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Witness Testimony of Shane McNamee MD, Hunter Holmes McGuire Richmond Veterans Affairs Medical Center, Director, Richmond, VA

Good afternoon, Mr. Chairman and members of the Committee.  Thank you for the opportunity to discuss the transition of our Wounded Heroes through the Veterans Health Administration.  My name is Dr. Shane McNamee and I will be testifying from the perspective of a clinician as well as in my role as the Medical Director of the Richmond Polytrauma program.  To frame the issue appropriately I will describe the typical transition process of severely Wounded Heroes and their families from the Military Treatment Facilities (MTF), through our programs and into communities.  It is my firm belief that this highly coordinated, effective system is unparalleled in this Nation’s medical system for those who have suffered a Traumatic Brain Injury (TBI).

The key concepts of Seamless Transition I will be discussing are as follows:

  1. The significance of medical record access across the continuum of care;
  2. The importance of Relationship Based Medicine: and
  3. The recognition of the Family as part the injury complex, and integration of family into the therapeutic plan of care.

Our four Polytrauma Rehabilitation Centers (PRC) are consulted by the MTFs when a Wounded Hero screens positive for a TBI.  The referrals that come to Richmond are processed by our Nursing Admissions Coordinator.  Following collection and analysis of clinical and family information, we provide the MTF a decision on the referral within twenty four hours of DoD’s request for referral.  At the earliest possible time the family members of the severely wounded are contacted by myself, the Nursing Admissions Coordinator and the Social Worker assigned to the case.  This step has proved essential for several reasons.  For the family, the transition of a Wounded Hero between medical facilities creates anxiety due to the unknown.  Importantly, this contact provides an early opportunity to build a relationship with key family members.  This relationship with the patient and family members forms the basis of successful rehabilitation.  The family also serves as an invaluable resource in the recognition of personality and cognitive changes that are common after TBI.

Numerous systems are used to develop an individualized plan of care prior to admission to our PRC.  Medical records are obtained through our direct access of Walter Reed Army Medical (WRAMC) and Bethesda National Naval Medical Center.  Up to date information about medications, laboratory studies, results of imaging studies and daily progress notes are reviewed to determine the individual case parameters.  We access the web based Joint Patient Tracking Application (JPTA) to gain further understanding of the patient’s clinical status.  Specifically the field notes from Balad, Iraq and follow up at Landstuhl, Germany are indispensable in determining the severity of the TBI.  Our Nursing Admissions Coordinator also obtains specific documentation through the VA/DoD liaison personnel stationed at both WRAMC and Bethesda.  As Medical Director, I contact the referring physicians and discuss the particulars of the case.  Our facilities have scheduled Video Teleconferences (VTC) to discuss the referral and to meet the Wounded Hero and family members “face to face”.  These tools are essential in developing an intensive, individualized rehabilitation medicine plan for each Wounded Hero before admission.  This also includes the coordination of resources necessary for the family; including housing, transportation, meals and psychosocial supports.

Upon admission to our facility, each member of our rehabilitation team individually evaluates the Wounded Hero within twenty four hours and pays particular attention to the functional needs.  Our team consists of a Physiatrist (Rehabilitation Physician), Rehabilitation Nurses, Physical Therapists, Occupational Therapists, Speech and Language Pathologists, Recreation Therapists, Kinesiotherapists, Neuropsychologists, Psychologists, Dieticians, Social Work/Case Managers (SW/CM), Military Liaisons and Blind Rehabilitation Therapists.  Our team meets three times weekly to discuss each patient and to continually adjust the therapeutic plan of care.  Each patient undergoes three to six hours of therapy each day tailored specifically to their individual functional and cognitive needs.  We actively work to reinstitute the roles that previously defined activities of our Wounded Heroes. 

As mentioned earlier, it is not just an individual who suffers a TBI.  Rather, the entire family structure is affected and requires attention.  The literature relating to TBI is very clear on the fact that those individuals with strong psychosocial support structures are more successful over time.  Our support is multimodal and includes health information through site specific literature, informal education sessions, a formalized lecture series and intensive discharge planning.  Traditionally we provide professional support, emotional support, logistical support, involvement in the care processes and the support of the Military Liaison Officer.  To further support the families, we have instituted a pager and cell phone that are covered 24 hours a day by members of our Social Work team.  This allows yet another level of support of our families.  Importantly, in a very real sense, the family members become an integral part of our team.  This programming serves to educate the family members, decrease their anxiety of the unknown and prepare them to care for their loved one over time.

In recognition of this need we have developed a model of care appropriately referred to as Relationship Based Medicine. We have found that it is the relationships with those involved in the continuum of care that drives the success.  Initially, we intensively work with the families and patients to gain their trust and instill the recognition that we are on their side.  Once this level of trust has been established, we can develop an effective treatment plan and approach.  It is important to point out that this relationship does not end once discharged from our facility.  Patients are followed at regular intervals by the SW/CM staff along with the Physiatrist. 

Intensive discharge planning is the cornerstone of any successful rehabilitation plan.  Our discharge plans are initiated the moment a patient is admitted to the facility.  On a weekly basis we discuss the discharge needs and timelines necessary for success.  These are communicated with the families and aligned with their needs.  Once a discharge disposition is provided by the family, we begin to contact necessary resources in their community.  Based upon location, a consult is opened either with one of the Polytrauma Network Sites (PNS) or appropriate level of private care within the patient’s community.

The consultation process includes a VTC or teleconference between our team, the consulting team, the family and patient.  These conferences allow for a smooth handoff of the plan of care and specific questions.  Because many patients are still an Active Duty Service Member, the Military Case Managers (MCM) are responsible to obtain authorizations from the Military regarding orders and follow up care based upon our team’s recommendations.   

Each family and patient is trained prior to discharge in medical and nursing care appropriate for the patient.  At the time of discharge each of them are encouraged to evaluate our system.  Their recommendations for improvement are always implemented if possible. After discharge our SW/CM follows each patient at prescribed intervals.  As the Medical Director, I continue to follow their medical issues from afar and advocate for them when appropriate.

The integrated transition plan of care from MTF to PRC and into the community is paramount in the success of our Wounded Heroes and families.  The system set up throughout VA is world class and has no equal for those suffering from TBI.  Across the system we continually monitor and incorporate improvements.  I am proud to be a part of the exceptional rehabilitation staff who are fully dedicated in their mission to serve those who have sacrificed so much.

Thank you Mr. Chairman and members of the committee for your time.