Department of Defense: Integrative Strategies for Recovery

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1 Department of Defense: Integrative Strategies for Recovery Compassionate Care in Practice: Illness Experience and Post-Traumatic Recovery Eric B. Schoomaker, MD, PhD Uniformed Services University of the Health Sciences Bethesda, MD

2 Principal Topics How can institutions innovatively respond to the overwhelming needs of veterans returning from war: The Walter Reed Army Medical Center experience. How can we develop innovative models of care: The Warrior Transition Unit experience. How can we incorporate compassion and innovation in healthcare leadership: The USUHS experience. There are no financial conflicts of interest. The opinions expressed represent solely the views of the presenter and do not reflect official policy of the DoD or USUHS.

3 the long war GEN John Abizaid "Americans should not expect one battle, but a lengthy campaign, unlike any other we have ever seen. President George W. Bush Address to a Joint Session of Congress September 20, 2001

4 Improved Survival Over Time 86.5% 89.9% % Survivability Over Time 69.7% 75.4% * May 2008 DoD Data **3 June 2010 DoD Data [Wounds Not Mortal / (Battle Deaths + Wounds Not Mortal)] * 100

equipment Far forward emergency & surgical care

5 Improvements in Warrior Care Improvements on the battlefield Better trained medics Improved equipment Far forward emergency & surgical care Improvements in evacuation Improvements in recovery & rehabilitation

6 Rising Musculoskeletal & Mental Disorders Ambulatory Visits

7 OIF Mental Health Advisory Team: Dwell-Time is Critical Page 7

8 Rising Hospitalizations for Mental Disorders

9 Increasing Combat TBI Cases ,963 23,002 27,507 20,199 DoD Total Deployed Forces ,282 (27%) 7,135 (26%) Data Source: AFHSC 4,133 (20%) OVERALL TBI CASES HAVE MORE THAN DOUBLED DoD Baseline DoD OIF/OEF DoD OIF/OEF DoD OIF/OEF (JAN-SEP ONLY)

10 Chronic Pain N= % The intersection of mind & body Prevalence of Chronic Pain, PTSD and TBI in a sample of 340 OEF/OIF veterans with polytrauma 10.3% 16.5% 2.9% PTSD N= % 42.1% 12.6% 6.8% TBI N= % 5.3% Lew, Otis, Tun et al., (2009). Prevalence of Chronic Pain, Post-traumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD. Slide 10

11 Trauma Spectrum Response Depression TBI Anxiety PTSD TRAUMA SPECTRUM DISORDER Substance dependence, abuse and tolerance Somatic dysfunction (sleep, appetite, sex, energy) Pain

13 Forty Days of Winter: Walter Reed, the Wounded and the Washington Post February - March 2007 February 15, 2007 Washington Post reporters met with the WRAMC Commanding General and Staff

14 February 18, Sunday First Washington Post Article

15 Media Storm

17 Changes in leadership

18 March 5 - Monday House Committee on Oversight and Government Reform Hearings at Walter Reed

19 My Personal Low Point

20 Combined effects of: Unprecedented Battlefield Survival Medical Regulating Challenges Limited Primary Care Capacity BRAC A-76 Workforce Privatization Long-standing PDES concerns Fragmented wounded warrior C2 Others At Walter Reed: The Perfect Storm North Atlantic Regional Medical Command

21 To stay a Soldier

22 Commanding General s Intent Walter Reed provides a continuum of integrated care and services from point of injury to return to duty or transition to active citizenship. Warriors and their Families should receive a quality of care and services that is commensurate with the sacrifice they provide to the Nation. End State: Warrior Transition Units are established with the Triad of support consisting of: primary care manager (PCM), case manager (CM) squad leader (SL) Streamline the issues affecting Family care and disposition. Soldier and Family Assistance Centers are established at our supported installations as entry points for Warriors in Transition. The Army & American people have a restored sense of confidence in the Army Medical Department. 4

23 Mission of the Warrior in Transition: to Heal I am a Warrior in Transition. My job is to heal as I transition back to duty or continue serving the nation as a Veteran in my community. This is not a status, but a mission. I will succeed in this mission because I AM A WARRIOR AND I AM ARMY STRONG.

Warriors in Transition Support Team I am a Warrior in Transition.

community. This is not a status, but a mission.

