The Shepherd Share Initiative Program has been existence since 2008 and has shown a history of success with treating military service members and veterans who suffered a TBI or SCI during the OEF and OIF wars. Over time the program has come to focus primarily on service men and women who suffered mild to moderate traumatic brain injuries/PTSD, considered by many to be the “signature injury” of the Afghan and Iraqi conflicts.
Symptoms associated with this type of injury include deficiencies in physical functioning (balance and dizziness), behavioral functioning (irritability and emotional distress) and cognitive functioning (memory, attention and concentration) and PTSD.
The SHARE Military Initiative Program treats between 8-12 individuals at a time 7 days a week, and the average length of stay in the program is approximately three months. They then are seen by our Military Transition Coordinator for up to one year. We have specific outcome measures that are patient/family centered that are monitored for success.
Since SHARE’s inception, the program has served 160 military TBI/PTSD patients, from all service branches and veterans. And over 450 have been served with Moderate to severe TBI and SCI in the Transition Program. We have no suicides or homicides.
SHARE provides a comprehensive continuum of care with a dedicated military team, specifically tailored to meet the needs of each client, including complimentary housing, life coaching, physical therapy, occupational therapy, vocational therapy, speech therapy, therapeutic recreation and legal, financial and psychological counseling, among many other programs.
All of these activities are available in one centralized location with a dedicated team and are treated by the same medical team, so that all aspects of the client’s care are working in concert with each other, as opposed to a more fragmented system that many of our clients have experienced throughout their time in the military’s treatment systems.
Beyond treating the injuries and associated symptoms that our patients have been afflicted with, SHARE provides a wide variety of additional programs that, although unfunded by insurance, are integral to the recovery and community reintegration of our wounded warriors. Included among these many “valued-added” programs are:
Assisting clients with the return to work and/or school.
Providing of peer support through military volunteers.
Assistance in navigating the VA system and the Med Board process.
Provide a minimum of one year post-discharge follow-up and or life skills coaching in our Transition Program of the Share Military Initiative Program.
Develop a circle of support in their communities that support a successful transition.
Provide onsite support in their communities if things break down.
Patients in the SHARE Military Initiative receive their care at no cost to them or their families as we have been successful in raising money from philanthropists and our community who in support of our military services members.
On average, insurance providers pay only 37 cents of every dollar’s cost of care when using Tricare Prime or Medicare, leaving Shepherd to cover the remainder of the costs. Shepherd Center must raise approximately $100,000 each month in order to keep the program running.
Shepherd has not been successful in getting any claims paid by VA centers in the SE regions.
Many tours of Generals, Commands, VA Directors, and Trauma Recovery Coordinators have been through Shepherd and were impressed.
Many meetings have occurred with the Defense Center of Excellence for Psychological Health and TBI (DCOE) and the Defense Veterans Brain Injury Center (DVBIC) the last 4 years. Both entities have developed clinical practice standards, etc. that support the needs of these service members. Shepherd has collaborated and been in communication with both entities.
Many educational seminars have been provided to numerous military service providers both for DOD and VA, educating on the needs of TBI and PTSD.
For five years, the Shepherd Center has reached out to the Atlanta VA's leadership in an effort to provide assistance and give back to our local Veterans. The Atlanta VA Director and Regional Director in the past have been to Shepherd to see the programs and services and were very supportive of our efforts. The VA Director even wrote a letter of support for the Share Military Initiative Program. The Atlanta VA Director set up meetings at the VA numerous times to have discussions with the staff to see how we could collaborate our efforts in serving their veterans. While they were very cooperative we saw no direct referrals and or collaboration. The PTSD/Psychiatric Division approximately 3 years ago was very supportive in the beginning and we began to get referrals as they saw the benefits and outcomes of their veterans. But that stopped short and they told us they had to give the referrals to the Mild TBI Clinic first before sending their veterans our way. We never saw a referral again. We had discussion with the FEE for Service folks to see how we could get paid for those veterans who found us by word of mouth but they said they had to have approval. (We were never able to find out who needed to approve). As you can see, these attempts for collaboration have been turned away. As a result, the Shepherd Share Military Initiative Program has become a safety net for a small number of veterans who heard about our program by word of mouth and needed a comprehensive program that delivers services in a timely fashion. Outlined below are key areas that we found would be of benefit for the Atlanta VA to support in managing veterans who are in need of comprehensive and timely care. Listed are some opportunities for improvement that we identified when treating Atlanta VA veterans in accessing care:
1. Opportunities for Improvement:
Back Log of Claims process’s resulting in long waits for services and timeliness of care.
