Polytrauma Rehabilitation: A New Model of Care Rose Collins, Ph.D. Minneapolis VA Medical Center VA Psychology Leadership Conference/ APA April 28, 2006 Rose Collins, Ph.D. Minneapolis VA Medical Center VA Psychology Leadership Conference/ APA April 28, 2006

Objectives Polytrauma: Definition and patterns Paradigm of Care Psychology in Polytrauma Care Treatment Issues and Considerations Future Concerns and Directions Polytrauma: Definition and patterns Paradigm of Care Psychology in Polytrauma Care Treatment Issues and Considerations Future Concerns and Directions

TBI, Blast Injury & Polytrauma TBI in peacetime: civilian vs. military Mechanism: MVA, falls Incidence TBI in combat: Mechanism: Blast Incidence Blast injury sequelae: Polytrauma TBI in peacetime: civilian vs. military Mechanism: MVA, falls Incidence TBI in combat: Mechanism: Blast Incidence Blast injury sequelae: Polytrauma

Common Sequelae of Blast Injury Brain injury Brain injury Amputation Amputation Fractures Fractures Wounds Wounds Psychological- PTSD Psychological- PTSD Crush injuries Crush injuries Burns Burns Auditory/vestibular Auditory/vestibular Brain injury Brain injury Amputation Amputation Fractures Fractures Wounds Wounds Psychological- PTSD Psychological- PTSD Crush injuries Crush injuries Burns Burns Auditory/vestibular Auditory/vestibular Eye, orbit, face, Eye, orbit, face, Dental Dental Renal Renal Respiratory Respiratory Cardiac and vascular Cardiac and vascular Gastrointestinal Gastrointestinal Pain Pain Peripheral nerve Peripheral nerve

Polytrauma: Definition Trauma to several body areas or organ systems Occur at the same time One or more is life threatening Trauma to several body areas or organ systems Occur at the same time One or more is life threatening

TBI in Combat Settings New mechanism of injury New constellation of injuries Challenges to TBI rehabilitation New expertise and new model of care New mechanism of injury New constellation of injuries Challenges to TBI rehabilitation New expertise and new model of care

Polytrauma Rehabilitation Centers (PRC) Level I New patterns of injury  new paradigm of care “Brain Injury Plus” Brain injury drives the care process Integrate care for complex polytrauma in single location—simultaneous tx of mult injuries Higher level of medical acuity Sequence and integrate treatment to meet patient need Coordinated team effort with expanded team of consultants New patterns of injury  new paradigm of care “Brain Injury Plus” Brain injury drives the care process Integrate care for complex polytrauma in single location—simultaneous tx of mult injuries Higher level of medical acuity Sequence and integrate treatment to meet patient need Coordinated team effort with expanded team of consultants

Extensive Team of Consultants Anesthesiology Audiology Chaplin Services Dentistry Driver Rehabilitation Gastroenterology General Surgery Infectious Disease Medicine Neurology Neuro-ophthalmology Neurosurgery Nutritionist Anesthesiology Audiology Chaplin Services Dentistry Driver Rehabilitation Gastroenterology General Surgery Infectious Disease Medicine Neurology Neuro-ophthalmology Neurosurgery Nutritionist Optometry Oral and Maxillofacial Surgery Orthopedics Orthotics Otolaryngology Pharmacy Plastic Surgery Prosthetics Psychiatry Pulmonology Radiology Urology Vocational Specialist

Care Across the Continuum: Coma to Community Multi-level national network of care Multi-level national network of care Delivery of specialized care close to home Delivery of specialized care close to home Comprehensive interdisciplinary assessment of previously unidentified TBI patients Comprehensive interdisciplinary assessment of previously unidentified TBI patients Proactive Case Management Proactive Case Management Continued management of existing and emerging sequalae Continued management of existing and emerging sequalae Care for the patient who can’t return home Care for the patient who can’t return home Telehealth Telehealth Identification of community resources Identification of community resources Collaboration with VBA Collaboration with VBA Multi-level national network of care Multi-level national network of care Delivery of specialized care close to home Delivery of specialized care close to home Comprehensive interdisciplinary assessment of previously unidentified TBI patients Comprehensive interdisciplinary assessment of previously unidentified TBI patients Proactive Case Management Proactive Case Management Continued management of existing and emerging sequalae Continued management of existing and emerging sequalae Care for the patient who can’t return home Care for the patient who can’t return home Telehealth Telehealth Identification of community resources Identification of community resources Collaboration with VBA Collaboration with VBA

VA Polytrauma System of Care Better Functional and Clinical Outcomes, Higher Satisfaction, Lower Costs Dynamic Links The Right Care, At the Right Time, In the Right Place Informed, Empowered Patient & Family Specialized Rehabilitatio n Services Polytrauma Teams (Level 3 ) Local VA Polytrauma Case Mgrs (Level 4) Polytrauma Network Sites (Level 2) Polytrauma Rehab Centers (Level 1) State & Community Resources VBA VHA VHA Continuum of Rehab Care DOD Healthcare Sys Seamless Transition Department of Veterans Affairs Department of Defense DVBIC

