Background: Since 2001, approximately 2 million troops have been deployed to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Service members are returning with a variety of physical and psychiatric conditions. Approximately 15-19% of returnees have been diagnosed with traumatic brain injury (TBI), which is associated with affective, cognitive, somatosensory, and vestibular symptoms. A major concern following mild TBI is the effect of brain injury on psychiatric conditions, such as posttraumatic stress disorder (PTSD), anxiety, and depression. Given the frequent comorbidity of these disorders, clinicians struggle in distinguishing between and treating the physical and psychological manifestations. Because of VA's organizational structure for polytrauma (PT)/TBI care, providers could potentially treat physical (e.g., TBI) and mental (e.g., PTSD) health symptoms in isolation from one another. The pervasiveness of physical and psychiatric sequelae in this cohort necessitates organizational structures that facilitate communication and coordination across disciplines to better address patients'multiple needs. Better coordination has been associated with better clinical outcomes in various settings, including in VA. Objectives: Focusing on the VA Polytrauma System of Care Polytrauma Network Sites (PNSs) and Polytrauma Support Clinic Teams (PSCTs) that provide care for OEF/OIF Veterans, we will examine simultaneously organizational factors, specifically structural integration (i.e. organizational and physical structures) and coordination processes (i.e. programming, feedback, relational coordination) and patient- related factors that are associated with PT/TBI clinic differences in healthcare utilization and patient outcomes, like community reintegration and satisfaction with health care. A secondary aim is to focus on gender differences in patient outcomes. To address our primary goal, we will address four research questions (RQs): RQ1) How do PNSs and PSCTs differ among and between themselves on three measures of coordination, when indices of structural Integration are considered? RQ2) Do patient characteristics, structural integration and coordination processes variables predict patient utilization? Is utilization associated with TBI status and referrals from the TBI evaluation clinic stop? RQ3) To what degree do patient characteristics, utilization, and structural integration and coordination processes predict differences in the patient outcomes of community reintegration and satisfaction with health care? RQ4) Based on the outcome of RQ3, what are the barriers to and facilitators of achieving the combinations of organizational characteristics and patient characteristics associated with better patient outcomes? Methods: This is a mixed methods study consisting of three phases. Phase 1 is a prospective quantitative study that will examine the PT/TBI clinic structural integration and coordination processes among employees of the PNSs and PSCTs via web survey. Phase 2 will involve a retrospective administrative database review of a large OEF/OIF cohort that was evaluated for TBI. Using VHA administrative databases, we will identify a Veteran sample (based on 8 PNSs and 16 PSCTs with adequate response rates from Phase 1) to examine their healthcare utilization 90 days post-TBI evaluation. This phase will also include a prospective survey of these OEF/OIF Veterans on (a) demographics, (b) health status, (c) community reintegration, and (d) satisfaction with VA healthcare services. In Phase 3, we will (a) select the 8 PNSs from Phase 2 and, based on the Phase 2 community reintegration survey measures, (b) identify the top 4 and bottom 4 performing PSCTs so that we may conduct qualitative interviews with PT/TBI patient healthcare providers to obtain a richer understanding of the organizational factors and coordination processes at these sites.
This proposal responds to OR&D's Deployment Health Research solicitation: OEF/OIF Veteran research issues on patient and system-level outcomes, and to HSR&D's (1) Priority A, addressing such topics as (a) impact of different organizations and structures/processes of care on access for specific populations (e.g., regionalization of care), (b) care access for Veterans with special needs (e.g., TBI, PTSD), and (c) vulner- able populations (e.g., women, those with multiple comorbidities);and (2) Priority F, for women Veterans' healthcare delivery, examining (a) care models, (b) patient characteristics, and (c) Veteran satisfaction. This research will identify structural integration and coordination processes within the Polytrauma System of Care that represent best practices to foster effective rehabilitation programs for OEF/OIF Veterans (secondary focus on women) with multiple, chronic conditions. These findings will inform future implementation studies that policymakers and healthcare managers need to translate research findings into policy and practice.
