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Keywords:

  • Rehabilitation;
  • case management;
  • head injury

Abstract

  1. Top of page
  2. Abstract
  3. Literature review
  4. Case studies
  5. Summary
  6. Acknowledgments
  7. References

Purpose

The conflicts in Afghanistan and Iraq, also known as Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn, have created unique challenges for rehabilitation teams, including nurse and social work case managers. Active duty service members, National Guard and Reservists have deployed in large numbers and as many as 20% have been exposed to blast injury, which can result in polytrauma and traumatic brain injury, the “signature injury” of the war, as well as psychological trauma, and painful musculoskeletal injuries. In addition, there are also documented emotional injuries associated with the constant stress of war and the frequency of exposure to the graphic scenes of war.

Findings/Conclusions

The Departments of Defense and Veterans Affairs work closely to provide comprehensive care coordination and case management for service members and veterans who have honorably served our country. This article describes the case management collaborative between Veterans Affairs and the Department of Defense that ensures service members and veterans receive their entitled healthcare services.

Clinical Relevance

The complex care needs of these returning service members require astute case management in addition to clinical care. This collaboration ensures the best life-long outcomes and will be discussed in detail in this article.

The purpose of this manuscript was to describe the collaborative efforts between Veterans Affairs (VA) and the Department of Defense (DoD) to ensure that injured service members (SM) and veterans receive services that address the complex, interagency, and interdisciplinary care associated with the trauma of war. The VA Polytrauma System of Care (PSC) was developed to address the unique challenges associated with polytrauma and traumatic brain injury (TBI) recovery. Case management is the central component that ensures seamless patient transitions throughout the rehabilitation and recovery continuum. The polytrauma case management model provides care delivery and coordination that includes Registered Nurse (RN) and Social Work (SW) case managers. The different clinical and educational backgrounds associated with these disciplines complement each other when providing support and coordination of clinical services for persons with complex issues. Although these roles are unique, when the term case management is used in describing the PSC it is inclusive of both RN and SW case managers, unless otherwise specified. This article portrays the transition from war injury to recovery and home, describing the importance of the involvement of case management and its crucial role across multiple systems of care and throughout the recovery continuum.

A key responsibility for the VA has been meeting the complex medical, rehabilitation, and psychosocial needs of the new generation of veterans and SMs from Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND). The methods of warfare used in OEF/OIF/OND, such as improvised explosive devices, have inflicted serious injuries to multiple body parts and organ systems, also known as polytrauma. Optimal healthcare services for veterans and SMs with polytrauma emphasize the importance of rehabilitation and a comprehensive continuum of integrated clinical and support services (Sayer, Cifu, McNamee, Chiros, Sigford, et al., 2009).

These injuries require care over multiple programs from both DoD and VA as these injuries often occur during deployment or active duty. Other injuries, for example, mild TBI (mTBI) or concussion, may not be recognized or diagnosed until the SM is discharged from the military and becomes eligible for VA medical benefits. Both of these very large healthcare systems overlap in various care options. The case manager plays a major role in coordinating care needs of these seriously injured individuals by providing expert clinical and rehabilitation case management oversight, having knowledge of both systems of care and by possessing expert case management skills.

Literature review

  1. Top of page
  2. Abstract
  3. Literature review
  4. Case studies
  5. Summary
  6. Acknowledgments
  7. References

Case management is an innovative approach to managing, coordinating, expediting, and facilitating care. Although case management is over a century old, historically the goal has been the same, the coordination of complex, fragmented services to meet the needs of the client while controlling costs (Kersbergen, 1996). A review of the historic literature reveals case management as a byproduct of creative health care with the combined disciplines of not only nursing, but also medicine, mental health, public health, and social work (Tahan, 1998). The DoD has further added “complex” to the definition to describe the health needs of the SM and veteran. This definition has been adopted by the United States and the international military healthcare community to describe case management (PRIME, 2012).

