Between 2001 and 2011, 2.2 million U.S. service members were deployed in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). These conflicts have resulted in long, frequent deployments for many of these service members, as well as historically high levels of participation by reserve forces. Although most service members cope well with deployment-related stresses, the wartime risks of the past decade have led to significant rates of physical injuries and psychological health problems.
Improvised explosive devices (IEDs), used extensively against U.S. forces in OEF and OIF, have been one of the leading causes of death and injury. Traumatic brain injury (TBI)—a frequent consequence of these IED blasts—has been called the signature injury of these conflicts. TBIs are not exclusively a combat injury, however. They can also result from training accidents, motor vehicle accidents, and other traumas. Depending on the severity, a TBI can include a loss or decrease of consciousness and can result in memory problems, confusion or disorientation, or neurological deficits (such as weakness, a loss of balance, and sensory changes).
Compared to service members who have never experienced a TBI, those who have are more likely to develop a psychiatric disorder, such as posttraumatic stress disorder (PTSD) or depression. Although recovery can occur without formal care, service members benefit from formal diagnostics, assessment, and treatment to help them to regain their original capabilities and return to full duty. For those for whom a full recovery and return to duty is not feasible, these same services can help them to adjust to their new baseline and effectively transition out of the service.
While the military health care system has adjusted proactively to meet the unique needs of service members recovering from physical and psychological injuries, not all patients can be optimally served by the standard infrastructure of local military treatment facilities. A small proportion of these patients may benefit from specialty services designed to treat comorbid TBI and psychological health conditions.
In response to this need for specialty services, the U.S. Department of Defense (DoD) opened the National Intrepid Center of Excellence (NICoE) in Bethesda, Maryland, in 2010. The NICoE provides interdisciplinary diagnostic evaluations, short-term treatment, and treatment planning for comorbid TBI and psychological health conditions with the goal of mitigating barriers some service members face in seeking treatment and supporting service members' ability to return to full service. Service members from across the country travel to the NICoE for a four-week stay, where they receive specialized assessments and individualized treatment plans. They then return to their home bases, with the expectation that local providers will implement these treatment plans. The NICoE facility accepts five new patients per week, for a total of 20 patients per month. At the time of this evaluation, approximately 400 service members had received services at the NICoE.
NICoE administrators and staff view comprehensive assessment, development of customized treatment plans, and education of the patient and family members as their primary clinical aims. The facility supports state-of-the-art diagnostic testing. In addition, the NICoE provides traditional and alternative treatments such as group counseling, psychoeducation, yoga, Tai Chi, and service dog training. Given the short stay, these treatments are also considered assessments. That is, patients engage in the treatment modality during their stay in order to assess whether continued engagement with a given treatment approach would be beneficial and should be added to their long-term treatment plan.
Because service members spend only four weeks at the NICoE and continue their treatment at their home stations, the NICoE's success in addressing the needs of service members and their families is impacted to a great degree by its relationships with home station providers, patients, and their families.
The RAND Corporation was asked to evaluate the complex communication and relationships between the NICoE, home station providers, and patients and provide recommendations for strengthening these ties in order to improve care for service members with mild to moderate TBI. Through surveys, site visits, and interviews, we examined the interactions between the NICoE, home station providers responsible for referring patients and implementing NICoE treatment plans, and the service members who receive care.
The aims of the RAND research team's evaluation were to
- evaluate the process for referring service members from the home station to the NICoE
- examine the NICoE assessment and treatment processes, including interactions with the home station during that time
- evaluate the patient's process of transitioning back to the home station and home station providers' implementation of the NICoE recommendations.
Our approach to achieving these aims was to examine the interactions between the NICoE and home stations from three perspectives: (1) providers and staff at the NICoE, (2) home station providers, and (3) service members with mild to moderate TBI and psychological health conditions and their families. The results allowed us to develop a series of recommendations for the NICoE as it seeks to better meet the needs of the population it serves and as it moves forward with its plan to open satellite facilities across the country.
