They were American, Iraqi, Afghani, Romanian, and other nationalities. Culturally and ethnically diverse, their backgrounds differed from group to group and even person to person. But they all had an important commonality: each had been severely injured while serving in or with the U.S. military in Iraq or Afghanistan.

As a case manager, my job was to assess their needs and identify resources, from inpatient treatment to community services "back home"-wherever that happened to be. For me, it was an invaluable experience with many lessons learned on how to serve the needs of a specialized population.

It began in 2010 when my husband was stationed with the U.S. military in Germany. I became a civilian employee of the Landstuhl Regional Medical Center (LRMC), working as an inpatient case manager. Some of the wounded military members received all their care at LRMC, including such services as physical therapy and/or occupational therapy. Others had traumatic injuries and needed further treatment in the United States. And, all of them needed case management services, from assessment and implementing a care plan to monitoring their progress and identifying additional resources.

Given the Veterans' Administration's drive in recent years to improve delivery of health services to military personnel (as well as to veterans and their dependents), LRMC made wounded warriors our priority. The patients I served included both U.S. military and foreign nationals fighting for the United States. Meeting the needs of this specialized population often required me to get creative in identifying resources postdischarge. "Alin," as I'll call him, was a Romanian national who served with the U.S. military in Iraq. Alin had been blinded by an improvised explosive device and sent to LRMC for treatment. As the point of discharge neared, I tried to find support and life skills/occupational training for Alin in Romania but was unable to find anything suitable, nor were resources available in Germany to help him live as independent a life as possible. Finally, I found a program in the United States that would accept Alin and arranged for him to be transported there, an option that required a visa and other documentation. Throughout this time, I worked closely with Alin to ensure his input and desires were at the center of the decision making. His resilience and willingness to be flexible encouraged me, just as I hope my resolve and commitment encouraged him.

Providing case management services to the specialized population of wounded warriors was extremely satisfying. This experience gave me full immersion into serving culturally and ethnically diverse people.

With each encounter, I was reminded that case management is patient-centric-that is, the individual must be empowered and supported to make informed decisions on his or her own behalf. Such was the case with "John," a soldier who had been traumatically injured, losing the lower half of his body. The nature of his injury made sitting on his own physically impossible. When arranging transportation for him, I asked John what he thought would be best, a wheelchair or a scooter. We tried different options until John found what worked for him in terms of comfort and mobility. Through the process, John was empowered in the decision making to find what suited his needs.

The Wounded Warrior Population

Across the health care spectrum today, case managers are encountering more former service members who were wounded or have other physical/mental health issues related to their military service. According to the Wounded Warrior Project, for every U.S. soldier killed in Operation Iraqi Freedom and Operation Enduring Freedom, seven were wounded. Combined, more than 48,000 service men and women were physically injured. In addition, as many as 400,000 service members may have combat-related stress, major depression, and posttraumatic stress disorder, whereas another 320,000 are believed to have experienced a traumatic brain injury while deployed (Wounded Warrior Project, 2016). Meeting the needs of this specialized population-whether in acute care, subacute, or another health care venue or practice setting-requires a holistic approach to address both physical and mental health and psychosocial needs.

With advocacy as the guiding value, case management must be:

* person-centric, focused on the individual and his or her specific needs;

* grounded in honesty and rapport, with open communication and candid discussion; and

* at the center of the interdisciplinary team that works together to provide services and identify resources.

At the same time, case managers also must be good stewards of resources, whether on behalf of the hospital, the insurance company, or another third party. This reality underscores the importance of being creative in identifying resources and exploring alternatives to meet the needs of the individual. In serving the wounded warriors, I learned valuable lessons that enabled me to become "creative" in identifying resources that could potentially lead to improved outcomes.

Applying Past Experiences to New Challenges

In every setting, it is essential to take a patient-centered approach that considers the uniqueness of everyone, including cultural sensitivities, psychosocial issues, and socioeconomic factors. Sometimes, these factors pose limitations on care options, such as postdischarge. In other situations, these factors escalate the risks. Consider the example of "Mary," a high-risk pregnancy patient who lived about an hour-and-a-half away from the hospital. As her due date neared, that distance further increased her risks. To address her needs, the case manager identified a hotel that had a discounted room rate with the hospital, such as for visiting physicians, educational trainings, meetings, and so forth. Arrangements were made for Mary to stay there for several days before going into labor, which enabled her to be monitored regularly. In addition, the case manager found resources to pay for Mary's stay.

Another example is when hospitals serve populations of homeless people who, postdischarge, do not have a suitable place to go. A resourceful case manager may be able to arrange with a homeless shelter to "reserve" a certain number of beds each night or to secure a place in a halfway house when someone needs a longer term arrangement.

Each experience adds to a case manager's arsenal of ideas; what worked in the past for one individual might be suitable for another or perhaps inspire a similar solution. Past experiences help inform the approach for a new challenge. When serving the needs of a specialized population, resilience and resourcefulness are valuable tools while never losing sight of the individual's unique needs.

Reference