#### **Department of Veterans Affairs VHA HANDBOOK 1172.1**

**Veterans Health Administration Transmittal Sheet**

**Washington, DC 20420 September 22, 2005**

# 

# POLYTRAUMA REHABILITATION PROCEDURES

**1.** **REASON FOR ISSUE.** This Veterans Health Administration (VHA)
Handbook describes the procedures for the Polytrauma Rehabilitation
Program and defines Polytrauma Rehabilitation Centers (PRC) in the
provision of comprehensive interdisciplinary rehabilitation, medical
care, and coordination of care.

**2. SUMMARY OF CHANGES.** This is a new Handbook defining the
parameters of the Polytrauma Rehabilitation Program.

**3. RELATED ISSUES.** None.

**4. RESPONSIBLE OFFICE:** The Office of Patient Care Services, the
Chief Consultant, Rehabilitation Strategic Healthcare Group (117) is
responsible for the contents of this VHA Handbook. Questions may be
referred to the Director, Physical Medicine and Rehabilitation Services
at 612-725-2044.

**5**. **RECISSIONS.** None.

**6.** **RECERTIFICATION.** This VHA Handbook is scheduled for
recertification on or before the last working day of September 2010.

  ------------------------------- ---------------------------------------
                                  

                                  Jonathan B. Perlin, MD, PhD, MSHA, FACP

                                  Under Secretary for Health
  ------------------------------- ---------------------------------------

  --------------- ------- ------------------------------------------------
  DISTRIBUTION:   CO:     E-mailed 9/27/05

                  FLD:    VISN, MA, DO, OC, OCRO, and 200 -- E-mailed
                          9/27/05
  --------------- ------- ------------------------------------------------

**CONTENTS**

**POLYTRAUMA REHABILITATION PROCEDURES**

# 

**PARAGRAPH** **PAGE**

1\. Purpose 1

2\. Background 1

3\. Definitions 2

4\. Scope 5

5\. Classification of Polytrauma Sequelae 6

6\. Polytrauma Rehabilitation Centers 7

7\. Admission Criteria 12

8\. Referral 13

9\. The Interdisciplinary Team 16

10\. Evaluations 18

11\. Interdisciplinary Treatment Plan 19

12\. Treatment 19

13\. Patient and Family Education 21

14\. Family Support 22

15\. Discharge Planning 23

16\. Follow-Up Case Management and Care Coordination 25

17\. References 26

**APPENDIXES**

A. Referral Area for Polytrauma Rehabilitation Centers (PRCs) A-1

# 

# POLYTRAUMA REHABILITATION PROCEDURES

**1. PURPOSE**

This Veterans Health Administration (VHA) Handbook describes the
procedures for the Polytrauma Rehabilitation Program and defines
Polytrauma Rehabilitation Centers (PRC) in the provision of
comprehensive interdisciplinary rehabilitation, medical care, and
coordination of care for the severely wounded with multiple complex
injuries.

**2. BACKGROUND**

a\. Recent combat has resulted in new patterns of polytraumatic injuries
and disability requiring specialized intensive rehabilitation processes
and coordination of care throughout the course of recovery and
rehabilitation. While serving in Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF), military service members are
sustaining multiple severe injuries as a result of explosions and
blasts. Improvised explosive devices, blasts, landmines, and fragments
account for 65 percent of combat injuries (see subpar. 17a). Congress
recognized this newly emerging pattern of military injuries with the
passage of Public Law 108-422, Section 302, and Public Law 108-447.

b\. Of these injured military personnel, 60 percent have some degree of
traumatic brain injury (TBI) (see <http://www.dvbic.org/>). Operating
under a national Memorandum of Agreement (MoA) with the Department of
Defense (DOD), the four current Department of Veterans Affairs (VA) TBI
Lead Centers have provided rehabilitation care to the majority of the
severely combat injured requiring inpatient rehabilitation.
Consequently, they have developed the necessary expertise to provide the
coordinated interdisciplinary care required. This experience has
demonstrated that treatment of brain injury sequelae needs to occur
before, or in conjunction with, rehabilitation of other disabling
conditions.

c\. Recognizing the specialized clinical care needs of individuals
sustaining multiple severe injuries, VA has established four PRCs. The
PRC mission is to provide comprehensive inpatient rehabilitation
services for individuals with complex physical, cognitive, and mental
health sequelae of severe and disabling trauma and provide support to
their families. Intensive case management is essential to coordinate the
complex components of care for polytrauma patients and their families.
Coordination of rehabilitation services must occur seamlessly as the
patient moves from acute hospitalization through acute rehabilitation
and ultimately back to the patient's home community.

d\. The Secretary of Veterans Affairs designated four PRCs, co-located
with TBI Lead Centers, at VA Medical Centers in Richmond, VA; Tampa, FL;
Minneapolis, MN; and Palo Alto, CA (see App. A). It is VHA policy that
the PRCs provide a full-range of care for all patients eligible for VA
care, who have sustained varied patterns of severe and disabling
injuries including, but not limited to: TBI, amputation, visual and
hearing impairment, spinal cord injury (SCI), musculoskeletal injuries,
wounds, and psychological trauma.

## 3. DEFINITIONS

a\. **[Admission and Follow-up Clinical Case Management.]{.underline}**
The PRCs provide clinical case management of referrals prior to
admission and follow-up case management for the ongoing rehabilitation
plan of care after discharge. Individuals assigned to this function, the
clinical case managers, require knowledge and clinical reasoning skills
necessary to review the medical status of the patient, identify all of
the current medical problems, evaluate the acuity level, assess factors
surrounding readiness for inpatient rehabilitation, and monitor the
patient's status until transferred. The clinical case manager makes
recommendations for alternative care settings when appropriate.
Following discharge from a PRC, the clinical case manager proactively
follows the patient to monitor medical and functional problems,
coordinates the ongoing rehabilitation plan of care and services,
advocates for the patient's medical treatment needs, and assesses
clinical outcomes and satisfaction. ***NOTE:** A Certified
Rehabilitation Registered Nurse (CRRN) who possesses the critical
clinical expertise and the knowledge of rehabilitation practice can best
perform these functions.*

b\. **[Clinical and/or Counseling Psychologist.]{.underline}** The
clinical and/or counseling psychologist must have expertise and
experience in rehabilitation psychology. Rehabilitation psychologists
provide clinical and counseling services assisting individuals in coping
with, and adjusting to, chronic or traumatic injuries or illnesses that
may result in a wide variety of physical, sensory, neurocognitive,
emotional, and/or developmental disabilities. These include, but are not
limited to: SCI, brain injury, stroke, amputation, and medical
conditions such as chronic pain, psychiatric disability, substance
abuse, impairments in sensory functioning, burns and/or disfigurement,
deafness and hearing loss, blindness and vision loss, and other
physical, mental, and/or emotional impairments with the potential to
limit functioning and participation in life activities. These services
include assessing and addressing neurocognitive status, moods and/or
emotions, desired level of independence and/or interdependence, mobility
and freedom of movement, self-esteem and self-determination, subjective
view of capabilities, quality of life, and satisfaction with
achievements in specific areas such as work, social relationships, and
being able to go where one wishes beyond the mere physical capability to
do so. Given the high likelihood of acute stress reactions and
post-traumatic stress disorder (PTSD) following polytrauma from combat
injuries, this clinical and/or counseling psychologist must have
expertise in the assessment and treatment of these conditions.

