Vocational Rehabilitation in the Veterans Health Administration Polytrauma System of Care: Current Practices, Unique Challenges, and Future Directions

Navigating the acute to post-acute transition with patients: a first characterization of medical student knowledge gaps in rehabilitation and post-acute care

PURPOSE

Clinical rehabilitation and post-acute care (PAC) learning experiences are not uniformly required within medical school core curricula in the United States or internationally. This study aims to characterize what medical students might know/need to know to support patients in the transition from acute hospitalization to post-acute rehabilitation settings.

MATERIALS/METHODS

The medical student cohort completing required clinical rotations in a United States quaternary care hospital system was provided a voluntary survey prompting reflection on experiences discharging patients to rehabilitation/PAC and related learning needs. Data were analyzed using descriptive statistics and qualitative grounded theory.

RESULTS

Response rate was 72% (39/54). All respondents reported at least one gap in rehabilitation/PAC knowledge, falling into 8 themes: daily experience of rehabilitation/PAC; determination of eligibility/screening processes; distinctions among levels of rehabilitation/PAC; insurance coverage/equity; rehabilitation/PAC clinical practice environment; post-rehabilitation/PAC discharge support; medical capabilities within PAC settings; developing rehabilitation goals.

CONCLUSIONS

Despite caring for patients discharged to post-acute rehabilitation settings, medical students lack essential knowledge about the process of rehabilitation and recovery, including patient eligibility for and service availability across PAC settings. Explicit rehabilitation/PAC education for medical students could enhance their ability to counsel and advocate for patients with disability and rehabilitation needs through care transitions.Implications for rehabilitationMedical students lack knowledge about rehabilitation and post-acute care that is important for helping patients navigate the acute to post-acute transition.Dedicated rehabilitation/post-acute care education could prepare trainees for counseling and advocating for patients during care transitions.Knowledge gaps identified in this study could inform development of curricular interventions to address medical student learning needs.

Implementation and use of video tele-technologies in delivery of individualized community-based vocational rehabilitation services to rural veterans

BACKGROUND: Telerehabilitation is an effective health delivery method for patients with a variety of health conditions. There is insufficient knowledge about use of telerehabilitation to support patients with disabilities and chronic illness in obtaining or sustaining competitive employment. Employment rates of Veterans are lower than civilian rates, and the employment gap is higher for Veterans living in rural areas. OBJECTIVE: To investigate factors that enabled and constrained routine use of video tele-technologies in delivering individualized community-based vocational rehabilitation (referred to as Tele-VR) services and to identify impacts and promising practices in implementation. METHODS: Semi-structured interviews with providers from two Veterans Health Administration Medical Sites that use telerehabilitation to supplement their existing face-to-face individualized community-based VR services. Interviews were analyzed using thematic analysis. RESULTS: Five themes in the implementation of Tele-VR were identified (1) Enhancing Workflow for Providers, (2) Improving Quality of Therapeutic Care, (3) Practicalities in Implementing Tele-VR, (4) Embedding Vocational Rehabilitation into Interdisciplinary Care as a Facilitator to Implementation, and (5) Impact of Tele-VR. CONCLUSIONS: The telerehabilitation delivery of employment service to Veterans with disabilities is a viable means for remotely providing or enhancing face-to-face individualized and community-based VR services that support Veterans’ competitive employment and job stability within their communities.

Network Analysis of Research on Mild Traumatic Brain Injury in US Military Service Members and Veterans During the Past Decade (2010-2019)

OBJECTIVE

To evaluate trends in the extant literature on mild traumatic brain injury (mTBI) in military service members and veterans using network analysis based on a comprehensive search of original, peer-reviewed research articles involving human participants published between January 1, 2010, and December 31, 2019. Specifically, we employed network analysis to evaluate associations in the following areas: (1) peer-reviewed journals, (2) authors, (3) organizations/institutions, and (4) relevant key words.

PARTICIPANTS

Included studies were published in peer-reviewed journals available on Web of Science database, using US military service members or veterans.

DESIGN

Bibliometric network analytical review.

MAIN MEASURES

Outcomes for each analysis included number of articles, citations, total link strength, and clusters.

RESULTS

The top publishing journals were (1) Journal of Head Trauma and Rehabilitation, (2) Military Medicine, (3) Brain Injury, (4) Journal of Neurotrauma, and (5) Journal of Rehabilitation Research and Development. The top publishing authors were (1) French, (2) Lange, (3) Cooper, (4) Vanderploeg, and (5) Brickell. The top research institutions were (1) Defense and Veterans Brain Injury Center, (2) Uniformed Services University of the Health Sciences, (3) University of California San Diego, (4) Walter Reed National Military Medical Center, and (5) Boston University. The top co-occurring key words in this analysis were (1) posttraumatic stress disorder (PTSD), (2) persistent postconcussion symptoms (PPCS), (3) blast injury, (4) postconcussion syndrome (PCS), and (5) Alzheimer's disease.

CONCLUSIONS

The results of this network analysis indicate a clear focus on veteran health, as well as investigations on chronic effects of mTBI. Research in civilian mTBI indicates that delaying treatment for symptoms and impairments related to mTBI may not be the most precise treatment strategy. Increasing the number of early, active, and targeted treatment trials in military personnel could translate to meaningful improvements in clinical practices for managing mTBI in this population.

Action Ethnography of Community Reintegration for Veterans and Military Service Members With Traumatic Brain Injury: Protocol for a Mixed Methods Study

BACKGROUND

Numerous studies of community reintegration (CR) in traumatic brain injury (TBI) have been conducted in civilian populations, but research is limited in veteran and military service member populations. Little is known about how knowledge from civilian studies translates into veterans' experiences and needs. The US Department of Veterans Health Administration (VHA) recognizes the distinctive health care needs of post-9/11 veteran and military service members, particularly with TBI, including the need to bridge health and rehabilitation-related services from acute care and inpatient settings to veteran and military service members' homes and communities to facilitate CR.

OBJECTIVE

The goal of this study is to better understand the experiences of veterans with complicated mild, moderate, or severe TBI; their families; and CR workers as veterans and servicemembers transition to and sustain living in communities. This paper describes the rationale, design, and methods used to reach this goal.

METHODS

This five-year longitudinal mixed methods study uses both a community-engaged research (CEnR) approach and an ethnographic approach. The sample includes 30 veterans and service members with TBI, 13 family caregivers, 11 CR specialists, 16 key stakeholders, and 82 community events. Interviews and observations are coded and analyzed using hierarchical coding schemes and thematic analysis. Analyses include data from surveys, interviews, and participant observations. Content analysis is used to highlight the complex social context of reintegration and to triangulate quantitative data. Egocentric (personal) social network analysis is used to examine the support system a veteran or service member has in place to facilitate reintegration.

RESULTS

Study enrollment and data collection are completed. Data analyses are underway.

CONCLUSIONS

The results of this study may provide a heightened understanding of environmental factors affecting CR in complicated mild, moderate, or severe TBI. Veteran, servicemember and family voices and insights provide VHA clinicians and policy makers with an ecological view of CR that is grounded in the life experiences of veterans, military service members, and families. The results of this study provide a roadmap for designing and testing interventions to maximize CR in a variety of domains. The longitudinal ethnographic approach allows for capturing detailed experiences within the naturalistic context. CEnR allows collaborative assessment of the social context of reintegration with community members.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14170.