41

Department of Veterans Affairs System of Care for the Polytrauma Patient

Chapter 3

DEPARTMENT OF VETERANS 

AFFAIRS SYSTEM OF CARE FOR THE 

POLYTRAUMA PATIENT

CINDY E. POORMAN, MS*; MICHELLE L. SPORNER, MS, CRC†; BARBARA SIGFORD, MD‡; MICAELA CORNIS-POP, 

PhD§; GRETCHEN STEPHENS, MPA¥; GEORGE ZITNAY, PhD¶; and MICHAEL PRAMUKA, PhD**

INTRODUCTION

DEVELOPMENT OF THE POLYTRAUMA SYSTEM OF CARE

COMPONENTS OF THE POLYTRAUMA SYSTEM OF CARE

SCOPE OF SERVICES

The Interdisciplinary Team

Specialized Programs

COORDINATION OF CARE AND CASE MANAGEMENT

FAMILY AND CAREGIVER SUPPORT

RESEARCH AND COLLABORATIONS

OUTCOME MEASURES

SUMMARY

* Rehabilitation Planning Specialist, VA Central Office, US Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC 20420

† Research Assistant, Human Engineering Research Laboratories, VA Pittsburgh Healthcare System/University of Pittsburgh, 7180 Highland Drive, 

Building 4, 2nd Floor, 151R1-H, Pittsburgh, Pennsyvlania 15206

‡ National Director, Physical Medicine, and Rehabilitation Service, VA Central Office, 810 Vermont Avenue, NW, Washington, DC 20420

§ Rehabilitation Planning Specialist, VA Central Office, 810 Vermont Avenue, NW, Washington, DC 20420

¥ Polytrauma/TBI Coordinator, VA Central Office, 810 Vermont Avenue, NW, Washington, DC 20420 

¶ Founder and Director, Defense and Veterans Brain Injury Center –Laurel Highlands, 727 Goucher Street, Johnstown, Pennsylvania 15905

**Assistant Professor, Department of Rehabilitation Science and Technology, University of Pittsburgh, 5044 Forbes Tower-Atwood, Pittsburgh,Pennsylvania 

15260; formerly, Neuropsychologist, Henry M. Jackson Foundation/San Diego Naval Medical Center, 34800 Bob Wilson Drive, San Diego, California
42

Care of the Combat Amputee

INTRODUCTION

Since the beginning of the global war on terror 

(GWOT), many combat veterans have been exposed to 

some type of blast explosion, with the most prevalent 

and devastating injuries resulting from improvised 

explosive devices (IEDs). Service members with 

devastating injuries resulting from blasts often have 

unique clinical presentations that affect multiple organ 

systems and physical structures of the body, including 

traumatic brain injury (TBI), amputations, complex 

orthopaedic injuries, burns, spinal cord injuries (SCIs), 

and injuries to the sensory organs, as well as posttraumatic stress disorder (PTSD) and other mental 

health disorders. The combination of multiple injuries 

sustained as a result of the same traumatic event was 

termed “polytrauma” by the Department of Veterans 

Affairs (VA) for the purpose of characterizing these 

injuries and defining the system of rehabilitation services required for treatment.

The term polytrauma, used to describe the 

complexity of GWOT injuries, has helped define 

the unique needs of the military and veteran 

healthcare systems that drive optimal treatment 

for these patients. 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.”1 Advances in body armor, 

field medical care, and rapid evacuation during Operation Enduring Freedom (OEF) and Operation Iraqi 

Freedom (OIF) have led to a dramatic reduction in 

mortality from combat injuries, resulting in common 

survival of injuries that were fatal in previous wars.

In response to the high number of service 

members returning from Iraq and Afghanistan 

with unique injuries, including polytrauma, the 

VA developed the Polytrauma System of Care 

(PSC). Because of the high association between 

polytrauma and TBI, expertise in treating TBI was 

critical for the system’s successful development. 

The PSC is an integrated system of specialized 

interdisciplinary services designed to meet the 

complex medical, psychological, rehabilitation, and 

prosthetic needs of veterans with polytrauma, TBI, 

and other injuries.

DEVELOPMENT OF THE POLYTRAUMA SYSTEM OF CARE

The PSC grew out of established expertise in specialized VA rehabilitation programs including TBI, 

amputation care, and blindness and low vision. These 

programs have been supported through congressional 

legislation as well as collaboration with the Department of Defense (DoD). In 1986 the VA and DoD established a Memorandum of Agreement for the referral 

and treatment of active duty service members with 

TBI, SCI, and blindness.2 This agreement provided authority for the VA to provide rehabilitative services for 

active duty service members with these impairments. 