c\. **[Clinical Spiritual Care.]{.underline}** The "spiritual dimension"
of patient care refers to values, beliefs, and sources of meaning that
enable the person to overcome adversity of the moment and look ahead
with hope toward recovery and healing of the whole person (holistic
care). VHA Handbook 5338.3 describes the roles and functions of VHA
Chaplains, which includes the assessment of the patient's spiritual
resources, their efficacy for coping, and appropriate pastoral care
interventions.

d\. **[Comprehensive Integrated Inpatient Rehabilitation.]{.underline}**
Comprehensive Integrated Inpatient Rehabilitation is "a program of
coordinated and integrated medical and rehabilitation services that is
provided 24-hours per day and endorses the active participation and
choice of persons served throughout the entire program. The persons
served, in collaboration with the interdisciplinary team members,
identify and address their medical and rehabilitation needs. The
individual needs of the persons served drive the appropriate use of the
rehabilitation continuum of care, the establishment of predicted
outcomes; the provision of care, the composition of the
interdisciplinary team, and discharge to the community of choice. An
integrated, interdisciplinary team approach is reflected throughout all
activities" (see subpar.17g).

e\. **[Interdisciplinary Team (IDT).]{.underline}** An interdisciplinary
team is characterized by a variety of disciplines working together as a
team in the assessment, planning, and implementation of a person's care
plan. To avoid fragmented care, continuous communication, collaboration,
and coordination is critical. IDT functions as a unit, cooperating among
disciplines to achieve maximum patient and family outcomes (see subpar.
17e).

f\. **[Neuropsychologist.]{.underline}** A clinical neuropsychologist is
a clinical or counseling psychologist

with training and expertise in the applied science of brain-behavior
relationships. Clinical neuropsychologists use this knowledge in the
assessment, diagnosis, treatment, and/or rehabilitation of patients
across the lifespan with neurological, medical, neurodevelopmental, and
psychiatric conditions, as well as other cognitive and learning
disorders. The clinical neuropsychologist uses psychological,
neurological, cognitive, behavioral, and physiological principles,
techniques, and tests to evaluate patients\' neurocognitive, behavioral,
and emotional strengths and weaknesses and their relationship to normal
and abnormal central nervous system functioning. Clinical
neuropsychologists are doctoral-level psychology independent
practitioners of diagnostic and intervention services. ***NOTE:*** *The
American Psychological Association recognizes the specialty of clinical
neuropsychology.*

g\. **[Nurse Case Management.]{.underline}** CRRNs or Certified Case
Managers provide a number of important services including an in-depth
assessment of functional status, acuity level and prognosis, and the
need for specific services and resources including the level of
rehabilitation. In collaboration with the rehabilitation team, they set
long- and short-term goals. The case manager may also make
recommendations for alternative care settings when appropriate.
Following discharge, nurse case managers may continue to monitor medical
care and the ongoing rehabilitation plan of care and services (see
subpar. 17b).

h\. **[Pain Management.]{.underline}** Pain is a multidimensional
phenomenon usually associated with injury or disease and involving the
experiences of pain and suffering, and is commonly associated with
disability and emotional distress. Effective pain management requires a
comprehensive assessment that considers multiple biomedical,
psychological, interpersonal, and spiritual factors; the development of
an individually tailored plan for care; ongoing reassessment of the
effectiveness of pain interventions; and patient and family education.
Particular challenges are associated with assessment and management of
pain in the cognitively-impaired veteran, and with efforts to balance
optimal pain management with rehabilitation goals. Consultation with a
range of specialists with expertise in the management of specific pain
conditions may routinely be necessary.

i\. **[Polytrauma.]{.underline}** Polytrauma is defined 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. TBI frequently
occurs in polytrauma in combination with other disabling conditions such
as amputation, auditory and visual impairments, SCI, PTSD, and other
mental health conditions. Injury to the brain is the impairment that
primarily guides the course of the rehabilitation in patients admitted
to the PRC's.

j\. **[Rancho Los Amigos Levels of Cognitive Function.]{.underline}**
The Rancho Los Amigos Levels of

Cognitive Function Scale is a descriptive instrument that characterizes
a patient's level of functional cognition. It describes typical stages
of recovery following moderate to severe brain injury. The scale ranges
from a lower level of no response to an upper level of purposeful and
appropriate behavior (see subpar. 17d).

k\. **[Rehabilitation Nurses.]{.underline}** The PRCs provide
rehabilitation nursing services for patients

and their families. Nursing care in a rehabilitation setting focuses on
assisting individuals with impairments resulting from injuries, illness,
or chronic disease reach their optimal level of health and function.
Rehabilitation nurses have additional expertise in the sequelae and
rehabilitation care of conditions such as amputation, brain injury,
neuromuscular conditions, orthopedic conditions, stroke, visual
impairment, etc. As integral members of the patient's IDT,
rehabilitation nursing integrates the rehabilitation plan of care
24-hours a day, 7-days a week (24/7). Rehabilitation nurses are also
involved in educating the patient and caregivers to facilitate optimal
transition to the next level of care (see subpar. 17b).

l\. **[Social Work Case Management.]{.underline}** In collaboration with
the clinical case management described, PRCs must provide social work
case management services for all patients and their families. Social
work case management differs from clinical case management in that the
social work case manager addresses the psychosocial needs of the
patient, advocates for the patient and family, provides supportive
services for the family and caregivers, and addresses home and community
environment issues. A social work case manager conducts a comprehensive
psychosocial assessment, which includes review of cultural issues,
patient support systems, family and caregiver support systems, financial
and vocational status, and the living situation. In partnership with the
clinical case manager, patient, and family, the social work case manager
develops treatment and discharge plans and provides ongoing case
management services including post-discharge services. The social work
case manager may also provide clinical services, such as individual and
family counseling and grief counseling. The social work case manager
contacts the patient and/or family prior to transfer to answer questions
they may have and to assist with the transition. Social work case
management services continue through the rehabilitation process and
post-discharge services providing assistance with transitions to a DOD
military treatment facility (MTF), or other VHA facility, or to the home
and community.

m\. **[VA-DOD Seamless Transition Social Work Liaison.]{.underline}**
The VA-DOD social work liaisons are assigned to the major MTFs receiving
service members returning from combat. The primary role of the VA-DOD
liaisons is to ensure the transfer of health care, both inpatient and
outpatient, from the MTF to the appropriate VA facility. They provide
education to the MTFs about the specialized care and rehabilitation
services available at the PRCs. They also support the PRCs by
reinforcing the need to have all polytrauma patients screened by a PRC
to ensure that the optimal care setting is identified.

## 4. SCOPE 

a\. **[Mission.]{.underline}** The PRC mission is to provide
comprehensive inpatient rehabilitation services for individuals with
complex physical, cognitive, and mental health sequelae of severe and
disabling trauma, to provide medical and surgical support for ongoing
and/or new conditions, and to provide support to their families.
Intensive clinical and social work case management services are
essential to coordinate the complex components of care for polytrauma
patients and their families. Coordination of rehabilitation services
must occur seamlessly as the patient moves from acute hospitalization
through acute rehabilitation and ultimately back to the patient's home
community. Transition to the home community may include a transfer from
a PRC to a less acute facility.

##  b. [Scope of Services.]{.underline} PRCs provide specific inpatient, transitional, and outpatient rehabilitation tailored to individual patterns of impairment sustained in the trauma as well as management of associated conditions through consultation with other specialties, as necessary. These programs include, but are not limited to:

\(1\) **Comprehensive Interdisciplinary Inpatient Evaluations.** The
PRCs offer short-term admissions to inpatient rehabilitation for
comprehensive interdisciplinary evaluations for patients with varying
levels of acuity and severity. A patient at any level on the Rancho Los
Amigos Level of Cognitive Function Scale may be appropriate for
admission. These evaluations help determine the range and types of
services needed to manage the full scope of medical, rehabilitation, and
psychosocial sequelae resulting from combat injury and the most
appropriate setting in which to deliver those services. Members of the
IDT administer a variety of assessment instruments and then meet as a
group to integrate results and recommendations. Suggestions for optimal
care settings vary depending upon the extent and severity of injury,
family and institutional support, and availability of services in the
community.

