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Polytrauma/TBI System of Care

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Rehabilitation Team

Interdisciplinary Teams

Optimal care for TBI and polytrauma is delivered by compassionate, experienced, interdisciplinary teams of specialty clinicians with a holistic approach and an emphasis on patient and family engagement.
Dedicated interdisciplinary teams (IDT) of rehabilitation specialists participate in the assessment, planning, and implementing the plan of care for each Veteran and Service Member enrolled in rehabilitation care in the PSC. Depending on the needs of the person served, the IDT may include physiatry, nursing, social work, psychology, physical therapy, occupational therapy, speech-language pathology, recreation therapy, and vocational counseling.  Other medical and support services may participate as active members of the IDT and contribute their expertise to the overall plan of care.

Patients and Caregivers

Veterans and their caregivers are integral members of the IDT. They participate in all aspects of the rehabilitation process including evaluation, development and implementation of the plan of care, and transitioning to the next level of care and into the community.
Veterans and their caregivers participate in education and training about the particular health challenges that they face. This allows them to make informed decisions and to engage fully in the rehabilitation process.
Polytrauma Case Managers serve as Lead Coordinators for care for Veterans and Service Members receiving services in one of the Polytrauma System of Care programs. They help to transition Veterans smoothly across levels of care and to coordinate resources to meet their medical and psychosocial needs.

Rehabilitation Plan of Care

Veterans with TBI and polytrauma requiring rehabilitation services receive an Individualized Rehabilitation and Community Reintegration (IRCR) Plan of Care.  The Plan of Care documents physical, cognitive, mental health and vocational problems that may affect the Veteran’s progress toward successful community re-integration and outlines Veteran’s goals and priorities for rehabilitation. The Plan of Care provides information about the treatments recommended, their intensity and duration. Rehabilitation treatments for TBI may include physical and cognitive therapy, interventions that promote independence with activities of daily living, counseling, vocational rehabilitation, and prescription and training with prosthetics and adaptive devices.