Polytrauma care provides integrated and coordinated services to deliver optimal outcomes to injured SMs. In “prescription for partnership,” Strasser, Uomoto and Smits (2008) reported a DoD and VA partnership resulting in an interdisciplinary team approach to create an updated paradigm in the treatment of the polytrauma SM. According to recent research by Gebhardt, McGehee, Grindal and Testani-DuFour (2011), rehabilitation will ultimately improve outcomes when congruence between caregivers and care managers are enhanced with a framework to design interdisciplinary interventions during the many phases of recovery. This interdisciplinary approach includes a focus on important roles, such as those involving work, play, and love. These are well documented crucial aspects of recovery and community reintegration (Ben-Yishay & Prigatano, 1990).

The current wars have resulted in an opportunity to develop evidence-based practice and a partnership between DoD and VA. A Memorandum of Agreement between these agencies outlined specialized care for rehabilitation services for active duty SMs sustaining a spinal cord injury, polytrauma, or blindness. The Management of Concussion/mTBI Work Group prepared the VA/DoD Clinical Practice Guidelines in March 2009 - a summary outlining evidence-based practice for rehabilitation specialty care (Department of Veterans Affairs & Department of Defense, VA/DoD Clinical Practice Guideline, Management of Concussion/mTBI, 2009). This clinical collaboration has been facilitated by a sophisticated triage and transfer system across the globe and between DoD and VA. SMs injured in Afghanistan or Iraq are evacuated to Landstuhl Regional Medical Center (LRMC) in Germany before being transferred back to the continental United States. See Figure 1 depicting the “Evacuation Route Across the Globe” for a schematic understanding of the SM's movement from combat theater operations.

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Figure 1. Evacuation route across the globe.

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The DoD and VA polytrauma teams collaborated with a visit to LRMC for a better understanding of the acute care process. This visit allowed both teams to gain valuable insight and supported the further development of comprehensive treatment plans across the continuum of care (Outlaw, 2009/2010). This shared commitment to professional practice and common goals became the building blocks to integrate strengths and skills in a collaborative patient-centered plan of care (Carr, 2009).

Positive outcomes depend on the integration of complex resources and highly functioning teams to provide a new and evolving paradigm of care for persons with polytrauma and TBI. In recent research by Spelman, Hunt, Seal and Burgo-Black (2012) best practices for care guidelines include integrated teams of primary care, mental health, and social work. As there is a significant overlap with a variety of physical, psychological, and psychosocial health concerns, interdisciplinary teams play a role in veteran–centered care (Spelman et al., 2012). DoD and VA case managers have integrated, collaborated, and incorporated a new and evolving care management paradigm to meet the complex bio-psychosocial, functional, and medical needs of Polytrauma veterans, SMs and their extended families (Amdur et al., 2011). The current case management model incorporates both RN and SW staff in this process. The veteran/SM reaps the benefits of someone working with them through many transitions in care (Amdur et al., 2011). Although one clinician is assigned as lead case manager, the staff collaborate to ensure both clinical and psychosocial needs are monitored and advanced.

Agencies of case management and care coordination

There are various case management options available to veterans and SMs depending on their status and specific care coordination needs at the time of entry into medical care. Despite some overlap of these roles, both DoD and VA case managers work closely to ensure seamless services for the veteran, SM and caregiver as appropriate. All echelons of DoD and VA case management are intended to maximize resource utilization, while promoting fiscally responsible quality and patient-centered care.

Care coordination or care management and case management have subtle but important differences. Care coordination or care management is briefly defined as oversight and management of a comprehensive health-care plan for a cohort of SMs or veterans. Case management is defined as services provided to individuals, their families or caregivers that require intensive support and monitoring due to complex medical, mental health or psychosocial factors. Case management interventions are necessary when the veteran, family or caregiver require a more intense level of support beyond the services offered by the care coordination team (Department of Veterans Affairs, 2009a).

The DoD Recovery Care Coordinators work in coordination with DoD and VA and are located at key military treatment facilities throughout the nation. They coordinate military activities between DoD and VA and when necessary, private-sector facilities, while serving as the ultimate resource for families. Through ongoing communication and a warm hand-off process the recovery care coordinator helps ensure services and other benefits are provided to seriously wounded, injured and ill SM and veterans. This “warm hand-off” or the detailed verbal communication of the plan of care is a key component to the successful military transition for patients from DoD to VA healthcare systems.