\(2\) **Acute Comprehensive Interdisciplinary Inpatient
Rehabilitation.** Acute comprehensive interdisciplinary inpatient
rehabilitation is a highly-specialized level of care designed to treat
patients as soon as they are sufficiently medically stable to tolerate
initial rehabilitation programming. The primary emphasis is to provide
intensive interdisciplinary rehabilitation services in the early months
after the injury. The focus of acute rehabilitation is on cognitive,
physical, emotional, and behavioral improvement. Goals include:
increased cognition, self-awareness, functional communication, mobility,
psychosocial skills, activities of daily living, productive activity,
and preparation for home and community. The treatment program is
goal-oriented with a focus on practical life-skills training,
individualized and cost-effective treatment, and patient and family
education, support, and preparation. Patients remain in acute
rehabilitation until goals are met or maximal improvement is realized.

\(3\) **Transitional Community Re-entry.** Patients at high-levels of
cognitive function who have progressed beyond the need for basic
rehabilitation interventions may be admitted for high-level cognitive
rehabilitation, advanced gait training, advanced prosthetic training,
vocational evaluation, evaluation for return to school, and other
transitional or community re-entry programming.

\(4\) **Outpatient Interdisciplinary Rehabilitation.** The PRCs provide
individualized, coordinated, and outcome focused outpatient services
including medical support, therapy services, education, and psychosocial
treatment and support to patients who live in their local service areas.

\(5\) **Reevaluations.** Reevaluations at a PRC are available as needed.
These interdisciplinary reevaluations of polytrauma patients are an
important component of the continuum of care for patients sustaining
severe injury and disabling impairments. In some instances, use of
telerehabilitation technology may be appropriate.

\(6\) **Ongoing Case Management and Follow-up.** Ongoing clinical and
social work case management services are provided to patients requiring
continued rehabilitation services. These services involve acting as the
point of contact for emerging medical, psychosocial, or rehabilitation
problems; managing the continuum of care; care coordination; acting as
patient and family advocate; and assessing clinical outcomes and
satisfaction. The assigned clinical and social work case managers make
proactive regular and routine contacts with the patient and family as
long as active treatment goals remain.

\(7\) **Consultation.** The PRCs serve as consultants to the VA system,
the military health care system, and non-VA care providers. Their staff
reviews patient records, provides recommendations for care, assists with
identifying an appropriate care setting, and provides continued support
as needed. Consultation through telerehabilitation is also available.

**5. CLASSIFICATION OF POLYTRAUMA SEQUELAE**

a\. Combat injuries are often the result of a blast. Blasts cause
injuries through multiple mechanisms. Severe blasts can result in total
body disruptions and death to those closest to the blast site or they
can result in burns and inhalation injuries. Blast injuries typically
are divided into four categories: primary, secondary, tertiary, and
quaternary or miscellaneous injuries.

\(1\) **Primary Blast Injuries.** Primary blast injuries are caused by
overpressure to gas-containing organ systems, with most frequent injury
to the lung, bowel, and inner ear (tympanic membrane rupture). These
exposures may result in traumatic limb or partial limb amputation.

\(2\) **Secondary Blast Injuries.** Secondary blast injuries occur via
fragments and other missiles, which can cause head injuries and soft
tissue trauma.

\(3\) **Tertiary Blast Injuries.** Tertiary blast injuries result from
displacement of the whole body by combined pressure loads (shock wave
and dynamic overpressure).

\(4\) **Miscellaneous Blast-related Injuries.** These are miscellaneous
blast-related injuries such as burns and crush injuries from collapsed
structures and displaced heavy objects. Soft tissue injuries, fractures,
and amputations are common.

b\. Animal models of blast injury have demonstrated damaged brain tissue
and consequent cognitive deficits. Indeed, the limited data available
suggests that brain injuries are a common occurrence from blast injuries
and often go undiagnosed and untreated as attention is focused on more
"visible" injuries. A significant number of casualties sustain emotional
shock and may develop PTSD. Individuals may sustain multiple injuries
from one or more of these

mechanisms. Explosions can produce unique patterns of injury seldom seen
outside combat.

  ----------------- -----------------------------------------------------
  **System or       **Injury or condition**
  organ**           

  Auditory or       Tympanic membrane rupture, ossicular disruption,
  vestibular        cochlear damage, foreign body, hearing loss,
                    distorted hearing, tinnitus, earache, dizziness,
                    sensitivity to noise.

  Eye, orbit, face  Perforated globe, foreign body, air embolism,
                    fractures.

  Respiratory       Blast lung, hemothorax, pneumothorax, pulmonary
                    contusion and hemorrhage, atrioventricular fistula
                    (source of air embolism), airway epithelial damage,
                    aspiration pneumonitis, sepsis.

  Digestive         Bowel perforation, hemorrhage, ruptured liver or
                    spleen, mesenteric ischemia from air embolism,
                    sepsis, peritoneal irritation, rectal bleeding.

  Circulatory       Cardiac contusion, myocardial infarction from air
                    embolism, shock, vasovagal hypotension, peripheral
                    vascular injury, air embolism-induced injury.

  Central nervous   Concussion, closed or open brain injury, petechial
  system            hemorrhage, edema, stroke, small blood vessel
                    rupture, spinal cord injury, air embolism-induced
                    injury, hypoxia or anoxia, diffuse axonal injury .

  Renal and/or      Renal contusion, laceration, acute renal failure due
  urinary tract     to rhabdomyolysis, hypotension, hypovolemia.

  Extremity         Traumatic amputation, fractures, crush injuries,
                    burns, cuts, lacerations, infections, acute arterial
                    occlusion, air embolism-induced injury.

  Soft tissue       Crush injuries, burns, infections, slow healing
                    wounds.

  Emotional or      Acute stress reactions, PTSD, survivor guilt,
  psychological     post-concussion syndrome, depression, generalized
                    anxiety disorder.

  Pain              Acute pain from wounds, crush injuries, or traumatic
                    amputations; chronic pain syndromes.
  ----------------- -----------------------------------------------------

***Source:** Centers for Disease Control and Prevention (CDC)
Classification of Blast Injuries*

c\. Understanding blast injury as a common mechanism-of-injury for
polytrauma patients helps guide assessments beyond the most obvious
physical problem. Understanding common associated injuries guides a more
comprehensive evaluation and care plan process to prevent more disabling
conditions from arising in the future. Such a mechanism-of-injury-based
approach to evaluation and treatment is more proactive and efficient
and, ultimately, cost effective.

## 6. POLYTRAUMA REHABILITATION CENTERS

a\. [**PRC Referral** **Areas.**]{.underline} The four PRCs utilize the
referral areas established for the TBI Lead Centers. The military is
accustomed to this existing pattern for making referrals. Individuals
with polytrauma are referred to the PRC based on the location of their
family and/or intended discharge location (see App. A).

b\. [**Accreditation** **and Certification**]{.underline}

\(1\) Rehabilitation programs are accredited by the Rehabilitation
Accreditation Commission (CARF) in Comprehensive Integrated Inpatient
Rehabilitation and Brain Injury Rehabilitation. ***NOTE*:** *Per VHA
policy, facilities with SCI Centers, Blind Rehabilitation Centers, or
other rehabilitation programs are CARF-accredited.*

\(2\) Prosthetists and/or Orthotists are board-certified by the American
Board for Certification in Orthotics and Prosthetics, Inc. (ABC), or the
Board for Orthotist or Prosthetist Certification (BOC).

