Portrait of a Returning Severely Injured OEFOIF Veteran: Who they are What they need Meeting those n

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Portrait of a Returning Severely Injured OEF/OIF
VeteranWho they are What they need Meeting
those needs

• Victoria Koehler, MSW, LCSW
• OEF/OIF Program Manager
• July 23, 2008

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OEF/OIF Program

• Case Management
• Support
• Advocacy
• Outreach
• Transition from DOD to VA
• Active Duty Med hold
• Convalescence leave

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OEF/OIF Program Design

• OEF/OIF Program Manager
• SW Case Manager
• RN Case Manager
• Transition Patient Advocate
• 1010.01 VHA OEF/OIF Program Handbook

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OEF/OIF Program Referrals

• MTF
• CBHCO
• PDHRA
• Walk-ins
• Across medical center
• VBA
• Community

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• 2.2 million deployments
• 1.5 million deployed
• 37,851 e-vaced
• 28,000 wounded in action
• 3,082 SI (TSLGI recipients)
• SI survival rate, 58 Vietnam 78 OEF/OIF
• The Presidents commission on care for Americas
  Returning Wounded Warriors. July 2007

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Iraq Combat Experience

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Seriously Injured defined by CO

• SCI
• Blindness
• TBI
• Amputation
• Burns
• Polytrauma
• Severe MH--GAF score less then 30

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SI Case Example

• 27yo, sole survivor of VB IED blast in Iraq
• Severe burns to 60 of body, wound care
• Chronic pain
• Lt arm amputee, high shoulder
• Rt eye blindness
• TBI
• PTSD-nightmares intrusive thoughts avoidance of
  anything that reminds him of Iraq including
  PVAMC social isolation anxiety and
  hypervigilance.
• Anger management struggles
• 100sc
• Recent separation from wife, no children
• Estranged from father, mother involved after
  estranged
• Purchased a home
• Great sense of humor, will to endure

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• Veterans Tracking Application, March 5, 2008

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• Veterans Tracking Application, March 5, 2008

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• Veterans Tracking Application, March 5, 2008

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• Veterans Tracking Application, March, 5, 2008

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• Veterans Tracking Application, March 5, 2008

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Although the world is full of suffering, it is
full also of the overcoming of it

• Helen Keller,
• 20th century American writer

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FY01-FY07 3,118 OIF/OEF
Sex Male 2,835 Female 283 Average Age 30
(8.3) Median 27 Range 17-64 Ethnicity Cauc
asian 923 Other 88 Unknown 2,107 Service
Connected SC 1,770 Average SC 44
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PVAMC OEF/OIF Service Component
7
12
67
14
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PVAMC OEF/OIF Eligibility
24
42
33
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PVAMC OEF/OIF Clinic Stops
9
43
71
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Polytrauma

• Polytrauma is defined as injury to the brain in
  addition to other body parts or systems resulting
  in physical, cognitive, psychological, or
  psychosocial impairments and functional
  disability. Injury to the brain is the
  impairment which guides the course of the
  rehabilitation.
• VHA 2005-24 Directive definition

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VA Polytrauma System of Care

• Polytrauma Rehab Centers
• Palo Alto, Tampa, Minneapolis, Richmond
• San Antonio (2008-09)
• Polytrauma Network Sites
• One site per VISN
• VISN 20, VA Puget Sound
• Polytrauma Support Clinic Teams
• Portland, Boise, Spokane, Anchorage (pending)

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Polytrauma Support Clinic Team

• MD/Physiatrist
• Psychologist
• Social work case manager
• RN
• PT/OT
• Speech Therapist
• Voc Rehab Specialist

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Polytrauma Fundamental Principles

• Accessibility to care
• Interdisciplinary model of care delivery
• Integrated treatment plan
• Proactive Case management and care coordination
  for each veteran
• Life long continuum of care

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• TBI
• The
• Signature
• Wound

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Traumatic Brain Injury (TBI) is a condition
that requires specialized medical care and
rehabilitation. Persons with a brain injury are
often referred to as the walking wounded.
Their greatest challenges are often invisible
to those who come in contact with themRobert
H Roswell, MDTraumatic Brain InjuryVeterans
Health Initiative, 2006
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TBI common symptoms

• Headaches
• Dizziness
• Excessive fatigue
• Concentration problems
• Memory problems
• Irritability
• Sleep problems
• Balance problems
• Ringing in the ears
• Vision change

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PTSD/TBIMultiple symptom overlap

• 43.9 loss of consciousness (mTBI) also meet
  criteria for ptsd
• mTBI reporting higher rates
• 1)poor general health
• 2)missed workdays and medical visits
• 3)somatic and post concussive symptoms
• After adjustment for ptsd and depression,
  headache was the only symptom associated with
  tbi.
• Hoge, C.W., et.al. NEJM (2008)

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Mental Health Symptoms Returning from Iraq

• Soldiers mental health status does not
  re-set after 12 months following return from a
  combat tour.

(Castro Hoge, 2005)
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Barriers to Seeking MH care
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Neuropsychological changes with combat deployment
alone Vasterling, J.J, et.al., August 2006

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Neuropsychological Impact of Deployment

• Compromise found 1) sustained attention 2)
  verbal learning 3) visual-spatial memory 4)
  concentration
• Improvement found
• 1) simple reaction time
• Vasterling, J.J., et.al., 2006

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Psychosocial Concerns

• Adjustment to civilian life
• Divorce
• Unemployment
• Low school performance
• No/Low income
• Substance abuse
• Lack of social supports, isolation
• Homelessness
• SI

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Suicide

• Army highest suicide rate in 26 years
• Army National Guard death FY 07
• 1) combat (47)
• 2) accidents (45)
• 3) suicide (42)
• GWOT Veterans age 20-24 highest suicide rate
  among all veterans, two and four times higher
  than civilians the same age
• non-veterans 8.3 per 100,000
• veterans 22.9 and 31.9 per 100,000
• Rathbun, S. 2005

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Violent Deaths in Oregon 2005
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What they need

• 1) Serve, multiple needs
• 2) Support, recovery and return
• 3) Simplify, delivery of medical care and
  disability programs.
• Patient-centeredness
• Fundamental changes in care management
• Requires a sense of urgency
• The Presidents commission on care for Americas
  Returning Wounded Warriors. July 2007

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What SI OEF/OIF veterans need Seamless Transition

• VA Enrollment before discharge
• VA appointments prior to arrival
• Clear Point of Contact
• Case management
• Prompt follow up

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What all OEF/OIF need

• One Point of Entry, Post Deployment Clinic
• Integrated Team Approach
• Case management
• System Education
• Outreach
• Follow up

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What they need from US

• Understanding of unique situation
• Compassion
• Respect
• Guaranteed Follow-up
• Clear, simple communication

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The future depends on what we do in the
present
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