Federal Watch (TBI) « Homeless Veterans Provider Technical Assistance Center


Federal Watch (TBI)
		May 4th, 2010
FEDERAL WATCH Federal Watch is a synthesis of Federal news and activities related to Traumatic Brain Injury (TBI). Federal Watch is disseminated on a quarterly basis to keep TBISERV subscribers informed on the Federal level. Issue Features: • INSTITUTE OF MEDICINE (IOM) OF THE NATIONAL ACADEMIES – Consensus Report Returning Home From Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families • U.S. DEPARTMENT OF DEFENSE (DoD) Defense and Veterans Brain Injury Center (DVBIC) – Multimedia TBI Curriculum DVBIC – TBI by the Numbers! Research Shows Promise for Wounded Warriors, Public Veterans Affairs (VA) Secretary Eric K. Shinseki: VA Tackles Root Causes of Homelessness • U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) Centers for Disease Control and Prevention (CDC) – Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006 Substance Abuse and Mental Health Services Administration (SAMHSA) – Homelessness Resource Center Announces New Special Issue on the Future of Homeless Services ________________________________________ INSTITUTE OF MEDICINE (IOM) OF THE NATIONAL ACADEMIES Consensus Report – Returning Home From Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families Unanswered Questions, Lack of Data Hinder Agency Efforts to Meet Needs of Iraq, Afghanistan Service Members, Veterans, and Families The report was requested by Congress and sponsored by the U.S. Department of Defense. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. To help current and former military personnel of the wars in Iraq and Afghanistan and their families readjust to post-deployment life, the U.S. departments of Defense and Veterans Affairs need to gather information to answer many uncertainties, including how many mental health care providers are needed and where, what works best in treating traumatic brain injury (TBI) over the long term, and whether giving service members time to decompress before returning home would be beneficial, says a new report from the Institute of Medicine. VA also needs to institute a process of forecasting the amount and types of resources necessary to meet the needs of the veterans and their families in the next 30 years or more when their demand for health care and disability compensation is likely to peak. In addition, VA and DoD should oversee coordination and communication among the dozens of public and private programs created to serve current and former Iraq and Afghanistan service members, veterans, and their families, said the committee that wrote the report. The agencies should organize an independent evaluation of the programs, given that it is unclear whether they are all effective and whether redundancy among the programs helps ensure the needs of service members, veterans, and their families are met. This report presents preliminary findings of a two-phase study of the readjustment needs of current and former service members deployed to Iraq and Afghanistan and their families. In this first phase, the committee sought to identify the most pressing needs of this population through an initial review of the limited scientific literature available as well as media reports and testimony from veterans and their families at town-hall meetings. The second-phase report will present more detailed findings and recommendations based on an in-depth review of additional information, including data anticipated from several ongoing studies. “DoD and VA deserve credit for what they have done thus far to respond to the readjustment needs of individuals who have served in Iraq and Afghanistan and their families, but in some instances the response has fallen short,” said committee chair George Rutherford, Salvatore Pablo Lucia Professor and vice chair, department of epidemiology and biostatistics; and director, prevention and public health group, Global Health Sciences, University of California, San Francisco. “For example, we heard repeatedly that there are not enough mental health providers to meet the demand. Job training and job loss due to multiple deployments are other serious issues facing these individuals, as is doctors’ ability to diagnose and treat traumatic brain injuries. Our goal in the next phase of this study is to describe in more detail the educational, health, rehabilitation, and other services needed by military personnel, veterans, and their families as they transition back into life in the United States.” Many wounds suffered in Iraq and Afghanistan will persist over veterans’ lifetimes, and some impacts of military service may not be felt until decades later. Requests for disability care and compensation by veterans of previous wars did not peak until 30 years or more after their service ended, suggesting that the maximum demand on support services for Iraq and Afghanistan military personnel and their families may not occur until 2040 or later, the report notes. The VA lacks a mandate and the resources to forecast future health care and disability needs of veterans and their families, limiting the agency’s ability to plan for the infrastructure, work force, and other needs when demand is likely to be greatest. VA should institute an annual process of projecting the future health and disability benefits