The VA/DoD Federal Recovery Coordination Program provides clinicians who support the seriously ill and injured person during the consequently long and complicated recovery and rehabilitation process. These coordinators are requested by either military command or clinicians providing care to the seriously ill and injured SM or veteran. Their responsibility is to oversee the plan of recovery with the patient and family to ensure all possible, necessary, and eligible services are offered for continued recovery at various facilities and levels of care.

The VA Liaisons for Healthcare are integral members in transitioning severely ill and injured SMs from the DoD to the VA healthcare system. Seriously ill and injured SMs that return from theater are typically sent to a Military Treatment Facility (MTF) for medical stabilization. During this time, it may be determined that the SM will be out-processed from active duty due to their injury or illness, therefore coordination of services from the military healthcare system to the VA healthcare system is needed. VA liaisons are strategically located in MTFs that have higher concentrations of recovering SMs. VA liaisons work closely with military nurse case managers, the SM, and their family to facilitate a transfer of care to a VA facility closest to their home and/or military unit. Their efforts are geared toward assisting the SM with enrollment for healthcare services in the VA healthcare system, identification of the closest facility to their home, referral to the OEF/OIF/OND Care Management team at that VA facility, and securing appointments for appropriate services in the VA prior to leaving the MTF.

Among all branches of the military, there are dedicated programs to provide assistance to SMs and veterans with combat related injuries or illnesses from the OEF/OIF/OND theaters. These programs include the Air Force Wounded Warrior Program, the Army Wounded Warrior Program, the United States Marine Corp Wounded Warrior Regiment, Navy Safe Harbor and the United States Special Operations Command Care Coalition. The overall focus of these programs is to provide personalized assistance and advocacy to SMs and their family during the transition from military to civilian life. These DoD funded programs serve the most severely wounded SMs. The mission of these programs is to assist and advocate for the SM through the transition from active duty to veteran status with focus on recovery, rehabilitation, and community reintegration (Wounded Warrior National Resource Directory, 2012).

Every VA facility has dedicated staff to assist those SMs and veterans who served in the combat theaters of OEF/OIF/OND and assist in the transition of healthcare services from the military to VA health care. These staff members are identified as the OEF/OIF/OND Care Management team. Each facility team is led by an OEF/OIF/OND Program Manager and has OEF/OIF/OND case managers and Transition Patient Advocates. The focus of OEF/OIF/OND case management is a holistic, patient and family centered approach to managing care for veterans or SMs that require integrated services or request case management services. As previously stated, these veterans are often diagnosed with physical, emotional, and psychosocial conditions that require a customized approach to coordinating care.

Veterans or SMs identified with conditions such as traumatic brain injury, spinal cord injury, blindness, severe burns, amputations, and severe mental health issues may have their case management provided by specialty care programs and case managers as found in the PSC (Sayer et al., 2009). Due to the clinical complexity of the aforementioned cohort, polytrauma specialty case managers serve as the lead case manager for patients as they move through the rehabilitation and recovery continuum with the primary responsibility of transitioning veterans and SMs seamlessly across VA levels of care while coordinating resources to meet medical and psychosocial needs (Department of Veterans Affairs, 2009b). The polytrauma case manager serves to support the individual's and family's health needs across sites and unique episodes of care within the PSC, to ensure the patient receives the highest level of quality integrated services. This requires frequent assessment, planning, advocacy, support, coordination of multiple services, and evaluation. It may be short or long term, based on the needs of the patient, their family and/or caregiver.

Polytrauma specialty case management requires a clinical understanding of the comorbidities and direct sequelae associated with TBI. A working knowledge of the severity, symptoms, and complexity associated with the diagnosis of TBI is essential in recognizing the challenges associated with the case management of persons after TBI and further supports the need for the sophisticated PSC (French, Parkinson & Massetti, 2011). An additional key member of this team includes the Polytrauma Rehabilitation Nurse Liaison. This liaison is located within the MTF and assists in communicating the complex clinical needs as the severely injured SM transfers to a VA inpatient Polytrauma Rehabilitation Center (PRC).