\(3\) Prosthetic and Orthotic Laboratories are accredited by ABC or BOC.

\(4\) Blind Rehabilitation Outpatient Specialists are certified in
orientation and mobility.

\(5\) Assigned nursing staff includes CRRNs.

c\. **[Staffing]{.underline}**

\(1\) **Core Staff.** Each PRC must ensure that the appropriate
disciplines are available and at sufficient levels to meet the
individual needs of patients with polytrauma. Due to the specialized
expertise necessary to manage this type of patient, staff needs to be
dedicated and non-rotating.

Recommended Core Staffing Levels Per Six Beds:

+-----------------------------------------------------------+----------+
| ## Discipline                                             | ### FTE  |
+-----------------------------------------------------------+----------+
| Rehabilitation Physician                                  | .5       |
+-----------------------------------------------------------+----------+
| Registered Nurse (1.0 must be CRRN)                       | 5.5      |
+-----------------------------------------------------------+----------+
| Licensed Practical Nurse and/or Certified Nursing         | 4.0      |
| Assistant                                                 |          |
+-----------------------------------------------------------+----------+
| Nurse Manager                                             | .5       |
+-----------------------------------------------------------+----------+
| Admission and Follow-up Clinical Case Manager             | .5       |
+-----------------------------------------------------------+----------+
| Social Worker Case Manager                                | 1.0      |
+-----------------------------------------------------------+----------+
| Speech-Language Pathologist                               | 1.0      |
+-----------------------------------------------------------+----------+
| Physical Therapist                                        | 1.0      |
+-----------------------------------------------------------+----------+
| Occupational Therapist                                    | 1.0      |
+-----------------------------------------------------------+----------+
| Recreation Therapist                                      | .5       |
+-----------------------------------------------------------+----------+
| Counseling Psychologist                                   | .5       |
+-----------------------------------------------------------+----------+
| Neuropsychologist                                         | .5       |
+-----------------------------------------------------------+----------+
| Social Worker                                             | .5       |
+-----------------------------------------------------------+----------+

\(2\) **Core Staff Education and Competencies**

\(a\) Medical and rehabilitation professionals provide services
consistent with: state practice acts, licensure requirements,
registration requirements, certification requirements, requirements of
their educational degrees, professional training to maintain established
competency levels, on-the-job training requirements, and professional
standards of practice.

\(b\) All PRCs need to have an ongoing educational program that
addresses the needs of all health care professional staff involved in
polytrauma care. Areas that need to be included are:

[1]{.underline}. Age-appropriate interventions;

[2]{.underline}. Amputation care;

[3]{.underline}. Assistive technology;

[4]{.underline}. Auditory impairment;

[5]{.underline}. Blast injuries;

[6]{.underline}. Blind rehabilitation system of care;

[7]{.underline}. Changes in sexuality due to altered physical and
cognitive function;

[8]{.underline}. Family needs and psychosocial support, including
psychological support for the impact of trauma on the family;

[9]{.underline}. Managing emergence from minimal responsiveness;

[10]{.underline}. Managing inappropriate sexual behaviors;

[11]{.underline}. Managing the family under stress or in crisis;

[12]{.underline}. Pain management;

[13]{.underline}. PTSD;

[14]{.underline}. Prosthetic equipment and appropriate selection;

[15]{.underline}. Psychological issues surrounding change in body image;

[16]{.underline}. Psychological issues surrounding change in vocation;

[17]{.underline}. Rehabilitation nursing;

[18]{.underline}. Techniques for managing agitation;

[19]{.underline}. Techniques for managing the patient in or emerging
from post-traumatic amnesia;

[20]{.underline}. TBI sequelae; and

[21]{.underline}. Visual impairment and rehabilitation techniques.

\(c\) PRC staff need to serve as education and/or training resources in
their areas of expertise for other health care providers in the medical
center, trainees, staff from other VA facilities, and health care
personnel from non-VA facilities, as appropriate.

\(3\) **Dedicated Consultative Specialists.** Consults to the
appropriate medical specialists must be made based on the acuity and
complexity of the patient's polytrauma sequelae. Staff from these
consultative services must be available 24/7 to respond to urgent
requests or emergent needs. The clinical specialties considered integral
to the PRC are:

\(a\) Audiology,

\(b\) Blind Rehabilitation,

\(c\) Clinical Chaplaincy,

\(d\) Clinical Nutrition,

\(e\) Clinical Pharmacy,

\(f\) Dentistry and/or Oral and Maxillofacial Surgery,

\(g\) Driver Training,

\(h\) Gastroenterology,

\(i\) General Medicine,

\(j\) General Surgery,

\(k\) Infectious Diseases,

\(l\) Kinesiotherapy,

\(m\) Neurology,

\(n\) Neuro-ophthalmology,

\(o\) Neurosurgery,

\(p\) Optometry,

\(q\) Orthopedic Surgery,

\(r\) Orthotics,

\(s\) Otolaryngology,

\(t\) Pain Management,

\(u\) Plastic Surgery,

\(v\) Prosthetics,

\(w\) Psychiatry,

\(x\) PTSD Team,

\(y\) Pulmonology,

\(z\) Radiology,

(aa) Urology, and

(bb) Vocational Rehabilitation.

\(4\) **Other Consultative Specialists.** Additional specialty services
that may be required include, but are not limited to:

\(a\) Cardiothoracic Surgery,

\(b\) Dialysis,

\(c\) Podiatry, and

\(d\) Vascular Surgery.

d\. **[Facility and Environment of Care]{.underline}**

\(1\) **Health and Safety.** PRCs have safety and security measures that
are consistent with the physical, cognitive, and behavioral needs of
patients with polytrauma, which need to address:

\(a\) Agitation and confusion;

\(b\) Chemical use, abuse, and dependency;

\(c\) Elopement risks;

\(d\) Equipment risks;

\(e\) Handicap accessibility;

\(f\) Physical hazards;

\(g\) Physically aggressive behaviors;

\(h\) Self-injurious behaviors; and

\(i\) Suicidal ideation.

\(2\) **Space Requirements**

\(a\) [Bed Unit.]{.underline} PRCs' inpatient beds are located in a
designated area and are contiguous to each other or to other inpatient
rehabilitation beds.

\(b\) [Rehabilitation Clinics.]{.underline} Clinical treatment areas are
available to appropriately meet the rehabilitation plan of care.

\(c\) [Distraction Free Areas.]{.underline} Private treatment area(s)
are available for evaluation and treatment when privacy and/or
distraction-free space are needed.

\(d\) [Multipurpose Room.]{.underline} Space for group (patient and/or
family) therapies is available for psychosocial support, therapeutic
recreation, cognitive rehabilitation, independent living skills
training, and education.

\(e\) [Day room.]{.underline} A rest and relaxation area is available
for families that promote interaction with the patient in a relaxed
therapeutic setting.

\(f\) [Prosthetic and Orthotic Laboratory.]{.underline} Space is
available for fabrication and fitting of prosthetic and orthotic
devices.

\(3\) **Equipment**. PRCs have the specialized equipment necessary to
meet the rehabilitation needs of this complex clinical population. This
equipment includes but is not limited to:

\(a\) Computer-aided Design and/or Computer-aided Manufacturing
(CAD/CAM);

\(b\) Specialized beds, wheelchairs, and other seating devices;

\(c\) Gait and balance evaluation equipment;

\(d\) Recreation materials for patient and family that are
age-appropriate;

\(e\) Specialized equipment associated with a Prosthetic and Orthotic
Laboratory; and

\(f\) Specialized patient lifts and transfer equipment.