In 1992 the VA designated four TBI lead centers in coordination with the Defense and Veterans Brain Injury 

Center (DVBIC). These centers were located at Minneapolis, Minn; Palo Alto, Calif; Richmond, Va; and 

Tampa, Fla.3 Their role was to provide specialized acute 

rehabilitation services for active duty service members 

and veterans with TBI. In 1996 Congress mandated that 

the VA maintain capacity for specialized services for 

veterans with special disabilities including TBI, SCI, 

and blindness, which require specialized rehabilitation services.4

 This mandate was followed by the 1997 

designation of a TBI network of care to support and 

coordinate services for veterans and service members 

with TBI across the VA system of healthcare.5

The VA has been a leader in amputation rehabilitation since World War II and has continued to develop

this expertise through special teams and programs. 

Public Law 102-405, Veterans’ Medical Programs 

Amendments, passed in 1992, identified veterans with 

amputations as a special disability group.6 The current 

Preservation Amputation Care and Treatment program 

provides a model of care focused on the prevention of 

amputations through early identification of veterans at 

risk of limb loss. It also provides comprehensive care 

for those with an amputation through interdisciplinary care management.7

 In addition, the VA currently 

has 62 prosthetic laboratories accredited by the Board 

for Orthotist/Prosthetist Certification or American 

Board for Certification in Orthotics and Prosthetics, 

and 76 outpatient amputation clinics throughout the 

VA system, 95% of which are headed by rehabilitation physicians. All of these programs are designed 

to improve the function of veterans with amputations. 

Amputation is often part of the polytrauma spectrum 

and, as a result, expertise in amputation rehabilitation 

in the VA has been emphasized through specialized 

training in state-of-the-art rehabilitation techniques 
43

Department of Veterans Affairs System of Care for the Polytrauma Patient

and technology for polytrauma and amputation care 

teams.

In 1997 the VA established an agreement with the 

Commission on Accreditation of Rehabilitation Facilities (CARF)8

 demonstrating the VA’s commitment to 

providing excellent care to veterans. All VA inpatient 

rehabilitation programs maintain accreditation by 

CARF for comprehensive interdisciplinary inpatient 

rehabilitation.

The 2005 Consolidated Appropriations Act (Public 

Law 108-447)9 charged the VA to develop a system 

of specialized expertise to provide the best available 

medical care and integrative rehabilitation. PL 108-422 

charged the VA to establish centers for research, education, and clinical activities on complex multitrauma 

associated with combat injuries.10 The PSC was developed to address these requirements. In February 2005, 

four polytrauma rehabilitation centers (PRCs) were 

designated at the four sites of the existing VA TBI lead 

centers.1 These sites are tertiary care medical centers 

that also have established amputation care programs 

and services for veterans with visual impairment and 

SCI. Further development of this system of care came 

in December 2005 when 21 polytrauma network sites 

(PNSs) were designated. The polytrauma telehealth 

network (PTN), which established state-of-the-art 

connectivity among PRCs and PNSs for the purposes 

of telemedicine and videoconferencing, was added in 

July 2006.

In March 2007, the remaining PSC components were 

established with the designation of 76 polytrauma support clinic teams (PSCTs) and 54 polytrauma points of 

contact (PPOCs) across the country. When the need for 

an additional PRC was recognized in 2007, the Audie L 

Murphy VA Medical Center in San Antonio, Texas, was 

selected due to its geographic location and proximity 

to major military facilities. Additional PSCTs are in 

continuous development as veterans with polytrauma 

and TBI enter the Veterans Health Administration for 

care. Also in 2007, President George W Bush formed 

the Dole-Shalala Commission to examine existing 

processes and find ways to improve care across the 

DoD and VA system and optimize outcomes. The commission made several recommendations applicable to 

the PSC11:

These recommendations were added to the programs already in place within the VA to ensure quality 

of care to veterans.

1. Immediately create comprehensive recovery 

plans for every seriously injured service 

member.

2. Aggressively prevent and treat PTSD and 

TBI.

3. Significantly strengthen support for families.

4. Rapidly transfer patient information between 

the DoD and VA.

COMPONENTS OF THE POLYTRAUMA SYSTEM OF CARE

In recognition of the wide range in the type and severity of injuries sustained in combat, and that veterans 

desire to receive care at locations close to their homes, 

the four components of the PSC were developed to balance access and expertise. The regional centers have 

the capability to provide care for the most seriously 

injured and require the greatest distance in travel, and 

local facilities, developed to provide ongoing, lifelong 

care, are located in closest proximity to the veteran’s 

home. Depending on the severity of the injury, the 

veteran may enter the PSC via any component and 

move from one to another based on assessed needs. 

Details of each component are as follows: 

1. PRCs serve as regional referral centers for 

acute medical and rehabilitation care, and 

as hubs for research and education on polytrauma and TBI. 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. These centers have the 

necessary expertise to provide the coordinated interdisciplinary care required for all 

patients who have sustained varied patterns 

of severe and disabling injuries. 

