rehabilitation programs because of the conflict in Afghanistan, a new cohort of patients began to be referred to VA facilities for rehabilitation services shortly after the initiation of combat operations in Iraq in March 2003. Because of a long-standing collaboration with the U.S. Department of Defense (DOD) and the Defense and Veterans Brain Injury Center (since 1992), these patients were transferred to 1 of 4 VA medical centers with a long history of special expertise in traumatic brain injury (TBI) rehabilitation. These 4 sites, Tampa, FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA, were designated as TBI lead sites in 1992 and have maintained dedicated beds and specially trained staff to provide specialized TBI rehabilitation. However, the active-duty service members admitted after the initiation of combat operations exhibited new patterns of injury. TBI remained a primary diagnosis, but it was usually accompanied by additional severe and devastating injuries. The U.S. Congress recognized the severity of injuries and the need for additional services through the passage of the Consolidated Appropriations Act of 2005¹ and the Veterans Health Programs Improvement Act of 2004.² These 2 laws, combined, required the VA to provide care for combat-injured service members with amputations and other severe and lasting injuries and to evaluate and treat soldiers who sustained injuries as a result of blasts. After the passage of this legislation, the Veteran Health Administration (VHA) began the implementation of the PSC.³

The VA has defined polytrauma as “two or more injuries to physical regions or organ systems, one of which may be life threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability.”^3(p3) The polytrauma patient has unique characteristics compared with the young active-duty service member previously cared for in VA rehabilitation centers, resulting in specialized rehabilitation needs as detailed by the articles in this collection. Some of the new challenges in caring for this population include a higher level of medical acuity and instability, complex patterns of injury, family units in great stress, and exceptionally high expectations for functional improvement. The pathways that bring these patients into the VA system of care are also different. Instead of coming from private-sector hospitals as had been the practice in the past, the journey of the combat-injured service member to the VA polytrauma rehabilitation centers (PRCs) takes them through multiple levels of care in the combat theater (forward surgical teams, combat support hospitals) and in DOD military medical facilities outside the continental United States, such as Landstuhl, Germany, as well as in the continental United States, such as Walter Reed Army Medical Center, Washington, DC; National Naval Medical Center, Bethesda, MD; Brooke Army Medical Center, FT Sam Houston, TX; and San Diego Naval Medical Center, San Diego, CA.

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A New Model of Care 

TBI is the most prevalent impairment in the severely injured accessing the PRCs. The etiology of the TBI may be related to 1 or more of the multiple mechanisms of injury because of blast exposure. Although there are multiple injuries and impairments, it is the TBI that most significantly impacts the plan of care. For example, impairments because of TBI must be considered in prescribing prostheses and in prosthetic training, determining optimal pharmacology for pain, and choosing interventions for low vision. The nature of polytrauma has resulted in expanded interdisciplinary teams and in increased attention given to coordinating the interventions of multiple consultants. Therapies are sequenced and integrated to meet the unique needs of the patient. Rehabilitation teams caring for polytrauma patients must also be well versed in identifying occult injuries that may not have been addressed by the trauma team, such as hearing loss and peripheral nerve injuries and sometimes even fractures. Care is provided in environments that are sensitive to the needs of the service member, such as their young age, family constellation, and the service and sacrifice that has been rendered.

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Developing the System of Care 

The VA PSC is comprised of 4 facility-based components (fig 1) and 4 elements that cross all facilities. All components and elements require a change in culture and education of all staff and providers who deliver care to the new generation of veterans. The 4 facility-based components include PRCs, polytrauma network sites (PNSs), polytrauma support clinic teams, and polytrauma points of contact. They are engineered to balance specialized care and access to service, the most specialized care being regionalized and the more general care being provided locally with efficient access.

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• Fig 1. 

  The PSC.

PRCs, formally designated in February 2005, are regional facilities located in tertiary care medical centers. They are located at the same sites as the VA TBI lead sites and build on the specialized expertise already in existence at these facilities. They provide acute comprehensive medical, surgical, and rehabilitation care for complex and severe polytraumatic injuries and maintain a staff of dedicated, specially trained rehabilitation professionals and dedicated consult services for all areas of polytrauma. The environment of care reflects the age and military status of the service members. For example, family lounges have activities for young children, Internet capability, and media resources appropriate for the age and interests of the persons served. Injured service members may be recognized by rank and may wear their military uniforms. They may live in transitional apartments to practice independent living skills before discharge, and active-duty military personnel specially assigned to these centers assist with the transition to VA facilities and lessen the trauma of separation from the military units. The PRCs also serve as resources for other facilities in the system of care for consultation, best practices, and educational programs.

PNSs are facilities that serve the host Veterans Integrated Service Networks (VISNs). Each of the 21 VISNs in the VA is a regional administrative unit responsible for providing all medical, surgical, mental health, and specialty care to the veterans residing in a multistate area. PNSs were designated in December 2005 based on an array of preexisting rehabilitation services such as a Commission on Accreditation of Rehabilitation Facilities–accredited inpatient rehabilitation unit, an amputation care team, and leadership in the area of physical medicine and rehabilitation. The role of the PNS is to manage the postacute sequelae of polytrauma and to coordinate lifelong rehabilitation services for those veterans with polytrauma living in their catchment area. They are responsible for identifying and coordinating VA and non-VA services available across the VISN to support the needs of patients and their families. Each PNS has a dedicated, specially trained rehabilitation team, but consultative services may be more limited at some locations. Recognizing that not all polytrauma patients may be initially referred to or require the services of a PRC, the PNSs are also charged with the initial evaluation and treatment of these individuals in consultation with their associated PRC.

