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SHP 08-185 – HSR&D Study

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SHP 08-185
Evaluation of Polytrauma Brain Injury Rehabilitation Transitional Program
Steven G. Scott DO MS BS
James A. Haley Veterans' Hospital, Tampa, FL
Tampa, FL
Funding Period: May 2008 - March 2009

BACKGROUND/RATIONALE:
Transitional programs provide comprehensive residential services to veterans or active duty military personnel who have sustained a brain injury and/or polytrauma who no longer require the intensity of inpatient program services but have the potential for increased independence. Delivery of a quality transitional program for polytrauma is complex due to the vulnerability of participants, the multiple needs of participants, the complexity of services required to address those needs, intense family involvement and close scrutiny by Congress, VA leaders and advocacy groups. Because transitional programs are new to the VA there is a great need to develop an interdisciplinary, team-oriented workforce that is able to provide numerous rehabilitation services. Given the challenges presented in the care of persons with polytrauma, the long term goal of this program of research will be to develop and test strategies to improve quality of life, patient satisfaction and community reintegration. The short term goal of this project is to begin to understand the educational and training needs of staff who provide transitional services and begin to explore the relationship between staff education and patient outcomes.

OBJECTIVE(S):
Objectives of this 6-month evaluation using multi-methods are to: (1) Identify learning needs (skills, knowledge, attitudes) of providers in the transitional program at one VAMC as perceived by staff as well as patients and family members; (2) Determine the content and processes of an educational program to meet the needs of providers; (3) Determine feasibility, test burden and content validity of a battery of outcome measures for patients and families. RESEARCH QUESTIONS: Research questions include: (1) What are the staff-, patient- and family-perceived learning needs for staff of transitional programs for persons with polytrauma? (2) What are potentially the most effective and efficient ways of delivering educational content to providers? (3) What are the best outcome measurement tools for patients, families and staff?

METHODS:
Focus groups and individual interviews were conducted with nine clinical staff, eight patients and nine family members. Open ended questions interview data were transcribed and content analysis was used to develop codes, higher level categories and finally a narrative account reflecting the perspectives of staff, patients, and families. Feedback was used from cognitive interviews to prioritize the utility of selected structured questionnaires to measure family functioning, patient satisfaction, and quality of life.

FINDINGS/RESULTS:
Interview results. Staff expressed numerous aspects of their work that gave them great satisfaction, for example, the opportunity to use their interpersonal skills (e.g. conflict resolution, de-escalation) at a high level to achieve positive patient outcomes and the high degree of teamwork required to provide care to this population. They also expressed the challenges in working in this program, such as working under high levels of scrutiny and visibility from oversight committees, helping families and patients to be realistic yet hopeful about treatment outcomes, feeling that politics and administration sometimes took precedence over clinical decision making. Staff had numerous suggestions for training that is necessary to work in this type of program including certification in brain injury and weekly in-services on special topics (such as dealing with difficult behaviors using role playing and other interactive methods, understanding role of each team member, advanced communication skills). Family members expressed gratitude for the services provided by the transitional care program and were appreciative of staff who showed patients towards their family members, were good listeners and communicators, had high tolerance for frustration, kept them informed about treatment plans and daily schedules, and attended to the physical safety of their loved ones. Family member preferred staff who had advanced training in TBI, who could navigate complex systems of care to "make things happen."

Questionnaire results. In general, patients preferred questionnaires that were shorter with brief directions and few response choices. They felt that the satisfaction questionnaires were not specific enough to address the transitional care program. Family members were generally positive about the family functioning questionnaires and said that they would be willing to complete them on a regular basis if it meant helping their family member.

IMPACT:
The proposed study launched a program of research in post-deployment health (one of the priority HSR&D topics) designed to improve rehabilitation outcomes to a priority VA population, persons who have sustained polytrauma/blast injuries in OIF/OEF. Understandings from the perspectives of staff and patients are being used to improve an existing comprehensive staff training program that will be empirically evaluated in future research.


PUBLICATIONS:
None at this time.


DRA: Military and Environmental Exposures, Acute and Combat-Related Injury
DRE: none
Keywords: Pain, Traumatic Brain Injury
MeSH Terms: none

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