 PRCs provide a continuum of rehabilitation 

services that include comprehensive acute 

rehabilitation care for complex and severe 

polytraumatic injuries, inpatient evaluation 

and treatment planning, specialized emerging consciousness programs for individuals 

with severe disorders of consciousness, and 

residential transitional rehabilitation programs. The centers maintain a full staff of 

dedicated rehabilitation specialists and medical and surgical consultants. They are able to 

manage high levels of medical acuity. PRCs 

serve as resources for other PSC facilities and 
44

Care of the Combat Amputee

spearhead the development of educational 

programs and best practice models of care. 

In addition to the PSC’s CARF accreditation, 

the PRCs maintain additional accreditation 

for comprehensive interdisciplinary brain 

injury rehabilitation. 

2. PNSs were established to manage the postacute phase of polytrauma rehabilitation 

and coordinate rehabilitation services for 

patients within their service network. PNSs 

have a dedicated interdisciplinary team of 

rehabilitation professionals who provide a 

high level of expert care, perform a full range 

of clinical and ancillary services, and serve 

as resources for other facilities within their 

network. Due to many referrals for care and 

treatment of service members and veterans 

not so seriously injured as to require inpatient 

rehabilitation, PNSs also evaluate and treat 

new referrals with polytrauma and TBI. The 

PNS sites are geographically dispersed across 

the country with one in each veterans integrated service network, which organize the 

medical care and services to veterans within 

their geographic area. 

3. PSCTs have been established in smaller Veterans Affairs medical centers across the country 

to deliver and coordinate the care of veterans 

with stable polytrauma or TBI sequelae. 

These local teams of rehabilitation professionals provide services in, or close to, the 

veteran’s home communities. PSCTs provide 

the lifelong care and follow-up for veterans 

with moderate to severe injuries requiring 

regular assessment and reassessment to 

maintain an optimal state of functioning, take 

advantage of new technology and advances 

in rehabilitation care, and address changes 

in developmental stage or goals. The teams 

also evaluate and provide treatment for new 

referrals not requiring inpatient rehabilitation 

services. 

4. PPOCs provide case management services to 

veterans with polytrauma and/or TBI and 

make referrals to programs that provide the 

level of rehabilitation care required. A PPOC 

is located at every VA medical center that 

is not designated as one of the above three 

components. 

All components of the VA PSC have shared characteristics, making them a unique system of care. These 

characteristics include a deep commitment and respect 

for the military mission and those who have served 

their country. In addition, each facility has taken steps 

to maintain a military identity and connectedness for 

those who seek care. The facilities in the PSC have a 

shared system of managing medical information and 

communication, an integrated system of care management, including several unique innovations such 

as transition patient advocates who can travel with 

veterans to their points of care as needed, an in-depth 

knowledge of veteran and military benefits, and a 

diverse array of services to meet an individual’s need 

across the full continuum of care. Extensive support to 

families is also available, and the environment of care 

is modified to meet the needs of young patients and 

their families. This comprehensive and coordinated 

system of care, in addition to the special programs 

found within the various components of the system, 

make the rehabilitation services provided unique to 

the VA.

The Interdisciplinary Team

Each service delivery component of the PSC has at 

its core an interdisciplinary team (IDT). These interdisciplinary teams are characterized by a variety of 

disciplines working together in the assessment, planning, and implementation of each patient’s care plan. 

The core IDT is responsible for the major therapeutic 

interventions of the rehabilitation program. To avoid 

fragmented care, continuous communication, collaboration, and coordination are critical. The IDT functions 

as a unit, ensuring cooperation among disciplines to 

achieve maximum patient and family outcomes. The 

membership of the team is determined by assessing the 

individual’s rehabilitation needs, predicted outcomes, 

SCOPE OF SERVICES

and medical needs. 

VA rehabilitation professionals have specialized

skills and knowledge based upon education, clinical 

training, and experience. They are certified or licensed 

according to their specific discipline requirements and 

receive additional training in specific treatment areas 

relevant to polytrauma and TBI. These areas include, 

but are not limited to, neurorehabilitation, cognitive 

rehabilitation, visual rehabilitation, and state-of-theart prosthetics and equipment. As well as having 

specialized training, new therapists receive mentoring 

by experienced therapists. They also attend training 

conferences sponsored by VA and DoD focusing on 

state-of-the-art practices in polytrauma rehabilitation. 

In addition, team members establish local, regional, 
45

Department of Veterans Affairs System of Care for the Polytrauma Patient

and national collaborations within the disciplines to 

share new and emerging best practices. 

The patient and the patient’s family, or other support system, are crucial members of the IDT and are 

included in all phases of the rehabilitation process. 

Their input is actively solicited by team members and 

is essential to the development of an individualized 

plan of care based on goals that are patient-centered 

and relevant. Goals and progress are continually 

reviewed with the patient and family and modified 

as needed to remain centered on the patient’s needs. 

Goals addressed include the full spectrum of function 

from basic skills to community reentry, including return to work, return to school, sports, and other leisure 

and recreational activities. 

