Project Background/Rationale: A high prevalence of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers is returning from the battlefield with multiple injuries, with traumatic brain injury (TBI) noted as their signature wound. Reflecting the priority placed on caring for OEF/OIF veterans' needs, VA established 22 Polytrauma Network Sites (PNSs) for post-acute rehabilitation. In the typical polytrauma patient, TBI occurs in combination with other disabling conditions that require ongoing, individualized, multidisciplinary medical and psychosocial care. Although establishing the PNS was a major advance, coordination of care remains challenging. Further study is needed to understand variation across PNSs on two known factors related to outcomes: level of structural integration and coordination mechanisms. Structural integration includes organizational features like formal reporting relationships, decision-making processes, physical space, and allocation of resources. Regarding coordination, key distinctions have been made between relational coordination, programming, and feedback as mechanisms for achieving communication among providers needed for effective patient care. Project Objectives: 1. Current Pilot: To refine previously developed structural integration and coordination interview and survey measures and assess their reliability and validity when adapted to PNS outpatient staff. 2. Future Study: Use adapted measures to understand whether variation in structural integration and coordination, in addition to other factors such as provider and patient characteristics, impact patient outcomes (e.g., treatment plan adherence, quality of life, employment), and what configurations of structural integration and coordination are associated with better outcomes. Project Methods: The proposed pilot study will proceed in three phases. Phase 1 will begin with a best-guess modification by the study team of the existing structural integration measure for use in the PNS context. This draft will be reviewed by the PNS director at VA Boston, home site of the study team, to ensure that the items are appropriate and sufficient for understanding PNS structural integration. The refined measure will then be administered to the remaining 21 PNS directors using a combination of web and telephone methodologies. The information obtained from Phase 1 will inform the Phase 2 initial modification of the survey-based coordination measures. The phrasing and sequence of questions in these measures must correctly reflect the relationship between the 'core' PNS staff and consulting specialties. The draft instrument will then be administered to VA Boston PNS providers and referral service employees, followed by a 'cognitive debriefing' in a focus-group setting to identify ambiguous or problematic elements of the coordination surveys. These will be revised accordingly, and the testing process repeated with another PNS focus group via teleconference. Based on these results, for Phase 3 we will create a web-based coordination survey and administer it to 5 randomly selected PNSs (excluding the PNSs piloted during Phase 2). The psychometric properties of the coordination scales will then be assessed by applying multitrait scaling analysis to these data, and final item-to- scale assignments adjusted to maximize content consistency, reliability, and convergent and discriminant validity.
Advances in battlefield treatment have produced a veteran cohort that would not have survived their wounds in prior wars. As a response to HSR&D Priority B: Care of Complex, Chronic Conditions, this and the proposed future research present an opportunity to examine the organizational infrastructure and practices of the Polytrauma System of Care, specifically the Polytrauma Network Sites, as a VA response to the recent influx of the immediate and urgent needs of a new veteran population with a unique constellation of injuries. Findings from this research will lead to future studies designed to identify organizational structures and coordination processes that represent best practices for fostering effective rehabilitation and treatment programs for those with multiple, chronic conditions in current and future systems of care. Policymakers, key stakeholders, and healthcare managers need this information for translating research findings into policy and practice.