This evaluation focused on the interactions between the NICoE, home station providers, and the service members who receive care. We note that the NICoE is involved in many other activities, such as research and educational activities and the development of satellite clinics, which were outside the scope of this evaluation. Further, we note that this evaluation did not focus on the effectiveness of the NICoE in improving patient outcomes nor on the cost-effectiveness of the NICoE model, both of which are worthy of investigation in the future.
Home Station Provider Perceptions of the NICoE
Overall, we found that home station providers and patients perceived the NICoE as mitigating some of the barriers service members face in seeking treatment for TBI or psychological health problems, including resource constraints, stigma, and provider turnover at home station facilities. There were differences in how home station providers viewed the role of the NICoE's diagnostic services, however. Providers at smaller, more rural sites viewed the NICoE's clinical role as extremely valuable. Providers from larger facilities were more likely to perceive the NICoE's role as duplicative or equivalent in quality. That said, most providers agreed that more communication and a better understanding of the NICoE's mission and services would help improve coordination among the facilities and providers involved with a patient's care.
Perceptions of the NICoE Referral Process
According to the NICoE, to be eligible for a stay at the NICoE, service members must meet the following criteria:
- Active-duty service member from any service branch (including the National Guard and reservists on orders)
- A mission-related mild or moderate TBI
- A comorbid psychological health condition(s)
- Failure to respond to TBI and mental health care offered at the service member's home station
- The potential and desire to return to duty.
The most common reasons for referring a service member to the NICoE, as reported by home station providers who had made such referrals, were that the patient's TBI or psychological health problems were complex and severe and that the patient's symptoms were not improving with the current treatment. These indicators are consistent with the NICoE's eligibility criteria. However, home station providers also reported referring patients who were undergoing medical evaluations as part of the process for separating from the military and were unlikely to return to full duty. The most commonly endorsed reasons for not referring a patient to the NICoE were that the patient did not have TBI and a co-occurring psychological diagnosis, he or she was responding well to the treatment the clinician was providing, or he or she did not have the capacity to engage safely in an outpatient setting.
While home station providers did not cite lack of access to adequate treatment at the patient's home station as a reason for referral, many former NICoE patients in our survey expressed low levels of satisfaction with the care received at their home station. During site visits, both patients and home station providers noted that patients often faced challenges accessing care, such as long wait times for appointments and staff shortages, and that many patients did not have access to complementary and alternative medicine (CAM) treatment modalities.
In general, the home station providers with whom we spoke during our site visits reported that the referral process was relatively easy, though some providers expressed a desire to have more information from the NICoE about the eligibility criteria and reasons why patients are or are not accepted into the program, to help inform future referrals. Overall, almost all patients who are referred to the NICoE accept the referral.
Perceptions of the NICoE Assessment and Treatment Processes
Our survey and site visit interviews included several questions about provider, patient, and family member satisfaction with the services provided during a patient's stay at the NICoE and the quality of communication between home station providers and NICoE staff. While opinions of the value of a stay at the NICoE, the facility's care model, and its efforts to involve family members in patient care were positive, some providers noted gaps in the NICoE's communication about patient progress to providers and limited knowledge of the services available at home station facilities.
Despite a generally positive impression of NICoE services, home station providers noted a number of concerns. Some providers—particularly those at well-resourced military treatment facilities (MTFs)—did not perceive a significant difference between the types of services offered at the home station and those offered at the NICoE. Other home station providers expressed concern that the NICoE assessment process can appear to question the competency of home station providers by repeating diagnostic assessments that had already been completed. They noted that this practice could contribute to lower levels of patient satisfaction with home station care.
The NICoE places a significant emphasis on education and the opportunity for family members to be informed and involved in a patient's care. Patients and their spouses had generally positive impressions of the NICoE's efforts in this area. We heard some suggestions from patients and their spouses that communication could be improved prior to patients' admission to the NICoE, with more information about what to expect during the stay and a more clearly defined role for family members who accompany patients. Overall, patients and their spouses who participated in our interviews believed that the NICoE's value was in the personal attention provided to patients by a team of providers, the ability to develop integrated and individualized treatment plans that take into account multiple problems, and the flexibility of the treatment options provided.
