Polytrauma Rehabilitation: A New Model of Care

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

ObjectivesObjectives

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 & PolytraumaTBI, 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

Common Sequelae of Blast Injury

Brain injuryBrain injury AmputationAmputation FracturesFractures WoundsWounds Psychological-Psychological-

PTSDPTSD Crush injuriesCrush injuries BurnsBurns Auditory/vestibularAuditory/vestibular

Brain injuryBrain injury AmputationAmputation FracturesFractures WoundsWounds Psychological-Psychological-

PTSDPTSD Crush injuriesCrush injuries BurnsBurns Auditory/vestibularAuditory/vestibular

Eye, orbit, faceEye, orbit, face,, DentalDental RenalRenal RespiratoryRespiratory Cardiac and Cardiac and

vascularvascular GastrointestinalGastrointestinal PainPain Peripheral nervePeripheral nerve

Eye, orbit, faceEye, orbit, face,, DentalDental RenalRenal RespiratoryRespiratory Cardiac and Cardiac and

vascularvascular GastrointestinalGastrointestinal PainPain Peripheral nervePeripheral nerve

Polytrauma: DefinitionPolytrauma: 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 SettingsTBI 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

Polytrauma Rehabilitation Centers (PRC) Level I

New patterns of injurynew 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 injurynew 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 ConsultantsExtensive Team of ConsultantsExtensive Team of ConsultantsExtensive 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

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

Care Across the Continuum:Coma to Community

Multi-level national network of careMulti-level national network of care Delivery of specialized care close to homeDelivery of specialized care close to home Comprehensive interdisciplinary assessment of Comprehensive interdisciplinary assessment of

previously unidentified TBI patientspreviously unidentified TBI patients Proactive Case Management Proactive Case Management Continued management of existing and emerging Continued management of existing and emerging

sequalaesequalae Care for the patient who can’t return homeCare for the patient who can’t return home TelehealthTelehealth Identification of community resourcesIdentification of community resources Collaboration with VBACollaboration with VBA

Multi-level national network of careMulti-level national network of care Delivery of specialized care close to homeDelivery of specialized care close to home Comprehensive interdisciplinary assessment of Comprehensive interdisciplinary assessment of

previously unidentified TBI patientspreviously unidentified TBI patients Proactive Case Management Proactive Case Management Continued management of existing and emerging Continued management of existing and emerging

sequalaesequalae Care for the patient who can’t return homeCare for the patient who can’t return home TelehealthTelehealth Identification of community resourcesIdentification of community resources Collaboration with VBACollaboration with VBA

VA Polytrauma System of VA Polytrauma System of CareCare

Better Functional and Clinical Outcomes, Higher Satisfaction,

Lower Costs

Dynamic LinksThe Right Care, At the Right Time, In

the Right Place

Informed, Empowered Patient &

Family

Specialized Rehabilitation 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 TransitionDepartment of

Veterans AffairsDepartment of Defense

DVBIC

Case Management ChallengesCase Management ChallengesCase Management ChallengesCase Management Challenges

FamilyFamily DoD/VA LiaisonDoD/VA Liaison Military Treatment Military Treatment

FacilityFacility Military TransportMilitary Transport

Military CommandMilitary Command

TRICARETRICARE

FamilyFamily DoD/VA LiaisonDoD/VA Liaison Military Treatment Military Treatment

FacilityFacility Military TransportMilitary Transport

Military CommandMilitary Command

TRICARETRICARE

Medical Holding Medical Holding CompanyCompany

““Home” VA Medical Home” VA Medical Center (Level II, III)Center (Level II, III)

Civilian HospitalCivilian Hospital State/Local ServicesState/Local Services

Veterans BenefitsVeterans Benefits

Medical Holding Medical Holding CompanyCompany

““Home” VA Medical Home” VA Medical Center (Level II, III)Center (Level II, III)

Civilian HospitalCivilian Hospital State/Local ServicesState/Local Services

Veterans BenefitsVeterans Benefits

Psychology in Polytrauma Psychology in Polytrauma RehabilitationRehabilitation

Psychology in Polytrauma Psychology in Polytrauma RehabilitationRehabilitation

Integrated, active, interdisciplinary team Integrated, active, interdisciplinary team membermember