A veteran submitted his claim electronically in April 2011. The claim was reported lost in the system even though it was filed electronically. The Veteran had inquired about the claim with his VSO and the claim was found and transferred to the Atlanta VA as requested by the veteran as he had moved to Atlanta. Upon meeting with his VSO in Atlanta the claim was again reported lost and a new claim was filed. This new claim was submitted in August 2011.
The veteran was contacted in October of 2011 and then sent to the QTC for his C &P examinations where the Veteran was told “I am so tired of you veterans”. The decision letter was received by the veteran in April 2012. Only half of the items on the claim were adjudicated.
In October of 2012 the veteran was sent to QTC for additional C&P examinations for the remaining claimed issues. In April of 2013 the veteran received another decision letter with issues still not adjudicated. In May of 2013 the veteran received his final decision letter with a final and complete rating. The veteran filed for reconsideration in June of 2013 on two items and is still awaiting a response from the VA.
Solution: Have benchmarks for times in processing claims and getting appointments.
2. Opportunity for Improvement:
Getting established in the Atlanta VA System for appointments and care needs. Veterans are required to establish a primary care physician prior to accessing care. The appointment can takes months to establish as there are waiting lists to get appointments. This long wait then creates a domino effect in getting medications that have been prescribed, seeing specialists for TBI, SCI, PTSD, pain, sleep, follow-up care, etc.
Several veterans who have participated in our program have had issues establishing enrollment in the Atlanta VA system. In particular it took one veteran 4 months to get an appointment with a primary care physician. The physician assessed the veteran and recommended the veteran be admitted to the Trauma program due to significant issues related to suicidal ideations. The time frame from the referral to possible admission has been over 2 months with no follow-up to check on the veteran. One contact was made to let the veteran know that she needed to attend a class on PTSD and get tested to determine the need.
Develop a process for centralized point person to assure the veteran is moving through the system and getting care in a timely fashion based on the needs of the veteran.
3. Opportunity for Improvement:
Coordination of care with a veteran who has multiple needs, i.e. TBI, PTSD, orthopedic needs, pain issues, sleep issues, and other complicated psychiatric needs.
Several of our veterans have never heard or been contacted by a case manager. One of our veterans was assigned a case manager in May 2012 but has never met or heard from the case manager to date.
Have accountability standards for timeliness of case management services for veterans who have comprehensive needs for care and support the veteran in getting timely and appropriate care
4. Opportunity for Improvement:
Lost records when transferring or getting appointments thus again resulting in long waits, frustration and then resulting in secondary complications
A Veteran in our program was seen at the VA and his records were lost when he submitted a claim. We had to assist the veteran in gathering his information so he could re-file his claim. Many of our veterans have requested records to be sent to Shepherd and we never receive them often requiring us to duplicate medical tests to assure veterans get what they need.
Electronic medical record
5. Opportunity for Improvement:
Lack of information for veterans to understand the benefits they are eligible for.
Many of our veterans are unaware of benefits or entitlements that are offered at the VA. Such as the unemployablity program that would allow them to receive 100% compensation and still work with the ability to earn a maximum of 16k a year.
Have a dedicated CM to support, educate and coordinate care. Developing patient centered care and relationships are proven to create efficiency in medical systems.
6. Opportunities for Improvement:
Collaboration and partnerships with community service providers for bridging gaps in services for veterans.
We have been told RFP’s would be an option for collaboration; however, these have not been forthcoming or available locally. We were told that a Fee basis could be established when the VA determined they could not provide the service. In one case we assessed the patient per their request and we recommended a comprehensive program for Physical, Occupational and Cognitive therapy. The veteran was approved for Physical therapy through the Share Military Initiative as they said they could provide the others. The veteran said they offered the other services two times a month. In recent cases we have submitted supporting documentation for diagnosing the veterans with TBI to assist the client in obtaining compensation. To date the VA has not reviewed Shepherd provider documentation. If the information was reviewed then the client would be receiving an appropriate compensation rating for his diagnosis.
We feel confident that the Atlanta VA has many services and process’s that work and can do good work for their veterans. However, not everyone can do everything and collaborating with providers who have certain expertise can be valuable in assuring care needs are met and or fill gaps in services till developed and implemented. We look forward to an opportunity to collaboratively work with the Atlanta VA to learn more about their services and assist in any services or gaps the veteran may need. Just last week our Military Transition Coordinator was asked to sit on their Advisory Board and we were invited to participate in their community partnership meeting later this month.
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