Experience of Transitioning Back to the Home Station
At the end of a patient's stay at the NICoE, NICoE staff develop an individualized treatment plan with recommendations for follow-up care. The NICoE's diagnostic findings and recommendations are described in a discharge summary intended to direct the treatment the patient will receive when he or she returns to the home station.
During our visit to the NICoE, we learned that the discharge planning process requires collaboration between the interdisciplinary team of NICoE providers and case managers, the home station providers and case manager, and the patient and his or her family. Many home station providers had positive things to say about these opportunities to discuss the NICoE's recommendations and treatment plan.
While some former NICoE patients experienced smooth transitions back to their home stations, others encountered challenges. Several patients recommended better preparation and communication between the two sets of providers and the patient to ensure that the NICoE's recommendations were understood. Home station providers generally agreed that the discharge summary was extremely thorough, though this was not always viewed as a positive. Some home station providers expressed frustration with the length and contents of the summary, and many recommended shortening the summary document and increasing communication between the NICoE and home station providers.
During interviews with NICoE staff and administrators, it appeared that little information is returned to the NICoE about what recommendations are or are not implemented by home station providers. NICoE staff worried about this information void and the possibility that they might be recommending care that the patient would not be able to access, such as CAM therapies that are not readily available in all areas. Indeed, we found that many patients were unable to access CAM treatment at their home stations, and some had difficulty accessing even traditional specialty care.
NICoE patients return home to a variety of treatment facilities. Given the diversity of home stations, it is perhaps not unexpected that satisfaction with home station care also varied. During interviews with former NICoE patients, some noted exceptional care on return to their home stations, and others were dissatisfied with home station services relative to the care they received at the NICoE.
It is important to consider the limitations of our study when interpreting its conclusions. In particular, there are some limitations to the generalizability of our findings. We did not survey or interview all former NICoE patients and their providers, and, thus, our sample may not be representative of the overall population of former NICoE patients and their providers. The response rates to our survey were only 20–30 percent, though this is in the expected range for web-based surveys. Similarly, we visited a limited number of home stations, and although we sought to maximize variability in experiences with the NICoE with our method of site selection, there may be opinions and experiences not represented in our evaluation. Furthermore, our data collection focused on providers and patients with some familiarity or experience with the NICoE. We cannot speculate on the extent to which our findings about home station TBI care generalize to service members and care providers who lack experience with the NICoE. It is also possible that the overall positive views about the NICoE expressed by former NICoE patients were biased by patients' pretreatment expectations that the NICoE would provide higher quality care than their home station. In particular, these positive expectancies could be due to a perception that more care is better care (Carman et al., 2010). In addition, the study relied on retrospective, self-report methods. Any participant may have recall difficulties, but patients with TBI-related memory impairments may have particular difficulty accurately recalling past experiences. Future evaluations should implement prospective, longitudinal designs to more rigorously assess service members' transitions to and from the NICoE. Still, the surveys and site visits provided rich, detailed information that may contribute to improved care for service members with TBI.
Finally, although the NICoE has become relatively well known among TBI providers and the general public, it had only been operational for four years at the time of this writing and has likely changed a great deal since its inception. It is possible that relationships and communication strategies between the NICoE and home stations have been streamlined and adjusted over time, and our findings do not necessarily account for such adaptations.
Despite these limitations, we believe the integration of multiple data sources, both quantitative and qualitative, provides key insights about communication patterns between NICoE and the home station providers and patient transitions between facilities.
We drew on key findings from the evaluation to develop four categories of recommendations to improve future care for service members with TBI: the NICoE's mission, the process of referring patients to the NICoE, the assessment and treatment services the NICoE provides, and the process by which patients transition back to their home stations.
The NICoE's Mission
Recommendation 1. Clearly define and communicate the clinical, research, and educational roles of the NICoE within the Military Health System (MHS). The NICoE's mission is to play a role in complex TBI treatment, research, and education, but for some NICoE staff and home station providers we spoke with, the role of the NICoE was not yet clear. We identified two specific recommendations in this area.
