Attachment 1 - PWS Exhibit D - Example Referral Guideline.xlsx

Polytrauma

RETURN TO INDEX POLYTRAUMA/BRAIN INJURY MEDICINE -

Traumatic Brain Injury (TBI) and Intrepid Spirit Center (ISC)

(Health Care

Otherwise, see Close Criteria.

Pending Acceptance/DOD - Pending Clinical Review.

Referrals from providers outside of TBI & ISC clinic requesting to establish care with Polytrauma/Brain Injury Rehabilitation program. • If patient has TBI diagnosis, accept if referral criteria is met after reading through the RPP.

***Service Members (SM) should have at least six months of active-duty status and availability on station to receive rehabilitation treatment. ***

• Any alteration in mental status (e.g., confusion, disorientation, slowed thinking, etc.).

• Any loss of memory for events immediately before or after the injury.

• Any period of loss of or a decreased level of consciousness, observed or self-reported.

External forces may include any of the following events: the head being struck by an object, the head striking an object, the brain undergoing an acceleration/deceleration movement without direct external trauma to the head, or forces generated from events such as a blast or explosion, including penetrating injuries.

Place into Status: Pending Acceptance Status and Substatus: DOD-Clinic Review

TBI Art Therapy TBI Chiropractic TBI Dance Movement Therapy TBI Massage Clinic TBI Neuropsychology TBI Occupational Therapy TBI Physical Therapy TBI Psychology Driving Simulator Group Art Therapy Sessions Neuro-Optometry Vestibular Rehab Vision Therapy Referrals from providers outside of TBI & ISC clinic requesting: **TBI Diagnosis is not required for the referral and will need clinic review** Driving Simulator Neuro-Optometry Vestibular Rehab Vision Therapy Service Members currently engaged in a Medical Evaluation Board • ADSM with six months or less remaining in active-duty status

• ADSM with six months or less remaining at current local duty station

- Only If the Dx IS NOT Spinal Cord related

- See DTN section if the referral is for Spinal Cord Dx Referrals that are requesting:

-University of Washington Comprehensive Spinal Cord Injury out-patient program or -University of Washington Rehabilitation Medicine Clinic or -TBI Injury Program Rehabilitation Clinic @ UWMC Montlake

AND generate referral to Pending Acceptance/DOD- Pending Clinical Review If the REFERRAL COMMENTS Section does NOT indicate ONE of the criteria is met:

- Injury sustained over 15 days ago AND Progressive Return to Activity (PRA) Protocol without successful progress/improvement

- Injury sustained over 12 weeks ago with symptoms that influence their quality of life/functionality and are worsening or resistant to traditional treatment at the PCM level

AND

If the REFERRAL COMMENTS Section does NOT indicate ONE of these criteria at the time of the injury:

- Any alteration of mental status (disorientation, Severe confusion)

- Any alteration in level of consciousness (unresponsiveness)

- Post Traumatic Amnesia (loss of memory directly before, during or after traumatic event)

AND

If the REFERRAL COMMENTS Section does NOT indicate ALL the criteria is met:

- Seen by their PCM or Specialist for evaluation/diagnosis

- Symptom management and Progressive Return to Activity Protocol (PRA) are initiated (EXCEPTION: not required for TBI > 12 weeks for referral to be processed)

- Service Members should have at least six months of active-duty status remaining on station

- Most recent TBI date, event description, severity

- Experienced Less than 3 concussions in the last 12 months? Question needs to be answered: Y/N (Only needed to determine scheduling criteria, NOT required in SBAR)

- Experienced 3 or more concussions in the last 12 months? Question needs to be answered: Y/N (Only needed to determine scheduling criteria, NOT required in SBAR)

AND

If the REFERRAL COMMENTS Section does NOT indicate TWO of the associated symptoms that are worsening or persistent >15 days: (Symptom can be from any of the associated symptom Category below) Physical: Headache, sleep disturbance, fatigue, dizziness, balance disorders, visual disturbances/light sensitivity.

Cognition: Changes in executive functioning (e.g., judgment, reasoning, decision making), decline in processing speed, poor concentration, slowed thinking, attention and/or memory concerns.

Emotional: Avolition, changes in mood, impulsivity, irritability, low frustration tolerance, and emotion regulation difficulties.

Only if written by TBI Clinic provider (see provider list below) Medical Service: Speech Therapy Defer to Network: Capability

DO NOT RE-ROUTE TO MAMC SPEECH THERAPY

1. ADFM, Retiree, Select, Medicare

2. All Ages

3. Medical Service: Physical Med & Rehabilitation

4. Add "INPATIENT BRAIN INJURY REHABILITATION" to beginning of referral reason

5. Send as Eval & treat

6. Capability IF ACCEPTING FACILITY IS NOT IN REFERRAL:

1. Close referral, ""This Polytrauma/Brain Injury Medicine referral is closed.

2. Please resubmit using Medical Service: Physical Med & Rehabilitation and include the accepting In-Patient Rehab facility Name and contact information in SBAR."

ONLY IF DX is Spinal Cord related **if not, see Place in Pending Acceptance Instructions**

1. ADSM, ADFM, Retiree, Select, Medicare

2. 18 and older

3. Medical Specialty: Physical Med & Rehabilitation

4. Send as Eval and Treat

5. Capability By Name Provider:

-University of Washington Comprehensive Spinal Cord Injury out-patient program

1. Check Documentation in the Chart to see if there was a conversation.

2. If there is no communication, Copy the referral reason and or Order Comment and paste into the Genesis message.

3. Send Genesis Message to Liza Stanley and Lynnette Row & Ordering provider/Care team

4. Subject Line: "TBI & ISC Guidance for urgent referral".

5. Copy the entire Genesis Message and paste into the "Comment" tab on the referral.

6. Change "Substatus" to AIN.

7. Copy and paste Specialty provider's response into the Comment tab.

8. Process the referral as directed.

2. 0-18

3. Medical Service: Neuropsychology

4. Refer to Location: 0125 Madigan Neurocognitive Referrals that are requesting VA Polytrauma or VA in-patient Rehab: Reroute to Referral Management Center

1. All HCDP's

2. All Ages

3. Refer to Location: 0125 Madigan Referral Management

If the required information is not included, send a Genesis message to the TBI & ISC clinic POC and place referral into status Pending Acceptance/DOD - Pending Clinical Review.

DO NOT go into patient’s health record to determine how to process the referral.

Close if ONE these symptoms are listed in notes or referral following acute head trauma:

• Progressively declining level of consciousness.

• Progressively declining neurological examination

• Pupillary asymmetry

• Seizures

• Repeated vomiting

• Neurological deficit: motor or sensory

• Double vision

• Worsening headache

• Cannot recognize people or disoriented to place

• Slurred speech

• Unusual behavior

AND generate referral to Pending Acceptance/DOD- Pending Clinical Review

Booking Criteria (enter into Instructions to Staff)

Optometrist

Occupational Therapist

Dance Movement Therapist

Contact Info