## 

## 7. ADMISSION CRITERIA

Individuals sustaining polytrauma have received acute medical care for
the conditions associated with the initial injury and are in the
recovery phase. Due to the medical complexity of these patients, PRCs
must be prepared to admit individuals who may have a higher level of
medical acuity and require interdisciplinary management by various
medical specialists. The general admission criteria to the PRC include:

a\. The individual with polytrauma is an eligible veteran or an active
duty military service member; and

b\. The individual has sustained multiple physical, cognitive, and/or
emotional impairments secondary to trauma; and

c\. The individual has the potential to benefit from inpatient
rehabilitation; or

d\. The individual has the potential to benefit from a transitional
community re-entry program; or

e\. The individual requires an initial comprehensive rehabilitation
evaluation and care plan.

## 8. REFERRAL

a\. VA has a longstanding national MoA with DOD to provide specialized
care to service members with SCI, TBI, and those requiring blind
rehabilitation. This MoA establishes each agency's responsibilities
concerning the transfer of active duty personnel to a VA facility
designated as a Center for SCI, TBI, or Blind Rehabilitation. Under this
MoA, there are special reimbursement rates and billing submission
procedures. ***NOTE:** The majority of polytrauma patients being
admitted to the PRCs have TBI as a primary diagnosis.*

b\. It is recommended that all patients experiencing a polytraumatic
injury be referred to a VA PRC. The PRC team has specialized expertise
to determine the most appropriate setting for care. If the patient does
not require admission to a PRC, the team can assist with coordination of
care at the most appropriate facility. Referral to a PRC also ensures
that the patient and family are integrated into the VA system of care
with the appropriate rehabilitation services. ***NOTE**: The SCI Chief
for the applicable region needs to be contacted by the PRC admissions
clinical case manager to consult on the transfer of patients with a
diagnosis of TBI and SCI.*

c\. Referrals to the PRC must be given the highest priority and the
screening process needs to be expedited to ensure that there are no
delays in transferring a patient to the Center. The PRC must accept
admissions on a 24/7 basis. To establish the medical needs and acuity of
the patient, there is a need to review medical documentation, consult
with the referring treatment provider, and coordinate a plan for
transfer.

d\. Referral of service members with polytrauma to a PRC is initiated by
DOD, typically by the MTF social worker or case manager, or other DOD
representative. Where assigned, the VA-DOD liaison social worker is
actively involved in the referral process, facilitating communications,
information exchange, transition of care, and family support. The PRC's
admissions clinical case manager coordinates the referral and screening
process for the accepting VA PRC. ***NOTE:** For those referral sources
that do not have VA-DOD liaisons, admission screening is to be
coordinated between the PRC admission clinical case manager and the
MTF.*

e\. The MTF is expected to provide the PRC admission clinical case
manager with information necessary to medically screen the patient and
manage the transition of care. Where assigned, the VA-DOD liaison social
worker obtains and ensures that the PRC receives the following:

\(1\) Names and contact information for the service member's attending
physician and case manager and/or social worker.

\(2\) Medical record information. Of particular importance are the
medical history, hospital course, procedures, diagnostic studies,
radiological reports, laboratory reports, microbiology reports,
medications, and any precautions or restrictions.

\(3\) Reports of progress in therapies.

\(4\) Documentation related to guardianship, powers of attorney,
capacity for decision-making or other legal documents.

\(5\) The service member's military command information including the
point of contact (POC), location, and phone number.

\(6\) Information on the military duty status of the service member,
e.g., Physical Evaluation Board (PEB), Medical Evaluation Board (MEB).

\(7\) The psychosocial history, family support needs, advance
directives, and other supplementary documentation.

f\. The PRC admission clinical case manager identifies all the current
medical problems, assesses acuity level, and factors surrounding
readiness for inpatient rehabilitation. The admission clinical case
manager reviews all clinical information with the Physical Medicine and
Rehabilitation Service (PM&RS) attending physician on the PRC.
***NOTE:** The PRC admission clinical case manager must ensure that the
VA-DOD Seamless Transition Liaison and the PRC OIF POC or OEF POC are
aware of the referral.* When a transfer to a PRC is planned, the
admission clinical case manager must:

\(1\) Monitor the patient's medical and rehabilitation status until
transfer occurs and update the PM&RS attending physician at the PRC.

\(2\) Contact the service member's family to begin orientation and
transition to the PRC. Orientation information includes the PRC
rehabilitation philosophy, facilities, typical day, therapies available,
team members, average length of stay, and any additional information
requested by the family.

\(3\) Provide the MTF with the name and pager number of the PRC PM&RS
attending physician.

\(4\) Involve the PRC social work case manager to ensure identification
of psychosocial support needs of the patient and family, particularly
regarding transportation, lodging, childcare, etc.

\(5\) Apprise the IDT of the planned admission, documenting
pre-admission screening information in the medical record.

\(6\) Obtain authorization for transfer to the PRC from the Military
Medical Support Office (MMSO)*,* [if not done by the MTF or VA-DOD
social work liaison]{.underline}.

\(7\) Coordinate with the MTF regarding logistics and transportation for
the active duty service member and family.

g\. The VA-DOD social work liaison continues to be involved in the
transition process by:

\(1\) Contacting the PRC's OIF POC or OEF POC for administrative
tracking purposes;

\(2\) Providing the patient and family with VA-developed information
materials describing the polytrauma program and the facility to which
the patient has been accepted;

\(3\) Facilitating communications between the MTF, the patient's family,
and the PRC during the transition process;

\(4\) Ensuring that any new information is shared with appropriate
staff;

\(5\) Ensuring that the PRC has all of the required medical and
administrative information to transfer care of the service member; and

\(6\) Being available to assist with any transition issues.

h\. When assessment of the referral identifies a more appropriate
treatment setting, the admission clinical case manager, in consultation
with the PM&RS attending physician at the PRC, makes recommendations as
to the most appropriate care setting, and assists the MTF and VA-DOD
social work liaison with locating this setting. This may be another
service within the PRC's medical center, e.g., medicine, surgery,
extended care, or another facility.

i\. The PRC Medical Director, or PM&RS staff physician designee, is
responsible for:

\(1\) Screening the patient in collaboration with appropriate medical
specialties and identifying the most appropriate admitting bed service,
e.g., PRC, surgery, medicine, and psychiatry;

\(2\) Responding to the referral promptly, preferably the same day
received;

\(3\) Personal communication with the responsible physician at the
referring facility, as needed, to determine current patient status,
readiness for transfer, and setting required at transfer; and

\(4\) Arranging for admission or transfer to an acute medical, surgical,
or psychiatric unit when warranted by the patient's condition.

**9. THE INTERDISCIPLINARY TEAM (IDT)**

Dedicated IDTs participate in the assessment, planning, and
implementation of the plan of care. Assignment of PRC core staff to an
IDT is a regular rather than a rotating duty. Close interaction and
integration among professionals from different disciplines ensure that
individuals with polytrauma receive optimal care. An IDT serves each
patient admitted to a PRC. The membership of the team is determined by
assessing the individual's rehabilitation needs, predicted outcomes, and
medical needs.

a\. **[Core IDT Membership]{.underline}**

\(1\) **Patient and Family.** The patient, as appropriate, and the
patient's family, or other support system, must be included in all
phases of the rehabilitation process. Their input is essential to the
development of an individualized plan of care and establishing goals
that are relevant to their needs. "The person at the focus of planning,
and those who love the person, are the primary authorities on the
person's life direction" (see subpar.17a).