for this population, and Congress should provide the agency the necessary funds to conduct these forecasts, the committee said. TBI has been called the signature wound of the fighting in Iraq and Afghanistan. VA established a comprehensive system of rehabilitation services for polytrauma, including TBI, focused on needs that arise in the initial months and years after injury. However, it lacks protocols to manage the lifetime effects of TBI because this issue has not been studied in either military or civilian populations. VA should sponsor research to determine the efficacy and cost effectiveness of developing protocols for the long-term management of polytrauma and TBI, the report says. The process of third-location decompression — sending service members to an interim place between the country where they served and their home nation to rest and prepare themselves for going home — has anecdotally resulted in other nations’ troops experiencing smoother transitions to civilian life than an immediate return home, the committee found. Since little research has been conducted to support these accounts, however, the committee stopped short of recommending the practice for U.S. personnel and called on DoD to conduct a formal assessment of third-location decompression. DoD and VA need to ensure there are enough mental health professionals in the health care systems serving current and former military personnel and their families to provide treatment to those who suffer from post-traumatic stress disorder, substance abuse, and other mental health problems, and that these providers are located where they are needed, the report says. Reports from health care providers as well as service members indicate that providers are overwhelmed and wait times for services are long. DoD also needs to deal with service members’ reluctance to report mental health problems and seek treatment, which may arise from agency policies to report these problems up the chain of command. DoD should review how it handles confidentiality and the relationship between seeking treatment and advancement in the armed services. Copies of Returning Home From Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.nap.edu. U.S. DEPARTMENT OF DEFENSE (DoD)* * Defense and Veterans Brain Injury Center (DVBIC) Multimedia TBI Curriculum A new multimedia, TBI curriculum will make training on traumatic brain injury (TBI) more accessible, exciting and, in some cases, required for duty. In 2007, the U.S. Army TBI Task Force toured a number of military treatment facilities to identify best practices in TBI assessment and treatment. One finding was that the most successful TBI programs had two key elements: effective case management/care coordination and strong TBI education. The Task Force discovered significant need for robust TBI training across the Military Health System to include TBI awareness materials for military line/leadership and military/line leadership materials, basic TBI clinical information, and focused TBI education specific to a variety of disciplines involved in TBI care. The Army Medical Command (MEDCOM) Proponency Office for Rehabilitation and Reintegration (PR&R), using congressionally allocated funds, spearheaded an effort to enhance TBI education across the DoD. They brought together subject matter experts (SMEs) from all Services, DCoE and DVBIC to develop a comprehensive multimedia curriculum. This ongoing process has culminated in an exciting modular program for individuals with a variety of backgrounds to include Service Members (SMs), Families, leaders and providers. The TBI curriculum is laid out in a tiered system that targets TBI education to specific audiences. The following categories will contain modules that may be viewed independently but, in most cases, are intended to build on knowledge gained as a provider completes multiple recommended modules for their profession. -100 General Audiences -200 Medical Personnel and Leaders -300 Deploying Medical Personnel -400 Continental US (CONUS) Primary Care Personnel -500 Discipline – Specific Training (for healthcare providers in their own field) -600 Patients and Families From the beginning of development, PR&R and the SMEs have worked to ensure that the final products would represent all the Services, from the uniforms seen in video clips and imaging to terminology used throughout the training. The first four modules of the TBI curriculum are expected to be on MHS Learn in Spring 2010, where registered healthcare providers will be able to complete the training and obtain continuing medical education credits/continuing education units/training certificates according to their profession. Civilian TRICARE healthcare providers will also be able to participate. In addition, the modules will be available on DVD, but without continuing education credit unless offered through a registered class. In recognition of the prevalence and risk of TBI in the military, all U.S. Army Service Members will be required to take some aspect of the TBI curriculum training. All MEDCOM SMs will be required to take the 200 module. Deploying healthcare personnel will take 200 and 300. 