The charge and goal for polytrauma rehabilitation case management is to assist the veteran or SM in returning to everyday life to the extent possible, reinforce alternative strategies for activities as necessary, and assist the survivor to focus on future life processes. For those who can, getting back to work or school or return to active military duty is often a major goal of the interdisciplinary community reintegration plan of care.

Case studies

  1. Top of page
  2. Abstract
  3. Literature review
  4. Case studies
  5. Summary
  6. Acknowledgments
  7. References

As described, overlapping levels and types of case management with special expertise are needed as the SM or veteran transitions between military and veteran healthcare systems and the private sector. A Lead Case Manager is determined at each transition in care. The identification of a lead case manager ensures clear communication during these times of transition, and helps to ease the anxiety for patients and families as they progress and reintegrate back into their community. The following case studies describe these case management handoffs.

Case study #1

This case study describes the all-encompassing transitions frequently required for SMs recovering from serious illness and/or injury. The study will describe the facility level responsibilities and layers of coordination needed to assist patients and families as they navigate from battlefield injury to home and the new normal.

This is a case study of a 21-year-old Marine, Lance Corporal (LCpl) injured in Afghanistan by a blast secondary to a road side bomb causing his Humvee to roll over and explode. His injuries include a moderate TBI, eye injuries, burns to both legs, the left hand and fractures to the right hand. He is triaged and 12 hours postinjury the LCpl is flown to LRMC for medical and surgical stabilization. At 72 hours postinjury, he is transferred to Walter Reed National Military Medical Center in Bethesda, Maryland (see Figure 1, Evacuation Route across the Globe, depicting typical triage route).

By day 4, the priorities for this SM include ongoing medical and surgical stabilization, initiation of acute rehabilitation, and psychosocial counseling. Acute rehabilitation at the MTF involves the early stages of physical recovery as well as intensive efforts to begin educating the patient and family regarding the importance of increasing functional capacity and independence. At 10 days postinjury, a video-teleconference is held with the appropriately chosen VA PRC. A medical update is provided to the team, and the patient and his family are given the opportunity to meet and question the PRC staff. A VA liaison located at the MTF maintains contact with the accepting VA and provides updates on the patient's condition. At 27 days postinjury, the patient is transferred with the following diagnoses: blindness, balance deficits, moderate cognitive-behavioral issues, healing second and third degree burns, and a significant decrease in strength and endurance.

At the PRC, the patient receives ongoing medical and surgical stabilization, interdisciplinary intensive rehabilitation including occupational, physical, recreational and speech therapies, blind rehabilitation services, vocational rehabilitation, and mental health services.

The SM makes progress in acute rehabilitation and at 120 days postinjury he is transferred to the Polytrauma Transitional Rehabilitation Program where he continues to work with the aforementioned professionals in an effort to maximize independence and safety with the overarching goal of successful community reintegration.

At 210 days postinjury, the patient and his support system are introduced and transferred to the VA Polytrauma Network Site (PNS) Day Treatment program close to the parent's home in Texas. The SM continues the hard work in rehabilitation taking another step closer to home.

At 4 years postinjury, this former SM, now veteran, has returned to his home in a rural community in Washington with his spouse and two young children. This journey is depicted in Figures 2 and 3. DoD and VA case managers worked diligently to ensure smooth care coordination supporting the veteran's maximum recovery and a level of independence that ultimately allowed for this successful transition home. Figure 3, Case management of the severely ill and injured, depicts the DoD and VA case management programs that support the often nonlinear and unpredictable recovery course.

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Figure 2. Movement across the continental United States (Conus).

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Figure 3. Case management of wounded III and injured.

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Throughout this case study, the patient and his family have encountered case management at each level of care. This includes the following: military case managers at Walter Reed National Military Medical Center, VA liaisons, a federal recovery coordinator, and polytrauma case managers. In this example, military and VA case managers worked all issues to ensure no detail was overlooked and served as the linchpin for communication between healthcare providers, the patient, and the family.