\(2\) **Rehabilitation Core Disciplines.** Each rehabilitation
professional has specialized skills and knowledge based upon education,
clinical training, and experience. To address the complex needs of
individuals with polytrauma, the core rehabilitation disciplines require
additional training in specific treatment areas. This includes, but is
not limited to: neurorehabilitation, cognitive rehabilitation,
state-of-the-art prosthetics, and visual rehabilitation. The core IDT is
responsible for the major portion of the rehabilitation program and
includes as members:

\(a\) Admission and follow-up clinical case manager,

\(b\) Attending PRC PM&RS physician,

\(c\) CRRN,

\(d\) Clinical neuropsychologist,

\(e\) Counseling psychologist,

\(f\) Occupational therapist,

\(g\) Physical therapist,

\(h\) Recreation therapist,

\(i\) Rehabilitation nursing staff,

\(j\) Social work case manager, and

\(k\) Speech language pathologist.

b\. **[Core IDT Responsibilities.]{.underline}** The responsibilities of
the Core IDT are to:

\(1\) Perform a full interdisciplinary assessment.

\(2\) Establish a coordinated and integrated interdisciplinary plan of
care that includes all required disciplines and reflects the goals of
the patient and family.

\(3\) Document the interdisciplinary care plan. The social work case
manager must review this plan with the patient and/or family within 24
hours of completion. ***NOTE:** It may be beneficial to provide a copy
of this plan to the family*.

\(4\) Collaborate with the patient and family when making decisions
regarding the plan of care.

\(5\) Ensure that all individuals involved in the care of the patient
and family are aware of the plan of care, including adjustments to the
plan as goals are met and new goals are established.

\(6\) Identify issues related to the patient and/or family, such as
individual family stressors and establish a plan to address these issues
and communicate such to all appropriate staff.

\(7\) Identify the characteristics of the intended discharge environment
and develop a discharge plan.

\(8\) Identify the skill sets necessary to be successful in the next
environment for the patient, family, support systems, and other
potential caregivers.

\(9\) Conduct IDT meetings as often as needed to monitor progress and
update the treatment plan to reflect progress and new goals.

c\. [**VA** **Polytrauma Dedicated Consultative Services.**]{.underline}
Individuals with polytrauma may have ongoing medical issues that require
the expertise of other medical specialties. [Attending staff from these
consultative services must be available 24/7 to respond to urgent
requests or emergent needs.]{.underline} Depending on the needs of the
patient, the consultant [may need to participate as an active
member]{.underline} of the PRC team. The consultants need to have
specialized expertise in polytrauma sequelae, e.g., a mental health
consultant with expertise in managing and differentiating problems
associated with TBI, PTSD, or substance abuse. ***NOTE:** The clinical
specialties that are identified as essential to the PRC are identified
in subparagraph 6c.*

d\. **[Referring Medical Facility.]{.underline}** The PRC staff needs to
maintain regular communications with the MTF or other facility that
referred the patient, particularly when the patient is in DOD's PEB
process or when there are unresolved medical problems. This ensures that
both agencies are aware of the status of the patient should questions
arise from family members as well as internal and external stakeholders.
***NOTE:** Weekly communication is recommended.*

**10. EVALUATIONS**

Evaluation is a systematic, ongoing process. Evaluations include
assessment of medical, physical, cognitive, psychological, functional,
and psychosocial conditions.

a\. **[Initial Evaluations.]{.underline}** Each member of the IDT has
discipline-specific evaluations to administer based on the individual
patient's impairments and sequelae. These evaluations assist the IDT to
establish the overall projected-achievable goals and timelines for
rehabilitation. The results of the evaluations must be completed and
documented within the following timeframes:

\(1\) The admission history and physical, initial assessment, problem
list, and treatment plan must be completed on the day of admission. The
PM&RS attending physician on the PRC must staff the patient with the
admitting clinician within 24 hours of admission;

\(2\) The nursing assessment must be completed on the day of admission
and there needs to be a continuation or reassessment of that completed
by the admissions clinical case manager;

\(3\) The core interdisciplinary evaluations must be initiated upon
admission, or the first day of regular scheduling following admission;

\(4\) Non-emergent consultations must be responded to within 48 hours of
the order;

\(5\) The social work case manager must complete a comprehensive
psychosocial assessment, including patient and/or family expectations
and goals, within 24 hours of admission or the first day of regular
scheduling following admission; and

\(6\) Results of consults, diagnostics, and other evaluations must be
communicated to the patient and/or family within 24 hours following
completion.

b\. **[Reevaluations.]{.underline}** Reevaluations need to occur as
clinical conditions necessitate, but not less often than weekly. Closely
monitoring all identified problem areas, including medical, physical,
functional, cognitive, and psychological, ensures that appropriate
adjustments are made to the plan of care. The results of reevaluations
are documented in the medical record and communicated to the team during
the weekly IDT meeting.

c\. **[Discharge Summaries and Evaluations.]{.underline}** A discharge
summary is required of all team members. It includes the medical,
functional, and psychosocial status of the patient at the time of
discharge, medications, progress, goals achieved, activity restrictions,
adaptive equipment, discharge setting, family and other support systems,
education provided, continued care needs, and follow-up services
arranged as appropriate to each discipline.

**11. INTERDICIPLINARY TREATMENT PLAN**

a\. Interdisciplinary treatment plans are a collaborative effort based
on active involvement of the patient, family, and discipline-specific
assessments of each patient.

b\. Treatment plans are intended to be dynamic rather than static
documents. They change in response to the patient's condition and
progress toward goals.

c\. The PM&RS attending physician at the PRC conveys to the team, and
documents, the medical plan of care. This plan describes the current
medical issues, treatments, procedures ordered, restrictions and
precautions, and any other information relevant to the patient's medical
care.

d\. Each member of the IDT is responsible for recommending
patient-specific interventions as a result of their assessments.

e\. The IDT's plan is reviewed during weekly team rounds. At this time
the IDT reviews progress toward treatment goals, identifies new goals,
time frames, treatment interventions, and revises the plan of care
accordingly.

f\. The social work case manager is available to communicate with the
patient and family on a daily basis to solicit feedback and bring any
concerns to the IDT.

g\. The social work case manager must provide the patient and family
with updates on progress and adjustments to the plan of care in a timely
fashion, and must document all patient and family interactions in the
medical record.

**12. TREATMENT**

a\. **[Medical Treatment.]{.underline}** The PRC PM&RS attending
physician is responsible for managing the medical treatment of patients
with polytrauma and ensuring that all appropriate medical specialists
are consulted and are active participants in the medical care of the
patient. [Due to the severity and complexity of polytrauma, the
attending physician needs to be alert to the possibility of rapidly
changing conditions and seek consultation services as
appropriate]{.underline}.

\(1\) The PRC PM&RS attending physician, or staff physician designee,
must make daily rounds on weekdays and as needed per patient's
condition. House staff provides care on weekends with PM&RS staff
physician input as needed.

\(2\) Consultative service providers are expected to be actively
involved in care according to the acuity of the patient, until the
reason for the consultation is resolved. Consultative service providers
may participate in bedside rounds with the PM&RS attending physician or
the IDT. Their assessments and recommendations must be documented in the
medical record in a timely fashion.

\(3\) If the acuity of the polytrauma patient warrants physical transfer
to another bed section, the rehabilitation plan of care must be
continued within the medical limits of the patient and the PRC PM&RS
attending physician continues to be actively involved in the care of the
patient. The PM&RS attending physician, or resident, must visit the
patient regularly and keep the family informed of the patient's status.

