Perspectives of veterans with mild traumatic brain injury on community reintegration: Making sense of unplanned separation from service.

For veterans separated from the military as a result of acquired mild traumatic brain injury (mTBI), the transition from a military identity to a civilian one is complicated by health, cognitive, and psychosocial factors. We conducted in-depth interviews with 8 veterans with mTBI to understand how they perceived the experience of departure from the military, rehabilitation services provided at a Department of Veterans Affairs (VA) Polytrauma Network Site, and reentry into civilian life. Two distinct patterns of thinking about community reintegration emerged. The first pattern was characterized by the perception of a need to fade one's military identity. The second pattern, conversely, advanced the perception of a need to maintain the integrity of one's military identity though living in a civilian world. These perceptions may be linked to individuals' roles while in the military and whether violent acts were committed in carrying out the mission of service, acts not consonant with positive self-appraisal in the civilian world. The crisis of unplanned, involuntary separation from the military was universally perceived as a crisis equal to that of the precipitating injury itself. The perception that civilians lacked understanding of veterans' military past and their current transition set up expectations for interactions with health care providers, as well as greatly impacting relationships with friend and family. Our veterans' shared perceptions support existing mandates for greater dissemination of military culture training to health care providers serving veterans both at VA and military facilities as well as in the civilian community at large. (PsycINFO Database Record

Templated Interdisciplinary Rehabilitation Care Plan Documentation for Veterans With Traumatic Brain Injury.

PURPOSE OF STUDY: Individualized interdisciplinary care is the hallmark for rehabilitation following traumatic brain injury (TBI). Veterans Health Administration (VHA) utilizes an electronic note template to document Interdisciplinary Rehabilitation and Community Reintegration (IRCR) care plans for Veterans with TBI requiring rehabilitation. All Veterans with a TBI diagnosis, receiving skilled therapy for TBI-related issues, and followed by a case manager must receive a care plan. The purpose of this study was to determine the level of compliance with the IRCR care plan requirements used to identify Veterans with TBI in need of the care plan and to evaluate the reasons for inconsistent compliance. In addition, the study sought to provide a more objective assessment of Veterans with TBI requiring an IRCR to assist in establishing a target metric. PRIMARY PRACTICE SETTING: TBI outpatient clinics. METHODOLOGY AND SAMPLE: Investigators conducted a retrospective medical record review of 546 Veterans with a TBI diagnosis seen at the Washington, DC VA Medical Center's outpatient polytrauma clinics in 2013. Cases were initially reviewed for referral or engagement with skilled therapy. Charts where Veterans were referred or engaged with skilled therapy were forwarded to 2 polytrauma clinicians to determine whether therapy was requested to treat a TBI-related condition. Finally, charts were reviewed for case management and analyzed for algorithm compliance. Analysis focused first on compliance with IRCR algorithm requirements and secondarily with identifying potential reasons for noncompliance. RESULTS: In 2013, 42% of the TBI cohort met the criteria for an IRCR. The vast majority of cases with a TBI diagnosis complied with IRCR algorithm criteria; however, 14% of all reviewed cases required an IRCR but did not receive one. Provision of case management outside of the TBI/polytrauma clinic characterized a majority of noncompliant cases. IMPLICATIONS FOR CASE MANAGEMENT: Interdisciplinary care can be challenging, particularly in the outpatient setting, due to patient availability and access to care. Improved documentation in the electronic health record may assist case managers and other clinicians in coordinating rehabilitation care for Veterans with TBI. Case managers in the VA and other settings may find templates and trackable health factors helpful to identify patients in need of care plans.

Executive functioning in TBI from rehabilitation to social reintegration: COMPASS (goal,) a randomized controlled trial (grant: 1I01RX000637-01A3 by the VA ORD RR&D, 2013-2016).

BACKGROUND: Traumatic brain injury is a major health problem that frequently leads to deficits in executive function. Self-regulation processes, such as goal-setting, may become disordered after traumatic brain injury, particularly when the frontal regions of the brain and their connections are involved. Such impairments reduce injured veterans' ability to return to work or school and to regain satisfactory personal lives. Understanding the neurologically disabling effects of brain injury on executive function is necessary for both the accurate diagnosis of impairment and the individual tailoring of rehabilitation processes to help returning service members recover independent function. METHODS/DESIGN: The COMPASS(goal) (Community Participation through Self-Efficacy Skills Development) program develops and tests a novel patient-centered intervention framework for community re-integration psychosocial research in veterans with mild traumatic brain injury. COMPASS(goal) integrates the principles and best practices of goal self-management. Goal setting is a core skill in self-management training by which persons with chronic health conditions learn to improve their status and decrease symptom effects. Over a three-year period, COMPASS(goal) will recruit 110 participants with residual executive dysfunction three months or more post-injury. Inclusion criteria combine both clinical diagnosis and standardized scores that are >1 SD from the normative score on the Frontal Systems Rating Scale. Participants are randomized into two groups: goal-management (intervention) and supported discharge (control). The intervention is administered in eight consecutive, weekly sessions. Assessments occur at enrollment, post-intervention/supported discharge, and three months post-treatment follow-up. DISCUSSION: Goal management is part of the "natural language" of rehabilitation. However, collaborative goal-setting between clinicians/case managers and clients can be hindered by the cognitive deficits that follow brain injury. Re-training returning veterans with brain injury in goal management, with appropriate help and support, would essentially treat deficits in executive function. A structured approach to goal self-management may foster greater independence and self-efficacy, help veterans gain insight into goals that are realistic for them at a given time, and help clinicians and veterans to work more effectively as true collaborators.