Combat Stress and PTSDCombat Stress and PTSD Complex Pain syndromesComplex Pain syndromes Behavioral management, adherenceBehavioral management, adherence Depression, SuicideDepression, Suicide IntimacyIntimacy Provider stressProvider stress Education to mental health staff, nursing, Education to mental health staff, nursing,

and all hospital staff, Level II sitesand all hospital staff, Level II sites

Integrated, active, interdisciplinary team Integrated, active, interdisciplinary team membermember

Combat Stress and PTSDCombat Stress and PTSD Complex Pain syndromesComplex Pain syndromes Behavioral management, adherenceBehavioral management, adherence Depression, SuicideDepression, Suicide IntimacyIntimacy Provider stressProvider stress Education to mental health staff, nursing, Education to mental health staff, nursing,

and all hospital staff, Level II sitesand all hospital staff, Level II sites

Family IssuesFamily Issues

Multiple stressorsMultiple stressors Away from home, support systems Away from home, support systems Care of other children, aging parentsCare of other children, aging parents Job loss, financial strainJob loss, financial strain

Adjusting to VA and rehab environment Adjusting to VA and rehab environment Duration, intensity & fluctuation of medical Duration, intensity & fluctuation of medical

course course Expectations: Advocacy vs entitlementExpectations: Advocacy vs entitlement

Multiple stressorsMultiple stressors Away from home, support systems Away from home, support systems Care of other children, aging parentsCare of other children, aging parents Job loss, financial strainJob loss, financial strain

Adjusting to VA and rehab environment Adjusting to VA and rehab environment Duration, intensity & fluctuation of medical Duration, intensity & fluctuation of medical

course course Expectations: Advocacy vs entitlementExpectations: Advocacy vs entitlement

Family IssuesFamily Issues Role strain and changeRole strain and change Stress, traumaStress, trauma Political contextPolitical context Anger, grief and lossAnger, grief and loss GuiltGuilt ““Ambiguous loss” (Boss, 1999; 2006)Ambiguous loss” (Boss, 1999; 2006) Depression, anxietyDepression, anxiety Stress increases at transfer to Level 2Stress increases at transfer to Level 2

Role strain and changeRole strain and change Stress, traumaStress, trauma Political contextPolitical context Anger, grief and lossAnger, grief and loss GuiltGuilt ““Ambiguous loss” (Boss, 1999; 2006)Ambiguous loss” (Boss, 1999; 2006) Depression, anxietyDepression, anxiety Stress increases at transfer to Level 2Stress increases at transfer to Level 2

Treatment ConsiderationsTreatment ConsiderationsTreatment ConsiderationsTreatment Considerations Pathologizing family vs family stress theoryPathologizing family vs family stress theory Psychodynamic interpretations, motivated Psychodynamic interpretations, motivated

forgettingforgetting Group size, durationGroup size, duration Directive, active, concrete, metaphorDirective, active, concrete, metaphor Multi-modal education and treatmentMulti-modal education and treatment Adjusting “to” and “with” cognitive impairments Adjusting “to” and “with” cognitive impairments Acceptance vs status quoAcceptance vs status quo Assistance: increasing dependency vs support for Assistance: increasing dependency vs support for

independence independence

Pathologizing family vs family stress theoryPathologizing family vs family stress theory Psychodynamic interpretations, motivated Psychodynamic interpretations, motivated

forgettingforgetting Group size, durationGroup size, duration Directive, active, concrete, metaphorDirective, active, concrete, metaphor Multi-modal education and treatmentMulti-modal education and treatment Adjusting “to” and “with” cognitive impairments Adjusting “to” and “with” cognitive impairments Acceptance vs status quoAcceptance vs status quo Assistance: increasing dependency vs support for Assistance: increasing dependency vs support for

independence independence

Future Issues & DirectionsFuture Issues & DirectionsFuture Issues & DirectionsFuture Issues & Directions

(Complicated) Mild TBI(Complicated) Mild TBI Vocational rehab & supportsVocational rehab & supports Community reintegrationCommunity reintegration Increase substance abuseIncrease substance abuse Increase suicideIncrease suicide Life span, aging, secondary Life span, aging, secondary

condidtionscondidtions

(Complicated) Mild TBI(Complicated) Mild TBI Vocational rehab & supportsVocational rehab & supports Community reintegrationCommunity reintegration Increase substance abuseIncrease substance abuse Increase suicideIncrease suicide Life span, aging, secondary Life span, aging, secondary

condidtionscondidtions