Continuity of Care Crucial To Soldiers' MH Treatment

Since Operation Iraqi Freedom (OIF) began in March 2003, more than 423 soldiers have been seen by Walter Reed Army Medical Center's (WRAMC) continuity service in the psychiatry department.

About 93 percent of those soldiers were evacuated from military operations in Iraq, 6 percent were evacuated from Operation Enduring Freedom (OEF) in Afghanistan, and 1 percent are civilians, according to the continuity service, which began collecting data on OIF/OEF soldiers in March 2003.

“Our mission in war time is to ensure that active-duty soldiers evacuated from military operations in OIF/OEF receive a high level of continuous care,” Col. Douglas Waldrep, MC, USA, told Psychiatric News. Waldrep, a psychiatrist at Walter Reed, directed the Continuity Care Services (CCS) between June 2001 and June 2004. Waldrep is currently the program director for the National Capital Consortium psychiatry residency training involving residents from the Army, Navy, and Air Force.

Waldrep was replaced by another psychiatrist, Col. Raymond Lande, MC, USA (Ret.) to lead the CCS interdisciplinary team of nurses including clinical nurse specialists, social workers, and psychiatric technicians.

The CCS runs an adult psychiatric day hospital and intensive outpatient services. The services include occupational therapy, individual and group counseling, and monitoring services for outpatients—for example, monitoring blood levels of patients on lithium, Waldrep said.

The continuity service was also charged by the psychiatry department in August 2003 with assessing all soldiers with psychiatric illnesses evacuated from OIF/OEF within 24 hours of their arrival (see chart).

“The soldiers are assessed twice within that 24-hour period. The psychiatrist on duty does the first triage when the psychiatrically ill soldiers arrive at Walter Reed, and our team provides the second triage,” said Waldrep.

Before they arrive at Walter Reed, soldiers have been assessed by a psychiatrist attached to a combat stress control unit or a combat support hospital in Iraq or Afghanistan. If soldiers don't respond to treatment within the seven- to 10-day time-frame established for medical combat support teams, they are evacuated to a military hospital in Landstuhl, Germany, for another assessment and stabilization.

Landstuhl is the medical center that treats U.S. military personnel stationed in the Middle East, Afghanistan, and Europe. Casualties who need more than the typical three or four days of treatment are then sent to Walter Reed.

Nurses on staff of the continuity service manage the soldier's cases to ensure continuous psychiatric care when soldiers are transferred to different levels of care in the department of psychiatry and the health care system at Walter Reed.

“Most soldiers seen by our service return home to their bases within a few weeks. When they are ready to be discharged from Walter Reed, our nurse case managers schedule their next appointments at local Veteran's Affairs mental health facilities,” said Waldrep.

With OIF continuing this year, thousands of Reserves and National Guard personnel have been called into active duty and sent to Iraq.

More than half the soldiers treated by the continuity service at Walter Reed are Reserves/National Guard. When they are ready to be discharged, nurse case managers contact local county hospitals or mental health clinics to schedule their follow-up appointments, Lt.Col. Mary Gary-Stephens, NC, USAR, told Psychiatric News. She is a clinical nurse specialist/case manager in the continuity service and care coordinator for OIF/OEF soldiers.

The continuity service nurses also coordinate psychiatric care for soldiers treated at Walter Reed and then transferred to the medical holding company. Soldiers are assigned there while they wait for the medical or administrative discharge process to be completed.

Because the proceedings can last from a few weeks to several months, the medical holding company provides soldiers with housing on post, case managers, and other services (Original article: see story below).▪