400 will be mandated for primary care providers. The strongest push right now for the new TBI curriculum is to make it widely available. As LTC Lynne Lowe, Clinical Staff Officer and Army TBI Program Manager in the Proponency Office for Rehabilitation and Reintegration, Health Policy and Services, Office of The Surgeon General states, “Tools must be placed where they can be accessed and utilized by as many people as possible.” DVBIC – TBI by the Numbers! Clinicians can assist in force health protection by accurately coding traumatic brain injuries (TBIs). Data on the number of TBIs sustained by Service Members (SMs), severity of injuries and course of recovery help shape clinical care, direct research and inform policy for protecting SMs. As described in the Winter 2008–09 DVBIC Brainwaves issue, DVBIC facilitated DoD participation in a tri-service multi-agency panel that met with U.S. Department of Veterans Affairs (VA) leaders to develop a joint proposal to refine use of the ICD [International Statistical Classification of Diseases and Related Health Problems] coding system to ensure that all cases of TBI are accurately documented. This joint VA-DoD proposal was officially adopted by the Centers for Disease Control and Prevention/Center for Health Statistics and has become official ICD-9 policy. These ICD-9 coding revisions for TBI were recently published in the Armed Forces Health Longitudinal Technology Application (AHLTA), the military electronic medical documentation system. Key points of the revised guidance will improve tracking and understanding of TBI symptoms and psychiatric comorbidities, as follows: -V-codes will better describe the severity of the TBI and association with the Global War on Terrorism (GWOT). -The appropriate V-15.52_x code will be used at the initial, and all subsequent, encounters. -The 8xx.xx series TBI codes are only to be used when a TBI is first diagnosed. -Upon follow-up, a late effect v-code plus the deployment v-code will be documented. -New codes for emotional and behavioral symptoms of TBI such as irritability, emotional lability, and impulsiveness (799.xx series) may be used when the patient does not have a psychiatric diagnosis. For more guidance on TBI coding, please visit the TBI Clinical Tools & Resources section at www.DVBIC.org. Research Shows Promise for Wounded Warriors, Public A sign on the highway identifying the exit ramp for Fort Detrick gives little indication of the revolutionary science being advanced behind its gates – aimed at unlocking everything from cures for breast and prostate cancer to new ways to treat post-traumatic stress and traumatic brain injuries. The U.S. Army Medical Research and Materiel Command is overseeing these and dozens more innovative projects through its Congressionally Directed Medical Research Programs. Congress funded the initial effort in 1992 to promote cutting-edge breast cancer research. Eighteen years later, CDMRP is the world’s second-largest funder for breast, prostate and ovarian cancer research. But with a $400 million budget now funding 17 different programs, it has expanded its focus to confront some of the world’s most devastating health problems. The CDMRP differs from many other medical research programs because it’s willing to take on promising but high-risk research, recognizing the potential payoffs, explained Navy Capt. (Dr.) Melissa Kaime, the program director. “Innovation has been our watchword from the beginning,” she said, with a goal of moving beyond incremental science to spawn big advances and even breakthroughs. The projects tap into some of the world’s most respected minds at universities and medical centers around the country, working together through consortia on some programs to conduct research and clinical trials. Many involve wounded warriors receiving care at military medical facilities or Department of Veterans Affairs’ clinics. One program will test new ways to identify and treat combat veterans suffering from post-traumatic stress disorder or traumatic brain injuries. Among eight planned clinical trials, one, to begin this spring, will test the benefit of administering a synthetic form of a neurosteroid drug to PTSD patients. The drug appears naturally in the brain, but at lower levels among some PTSD patients, explained Dr. Holly Campbell-Rosen, grants manager for the program. “The idea is that by giving it to people, it will help relieve them of some anxiety, rage, aggression and other PTSD symptoms,” she said. Another program aims to assess behavioral therapies to treat combat-related PTSD – something Dr. Kim del Carmen, grants manager for the 15 associated research projects that are part of the STRONG STAR consortium, says has not been done for active duty service members. Another research project under her purview is studying the benefit of providing treatment in primary-care facilities, rather than dedicated mental health clinics. Anecdotal evidence shows there’s less stigma associated with getting care in primary-care settings, but the study will provide scientific evidence of its impact, del Carmen said. One project already under way in central Texas is studying the benefit of providing troops diagnosed with PTSD four 30-minute sessions with a behavioral health consultant over the course of six weeks. Just over a dozen participants have completed their full treatments to date at Brooke Army Medical Center, Wilford Hall Medical Center and the South Texas Veterans Health Care Services facility. The