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Research Questions

  1. What services were critical to amputation care and rehabilitation in the early 2000s, when combat-related amputations were at their peak?
  2. What core competencies are common to all services? What are the best means for inculcating them?
  3. Are there military frameworks that can be used to implement and evaluate them?
  4. Can best practices, knowledge, and skills from the civilian sector be adapted to the military setting?

Since September 11, 2001, the Department of Defense (DOD) has rehabilitated more than 2,000 service members and veterans who experienced one or more deployment-related amputation(s), with the number of new amputations peaking in 2011. As a consequence of lower deployment, the number of new amputations has shrunk in each subsequent year, bringing with it the risk that provider skills will atrophy. In order to prevent this and to capture best practices, knowledge, and skills that were developed by DOD during the conflicts in Iraq and Afghanistan, RAND Arroyo Center researchers interviewed providers working in military treatment facilities to identify a set of services that are integral to optimal amputation rehabilitation. These services are behavioral health, biomedical engineering, case management, diet/nutrition, occupational therapy, orthopaedic surgery, physical therapy, physical medicine and rehabilitation, and prosthetics and orthotics. For those nine services, the researchers defined and documented the core competencies that are needed by health care provides who offer those services, as well as behaviors that demonstrate that a provider has the competency. The competencies common to all nine services fall into the following categories: teamwork, patient and family education, military and other cultural awareness, patient-centered care, evidence-based practice, and ethical and professional behavior. Using technical expert surveys, researchers asked providers in each service area to discuss their use and understanding of the core competencies, along with means for evaluating them, and then developed recommendations for how to adopt and implement them in the military health setting.

Key Findings

After September 11, 2001, the military sought to build a new system of care for combat amputees

  • The system included a new team approach to patient care.
  • The system included establishment of three advanced rehabilitation centers and the Extremity Trauma and Amputation Center of Excellence.
  • The system included the goals of returning patients to their pre-injury level of activity and giving them the option to remain on active duty.

Interviews with providers who have provided care to patients with amputation revealed six key competencies and associated behaviors, which can be used as a basis for further training, education, and professional development

  • These key competencies are teamwork, patient and family education, military and other cultural awareness, patient-centered care, evidence-based practice, and ethical and professional behavior.

These core competencies apply to nine services

  • These services are behavioral health, biomedical engineering, case management, diet/nutrition, occupational therapy, orthopaedic surgery, physical therapy, physical medicine and rehabilitation, and prosthetics and orthotics.

Recommendations

  • Core competencies need to be formally accepted by those leading and working in military health care settings. In order for this to occur, the competency framework must become part of standard operating procedure and include a common agreement for how it should be used in military provider settings.
  • Once competencies are accepted, those in military health care settings must decide how to use them. Performance appraisals are one key area, and Medical Command's existing competency assessment files can be adapted for this purpose.
  • Military health system leadership should adopt a proficiency framework for assessing individual and system-wide competencies to determine which levels and combinations of skills are appropriate for various installations and the system as a whole.
  • Metrics and assessment time frames associated with competencies must be validated for military health care settings. Linking metrics to patient outcomes and conducting assessments in such a way that patient outcomes are a focus, especially by including patients and family members in those assessments, will yield improvements in the quality of care.
  • Once optimal skill mix has been identified, mitigation strategies for competency gaps need to be developed. Here, partnerships between military and civilian sites can help expose military health care providers to more patients rehabilitating from amputations.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Amputation Rehabilitation Since September 11, 2001

  • Chapter Three

    Developing a Competency Model: Interviews and Technical Expert Surveys

  • Chapter Four

    Best Practices in Civilian Amputee Care for DOD Consideration

  • Chapter Five

    Conclusions and Recommendations

  • Appendix A

    Context of Battlefield Amputations

  • Appendix B

    Studies of Patient Outcomes and Examples of Recent Technological Advancements in Amputation Rehabilitation

  • Appendix C

    Interview Guides

  • Appendix D

    Codebook for Qualitative Analysis

  • Appendix E

    Results of the Technical Expert Survey

  • Appendix F

    Training and Education in Amputation Rehabilitation

Research conducted by

The research described in this report was sponsored by the U.S. Army Medical Command and conducted by the Personnel, Training, and Health Program within the RAND Arroyo Center.

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