Staying Power: Army Program Reinvents Wounded Care

By Fred W. Baker III
American Forces Press Service

Nov. 6, 2008 - When the first news stories broke in February 2007 detailing a breakdown in soldier and family care at Walter Reed Army Medical Center in Washington, D.C., senior Army leaders scrambled into action. Headlines screamed of neglect as the nation's highest leaders, from the Pentagon, Congress and the White House demanded an answer as to how this could have happened.

In fact, there was no single answer. And Army officials soon discovered that the problem was systemic and not isolated at Walter Reed.

Five-and-a-half years of combat on two fronts, coupled with historically high combat survival rates, had thrust hundreds of soldiers, battered and broken, and their families, into a bureaucratic health and rehabilitation system that had all but lay dormant for nearly 30 years.

"Once we became engaged in the two wars, when we started to look for those rehabilitative capabilities, they really didn't exist," said Army Brig. Gen. Gary Cheek, the Army's assistant surgeon general for warrior care and transition. "We didn't take good care of the families. We weren't watching out for the soldiers. ... We also really didn't know what was going on."

Soon, Defense Secretary Robert M. Gates would proclaim that, next to fighting the wars in Afghanistan and Iraq, taking care of wounded warriors was to become the Defense Department's highest priority.

What followed was an all-out Army assault on the broken systems, substandard living conditions, scattered family support programs, and even passive leadership that had contributed to the breakdown in wounded warrior care.

Over the past 20 months, the Army has reinvented its wounded warrior care program, creating a system that puts soldiers and family members at the center of care, surrounded by protective layers of leadership, case managers, doctors, support specialists and senior leader oversight.


Transformation Goes Full Circle


The model for the transformation began at the same place the problems were first discovered. The first newly-designed wounded warrior brigade stood up at Walter Reed only three months after its hand-picked top leaders put boots on the ground there.

"We have made tremendous progress here at Walter Reed, and even more importantly, across the Army in establishing systems that provide much more comprehensive care for our warriors," said Army Col. Terrance McKenrick, the brigade's first commander.

McKenrick arrived at Walter Reed on March 2, 2007. Three months later, he had a fully operational brigade – a warrior transition unit – with three companies and more than 200 cadre in place to take care of 700 warriors.

Outpatient soldiers who had been scattered in apartments off post with little or no supervision were consolidated in one massive, renovated barracks on the hospital complex where they would be within walking distance of medical care.

Before the brigade was in place, platoon sergeants, who often also were patients, would care for about 50 soldiers each, McKenrick said.

"Most of his day was spent just trying to get accountability," McKenrick said. "He did not have the time ... to be able to help individual soldiers and families with all of their issues."

Each platoon sergeant there now has three squad leaders who care for about 12 soldiers each. The squad leader is the point man in what the Army has coined the "triad of care." Central to the newly formed layers of support, every soldier has a squad leader, a nurse case manager and a primary care physician.

Before, there were 24 case managers handling an average of 55 soldiers each. Now, there are 39 case managers watching over about 18 soldiers each, McKenrick said.

"It's a much more proactive involvement ... in helping individual warriors," he said. "They now have the time to do that well and manage those care plans a lot closer than they did in the past."


Delivering Quality Care


There were no primary care physicians in the past, either, McKenrick said. If a wounded soldier needed to see a doctor for something other than his main injury, specialists at the hospitals had to fit those appointments into their already packed schedules. Now each company has an assigned primary care physician who takes on no other patients. Each cares for about 230 soldiers.

The nurse case managers and the physicians are supported by about 20 other staff in a newly renovated warrior clinic housed on the first floor of the main hospital. The area is only for wounded warriors and gives them a central location for all of their primary medical needs. Appointments with specialists throughout the hospital are scheduled by the nurse case managers and squad leaders to ensure the soldiers know when and where to make their appointments.

Also new is the development of a comprehensive transition plan. Launched across the Army's medical command in March, the plan is a collaboration of doctors, case managers, occupational therapists, specialty care providers and the soldiers. The idea is to map out goals that are needed for each wounded soldier to successfully transition either back into the Army or into civilian life.

The plan is in place within a month of the soldier's arrival at the transition unit in outpatient care, said Army Lt. Col. Suzanne Shaw, the senior case manager for the Warrior Transition Brigade at Walter Reed.

"Every warrior ... is here because they are going to have a major life change. We like to start from the very beginning ... with developing a plan for the future," Shaw said. "This will really help focus our warriors away from illness and injury and on to productive civilian life or returning to duty."

