As with every military engagement, the Operation Iraqi Freedom and Operation Enduring Freedom casualties present unique combat-related healthcare issues. Because of better body armor protection and sophisticated weaponry, casualties are surviving with complex injuries and rehabilitation requirements never seen before. The casualties no longer have a single injury but rather several injuries (polytrauma or multitrauma), such as traumatic brain injury (TBI) and blindness, TBI with amputation and prosthetic requirements, or TBI with vision injuries.1 Trauma to multiple organ and sensory systems requires complex coordination rehabilitation and a multidisciplinary team functioning in tandem. Involvement by the case manager is paramount in supporting not only the casualties and their families but also the providers and facilities while arranging and staging their care.2
With the increasing presence of polytrauma injuries, there is a clear need to organize the casualty's multiple specialty requirements. Situations that encompass treatment such as surgical revisions must be considered because they may result in increased rehabilitation requirements. It becomes easy to lose track of the whole picture, making the case management's role foremost in brokering communication between facilities, providers, and families to foster optimization of the discharge outcome. Case management has a pivotal role in ensuring that care arranged prior to discharge is executed after discharge to foster enhanced continuity of care. Maintaining a caseload of patients with polytrauma requires that the case manager implement a refined organizational and clinical skill set.
Since the extensive and complex injuries sustained by the casualties have not existed previously, it is crucial to anticipate and address the multiple specialty needs of the casualty.3 Arranging care and subsequent follow-up provisions pose a variety of challenges, particularly when obtaining and consolidating required authorizations for care (planned and emergent) and clinical reports from a multitude of providers. The need for an average of 7 specialists to treat each casualty exemplifies the intricacy of care.
During 2007, the case management division at our medical center case managed an average monthly workload of 260 polytrauma cases with an average discharge rate of 27 cases per month. Each casualty required services from an average of 7 specialists over a period of 1 to 2 years. Depending on the injuries sustained, a cascading series of needs was addressed. For instance, if a casualty received a blast exposure to the face, depending on the extent of injury, the casualty would require the care and services of neurosurgery, oral/maxillary/facial surgery, and plastic surgery for reconstruction. If the blast affected an eye, a need for care by an ophthalmologist and perhaps optometrist would arise. If there was loss of the eye, subsequent services of a prosthetician would result. Should skull structures need to be replaced because of the blast, radiology and three-dimensional imaging would be required to fabricate missing structures with prosthetics.
Depending on the extent of facial/brain/eye involvement and the casualty's comprehension, a blind rehabilitation specialist may be introduced during the inpatient stay to assess readiness for rehabilitation. Assistive and adaptive devices such as talking watches may be supportive during the inpatient stay. Early initiation of an evaluation of the casualty by a blind rehabilitation specialist allows for establishment of rapport with the patient and family. The rehabilitation specialist is well equipped to manage the notable degree of anxiety that often exists at this time.
Regardless of injury, the casualty would receive audiology testing and neuropsychological evaluation for blast exposure. Depending on the extent of the facial injury, affected oral structures, such as the mandible, would necessitate the need for involvement of an oral maxillofacial specialist to address dental needs. Additional implications exist, as often the blast may affect other body systems, such as hands, arms, and/or legs. The presence of additional injuries would signal the need for additional or concurrent rehabilitation with accompanying specialists, such as physical medicine and rehabilitation.
To ensure effective monitoring of the caseload, an instrument was developed for the case manager to track and trend specialists' recommendations. This tool was developed to assist case managers in readily identifying the evaluations and recommendations or treatment suggestions rendered by different specialists. The tool serves to track the myriad of specialists for each casualty to ensure that the highest quality standard of care is preserved. The tracking tool ensures that each casualty receives consultation, and it assists in identifying areas still needing further efforts. Although the tool assists the case manager in ensuring all issues have been addressed, a more comprehensive care plan is developed in tandem with the casualty and family members.