results are showing promise, del Carmen said, with almost half of the participants no longer being diagnosed with PTSD and most others exhibiting less-severe symptoms. Yet another consortium, being conducted by four academic institutions and their associated hospitals and training centers in the Houston area, is seeking to develop better ways to diagnose mild traumatic brain injury and improve patients’ prospects of overcoming it through almost immediate treatment. One clinical trial will study the link between endocrine dysfunction in participants with mild TBI, and the benefit of treating them with hormone supplements, explained Dr. Charmaine Richman, grants manager for the program. Another trial will attempt to identify biomarkers – biological changes in the cells or blood – associated with TBI. The idea, Richman explained, is to come up with a quick, relatively noninvasive way to diagnose TBI, ideally, within 24 hours of the injury when the signs are the most obvious. This, she said, will lead to faster intervention and a better likelihood of reversing the damage. Research being funded through the Congressionally Directed Medical Research Programs will benefit not only warfighters, but society as a whole, Kaime said. “Good research has a way of extending itself beyond its borders,” she said. “So if we find good research techniques or novel pathways and it can be translated into the broader scientific context, we all win – in ways we can’t even imagine now.” * Veterans Affairs Secretary Eric K. Shinseki: VA Tackles Root Causes of Homelessness No one who has ever served the United States in uniform should ever end up living on the street, Veterans Affairs Secretary Eric K. Shinseki insists. So he’s committed to ending homelessness among America’s veterans within the next five years, and reports he’s already seeing signs of progress through a plan that provides not just beds, but also services to address the root causes. With increased funding in VA’s fiscal 2011 budget request, Shinseki told American Forces Press Service, he’s intent on expanding the homeless program to include more preventive services: education, jobs and health care. “When I arrived [at VA], the homeless program primarily involved engaging the veterans that sleep on the streets and getting them to shelter,” he said. “The deeper I dug into it, I realized it assured that we’d be dealing with homeless veterans forever, because [the system] is reactive. You wait to see who shows up on the street, you go out and try to encourage them to leave the streets and provide them safe shelter and warm meals.” To break that spiral, 85 percent of VA’s budget request for the homeless program will go toward medical services to confront substance abuse, depression, post-traumatic stress disorder, traumatic brain injury and other issues linked to homelessness. “I looked at it as a funnel, and out of the bottom comes a homeless person,” he said. “Well, in the funnel, there is the missed opportunity of education. … It’s the missed opportunity to have a job.” Shinseki is committed to ensuring veterans don’t miss out on these opportunities and wind up in the “downward spiral” that too often leads to homelessness. The new Post-9/11 GI Bill signed into law in June will make education more accessible for more veterans, he said, as well as a broad range of other VA-funded educational programs. Meanwhile, VA is working through the interagency process and with a host of other organizations to improve veterans’ job opportunities. Shinseki and Labor Secretary Hilda L. Solis co-chair an interagency task force committed to getting federal agencies to hire more veterans. VA, the Labor Department and the Small Business Administration also are encouraging more veteran-owned small businesses to compete for contracts, and helping to connect these business owners with other veterans. “We know that veterans hire veterans. They know veterans, and they are comfortable with hiring veterans,” Shinseki said. “So the idea is to get the churn going [and] to get more employment for veterans.” Early indications show progress since Shinseki announced his homeless initiative last fall, with homelessness among veterans dropping by about 18 percent from an estimated 131,000 to 107,000 homeless veterans today. “This is a good start,” Shinseki said, but he vowed to be the driving force behind a “full-court press to keep driving those numbers down.” Anything less, he insisted, represents a failure of the system to provide the support its veterans deserve. “This is not about reducing homelessness. This is ending veteran homelessness in five years,” he said. “I don’t have all the answers about how this will all happen, but a lot of people are committed to this and working to prevent … this downward spiral.” U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) Centers for Disease Control and Prevention (CDC) Report – Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006. At least 1.7 million people sustain a traumatic brain injury (TBI) in the United States each year. Of those individuals, about 52,000 die, 275,000 are hospitalized, and 1.365 million are treated and released from an emergency department. The number of people with TBI who are not seen in a hospital or emergency department or who receive no care is currently