The warrior in transition units now serve as the Army-wide model. In the past, there were 300 cadre taking care of wounded warriors in companies spread out across the Army. Now there are 2,500 cadre caring for 12,000 wounded warriors in 35 transition units and nine community-based health care groups across the United States. The Army plans to build 21 transition complexes that will place the staff, barracks, hospitals and support services in one central location. The first will be built on Fort Riley, Kan., where construction is slated to begin next year.

The 12,000 soldiers in the transition units now represent a cross section of illnesses and injuries, and all are not necessarily combat related. Of those 12,000, only 1,500 are Purple Heart recipients. The move to include all wounded, ill and injured was made, said officials, so they can offer the same level of health care to all soldiers.

"I suppose we could consider a special program for only our [combat] wounded soldiers. But then when I have a soldier who has three combat tours and he's injured in a motorcycle accident, he's not eligible," Cheek said. "Do we not have an obligation to take care of him?"


Wounded Warrior Program Adds Oversight


For some seriously injured soldiers, the Army also has added another layer of advocacy and oversight.


The Army's Wounded Warrior program, or AW2, includes in its fold soldiers who have a single disability rating of 30 percent or a combined disability rating of 50 percent. If a soldier is injured and is anticipated to receive either of those disability ratings, he is entered into the program even before the rating is awarded.

More than 3,000 soldiers and veterans are now in the AW2 program and of those, about 900 have a 30 percent disability rating. Army officials expect the program to grow as they work to incorporate those with the combined 50 percent rating.

The AW2 program began in 2004 as The Disabled Soldier Support System, but later changed its name because soldiers didn't view themselves as disabled, officials said. All soldiers in the program have been injured since Sept. 11, 2001. The program encompasses soldiers injured in combat, as well as in training and off-duty accidents.

The soldiers and families are assigned an AW2 advocate that oversees their care, even as they are still being cared for at the transition units by the "triad of care."

"I'll be frank. A number of leaders have asked 'Isn't that redundant?'" said Col. Jim Rice, the AW2 program director. "I'll admit to some redundancy. What makes us unique is that advocate will be with that soldier and family when the [transition] leadership is no longer responsible for them."


An Advocate for Life


Over time, the role of the AW2 advocate increases as the nurse case manager's role decreases, so that by the time the medical board makes a determination, "the person working with them most is the one that is going to be with them for the rest of their life," Rice said.

In fact, the advocate will continue to work with the soldier and family as long as needed, even if the soldier transitions back to active duty, Rice said. So far, 70 soldiers have returned to duty, he said. Most have been medically retired and have returned to their communities where they receive care at Veterans Affairs facilities.

There are about 80 advocates stationed around the United States, Rice said. Some advocates are stationed at major military treatment facilities, others at VA rehabilitation centers, and still others are in remote locations, working out of their homes. All advocates are civilians, either contractors or civil servants, and many are retired military. Some have medical backgrounds, but not all, Rice said. They manage about 40 cases each, but the Army's goal is to get that down to about 30 each, he said.

The advocates typically are generalists and their powers lie in knowing whom to call when there is a problem. They become community-based experts and they have access to senior military leaders in the beltway that soldiers and families don't have.

Even as the soldier begins his treatment in the military hospital, it is the advocates who give him a picture of the options for the future. Using an elaborate software program, the advocates input factors like rank, age, number of family members, finances and education and create financial predictions for their future based on the data.

The advocates are required to contact their soldiers and families monthly. While they are in the transition unit, contact could be more often, Rice said. There is no requirement for increased interactions, but the advocates make the judgment based on need, he said.

Many soldiers and families have successfully transitioned to active duty and back to their communities and case management is no longer needed, Rice said. For those who do still need it, contact is made every month, at least for now, he said.

"There is no real graduation from the AW2," Rice said. "The last thing we want to do is leave someone out there who needs some support."

Senior Army officials agree that there is more work to be done in the programs, mostly in the way of fine-tuning the massive overhaul. When surveyed this year, nearly 80 percent of the 12,000 soldiers in the warrior transition units said they were satisfied with the Army's efforts, Cheek said.

"I think the difference for families from February 2007 to now is night and day," Cheek said. "We have simplified things. We have given them single points of contact. We take care of them from day one and work with them through the entire process."

While soldiers recognize the Army's investment, they also will give honest assessments of the program, Cheek said. "It's not all milk and honey from them," he said. "Soldiers are going to tell the things they like and don't like."

For Rice and his AW2 program, success is measured as all or nothing.

"I can't be satisfied until we go out with a survey to all 3,000 and every one of them says ... 'I'm getting everything I need,'" Rice said.

(Editor's note: This is the 2nd article in an AFPS special report about seriously wounded servicemembers who return to active duty).