CASE MANAGEMENT AND CARE PLANNING PROCESS
Case management is an iterative process in that lessons learned from each discharge plan help in further refining future planning of needs. The constant evaluation of outcomes decreases unwarranted variation in practice and improves beneficiary and provider satisfaction.
Understandably, families desire to have their injured service member home with them while undergoing their rehabilitation. On the basis of Operation Iraqi Freedom experience, the case managers must be proactive to anticipate, identify, and take corrective action on behalf of the casualty member and/or families as their needs and circumstances change.
The casualty's care is coordinated with consideration to the timing and pacing of convalescence, reconstruction, and rehabilitation requirements. The selection and recommendation of rehabilitation facilities is based on a delicate balance of these needs and patient/family preference. Although patient and family preference is a priority, careful consideration should be made with respect to a facility's experience and facility treatment outcomes with military casualties. The casualty may require multiple rehabilitation stays on the basis of the level, extent, and complexity of injuries. Frequently the injuries and comorbidities include blindness, TBI, spinal cord injuries, amputations, and burns. Depending on the level of severity and injury, the casualty can and should receive rehabilitation for blindness and TBI and perhaps amputation at the same time rather than segmented rehabilitation. It is the responsibility of the case manager to coordinate with the multiple treatment centers and providers to ensure that the receiving providers have the necessary clinical information.
Depending on the individual circumstance and readiness, the case manager meets and visits throughout the hospitalization course to establish a therapeutic relationship and start the dynamic assessment process including the needs of the patient's family. Prior to discharge, the case manager reviews the care plan with the family to give an overview of the rehabilitation requirements and validate the specialist treatment plans. The care plan is dynamic and expands to include the changes and improvements and setbacks along the way.
CASUALTY CARE PLAN TEMPLATE
Safety
Current or potential. If this patient is physically impaired, identify environmental hazards during convalescence. Watch for alteration in mental functioning related to injuries, medications, psychosocial issues, etc. If the patient is cognitively impaired, review with patient/family and/or responsible significant other decision-making limitations such as driving, financial/legal decisions, medication administration, ability to call for help, and effects of medications on abilities, which may further require supervision. Review safety measures needed for the patient's welfare, especially if pain medication and medication administration are needed.
Psychosocial
Assess perception of current problems related to the casualty and impact on family. Evaluate effectiveness of support system. Review patient and family's coping methods and effectiveness in dealing with current problems. Discuss family's expectations (long and short term). Assist patient and family in identifying personal and collective strengths to cope with current and future problems. Offer supportive services as appropriate. Consider the use of chaplain care and other mental health care professionals. Review current agencies/community services being utilized. Assess family members' need for additional financial resources such as Traumatic Servicemembers' Group Life Insurance and/or community resources such as the Navy Marine Corps Relief Society visiting nurses and other resources.
Disease process
Review with patient/family and/or responsible significant other disease process symptoms/issues and impact on family life. Assess patient/family's ability to understand injuries. Assess patient/family's understanding of recovery/rehabilitation process and long-term plan. Review potential for infections with corresponding action plans.
Medications
Verify correct medications, dosages, strengths that are available at home. Review and reinforce purpose, actions, and adverse effects. Instruct on medication changes and plans for obtaining refills. Address effects and interaction on body systems.
Activity
Assess functional status and ability to perform activities of daily living/instrumental activities of daily living. Review current activity and tolerance. Review allowed activity and any current physical therapy/ occupational therapy (PT/OT) home plans if indicated. Identify if medical clearance is needed for increased activity.
Should the casualty have permanent disabilities, the case manager needs to reinforce the outcome opportunities to prepare for separation from the military. As the military engagement continues, these interventions are becoming more critical in assisting the casualty to transitioning to civilian status. In many instances, the military has been the only "family" and stabilizing influence in the casualty's life. In an effort to better support the casualty's transition to the next phase in his life as a veteran, the military case manager must partner with the Veteran's Affairs case manager and federal recovery care coordinator. Emotional support is the chief priority at this critical juncture and must remain ongoing throughout this vulnerable time. The process and transition must be transparent to support service member's reintegration into the community.
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