Templated Interdisciplinary Rehabilitation Care Plan Documentation for Veterans With Traumatic Brain Injury.

Purpose Of Study: Individualized interdisciplinary care is the hallmark for rehabilitation following traumatic brain injury (TBI). Veterans Health Administration (VHA) utilizes an electronic note template to document Interdisciplinary Rehabilitation and Community Reintegration (IRCR) care plans for Veterans with TBI requiring rehabilitation. All Veterans with a TBI diagnosis, receiving skilled therapy for TBI-related issues, and followed by a case manager must receive a care plan. The purpose of this study was to determine the level of compliance with the IRCR care plan requirements used to identify Veterans with TBI in need of the care plan and to evaluate the reasons for inconsistent compliance. In addition, the study sought to provide a more objective assessment of Veterans with TBI requiring an IRCR to assist in establishing a target metric.

Primary Practice Setting: TBI outpatient clinics.

Methodology And Sample: Investigators conducted a retrospective medical record review of 546 Veterans with a TBI diagnosis seen at the Washington, DC VA Medical Center's outpatient polytrauma clinics in 2013. Cases were initially reviewed for referral or engagement with skilled therapy. Charts where Veterans were referred or engaged with skilled therapy were forwarded to 2 polytrauma clinicians to determine whether therapy was requested to treat a TBI-related condition. Finally, charts were reviewed for case management and analyzed for algorithm compliance. Analysis focused first on compliance with IRCR algorithm requirements and secondarily with identifying potential reasons for noncompliance.

Results: In 2013, 42% of the TBI cohort met the criteria for an IRCR. The vast majority of cases with a TBI diagnosis complied with IRCR algorithm criteria; however, 14% of all reviewed cases required an IRCR but did not receive one. Provision of case management outside of the TBI/polytrauma clinic characterized a majority of noncompliant cases.

Implications For Case Management: Interdisciplinary care can be challenging, particularly in the outpatient setting, due to patient availability and access to care. Improved documentation in the electronic health record may assist case managers and other clinicians in coordinating rehabilitation care for Veterans with TBI. Case managers in the VA and other settings may find templates and trackable health factors helpful to identify patients in need of care plans.