longitudinal designs, probability sampling, comprehensive clinical assessment of key outcomes, and more fully specified models that include objective biologic measures should be considered.

In Chapter 4, the committee presents many of its preliminary findings and notes that research and program development are needed to substantiate the potential efficacy and cost effectiveness of developing protocols for the long-term management of TBI and polytrauma. The array of potential health outcomes associated with TBI suggests that injured service members will have long-term psychosocial and medical needs from both persistent deficits and problems that develop in later life. Access to rehabilitation therapies—including psychologic, social, and vocational—is required initially with the onset of deficits and will persist over time as personal and environmental factors change leading to loss of functional abilities. VA has put into place a comprehensive system of rehabilitation services for polytrauma, including TBI (see Chapter 5), that addresses acute and chronic needs that arise in the initial months and years after injury. However, protocols to manage the lifetime effects of TBI are not in place and have not been studied for either military or civilian populations. As in other chronic health conditions, long-term management for TBI may be effective in reducing mortality, morbidity, and associated costs.

The committee recommends that the Department of Veterans Affairs conduct research to determine the potential efficacy and cost effectiveness of developing protocols for the long-term management of service members who have polytrauma and traumatic brain injury. The approaches considered should include

  • Prospective clinical surveillance to allow early detection and intervention for health complications.

  • Protocols for preventive interventions that target high-incidence or high-risk complications.

  • Protocols for training in self-management aimed at improving health and well-being.

  • Access to medical care to treat complications.

  • Access to rehabilitation services to optimize functional abilities.

Another issue of concern, discussed in Chapter 4, is the critical shortage of health-care professionals—especially those specializing in mental health—to meet the demands of those returning from theater in Iraq and Afghanistan and their family members. Psychologists, psychiatrists, social workers, and other mental health professionals who do serve the military and veteran communities have large caseloads, especially in some locations that result in underserving of patients, high rates of burnout, and turnover. The committee heard of those problems repeatedly in its town hall meetings both from mental health professionals and from those who were waiting for appointments for treatment. Many of the people who spoke at the committee’s meetings, from Fort Hood to Camp Pendleton, emphasized that those who are in need of mental health treatment have to wait too long for initial appointments or between appointments.

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