Case study #2

The following is a case study of a 23-year-old Army Reservist with various medical and psychosocial needs often encountered during the recovery course after a mTBI. He served two tours of duty, one in Iraq and one in Afghanistan as a medic with an infantry division. He returned from his most recent tour and during his stateside demobilization process with the military the service member reported exposure to a blast event and endorsed symptoms consistent with mTBI. The SM was seen by the military TBI clinic provider with complaints of headaches, balance issues, tinnitus, blurred vision, photophobia, anxiety, irritability, sleep disturbance, memory, and concentration problems (Hicks, Fertig, Desrocher, Koroshetz & Pancrazio, 2010). The provider completes a history identifying a single blast event that is consistent with a mTBI based on brief loss of consciousness for less than 1 minute and alteration in consciousness less than 30 minutes (MacDonald et al., 2011). The SMs current symptoms are most likely a combination of mTBI and Post Traumatic Stress Disorder. The SM is prescribed treatment based on the TBI Clinical Practice Guidelines (VA & DoD, 2009). The wife has been supportive but reports that she is tired and feels depressed about their deteriorating financial situation. She reports that she is currently working two jobs “to make ends meet” and worries about her child when she is working.

During this time, case management involvement includes DoD case manager (DoD CM), a VA Liaison, and a Recovery Care Coordinator. The decision regarding who will serve as the lead case manager is dependent on the patient's primary healthcare needs and geographic location. His care is assigned to the DoD CM. Case management is focused on supporting the SM throughout the evaluation and early treatment phases both medically and psychosocially. There is also an identified need for support of the spouse as the SM recently returned home and the lack of immediate coping skills has resulted in financial and child care issues. At a follow-up appointment, the SM is seen to assess the effectiveness of the newly prescribed medications. He reports a decrease in headache frequency, that his mood has stabilized, and he is sleeping better. The SM is being sent home for continued recovery with plans for follow-up with the primary care physician and polytrauma team at the SM's local VA Medical Center (VAMC). The patient transitions to retired status and the DoD CM relays this change to the local VAMC case management teams regarding the relocation of the SM/veteran to his catchment area. A warm hand-off is provided.

Key Practice Points
  • Case management is the central component that ensures seamless patient transitions throughout the rehabilitation and recovery continuum.
  • The complex care needs of these returning service members requires astute case management skills across a range of military branches and government agencies.
  • The identification of a lead case manager ensures clear communication during these times of transition and helps to ease the anxiety for patients and families as they progress and reintegrate back into their community.
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During the first appointment at the veteran's local VAMC, the patient reports that he is about to be fired from his civilian job because of an altercation with a co-worker, his headaches have increased in frequency and intensity, he is not sleeping, he reports an increase in nightmares and has quit taking all medications. His wife reports he is drinking heavily and she is thinking of leaving with their child. Discussion occurs at this appointment regarding postdeployment and medical issues since returning home. Presenting symptoms are prioritized, he is restarted on medications and both the wife and veteran are educated regarding the importance of taking medications as ordered and who to notify if medication efficacy is not as expected. Therapy is initiated for attention and cognitive concerns, dizziness, sleep hygiene, and mental health interventions. Neuropsychological testing is also scheduled. A Vocational Rehabilitation Specialist engages the patient in discussion regarding work status and to determine if the veteran's long-term plan is for continued employment or possibly for return to school. The polytrauma case manager, now the lead case manager coordinates with the veteran and family, and serves as the main point of contact for all other involved case managers. A plan of care is developed by the polytrauma interdisciplinary team, which includes input from the veteran and wife and a timeline for clinic visits is strategized according to their work schedules.

A clinic follow-up visit 3 weeks later reveals that the patient is beginning supported employment strategies at a local warehouse. He reports that he is sleeping better and that his headaches have improved. His wife reports that he is compliant with his medication regimen through the use of his SmartPhone, which he uses as an electronic memory reminder. The wife and patient are being seen by a polytrauma family counselor and report that the home environment has improved. Two months later, the veteran is successfully working full-time at his job without vocational support. Team meetings with OEF/OIF/OND and polytrauma conclude that the patient should begin follow-up and maintenance care through the primary care clinic.