Members of the IDT include, but are not limited 

to, a physician specializing in physical medicine and 

rehabilitation (physiatrist), rehabilitation nurse, neuropsychologist, rehabilitation psychologist, physical 

therapist, kinesiotherapist, occupational therapist, 

speech language pathologist, social worker, recreational therapist, and a military liaison.12 Each member

contributes to the interdisciplinary team goals individualized to the specific patient.

the patient and family. Case managers help to 

answer questions and locate needed services 

for the service member or veteran. The social 

worker case manager collects background 

information about financial resources, education level, work history, living situation, and 

level of social support to help with treatment 

and discharge planning. A case manager is 

also part of the postdischarge team to ensure 

that follow-up plans are implemented. 

	 •	 A speech language pathologist addresses 

communication deficits and evaluates and 

treats cognitive deficits such as problems with 

attention, memory, reading comprehension, 

and planning and sequencing. The speech 

language pathologist may also help if there 

are deficits in swallowing. 

	 •	 Physical therapists and kinesiotherapists

work to aid in the restoration of function, 

improve mobility, relieve pain, and prevent 

or limit permanent physical disability. These 

therapists also teach service members or veterans how to use assistive devices such as gait 

aides, prostheses, and wheelchairs. 

	 •	 A recreational therapist assists the individual 

with community reintegration by applying 

practical skills to real-life situations and ensuring safety in environments with various barriers 

such as curbs, stairs, and uneven surfaces. Recreational therapists also assess and assist with 

adaptations for leisure activities such as sports.

	 •	 A rehabilitation psychologist is a specialist 

with an advanced degree in psychology who 

works with clients in coping and adjusting 

to traumatic injury. The rehabilitation psychologist works with the patient and family 

to recognize and address specific issues that 

may occur after injury, in areas such as mood 

and emotions, stress management, body image, quality of life, and role changes. 

	 •	 The neuropsychologist has a similar education to a rehabilitation psychologist, but specializes in the relationship between the brain 

and behavior. A neuropsychologist may administer cognitive or emotional assessments to 

identify strengths and weaknesses after injury. 

	 •	 The DoD military liaison provides support to 

service members as they transition from military healthcare to the VA healthcare system in 

areas such as processing travel vouchers and 

claims. The military liaison also serves as a 

connection between the service member and 

his or her chain of command and consults 

with the IDT on military matters.12

	 •	 The physiatrist is a medical doctor who serves 

as the IDT leader to direct and coordinate 

the patient’s care. Physiatrists specialize in 

the treatment of conditions associated with 

impairments of function due to disease or 

injury. 

	 •	 A rehabilitation nurse combines traditional 

patient care skills with training in care of 

individuals who are experiencing an illness 

or disability that alters normal functioning. 

The rehabilitation nurse works to assist the 

family and individuals in implementing the 

different treatments and therapies to complete 

the treatment plan. The rehabilitation nurse 

also educates the patient and family about the 

patient’s condition. 

	 •	 An occupational therapist is on staff to help 

service members or veterans with motor function, basic, and instrumental activities of daily 

living (ADLs), as well as making recommendations for environmental modifications that 

allow the individual to function more independently after discharge. Occupational therapists 

also help to address cognitive impairment and 

assist with compensatory strategies.

	 •	 A case manager is made available and is responsible for ensuring that all components of 

the plan of care are implemented thoroughly 

and efficiently and according to the desires of 
46

Care of the Combat Amputee

Specialized Programs

Acute Rehabilitation 

This phase typically occurs directly following initial medical and surgical stabilization and provides 

high-intensity rehabilitation care while optimizing the 

patient’s medical condition. During this stage, typically 

occurring at the PRCs, active duty service members 

and veterans frequently continue to require significant

medical and surgical support, unlike patients admitted 

to many private sector rehabilitation facilities. Thus, 

these medical and surgical services are available on an 

emergent basis at all four PRCs. Data collected at the 

PRCs reveal that approximately 90% of polytrauma 

patients in the acute rehabilitation setting have TBI as 

one of their impairments. Therefore, the environment 

of care and the expertise of the treating professionals 

are adapted to the specialized techniques required for 

neurological and particularly TBI rehabilitation, unlike 

many generalized rehabilitation units, which may have 

a very low census of TBI patients and limited experience with their rehabilitation. 

Acute rehabilitation includes treatment planning, 

based upon medical stability, types of impairment, 

level of consciousness, and current cognitive and functional status. The focus may initially be on alertness 

and responsiveness and progress through developing 

basic skills such as bowel and bladder control, communication, mobility, basic hygiene, orientation, and 

basic ADLs, and advance to higher level ADLs such 

as meal preparation, managing money, community 

safety, and driving. Acute rehabilitation in the PSC 

requires the expertise of multiple healthcare professionals who work as an IDT, as well as dedicated 

medical and surgical consultants available around the 

clock, every day of the week. 

education for families and caregivers. 