Case Management Challenges Family Family DoD/VA Liaison DoD/VA Liaison Military Treatment Facility Military Treatment Facility Military Transport Military Transport Military Command Military Command TRICARE TRICARE Family Family DoD/VA Liaison DoD/VA Liaison Military Treatment Facility Military Treatment Facility Military Transport Military Transport Military Command Military Command TRICARE TRICARE Medical Holding Company Medical Holding Company “Home” VA Medical Center (Level II, III) “Home” VA Medical Center (Level II, III) Civilian Hospital Civilian Hospital State/Local Services State/Local Services Veterans Benefits Veterans Benefits

Psychology in Polytrauma Rehabilitation Integrated, active, interdisciplinary team member Integrated, active, interdisciplinary team member Combat Stress and PTSD Combat Stress and PTSD Complex Pain syndromes Complex Pain syndromes Behavioral management, adherence Behavioral management, adherence Depression, Suicide Depression, Suicide Intimacy Intimacy Provider stress Provider stress Education to mental health staff, nursing, and all hospital staff, Level II sites Education to mental health staff, nursing, and all hospital staff, Level II sites Integrated, active, interdisciplinary team member Integrated, active, interdisciplinary team member Combat Stress and PTSD Combat Stress and PTSD Complex Pain syndromes Complex Pain syndromes Behavioral management, adherence Behavioral management, adherence Depression, Suicide Depression, Suicide Intimacy Intimacy Provider stress Provider stress Education to mental health staff, nursing, and all hospital staff, Level II sites Education to mental health staff, nursing, and all hospital staff, Level II sites

Family Issues Multiple stressors Multiple stressors Away from home, support systems Away from home, support systems Care of other children, aging parents Care of other children, aging parents Job loss, financial strain Job loss, financial strain Adjusting to VA and rehab environment Adjusting to VA and rehab environment Duration, intensity & fluctuation of medical course Duration, intensity & fluctuation of medical course Expectations: Advocacy vs entitlement Expectations: Advocacy vs entitlement Multiple stressors Multiple stressors Away from home, support systems Away from home, support systems Care of other children, aging parents Care of other children, aging parents Job loss, financial strain Job loss, financial strain Adjusting to VA and rehab environment Adjusting to VA and rehab environment Duration, intensity & fluctuation of medical course Duration, intensity & fluctuation of medical course Expectations: Advocacy vs entitlement Expectations: Advocacy vs entitlement

Family Issues Role strain and change Role strain and change Stress, trauma Stress, trauma Political context Political context Anger, grief and loss Anger, grief and loss Guilt Guilt “Ambiguous loss” (Boss, 1999; 2006) “Ambiguous loss” (Boss, 1999; 2006) Depression, anxiety Depression, anxiety Stress increases at transfer to Level 2 Stress increases at transfer to Level 2 Role strain and change Role strain and change Stress, trauma Stress, trauma Political context Political context Anger, grief and loss Anger, grief and loss Guilt Guilt “Ambiguous loss” (Boss, 1999; 2006) “Ambiguous loss” (Boss, 1999; 2006) Depression, anxiety Depression, anxiety Stress increases at transfer to Level 2 Stress increases at transfer to Level 2

Treatment Considerations Pathologizing family vs family stress theory Pathologizing family vs family stress theory Psychodynamic interpretations, motivated forgetting Psychodynamic interpretations, motivated forgetting Group size, duration Group size, duration Directive, active, concrete, metaphor Directive, active, concrete, metaphor Multi-modal education and treatment Multi-modal education and treatment Adjusting “to” and “with” cognitive impairments Adjusting “to” and “with” cognitive impairments Acceptance vs status quo Acceptance vs status quo Assistance: increasing dependency vs support for  independence Assistance: increasing dependency vs support for  independence Pathologizing family vs family stress theory Pathologizing family vs family stress theory Psychodynamic interpretations, motivated forgetting Psychodynamic interpretations, motivated forgetting Group size, duration Group size, duration Directive, active, concrete, metaphor Directive, active, concrete, metaphor Multi-modal education and treatment Multi-modal education and treatment Adjusting “to” and “with” cognitive impairments Adjusting “to” and “with” cognitive impairments Acceptance vs status quo Acceptance vs status quo Assistance: increasing dependency vs support for  independence Assistance: increasing dependency vs support for  independence

Future Issues & Directions (Complicated) Mild TBI (Complicated) Mild TBI Vocational rehab & supports Vocational rehab & supports Community reintegration Community reintegration Increase substance abuse Increase substance abuse Increase suicide Increase suicide Life span, aging, secondary condidtions Life span, aging, secondary condidtions (Complicated) Mild TBI (Complicated) Mild TBI Vocational rehab & supports Vocational rehab & supports Community reintegration Community reintegration Increase substance abuse Increase substance abuse Increase suicide Increase suicide Life span, aging, secondary condidtions Life span, aging, secondary condidtions