Care Transitions to and from the National Intrepid Center of Excellence (NICoE) for Service Members with Traumatic Brain Injury

by Lynsay Ayer, Coreen Farris, Carrie M. Farmer, Lily Geyer, Dionne Barnes-Proby, Gery W. Ryan, Lauren Skrabala, Deborah M. Scharf

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Research Questions

  1. How effective is the process for referring service members from the home station to the NICoE?
  2. What characterizes the NICoE assessment and treatment processes, including interactions with the home station?
  3. How successful are the patient's process of transitioning back to the home station and home station providers' implementation of the NICoE recommendations?

Improvised explosive devices (IEDs) have been one of the leading causes of death and injury among U.S. troops. Those who survive an IED blast or other injuries may be left with a traumatic brain injury (TBI) and attendant or co-occurring psychological symptoms. In response to the need for specialized services for these populations, the U.S. Department of Defense (DoD) established the National Intrepid Center of Excellence (NICoE) in Bethesda, Maryland, in 2010. The NICoE's success in fulfilling its mission is impacted by its relationships with home station providers, patients, and their families. The RAND Corporation was asked to evaluate these relationships and provide recommendations for strengthening the NICoE's efforts to communicate with these groups to improve patients' TBI care. Through surveys, site visits, and interviews with NICoE staff, home station providers, service members who have received care at the NICoE, and the families of these patients, RAND's evaluation examined the interactions between the NICoE and the providers responsible for referring patients and implementing treatment plans.

Key Findings

Communication between home stations and the NICoE is insufficient

  • Better communication about patients would improve coordination of patient care and ease transitions to and from the NICoE.

Understanding of the NICoE's mission, eligibility criteria, and services varies across the Military Health System

  • Better messaging about the purpose and function of the NICoE would improve coordination of patient care.

The NICoE is seen to mitigate barriers service members face in seeking treatment for TBI or psychological health problems

  • Barriers include resource constraints, stigma, and provider turnover at home station facilities.

Home station providers had a favorable impression of NICoE services but noted concerns

  • Some didn't see a big difference in types of services; others saw problems with the NICoE's attitude toward home station care and creation of unrealistic expectations in patients returning to home station care.

The NICoE patient discharge planning process requires collaboration between NICoE and home station personnel, the patient, and the family

  • Some former NICoE patients encounter challenges in this transition.
  • It appears that little information is returned to the NICoE about what recommendations. are or are not implemented by home station providers.
  • Patient satisfaction with home station care is varied.

Recommendations

  • Clearly define and communicate the clinical, research, and educational roles of the NICoE within the Military Health System.
  • Foster a collaborative culture between the NICoE and home station providers
  • Inform home station providers about the NICoE's eligibility criteria.
  • Focus patient recruitment on service members in greatest need.
  • Evaluate the effects of NICoE assessment and treatment services on patient outcomes.
  • Increase and formalize communication and coordination between the NICoE and home station providers.
  • Streamline discharge summaries and provide recommendations in the context of the treatment already delivered by the home station.
  • Ensure that service members can access recommended care at or near their home station and are aware of its cost.
  • Enhance patient tracking and follow-up after discharge.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Evaluation Methods

  • Chapter Three

    History and Mission of the NICoE

  • Chapter Four

    Who Is Referred to the NICoE, and How Does the Referral Process Work?

  • Chapter Five

    NICoE Assessment and Treatment Processes

  • Chapter Six

    Transitioning from the NICoE to the Home Station

  • Chapter Seven

    Discussion and Recommendations

  • Appendix A

    NICoE Site Visit Discussion Guide

  • Appendix B

    Home Station Installation Patient Discussion Guide

  • Appendix C

    Home Station Installation Spouse/Caregiver Discussion Guide

  • Appendix D

    Home Station Installation Provider Discussion Guide

  • Appendix E

    Survey Measures

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.

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