WELCOME TO THE SOLDIER FAMILY ASSISTANCE CENTER RNCM RTD VA Citizen SFAC Legend: SFAC: Soldier

24 Warriors in Transition Support Team I am a Warrior in Transition. My job is to heal as I transition back to duty or continue serving the nation as a Veteran in my community. This is not a status, but a mission. I will succeed in this mission because I AM A WARRIOR AND I AM ARMY STRONG. WELCOME TO THE SOLDIER FAMILY ASSISTANCE CENTER RNCM RTD VA Citizen SFAC Legend: SFAC: Soldier Family Assistance Center PCM: Primary Care Manager RNCM: Registered Nurse Case Manager SQD LDR: Squad Leader Administrative Services & Benefits 15 AUG = Clinical Services & Leadership Total Continuum of Warrior Care

25 Prescription Opioids

26 An Epidemic in Opioid Problems in the US

Pain Management Task Force Provide recommendations for a DoD comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach, utilizes state of the

27 Pain Management Task Force Provide recommendations for a DoD comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for Soldiers and other patients with acute and chronic pain. Army Pain Management Task Force Charter; signed 21 Aug 2009 Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research Institute of Medicine; June 2011

Alternative Therapeutic Modes Acupuncture

28 Comprehensive Pain Management Evidence-Based Complementary and Alternative Therapeutic Modes Acupuncture Biofeedback Yoga Meditation Standardizes Pain Management Services at echelons of care across our Medical Treatment Facilities: Team-Based Provides optimal quality of life for Soldiers and patients with acute and chronic pain

DoD and VHA pain assessment tool with visual cues and

29 Defense and Veterans Pain Rating Scale (DVPRS) Goal: Standardized Pain Assessment Tool A common language DoD and VHA pain assessment tool with visual cues and a common set of measurement questions linked to function.

30 PASTOR/PROMIS: Patient Reported Outcomes RESEARCH * OUTCOMES REGISTRY * CLINICAL DECISION TOOL Center for Disease Control and Prevention: (Health People 2020 will include PROMIS Global Measure) Bravewell Collaborative Integrative Medicine Outcomes Study (PRIMIER) Defense & Veterans Center for Integrated Pain Management (DVCIPM) Research Pain Management Rx Med Abuse Interdisciplinary Care

31 Auricular Acupuncture or Battlefield Acupuncture

32 Mind-Body Medicine with Guided Imagery

33 Special Pain Medicine Supplement on Active Self-Care Complementary & Integrative Therapies for Chronic Pain

34 Examples of Holistic Care Ready for Integration Mind-body stress management Nutrition for optimal human performance Acupuncture, yoga, music therapy and exercise for the TSR Stars and Stripes January, 2011 Integrated Family and Team Care approaches Individual and Enterprise Total Fitness Metrics

Only when we know our own darkness well can we be present with the darkness of

35 Compassion is not a relationship between the healer and the wounded. It's a relationship between equals. Only when we know our own darkness well can we be present with the darkness of others. Compassion becomes real when we recognize our shared humanity. Pema Chödrön, The Places That Scare You: A Guide to Fearlessness in Difficult Times

36 USUHS Medical Education: Compassion and Innovation in Leadership Experiential Self-reflective: behaviors, cognitions and emotions Values-based: personal, professional and cultural Context is essential: situational and interpersonal 4-C s: Character Competencies Context Communication

37 USAFA PITO Leadership Model Leadership Focus Areas: Personal Interpersonal Teams Organization

38 Military and Emergency Medicine Leadership Curriculum Leadership Focus Levels MEM 101 Pre-Clerkship Fundamentals of Military Medical Practice Clerkships Emergency Medicine MEM 201 BBB & Post-Clerkship Advanced Military Medical Practice Organizational Team Interpersonal Personal Military Medical Practice Learning Activities MFP 101 Antietam Medical Staff Walk Summer Operational Experience MFP 102 Emergency Medicine Selective (Optional) Emergency Medicine 4 th Year Clerkship MFP 201 Military Contingency Medicine MFP 202 Bushmaster Leadership Capstone (Optional) LEADERSHIP GROWTH AND DEVELOPMENT

39 Use of Films

40 Teaching Our Own

41 Take Away Messages Maintaining and restoring the health of Warriors and their Families of all eras is paramount for the military, the military health system and the nation. It is team-based, multi-disciplinary and rests on honoring the service and commitment of each Service Member. Lessons abound in how we can improve health & well-being and restore health & function. Compassion is an essential element. Management of chronic pain is a complex, individual experience often with comorbid elements for which care must be patient-centered and individualized. Leadership in military health & healthcare is an inherent feature of service in uniform and must be taught carefully and deliberately.

42 Thank you! Questions?

Report to the Armed Services Committees of the Senate and House of Representatives

Report to the Armed Services Committees of the Senate and House of Representatives The Military Health System (MHS) Pain Assessment Screening Tool and Outcomes Registry (PASTOR) REPORT ON EFFORTS TO IMPLEMENT