Emerging Consciousness Program 

This is a unique, specially developed program, 

based on the most up-to-date evidence, that is operational at the four PRCs. It is designed to optimize longterm functional outcomes after severe brain injury in 

patients who are not yet ready to participate in acute 

rehabilitation. It promotes return to consciousness, 

and facilitates progress to the next level of rehabilitation care. Individuals who benefit from this program 

have suffered severe polytraumatic injuries leading 

to ongoing impaired consciousness. The program encompasses nursing and rehabilitation medical services, 

an individualized therapy program, intensive case 

management, and psychological support services and 

Residential Transitional Rehabilitation Program 

Subacute Rehabilitation 

Outpatient Therapy 

Following acute or subacute rehabilitation, a person 

with a traumatic injury may continue to receive outpatient therapies to meet ongoing goals. Additionally, 

a person with polytrauma or a brain injury that was 

This program is for veterans and active duty service members with polytrauma and/or TBI who have 

physical, cognitive, and/or behavioral impairments 

that delay or inhibit their effective reintegration into 

the community or return to duty after the acute phase 

of rehabilitation. It was developed based on a thorough 

review of research on the effective components of existing transitional rehabilitation models. Transitional 

rehabilitation offers a progressive return to independent living through a milieu-based, structured program focused on restoring home, community, leisure, 

psychosocial, and vocational skills in a controlled, 

therapeutic setting. Services provided typically include 

group therapies, individual therapies, case management and care coordination, medical care, vocational 

and educational rehabilitation services, discharge 

planning, and follow-up. Services are often provided 

in community settings. These programs have been 

implemented at the PRCs. 

This program provides services for persons with 

polytrauma who are medically stable and need a less 

intensive level of rehabilitation services, over a longer 

period of time than provided in the acute setting. In 

the PSC, patients typically are admitted to a subacute 

rehabilitation program after a period of acute rehabilitation. Subacute rehabilitation programs are often 

utilized for persons who have made progress in the 

acute rehabilitation setting and are still progressing, 

but are not making rapid functional gains and wish 

to be closer to their home community. The programs 

are also utilized during the transition home, providing 

education to families and caregivers, identifying community resources available for transitional support, 

and acquiring any necessary equipment. Subacute TBI 

rehabilitation is typically provided at the VA PNSs, 

where continued interdisciplinary treatment to meet 

patient and family goals is provided. 
47

Department of Veterans Affairs System of Care for the Polytrauma Patient

not severe enough to require inpatient hospitalization 

may attend outpatient therapies to address their functional impairments. Outpatient therapies are typically 

provided at PNS and PSCT facilities. The outpatient 

interdisciplinary rehabilitation team addresses basic 

functional impairments, basic and advanced ADLs, 

and return to work, return to school, and community reintegration including driving and leisure skills. 

Therapies are geared to both restoration of function 

and compensation for fixed impairments.

Day Treatment 

This program provides rehabilitation therapies in 

a structured group setting during the day and allows 

the participant to return home at night. Several PNSs 

offer day treatment programs for veterans with polytrauma and TBI. 

COORDINATION OF CARE AND CASE MANAGEMENT

Case management, an integral part of services 

provided throughout the PSC, plays a crucial role in 

ensuring lifelong coordination of services for patients 

with polytrauma and TBI. Several processes have been 

established to facilitate the transition of patients from 

DoD to VA care at the appropriate time, under optimal 

conditions of safety and convenience for the patients 

and their families. These processes address continuity 

of medical care and psychosocial support for patients 

and families. 

Families of injured service members require particular assistance with transitioning from the acute medical 

setting of the military medical treatment facility (MTF) 

to the VA rehabilitation setting at the PRCs. Multiple 

levels of clinical, psychosocial, and logistical support 

have been put into place to ensure a smooth transition 

and continuity of care. At Walter Reed Army Medical 

Center (Washington, DC) and Bethesda (Maryland) 

National Naval Medical Center the process begins 

with the VA polytrauma rehabilitation nurse liaison, 

who meets the active duty members and their families while they are still in the acute treatment phase 

of care. The nurse liaison provides education about 

TBI, the rehabilitation process, and the PRC environment of care. Additionally, VA social workers at the 

MTFs provide logistical and psychosocial support 

during the transition process from DoD to the VA. At 

the same time, the admission case manager from the 

PRC maintains personal contact with the family prior 

to transfer to provide additional support and further 

information about the expected plan of care. PRCs 

also schedule video teleconferences with the MTFs to 

discuss the referral with the transferring team, and to 

meet the patient and family members “face-to-face” 

whenever feasible.

Social worker case managers at the PRCs assess 

the psychosocial needs of each patient and family, 

and match treatment and support services to meet 

identified needs, coordinate services, and oversee the 

discharge planning process. As the veteran moves to 

the next level of care, the social worker case manager 

is responsible for a “warm hand-off” of care to the case 

manager at the receiving facility closer to the veteran’s 

home. This is accomplished via personal communication through a phone call or through the PTN’s 

state-of-the-art video conferencing capability. The case 

manager continues to follow the patient until transfer 

of care is complete, and services recommended in the 

discharge plan of care are fully implemented.