\(4\) The PM&RS attending physician must be accessible to the patient
and family, and provide the family with a means to maintain contact.

\(5\) Polytrauma medical sequelae may include: agitation and aggressive
behavior, amputation, burns, contractures, deep vein thrombosis and
pulmonary embolus, dental injuries, depression and other mood disorders,
fractures, often complex gastrointestinal complications and feeding
tubes, headache, hearing impairment, heterotopic ossification,
hydrocephalus, infection, nerve injuries, pain, peripheral and central
vestibular disorders, PTSD, seizures, soft tissue damage, spasticity,
SCI, visual impairment, and wounds.

##  b. [Rehabilitation Treatment]{.underline}

\(1\) Patients with polytrauma are involved in various therapies
according to their individual needs. Therapy services are integrated
with the interdisciplinary plan of care and established goals.
Rehabilitation treatment and procedures may include, but are not limited
to:

\(a\) Activities of daily living,

\(b\) Architectural barriers,

\(c\) Assistive technology,

\(d\) Augmentative communication,

\(e\) Cognitive rehabilitation,

\(f\) Communication,

\(g\) Community reintegration,

\(h\) Driving,

\(i\) Durable medical equipment,

\(j\) Gait training,

\(k\) Instrumental activities of daily living,

\(l\) Mobility,

\(m\) Neurobehavioral management,

\(n\) Neuromuscular balance and coordination,

\(o\) Oculomotor rehabilitation,

\(p\) Orthotics,

\(q\) Physical performance and conditioning,

\(r\) Prosthetic fitting and training,

\(s\) Psychosocial skills,

\(t\) Sexuality,

\(u\) Swallowing,

\(v\) Vestibular rehabilitation,

\(w\) Visual motor and perceptual skills, and

\(x\) Wheelchair prescription and training.

> \(2\) Co-treatment is promoted to meet the individualized needs of the
> polytrauma patient.

\(3\) Family involvement needs to be encouraged in all phases of the
rehabilitation process.

\(4\) Age appropriate goals, activities, and materials are incorporated
into the rehabilitation treatment plan.

\(5\) Treatment plans are implemented 24/7 through the collaboration of
therapy, nursing, and medical staff.

\(6\) Treatment is provided according to needs and goals of the patient
and family.

**13. PATIENT AND FAMILY EDUCATION**

a\. Patients, their families, and significant others, need to receive
appropriate education and training to increase their knowledge of the
patients' illnesses or disabilities and treatment needs, and to learn
the skills and behaviors that promote recovery and maximize function.

b\. All rehabilitation personnel are responsible for providing education
to patients and their families as appropriate to their specific
disciplines and documenting the education when provided. All staff need
to continually assess and document the patient and family's educational
needs and readiness to learn so that educational efforts will be
appropriate and effective.

c\. Education is provided as a part of ongoing therapy, through patient
and family meetings, through written information (handouts and
booklets), and through the medical center's ongoing televised Patient
Education Series.

d\. Education may include, but is not limited to, instructions in:

\(1\) Rehabilitation techniques to facilitate adaptation to and
functional independence in the anticipated discharge environment;

\(2\) Accessing available community resources;

\(3\) The safe and effective use of prosthetic, orthotic, and durable
medical equipment;

\(4\) The safe and effective use of medication;

\(5\) Polytrauma sequelae and conditions as appropriate to the patient;

\(6\) Restrictions and precautions, e.g., driving, alcohol, physical
activity level;

\(7\) Behavior management techniques; and

\(8\) How to handle emergencies.

e\. All education provided must be based upon, and appropriate to, the
assessed needs, educational level, cultural background, and readiness to
learn of the patient, family member, or significant other to whom it is
offered.

##### 14. FAMILY SUPPORT

Families of polytrauma patients have unique psychosocial needs due to
the etiology of their family member's catastrophic injuries, the
severity of the injuries, and the possible long-term impairments. The
PRCs are responsible for ensuring that patients and their families
receive all necessary support services to minimize stress during the
hospital stay.

a\. Each polytrauma patient and family has a designated social work case
manager who has the responsibility for ensuring that their psychosocial
needs are identified and addressed. These responsibilities include, but
are not limited to:

\(1\) Ensuring that the patient and family have received an orientation
to the PRC. This includes providing orientation information; written
materials; a tour of the facility, bed unit, and therapy clinics; what
to expect; and introductions to members of the IDT. ***NOTE:** This
orientation should occur on the day of admission or the first day of
regular scheduling following admission*.

\(2\) Assessing patient and family psychosocial support needs,
documenting the assessment and plan in the medical record, and providing
psychosocial interventions;

\(3\) Establishing a regular schedule for communication that meets the
needs of the family, and providing the family with information on how to
contact the social work case manager, or the on-call designee, during
and after business hours, including a phone or pager number;

\(4\) Documenting the content of communications with family in the
medical record;

\(5\) Facilitating involvement of the family and advocating for the
family's needs and interests throughout the rehabilitation process;

\(6\) Providing the family with updates on progress and adjustments to
the plan of care in a timely fashion;

\(7\) Providing the referring MTF and local military health care
provider and duty station, as appropriate, with updates on progress; and

\(8\) Working closely with Voluntary Service and Chaplain Service to
ensure availability of resources to meet the immediate needs of the
family.

b\. Through the social work case manager, PRCs involve VA and community
programs and services to support polytrauma patients and their families.
This includes:

\(1\) Ensuring that representatives from Chaplain Service and
Readjustment Counseling Service are available to patients and families
soon after admission and as needed; and

\(2\) Collaborating with Voluntary Service and Chaplain Service, who in
turn work with local Veterans Service Organizations and community
faith-based groups to provide supportive services, including safe and
convenient lodging, transportation to and from the medical center, food,
personal items, childcare, recreational opportunities, and other
services as identified.

###### 15. DISCHARGE PLANNING

Discharge planning is a process, not a single event. It is that part of
the continuity of care process, which prepares the patient for the next
level of care and assists the patient in making necessary arrangements
for that transition. Creating a partnership with the patient and family
is essential to an effective discharge plan.

##  a. [Pre-Discharge Procedures.]{.underline} Discharge planning is the responsibility of the IDT. The clinical case manager and social work case manager ensure that the process is coordinated and all issues are addressed. This includes:

\(1\) Providing the family or caregiver with a notebook or folder to
keep discharge information, e.g., resources, tip sheets, names and phone
numbers, equipment requests, restrictions, and medications.

\(2\) Providing the family or caregiver with information and resources
related to the intended discharge location that can be explored during
the inpatient phase.

\(3\) Identifying any limitations of the family or caregiver, e.g.,
physical and emotional that may impact the discharge plan.

\(4\) Providing the patient and family with a therapeutic pass to
practice skills learned in therapy. ***NOTE:** The IDT needs to provide
specific goals and objectives for this experience.*

\(5\) Providing ample time in therapy sessions, early in the
rehabilitation process, for the family or caregiver to become
comfortable and skilled with the patient's ongoing care needs.
***NOTE:** Videotapes of complex techniques provide the patient and
family additional support at home.*

\(6\) Providing the family or caregiver with techniques on minimizing
stress.

\(7\) Identifying medical and rehabilitation needs that require ongoing
follow-up after discharge from the PRC.

\(8\) Assessing the intended discharge location for access, barriers,
safety, required durable medical equipment, and other relevant
characteristics.

b\. **[Discharge Procedures.]{.underline}** Discharge recommendations
and other appropriate discharge records must be provided to patient and
family in writing. All medical restrictions must be clearly documented
and, at a minimum, a 30-day supply of medication and supplies are
provided.