Polytrauma support clinic teams are facilities located closer to the veteran’s home that have a strong rehabilitation service but may not have the expertise or consultation services of the PRCs or PNSs. Their responsibility is to follow and manage stable polytrauma sequelae. They monitor for changes or the emergence of new complications requiring the specialized expertise of a regional or VISN site to which they refer when necessary. They receive referrals and consultations from their associated PNSs and PRCs.

Polytrauma points of contact are people identified at all other VHA facilities who have the responsibility to assist polytrauma patients in their local area with accessing the necessary and appropriate services from the PSC. These people are often social workers and are trained to be knowledgeable about the components of the PSC. They do not provide direct polytrauma services but they refer patients to another facility in the PSC.

The 4 elements of the PSC that cross all facility-based components are proactive case management, lifelong specialized follow-up care, telehealth, and care for patients who are unable to return to their homes or require extensive in-home services because of the severity of their injuries.

The PSC has adopted a proactive model of intensive case management. Involved in providing case management are nurses for clinical case management and social workers for psychosocial case management. Activities and services comprising case management include contacting patients regularly to monitor the implementation of the care plan, assessing for new emerging problems or changes because of social situation or developmental stage, identifying and coordinating VA and non-VA resources, providing ongoing patient and family support and education, and assisting with transition from military to veteran status. As patients move through the system of care, the case managers at each component are responsible for a “warm handoff” to the next component site including personal communication with the accepting team. Standardized case-management protocols are under development to guide these activities.

It is well recognized that sequelae of polytrauma such as spasticity, limb loss, and cognitive impairment may be lifelong. The PSC will provide lifelong specialized care for polytrauma patients. This includes regular follow-up at the PSC facility closest to the patient’s home that is able to provide the level of care required. Routine follow-up ensures continued support and reduces the isolation that can result from severe disability.

A new Polytrauma Telehealth Network (PTN) links the PSC facilities with high-quality videoconferencing capabilities. New equipment and broadband communication technology have been installed at the PRCs and PNSs to allow close collaboration and consultation. The PTN is used to facilitate discharge planning, coordination of care, and evaluation for specialized services or equipment. It allows remote provider-to-provider consultation, and it can also be used for educational purposes for providers, patients, and families. Telehealth technology is also being used to link providers and patients at the DOD military medical facilities, including those in Germany and Iraq, with the PRCs. This has offered remarkable opportunities to coordinate clinical care, initiate quality improvement activities, and facilitate a warm handoff of care.

Finally, the VHA is committed to providing care for those who are severely injured and unable to return home or need intensive support services in their homes. For these veterans, there is a broad array of services aimed at creating an environment that promotes continued recovery, maintains health and function, prevents complications, provides meaningful daily activities, and allows continued evaluation and monitoring for change in status that might alter the level of care and result in need for new services. These include in-home care, day activity programs, home-based primary care, and homemaker home health services as well as others, all of which are delivered by appropriately trained staff in the home.

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Entering and Traversing the PSC 

Veterans and active-duty service members both are eligible for treatment and may enter the system of care at any of the 4 facility-based components depending on the severity of their injuries. The most severely injured will be referred from a military medical facility to a PRC. Those with less severe injuries may be referred from the military medical facility or other DOD or community providers and may enter the system at any facility in the PSC that would then assess their needs and provide services or refer them to the appropriate level of care. Assisting with the transfer process from the military medical facility are VA social workers who are assigned there. They are embedded with the military treatment teams and are often the first to talk to the active-duty service members and their families about VA care including the PSC. They are responsible for contacting the receiving VA PSC facility and providing necessary information to the admission case manager. They remain in contact until the transition takes place and also assist with return to the military medical facility if a follow-up is required.

Once entered into the PSC, veterans and active-duty service members move between the facilities and components of the system based on their current needs. Active-duty service members continue to receive treatment as long as needed. The polytrauma case managers are responsible for life-long management of this process and facilities remain in contact by using the PTN.

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Conclusions 

The PSC is a unique system of care developed by the VA to meet the needs of the combat injured returning from Iraq and Afghanistan. A new model of integrated, specialized, comprehensive service delivery that recognizes the unique characteristics and rehabilitation needs of these individuals has been deployed throughout the VHA medical system.

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References 

1. Consolidated Appropriations Act of 2005. Pub L No. 108-447, 118 Stat. 2809 (Dec 8, 2004).
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2. Veterans Health Programs Improvement Act of 2004. Pub L No. 108-422, 118 Stat. 2379 (Nov 30, 2004).
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3. U.S. Department of Veterans Affairs, Veterans Health Administration. Polytrauma rehabilitation procedures. Washington (DC): DVA, VHA; Sept 2005. VHA Handbook 1172.1.
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