unknown. Population-based data on TBI are critical to understanding its impact on the American people. Knowing who is affected by TBIs and how they occur can help shape prevention strategies, priorities for research, and also support the need for services among individuals living with TBI. CDC’s report Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths, 2002-2006 presents data on the incidence of TBI and is an update to CDC’s previously published report released in 2006. This current report presents data on emergency department visits, hospitalizations, and deaths for the years 2002 through 2006. Data in the Report Include: -TBI as a portion of All Injuries -TBI by Age -TBI by Sex -TBI by Race -TBI by External Cause -Additional TBI Findings Get the Facts* -Visit http://www.cdc.gov/traumaticbraininjury/tbi_ed.html to download a copy of the report or the fact sheet/press release for an overview of key findings in the report. TBI Estimates by State CDC currently funds 30 States to conduct basic TBI surveillance through the CORE State Injury Program. For more information, visit http://www.cdc.gov/injury/stateprograms/index.html. *Substance Abuse and Mental Health Services Administration (SAMHSA) – Homelessness Resource Center Announces New Special Issue on the Future of Homeless Services SAMHSA’s Homelessness Resource Center is announcing the release of a special issue of the Open Health Services and Policy Journal on “The Future of Homeless Services.” Guest edited by the Homelessness Resource Center, the special issue describes the services and supports needed to help individuals and families exit homelessness and maintain housing. All articles in the special issue are available for free via open access. Visit the Homelessness Resource Center website to access the electronic full-text of articles in the special issue, at http://homeless.samhsa.gov/Channel/Future-of-Homeless-Services-503.aspx . To continue to improve the delivery and financing of prevention, treatment, and recovery support services, SAMHSA has identified 10 Strategic Initiatives to focus the Agency’s work. As part of this effort, SAMHSA’s housing and homelessness initiative is designed to end and prevent homelessness by increasing the availability of sustainable supportive housing and other services linked to permanent housing for individuals and families who are homeless or at risk of being homeless due to mental and/or substance use disorders. Homelessness affects men, women, families, children, youth, and veterans. While outside factors like economic conditions or the scarcity of affordable housing may in some cases cause homelessness, certain vulnerabilities may determine who is at higher risk of becoming homeless. These include addictions, mental illness, domestic violence, medical conditions, traumatic stress, and lack of education or job skills. To date, there is limited research documenting which services are most effective, the best models of delivery, and recommended intensity and duration. The aim of this special issue of the Open Health Services and Policy Journal on “The Future of Homeless Services” is to highlight services that may be most effective in helping individuals move out of homelessness and maintain a stable housing environment. The special issue includes research and review articles on: -Approaches to primary, secondary, and tertiary homelessness prevention. -A synthesis of the evidence base for two best practices in the homelessness field: outreach and engagement and trauma-informed care. -A framework for understanding the multiple service needs of families experiencing homelessness. -How a recovery framework benefits consumers of homeless service programs. -Strategies for understanding the current state of the homeless services workforce and increasing its capacity. Additionally, the special issue includes two commentary articles. Steven Gaetz, director of the Canadian Homelessness Research Network and the Homeless Hub, offers a review of the current Canadian approach to homelessness. Martha Fleetwood, founder and executive director of HomeBase/the Center for Common Concern in San Francisco, California contributes her perspective on the U.S. response to homelessness over the past thirty years. The Open Health Services and Policy Journal is a peer-reviewed Open Access online journal that publishes original research articles, reviews, and short articles in all areas of health services and health policy. The journal covers the research, organization, planning, evaluation, management, financing, policy, and provision of health services and healthcare. Funded by SAMHSA, the Homelessness Resource Center (HRC) is dedicated to improving the daily lives of people who are homeless and who have mental illness, substance use problems, co-occurring disorders, or trauma histories. HRC is funded by SAMHSA’s Homeless Programs Branch, within the Center for Mental Health Services’ Division of Services and Systems Improvement. HRC’s work includes on-site and virtual training, technical assistance, knowledge products, and an interactive 2.0 website targeted to direct service providers. Join the HRC community by visiting: http://www.homeless.samhsa.gov/ and clicking on “Register.” Community members can rate and comment on resources, network, and receive electronic newsletters from the HRC.