The PTN provides a reliable, easily accessible tool 

to further support care coordination and case management. The PTN was expanded during fiscal year 2007 

to include all PRCs and PNSs and several DoD MTFs, 

ensuring that the polytrauma and TBI expertise available at the PRCs is readily accessible to locations closer 

to the veteran’s home community.

FAMILY AND CAREGIVER SUPPORT

PSC programs are responsible for ensuring that 

patients and their families, or other caregivers, receive 

all necessary support services to enhance the rehabilitation process and minimize the inherent stress 

of recovery from a severe injury. The PRCs and PNSs 

strongly advocate involvement of families and caregivers throughout the rehabilitation process. Family 

members and caregivers actively engage in treatment 

and treatment decisions. They are invited to join 

therapy sessions and to participate in interdisciplinary 

team meetings where treatment plans are discussed. 

Support groups and individual counseling for family 

members are available at all PRC sites. 

 Within the PSC, each service member or veteran 

identifies those individuals whom they consider family members, caregivers, or members of their social 

support network. Services described in this section 

would be provided to anyone identified by the patient 

as part of this extended network. For patients without 

good family or social support, the case manager tries
48

Care of the Combat Amputee

to identify the best support available and provide the 

necessary education and training to enhance these 

connections. The designated polytrauma case manager 

(social worker and/or nurse) assigned to every veteran

and active duty service member receiving care in the 

PSC coordinates the core needs and support efforts 

to match the needs of each family or caregiver. At the 

PRCs in particular, where patients and families spend 

extended periods of time away from home, an entire 

support system has been implemented that includes, 

but is not limited to, dedicated social worker case managers advocating for needs and interests throughout 

the rehabilitation process; access to a VA social worker 

24 hours a day, 7 days a week; and counseling, education, and logistical support such as transportation, 

housing, nutrition, and child care. 

Education and training for family caregivers are 

provided throughout the rehabilitation process. The 

goal of education is to empower families to support 

their loved one through the recovery process, and to 

provide strategies that will facilitate reintegration into 

the home community. VA services provided directly 

to families of polytrauma and TBI veterans include 

screening, assessment, education, and treatment for 

marital and family related problems. Family members 

may also receive respite care, home health services, 

education about the care of the veteran, referral to 

community resources, limited bereavement counseling, and support group services. 

Resources have also been assembled nationally and 

locally to meet the special needs of families who accompany the seriously injured service members to the 

PRCs. Several educational products for patients and 

families were developed at the PRCs and distributed 

nationally in fiscal year 2007, including a TBI family 

education manual, a TBI information brochure, and a 

TBI screening brochure. A new PSC Web site is being 

planned.

Generous donations from VA Voluntary Services, 

Operation Helping Hand, Fisher House Foundation, 

other foundations and agencies, and local businesses 

frequently provide free housing, free or discounted 

meals, transportation, and entertainment for veterans’ 

family members at or near the PRC sites. Additional 

donations have included laptop computers, media 

equipment, telephone cards, and gift cards for meals 

and entertainment. Voluntary Services at each PRC 

facility guide donations to meet the families’ specific 

needs.

The PSC is committed to supporting the military 

identity of the wounded service members served at its 

facilities. Each of the PRCs has an Army and Marine 

liaison assigned full time. Their role is to help all active 

duty military and their families with invitational travel 

orders, medical boards, and access to military benefits. 

Additionally, several sites have a representative from 

the Military Severely Injured Service Center and Army 

Wounded Warriors available to provide information 

and assistance. While these professionals often work 

with patients independently, their interventions are 

integrated through collaboration with the social work 

case manager. 

 VA also spports GWOT veterans through the OEF/

OIF program, a coordinated program that offers case 

management to all veterans transitioning into civilian life who have served in combat. Since 2003, VA 

has collaborated with DoD and MTFs to seamlessly 

transition the healthcare of injured or ill combat veterans and active duty service members from MTFs to 

VHA facilities. VA social worker liaisons are assigned 

to major MTFs to assist with transfers and to provide 

information to active duty patients and families about 

VA healthcare services. OEF/OIF case managers, 

both social workers and nurses, are also at the VA 

healthcare facilities to aid with the transition once the 

veteran or active duty service member presents for 

care. Services include helping veterans obtain the appropriate information about their healthcare benefits 

and eligibility.13 PSC case managers work closely 

with this program.

RESEARCH AND COLLABORATIONS

The Polytrauma and Blast-Related Injuries (PT/BRI) 

Quality Enhancement Research Initiative (QUERI), 

located at the Minneapolis VA Medical Center, is the 

coordinating center for collaborative research activities 

for the PSC. The mission of the PT/BRI QUERI is to 

promote the successful rehabilitation, psychological 

adjustment, and community reintegration of individuals who have sustained polytraumatic and blast-related 

injuries. Based on needs assessment studies conducted 

in fiscal year 2006, and input from stakeholders, PT/

BRI QUERI has identified four priority areas for 

research: (1) database development, (2) screening/

evaluation of high-frequency comorbidities, (3) caregiver family members, and (4) care coordination. In 

addition, individual sites in the PSC have their own 

research programs funded through VA research offices, such as rehabilitation research and development 

and health services research and development, DoD 

research programs, and the DVBIC. These programs 

utilize the standard methodologies for applications 

for research grants.