Recommendation 1a. Review and adapt the NICoE's strategic plan as the NICoE and the MHS evolve. In reviewing and considering revisions of the NICoE's strategic plan, stakeholders should consider the history of the NICoE, the changing context of the MHS, and an articulated vision for the NICoE over the next five or ten years. The strategic plan should also identify measurable goals for the NICoE, with a clear strategy for meeting those goals.
Recommendation 1b. Develop a consistent message about the role of the NICoE and disseminate this message widely. Once the optimal role for the NICoE is determined, the NICoE should clearly, broadly, and routinely disseminate its message about its role, as well as any changes to its policies and how it interacts with service members and home station providers. A strategic plan could be used as a guiding document for developing outreach and messaging materials. Other DoD organizations with similar goals (e.g., DCoE, Defense and Veterans Brain Injury Center [DVBIC]) should work with the NICoE to communicate with stakeholders about the NICoE's role.
Recommendation 2. Foster a collaborative culture between the NICoE and home station providers. Some home station providers felt that their patients returned from the NICoE with a lower opinion of the care they received at their home stations. NICoE and home station providers may have different treatment philosophies and models of care. However, they should work together to develop a clear and collaborative message about the roles of the NICoE and the home station.
Referral of Service Members to the NICoE
Recommendation 3. Inform home station providers about the NICoE's eligibility criteria. We identified three specific recommendations in this area.
Recommendation 3a. List and regularly update eligibility criteria on the NICoE referral form and website. Home station providers expressed confusion about the NICoE's inclusion and exclusion criteria. Eligibility criteria should be clearly stated on the NICoE referral form and on the NICoE website.
Recommendation 3b. Reconsider “potential and desire to return to active duty” as a NICoE eligibility criterion. This criterion appears to be in conflict with other eligibility criteria and does not seem to be consistently implemented, as many NICoE patients reported being in the process of a Medical Evaluation Board review prior to and while at the NICoE. From a force strength perspective, it may be important to restrict access to the NICoE to only those service members who are most likely to return to active duty. If this is the priority, potentially conflicting eligibility criteria may need to be eliminated or revised for clarity.
Recommendation 3c. Adhere to eligibility criteria consistently and clearly communicate to home station providers the rationale for any exceptions or modifications. Eligibility criteria may evolve as the NICoE satellites open and as the needs of service members and the MHS change over time. The NICoE should ensure that its intake and referral processes are as consistent, fair, and transparent as possible. When exceptions or revisions to eligibility criteria must be made, their rationale should be clearly communicated with home station providers.
Recommendation 4. Focus patient recruitment on service members in greatest need. We identified two specific recommendations in this area.
Recommendation 4a. Actively seek referrals for service members at low-resource home stations. Our findings suggest that the patients and providers who perceived the greatest benefit of the NICoE were those located at sites with few resources and who were geographically isolated from major hospitals and treatment centers. Outreach to a wider variety of providers and service members may bring referrals and simultaneously help connect underserved service members with the TBI care they need. In addition to direct patient recruitment, NICoE outreach could include education about the NICoE and its services and consultation with home station providers. If this recommendation is implemented, it will be important to carefully tailor the treatment plan for service members at these sites to ensure the availability of recommended care once they return to their home stations. In addition, unlike patients from high resource stations, these patients may not have completed first-line clinical practice guideline (CPG) recommended treatments for TBI and comorbid mental health conditions (VA/DoD, 2009a; 2009b; 2010). Treatment plans should therefore focus on obtaining evidence-based care for these patients, as opposed to the alternative treatments that are more appropriate for those who have already tried and failed first-line care.
Recommendation 4b. In deciding which patients to accept at the NICoE, consider prioritizing service members who have very complex presentations or who have exhausted all home station treatment options. To conserve resources, the NICoE should consider a more conservative intake process, limiting referrals from high-resource home stations to only the most complex cases and those who have exhausted local treatment options. The NICoE could also offer consultation to home station providers treating patients with complex symptoms in need of certain expertise or a second opinion as a first step before accepting these patients into the NICoE.