Summary

  1. Top of page
  2. Abstract
  3. Literature review
  4. Case studies
  5. Summary
  6. Acknowledgments
  7. References

The case management of our nation's injured and ill heroes is highly complex. The purpose of this article has been to describe the collaborative case management between the Department of Defense and Veterans Affairs which ensures SMs and veterans receive their entitled healthcare services. The complex care needs of these returning SMs requires astute case management skills across a range of military branches and government agencies.

In addition to the significant physical injuries, the psychosocial issues impacting SMs and veterans as they attempt to return to a meaningful life can be a challenge that compounds the existing physical and psychological trauma. It is assumed that there will continue to be an ongoing need for psychosocial support and counseling as SMs and veterans recover and attempt to return to their home communities. Limitations of this article include a focus on the care management of the physical injuries and coordination needs of the returning SMs and veterans. A comprehensive look at the psychosocial and psychology sequela have not been addressed in this article. It is assumed that the demand for case management assistance will continue to grow as the returning combat veteran will continue to seek case management psychosocial and logistical supports.

A crucial component in the successful return home lies in this extensive care coordination and DoD–VA partnership. The development of these programs and comprehensive case management systems across multiple agencies and echelons of care has been a monumental feat. Further in-depth analysis of DoD and VA case management programs are the next steps for streamlining this process. This includes the development of a lifetime care plan to support flawless transitions for the SM and veterans who honorably serve our country.

Table 1 Veteran Affairs/Department of Defense acronym table

AFW2Air Force Wounded Warrior Program
ATAssistive Technology
AW2Army Wounded Warrior Program
BASBattalion Aid Station
CASEVACCasualty Evacuation
CBOCCommunity Based Outpatient Clinic
CSHCombat Support Hospital
CMCase Management
CONUSContinental United States
DoDDepartment of Defense
EMFExpeditionary Medical Facility
EMEDSExpeditionary Medical Support
FRC/FRCPFederal Recovery Coordinator/Federal Recovery Coordination Program
IEDImprovised Explosive Device
LCMLead Case Manager
LRMC (AE)Landstuhl Regional Medical Center
MEDEVACMedical Evacuation
MCMMilitary Case Management (DoD CM)
MHMental Health
mTBIMild Traumatic Brain Injury
MTFMilitary Treatment Facility
OEF/OIF/ONDOperation Enduring/Operation Iraqi Freedom/Operation New Dawn
PACTPatient Aligned Care Teams
PNSPolytrauma Network Site
PRCPolytrauma Rehabilitation Center
PRNLPolytrauma Rehabilitation Nurse Liaison
PSCPolytrauma System of Care
PTRPPolytrauma Transitional Rehabilitation Program
PTSDPost Traumatic Stress Disorder
RCCRecovery Care Coordinator
RNRegistered Nurse
SCISpinal Cord Injury
SMServicemember
SWSocial Worker
TBITraumatic Brain Injury
TPATransition Patient Advocate
USOCOMUnited States Special Operations Command Care Coalition
VAVeteran Affairs
VAMCVeterans Administration Medical Center
VISTVisual Impairment Specialist
VRSVocational Rehabilitation Specialist
WRNMMCWalter Reed National Military Medical Center
WWRWounded Warrior Regiment (US Marine Corp)

Acknowledgments

  1. Top of page
  2. Abstract
  3. Literature review
  4. Case studies
  5. Summary
  6. Acknowledgments
  7. References

The authors would like to acknowledge their colleagues Dr. David Cifu, Micaela Cornis-Pop, PhD, David Chandler, PhD, Alison Cernich, PhD, M. Sue Biggins, RN, BSN, MBA, and Jennifer Perez, LICSW, for their assistance in the writing of this manuscript. The authors would also like to thank the military and Veterans Affairs medical and surgical providers who work tirelessly to save the lives of our nation's heroes. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Defense, Veterans Affairs or the U.S. Government.

References

  1. Top of page
  2. Abstract
  3. Literature review
  4. Case studies
  5. Summary
  6. Acknowledgments
  7. References
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