The VA PSC actively collaborates with multiple 
49

Department of Veterans Affairs System of Care for the Polytrauma Patient

DoD and civilian sector programs and agencies. One 

of the most prominent and long-standing is that with 

the DVBIC. Collaboration with the DVBIC, even before 

GWOT, helped to lay the foundation for the system.

DVBIC, then known as the Defense and Veterans Head 

Injury Program, was established in 1992 to help coordinate efforts across the VA, DoD, and the civilian sector 

in diagnosing and treating TBI. DVBIC is a congressionally supported program charged with developing 

military-relevant research to increase understanding 

of how TBI impacts troop readiness and improve outcomes, leading to return to active duty or productive 

community reintegration. Its mandate also calls for 

innovative rehabilitation for TBI, utilizing emerging 

technology, and the development of educational materials and programs for professionals, providers, and 

family members. Since its founding, DVBIC’s role has 

expanded to include screening for mild TBI in the DoD, 

development of practice guidelines, data collection, 

and analysis and care coordination and case management.14 These efforts are apparent in the four PRCs.

The PSC has also established collaborative relationships with other rehabilitation organizations. 

VA works closely with CARF to help identify and 

promote quality rehabilitation programs within the 

VA, utilizing CARF’s directory of rehabilitation providers to ensure that care provided outside the VA 

system meets an established benchmark for quality 

rehabilitation. Leadership in VA rehabilitation also 

works closely with other national professional rehabilitation organizations such as the American Medical 

Rehabilitation Providers Association and the American 

Academy of Physical Medicine and Rehabilitation for 

the common goal of improved rehabilitation services

to the nation’s service members and veterans. A new 

collaboration has recently been established with the 

TBI Model Systems Program, a long-standing research 

consortium of private sector TBI treatment facilities 

that have established a common database and support 

joint research initiatives, to share in data collection for 

outcomes and joint research ventures. PSC facilities 

are also encouraged to form local collaborations with 

providers in their communities to ensure the best care 

without gaps as close to home as possible. 

Many of the programs in the PSC have affiliations 

and collaborative relationships with academic medical 

centers. VA rehabilitation providers are often part of 

the academic medical rehabilitation community for 

training and affiliations, and share VA and affiliated 

positions in medical rehabilitation. VA clinicians are 

also frequently invited lecturers on polytrauma and 

TBI rehabilitation.

OUTCOME MEASURES

Rehabilitation programs in the VA utilize a standardized outcomes measurement system, the Functional Status Outcomes Database. This system allows 

tracking of functional outcomes in motor, self care, 

and cognitive domains across the continuum of care. 

Standardized reports are provided on a quarterly basis 

to inpatient rehabilitation units by the US Department 

of Health and Human Services’ Uniform Data System 

program, which tracks information on the operation 

and performance of health centers. In addition, facilities can create their own customized reports based 

on their individualized data. Data can be utilized to 

measure change in function, length of the rehabilitation 

stay, discharge destination, and various demographic 

variables. With the establishment of the PSC, the 

Functional Status Outcomes Database was modified to 

include new variables relevant to polytrauma and the 

military experience. Reports of outcomes are presented 

in educational meetings as well as used to inform the 

development of the system. 

The PSC also collaborates with the DVBIC in collection of outcome data. The DVBIC has primarily 

focused on ensuring the best practices for service 

members and veterans with TBI. Although data on the 

long-term consequences of TBI are not yet available, 

DVBIC has established a national database of individuals who have received care within the program. 

The database includes such descriptive information 

as mechanism of injury (blast or other type of injury), 

severity of injury, and measurements of neurologic 

function. These descriptive points are collected to make 

comparisons of outcomes based upon mechanism 

of injury, severity, and other injury types (closed or 

penetrating). This database is currently being used 

to allow longer follow-up of individuals receiving 

services to examine and address issues related to longterm outcomes (up to 10 years). The DVBIC also funds 

specific research endeavors at the PRCs. One important 

activity often associated with long-term outcomes is an 

individual’s ability to return to independent driving. 