NICoE Assessment and Treatment Services
Recommendation 5. Evaluate the effects of NICoE assessment and treatment services on patient outcomes. Future studies using experimental designs or matched comparison groups may help to determine the extent to which NICoE services result in improved patient outcomes compared with treatment as usual.
Recommendation 5a. Conduct a cost analysis of the NICoE. Because the NICoE represents a considerable investment of resources, an analysis should be conducted to determine the costs associated with providing services to service member populations at the NICoE compared with home stations and to identify which services could be provided at home stations for the same or lower cost. We note that any cost analysis should take into account the unique nature of the NICoE as a public-private partnership.
Transitioning from the NICoE Back to the Home Station
Recommendation 6. Increase and formalize communication and coordination between the NICoE and home station providers. We identified two specific recommendations in this area.
Recommendation 6a. Bolster communication and coordination early on in the treatment process (ideally at intake) and sustain this level throughout the patient's stay at the NICoE. Currently, the NICoE communicates with the referring home station provider primarily at intake and discharge and not as much throughout the patient's stay at the NICoE. To improve communication, the NICoE may wish to coordinate the time of these calls with home station providers' schedules to increase the likelihood that the home station provider can attend.
Recommendation 6b. Enhance communication between the NICoE and home station specialty providers. Given that the NICoE is unusual in its integrated interdisciplinary approach to care, we suggest connecting specialists with one another. Improved information sharing may also allow the NICoE to ensure that all treating home station providers—not just the referring provider—are invited to the discharge conference call and directly sent the discharge summary.
Recommendation 7. Streamline discharge summaries and provide recommendations in the context of the treatment already delivered by the home station. We identified two specific recommendations in this area.
Recommendation 7a. List treatment recommendations near the beginning of the report. Several patients and providers noted the NICoE discharge summary is somewhat cumbersome due to its length. They mentioned that the summary would be more helpful if there were a “bottom line up front.” For instance, recommendations could be listed on the first page rather than the last page.
Recommendation 7b. Ensure that discharge summaries clearly acknowledge services previously delivered and provide a rationale. Home station providers noted that NICoE treatment recommendations sometimes suggested treatment modes that have already been completed or were ineffective. These providers were uncertain as to whether this was because NICoE providers were unaware of the services previously delivered or because they believed more of that treatment—or a different version of it—would be helpful. In such cases, NICoE providers should explicitly acknowledge previous treatment when they are aware of it and explain the reasoning for suggesting more of the same intervention.
Recommendation 8. Ensure that service members can access recommended care at or near their home station and are aware of its cost. The CAM approaches offered by the NICoE were commonly recommended but often difficult to access at service members' home stations. Before completing the discharge summary, the NICoE should work with the patient and with home station providers to determine (1) whether specific services are available at or near the home station and (2) whether they are covered by the service member's insurance. When a treatment is not covered or easily accessible, the team should prepare a backup plan.
Recommendation 9. Enhance patient tracking and follow-up after discharge. According to participating NICoE staff members, the NICoE aims to follow all of its patients indefinitely after they are discharged to determine whether treatment gains are sustained and whether patients are accessing needed care, as well as to identify gaps in services or barriers to care that must be addressed. To successfully follow the growing number of NICoE patients after discharge and to identify barriers to care and gaps in services, more resources must be invested in this effort, in terms of both manpower and devising a better method for patient follow-up.
VA/DoD—see U.S. Department of Veterans Affairs and U.S. Department of Defense.
U.S. Department of Veterans Affairs and U.S. Department of Defense, VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury, version 1.0-2009, 2009a. As of July 2, 2014:
U.S. Department of Veterans Affairs and U.S. Department of Defense, “VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder (MDD),” 2009b. As of July 25, 2014:
U.S. Department of Veterans Affairs and U.S. Department of Defense, “VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress Disorder. Version 2.0,” 2010. As of July 25, 2014:
This research was sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.