\(1\) Upon request, the PRC provides recommendations associated with the
patient's ability to return to duty or other specific needs, e.g.,
2-weeks' convalescent leave followed by light duty to include work
hardening and close supervision to monitor accuracy of work; no lifting
over 30 lbs.

\(2\) Upon request, the PRC provides clinical information to military
medical boards.

## 

c\. **[Social Work Case Manager.]{.underline}** To ensure a smooth
transition from the PRC, the social work case manager is responsible
for:

\(1\) Reviewing the discharge plan with the patient and family or
caregiver and obtaining any needed clarification.

\(2\) Providing the patient or family with phone numbers for VA and
military POCs to assist with any ongoing administrative issues.

\(3\) Providing the discharge recommendations to the appropriate
entities, which may include, but is not limited to the: referring MTF,
local VA responsible for following the patient, TRICARE, military
medical holding company, military command, military case manager, and
Seamless Transition Liaison.

\(4\) Confirming that all adaptive devices, durable medical equipment,
and requests for home modifications have been completed.

\(5\) Notifying the patient's home VA facility's OIF POC or OEF POC of
the planned discharge.

\(6\) Coordinating patient travel through the air evacuation office, to
include contacting the MMSO and Global Patient Movement Requirement
Center. ***NOTE:*** *PRC medical staff must assess the need for a
medical or non-medical attendant to travel with the patient.*

\(7\) Arranging or coordinating ongoing services and treatment.

\(8\) Forwarding legal documents, such as guardianship or powers of
attorney to appropriate POCs.

\(9\) Confirming that appropriate applications for special programs have
been generated, e.g., Vocational Rehabilitation and Employment Service
or Education Service in the Veterans Benefits Administration.

**16. FOLLOW-UP CLINICAL CASE MANAGEMENT AND CARE COORDINATION**

a\. Individual case management is a distinct and customized approach to
managing care for a beneficiary whose needs are usually multiple,
complex, and costly. When individuals are diagnosed with a severe
impairment, their physical, emotional, and psychosocial responses vary
significantly. Because health care circumstances differ, a more tailored
and customized approach to coordinating care is required. These
beneficiaries must have care plans unique to their needs and often
require extensive monitoring and care coordination.

b\. Ongoing clinical and social work case management are provided to
patients requiring continued rehabilitation services. This involves
acting as POC for emerging medical, psychosocial, or rehabilitation
problems; managing the continuum of care; care coordination; acting as
patient and family advocate; and assessing clinical outcomes and
satisfaction.

c\. The clinical or social work case manager, as assigned, makes regular
and routine contact with the patient and family as long as active
treatment needs remain, to include:

\(1\) Establishing regular communications with the patient and family.
Initially this needs to occur at least weekly and then based on the
needs and requests of the patient and family.

\(2\) Assessing and monitoring the patient's integration back to the
home environment.

\(3\) Monitoring implementation of the discharge plan and facilitating
access to recommended services as needed.

\(4\) Monitoring ongoing medical, functional, and psychosocial issues.

\(5\) Assessing clinical outcomes and satisfaction.

\(6\) Assessing and monitoring support systems and family dynamics.

\(7\) Following up with ongoing military and/or VA administrative issues
and facilitating resolution when possible.

\(8\) Proactively monitoring for identification of new issues.

d\. If there are new issues or a change in the patient's condition, the
clinical case manager must report these to the PM&RS attending physician
on the PRC immediately. For urgent issues, the clinical case manager
must advise the patient or family to seek care immediately at a
community hospital or their local VA medical center. For non-emergency
issues, the PRC provides consultation and assists with obtaining
appropriate services.

**17. REFERENCES**

a\. Amado, AN and McBride, M, [Increasing Person-Centered Thinking:
Improving the Quality of Person-Centered Planning: A Manual for
Person-Centered Planning Facilitators.]{.underline} Minneapolis,
Minnesota: University of Minnesota, Institute on Community Integration,
2001.

b\. Association of Rehabilitation Nurses, [Rehabilitation Nurse Case
Manager Role Description and Definition and Scope of
Practice]{.underline}, <http://www.rehabnurse.org/>

c\. Defense and Veterans Brain Injury Center, <http://www.dvbic.org/>

d\. Hagan, Malkmus, and Durham, "Levels of Cognitive Functions. In
Rehabilitation of the Head-Injured Adult: Comprehensive Management,"
Downey, CA, Professional Staff Association, Rancho Los Amigos Hospital,
1979.

e\. P. Quigly, S. Smith, J. Strugar*, "*Successful Experiences with
Clinical Pathways in Rehabilitation," [Journal of
Rehabilitation.]{.underline} April-June, 1998.

f\. Peake, JB, "Beyond the purple heart continuity of care for the
wounded in Iraq," [New England Journal of Medicine.]{.underline} 2005
Jan 20; 352(3): 219-222.

g\. Rehabilitation Accreditation Commission (CARF), [Medical
Rehabilitation Standards Manual.]{.underline}

h\. Veterans Health Initiatives: Caring for War Wounded, Hearing
Impairment, PTSD, Spinal Cord Injury, Traumatic Amputation, Traumatic
Brain Injury, Visual Impairment, *<http://vaww1.va.gov/vhi/>.*

**REFERRAL AREA FOR POLYTRAUMA REHABILITATION CENTERS (PRCS)**

**AND TRAUMATIC BRAIN INJURY (TBI) LEAD CENTERS**

+------------------------------------+---------------------------------+
| #                                  | # Referral Area                 |
| # Polytrauma Rehabilitation Center |                                 |
+------------------------------------+---------------------------------+
| McGuire Veterans Affairs Medical   | Maine, Massachusetts, Rhode     |
| Center                             | Island, Connecticut, Vermont,   |
|                                    | New Hampshire, New York,        |
| Physical Medicine and              | Pennsylvania, Delaware,         |
| Rehabilitation Services            | Maryland, District of Columbia, |
|                                    | Virginia, West Virginia, and    |
| 1201 Broad Rock Blvd.              | North Carolina.                 |
|                                    |                                 |
| Richmond, Virginia 23249           |                                 |
+------------------------------------+---------------------------------+
| James A. Haley Veterans Affairs    | Tennessee, Kentucky, South      |
| Medical Center                     | Carolina, Georgia, Alabama,     |
|                                    | Florida, Puerto Rico, Arkansas, |
| Physical Medicine and              | Louisiana, Mississippi, and     |
| Rehabilitation Services            | Texas.                          |
|                                    |                                 |
| 13000 Bruce B. Downs Blvd.         |                                 |
|                                    |                                 |
| Tampa, Florida 33612               |                                 |
+------------------------------------+---------------------------------+
| Minneapolis Veterans Affairs       | Ohio, Michigan, Indiana,        |
| Medical Center                     | Illinois, Wisconsin, South      |
|                                    | Dakota, North Dakota,           |
| Physical Medicine and              | Minnesota, Oklahoma, Iowa,      |
| Rehabilitation Services            | Nebraska, Kansas, and Missouri  |
|                                    |                                 |
| One Veterans Drive                 |                                 |
|                                    |                                 |
| Minneapolis, MN 55417              |                                 |
+------------------------------------+---------------------------------+
| Palo Alto HealthCare System        | New Mexico, Arizona, Wyoming,   |
|                                    | Colorado, Montana, Utah,        |
| Physical Medicine and              | Nevada, Idaho, Oregon,          |
| Rehabilitation Services 3801       | Washington, Alaska, California, |
| Miranda Avenue                     | and Hawaii                      |
|                                    |                                 |
| Palo Alto, California 94304        |                                 |
+------------------------------------+---------------------------------+