PRCs and military treatment facilities have utilized 

driving simulators to assist in retraining individuals 

to drive. These driving simulators are not only used 

for skills training, but also provide valid predictive 

measures of long-term performance in the community 

for individuals with TBI.15

VA medical care in general has achieved significant 

recognition for quality of care; in 2005, VA achieved a 

satisfaction score of 83 out of 100 for inpatient care and 

80 out of 100 for outpatient care as rated by the Ameri-
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can Customer Satisfaction Index. These scores were recognized as higher than the private sector, which scored 

73 and 75, respectively.16 VA also continually tracks its 

service quality using Clinical Practice Guidelines and 

the Prevention Index II. Clinical Practice Guidelines 

help to ensure that all healthcare professionals follow 

a nationally recognized standard of care, and Prevention Index II tracks compliance with the Guidelines 

for preventative care, which is associated with better 

health and well-being. In 2006 the mean scores of these 

measures were reported at 87% for the Clinical Practice 

Guidelines and 90% for the Prevention Index II.16

SUMMARY

The VA PSC was created to provide comprehensive 

care to severely injured service members, especially 

those presenting with unique injury patterns and 

complex rehabilitation needs associated with blast 

exposure. This network of care is committed to providing veterans access to the highest quality of care and 

helping them regain the functional skills to successfully return to active duty military service or reenter 

the community. In pursuing these goals, the PSC has 

achieved an unprecedented level of integration and coordination among the many DoD, VA, civilian, national, 

regional, and local facilities and systems involved in 

rehabilitation services for veterans. The standard of care 

in the PSC meets or exceeds that of the private sector.

REFERENCES

1. Department of Veterans Affairs, Veterans Health Administration. Polytrauma Rehabilitation Procedures. Washington DC: 

VA; 2005. VHA Handbook 1172.1. Available at: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_

ID=1317. Accessed January 5, 2008.

2. VA/DoD Health Executive Councils. Department of Veterans Affairs (VA) and Department of Defense Memorandum of Agreement (MoA) Regarding Referral of Active Duty Military Personnel Who Sustain Spinal Cord Injury, Traumatic Brain Injury, 

or Blindness to Veterans Affairs Medical Facilities for Health Care and Rehabilitative Services. Washington DC: DoD, VA: 

2004. Available at: http://vadodrs.amedd.army.mil/legislation/MOA_DoD_Refera_SCI_TBI_Blindness_to_VA.pdf. 

Accessed July 15, 2008.

3. Schwab KA, Warden D, Lux WE, Shupenko LA, Zitnay G. Guest editorial: Defense and Veterans Brain Injury Center: 

peacetime and wartime missions. J Rehabil Res Dev. 2007;44(7):xiii–xxi.

4. Veterans’ Health Care Eligibility Reform Act of 1996. Public Law 104-262. 9 October 1996. Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=104_cong_public_laws&docid=f:publ262.104. Accessed September 

19, 2008.

5. Department of Veterans Affairs Employee Education System. Traumatic Brain Injury. Washington DC: VA; 2004. Available at: http://www1.va.gov/vhi/docs/TBI.pdf. Accessed July 15, 2008.

6. Veterans’ Medical Programs Amendments of 1992. Public Law 102-405. 9 October 1992. Available at: http://uscode.

house.gov/download/pls/38C73.txt. Accessed July 15, 2008.

7. Department of Veterans Affairs, Veterans Health Administration. Preservation-Amputation Care and Treatment (PACT) 

Program. Washington DC: VA; 2006. VHA Directive 2006-050. Available at: http://www1.va.gov/vhapublications/

ViewPublication.asp?pub_ID=1483. Accessed June 15, 2008. 

8. Commission on Accreditation of Rehabilitation Facilities. CARF Connection Web site. Available at: http://www.carf.

org/Providers.aspx?content=content/Publications/Online/eConnection/JanFeb05/VA.htm. Accessed January 31, 

2008.

9. Consolidated Appropriations Act, 2005. Public Law 108-447. 8 December 2004. Available at: http://www.dsca.osd.

mil/programs/LPA/2005/getdoc.cgi_dbname=108_cong_public_laws&docid=f_publ447.108.pdf. Accessed July 15, 

2008.

10. Veterans Health Programs Improvement Act of 2004. Public Law 108-422. 30 November 2004. Available at: http://

thomas.loc.gov/cgi-bin/bdquery/z?d108:HR03936:@@@D&summ2=m&. Accessed July 15, 2008.
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11. Dole R, Shalala D. A duty to the wounded: our newest veterans need help now. Washington Post. July 26, 2007. A11.

12. Department of Veterans Affairs Employee Education System. Polytrauma Rehabilitation Family Education Manual. Washington, DC: VA; 2007. Available at: http://dva.state.wi.us/Docs/TBI/Family_Ed_Manual112007.pdf. Accessed July 

16, 2008.

13. Department of Veterans Affairs. Operation Iraqi Freedom/Operation Enduring Freedom Program. Washington, DC: VA; 

2007.

14. Zitnay G. Defense and Veterans Brain Injury Center. Paper presented at: Hiram G Andrews Center Returning Veterans 

Symposium; July 24, 2007; Johnstown, Pa. 

15. Lew HL, Poole JH, Lee EH, Jaffe DL, Huang HC, Brodd E. Predictive validity of driving-simulator assessments following traumatic brain injury: a preliminary study. Brain Injury. 2005;19(3):177–188.
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