An instrument of hope, healing, discovery, and learning

The National Intrepid Center of Excellence Mission We improve the lives of patients and families impacted by traumatic brain injury (TBI) through excellence and innovation Vision We aim to be a global leader in TBI care, research, and education Guiding Principles We are guided by the principles of excellence, innovation, compassion, honor, and collaboration May 2016

Founding the NICoE In the wake of the wars in Iraq and Afghanistan, investigating TBI and its impact on PH is of high importance. The effects of combat-related TBI and PH conditions are expected to persist for years to come, making treatment and prevention advances extremely valuable. The NICoE opened in 2010 as a result of the generosity of the Intrepid Fallen Heroes Fund (IFHF), and continues to be an integral entity within the MHS continuum of care in the present day. The IFHF, dedicated to the mission of helping service members and veterans, was established in 2000. This continued an effort begun in 1982 by Zachary and Elizabeth Fisher, founders of the Fisher House Foundation and the Intrepid Sea-Air-Space Museum in New York. The Center for the Intrepid opened at Brooke Army Medical Center in 2007 for amputation prostheses and functional limb loss care. The successful fundraising efforts of Zachary Fisher’s nephew, Arnold, have generated philanthropic contributions to the IFHF for advanced medical facilities for service members. The NICoE is a gift from the American people through the IFHF, built at the WRNMMC in Maryland. The dedication ceremony was on June 2010 and treatment of patients began in October 2010. The generosity of the IFHF has funded nine additional facilities, called Intrepid Spirit centers, which are located on major military bases throughout the country. They operate using a NICoE-influenced clinical care model with a focus on diagnosis and treatment. May 2016

Medical Imperative: Challenging Comorbidity TBI and PH conditions, such as Post-Traumatic Stress Disorder (PTSD), are complicated, and patients seen at the NICoE can have a combination of these conditions. Understanding the comorbid disease state is key to successful treatment. The NICoE strives to find better ways to treat comorbid TBI and PH conditions through clinical interventions and contributes to knowledge and best treatment practices by researching areas of overlap. Pain/Suffering Comorbid symptoms may include: Anxiety Avoidance Cognitive Deficits Depression Dizziness Fatigue Headache PH TBI May 2016

Clinical Programs Offered at the NICoE NICoE Intensive Outpatient Program (IOP) NICoE Outpatient Services NICoE Evaluation Track (NET) Brain Fitness Center (BFC) Patient Demographics: Active-duty service members suffering from complex, comorbid TBI and PH conditions. Program Description: A four-week outpatient program with an innovative, interdisciplinary care model Utilizes co-located teams of specialized providers Patients meet with a team of providers that collects a comprehensive history, performs a clinical evaluation, and develops individualized patient- and family-centered treatment plans Patient Demographics: Active-duty service members, Guardsmen, Reservists, veterans, and their beneficiaries with mild, moderate, severe, and penetrating TBI. Program Description: An outpatient clinic that provides diagnostic evaluations and case management to ensure patients receive care that aligns with their sustained injury Patients are able to attend treatment as long as clinical demands require Patient Demographics: Active-duty service members, TRICARE eligible adult beneficiaries, and veterans with a history of TBI. Program Description: A one-week evaluation program A diagnostic and evaluation tool to provide clarity of TBI diagnosis and identify treatment recommendations Patient Demographics: Service members and beneficiaries with cognitive deficits. TBI not required. Program Description: Offers computer-based brain training programs, biofeedback, and mind-body opportunities for cognitive rehabilitation and enhanced mental performance Investigates the effects of these programs through research protocols while supporting patients’ therapeutic goals and instilling healthy brain habits May 2016

Clinical Capabilities The NICoE delivers a broad range of patient- and family-centered assessment and treatment interventions, encompassing traditional medicine, advanced diagnostic techniques, and integrative medicine. NICoE TBI services include: Acupuncture Animal-Assisted Therapy Art Therapy Assistive Technology Audiology Biofeedback Case Management Cognitive Rehabilitation Driving Assessment and Rehabilitation Education Family Counseling Music Therapy Neuroimaging Neuropsychology Nutrition Occupational Therapy Ophthalmology Optometry Physical Therapy Primary Care Psychiatry Psychotherapy Sleep Medicine Speech Language Pathology Spiritual Counseling Vestibular Assessment and Treatment May 2016

Typical Intensive Outpatient Program Experience Weeks One and Two: Clinical Evaluation Patients are exposed to the full spectrum of TBI services during Weeks One and Two. In partnership with their clinical team, the most effective treatment options are identified for patients’ unique health needs, and patients and families are educated on tools for TBI management and recovery. This patient-centered care enables the clinical team to develop a tailored clinical treatment program for each patient, and support the patient in setting short- and long-term health care goals for the duration of the program and beyond. Patients attend courses focused on improving confidence, setting goals, staying focused, and managing energy, which continues through Weeks Three and Four. Weeks Three and Four: Treatment Planning and Family-Focused Participation, Now and Beyond Based on evaluations and identified treatment options in Weeks One and Two, Weeks Three and Four are dedicated to establishing an effective individualized, ongoing treatment plan for the patient and family. Families are also included in this time of exploration and planning, with the goal of providing the patient and their support system with the tools, skills, and education needed for sustained rehabilitation and reintegration. Recommendations are shared with the patient, their family, and their home station treatment team to ensure continuity of care upon discharge. May 2016

NICoE Outpatient Services NICoE Outpatient Services identifies TBI and post-traumatic symptomatology The program operates from a flexible, patient-centric model that provides individualized care and treatment plans for as long as medically needed Rehabilitation team providers meet regularly to discuss and monitor patients’ needs Treatments range from occupational and physical therapy to driving assessment and rehabilitation May 2016

NICoE Brain Fitness Center The BFC provides patients with computer- based brain training programs for cognitive rehabilitation and to enhance mental performance The BFC instills healthy brain habits by providing cognitive-stimulating activities while supporting patients’ therapeutic goals The BFC treats cognitive deficits from multiple causes including acquired brain injuries, psychological disorders, neurological diseases, and cognitive changes due to cancer-related treatments May 2016

NICoE Inpatient Services The NICoE inpatient consult service team (made up of a physician’s assistant, nurse practitioner, psychologist, and neurologist) sees every patient admitted to the hospital in wards and ICUs where there is concern of a sustained TBI and: Provides a diagnosis Helps the attending/primary care team manage issues (e.g. agitation, confusion, psychological distress) Creates a discharge plan Works with the family to understand the nature of the sustained TBI and potential impacts The NICoE integration with WRNMMC included a functional integration with Ward 7-East. NICoE staff: Work with admitted patients for case management services Create an appropriate discharge plan Provide continuity of care following discharge for local patients Additionally, for those in another part of the NICoE care system, like the IOP, can be admitted to Ward 7-East if they experience a worsening of symptoms that require inpatient treatment. Provides a diagnosis for what? May 2016

NICoE Directorate Research NICoE Directorate research is supported by the TBI Research Synergy Board (RSB), which was created to facilitate collaboration, maximize assets, and improve efficiency of TBI care and research efforts across the National Capital Region. The Uniformed Services University of the Health Sciences (USU), the NICoE Directorate, and the National Institutes of Health (NIH) collaborate through the RSB. May 2016

Research Collaborations Naval Hospital Camp Pendleton Chronic Effects of Neurotrauma Consortium Department of Veterans Affairs Fort Belvoir Community Hospital Naval Medical Center San Diego Naval Medical Research Center U.S. Army Medical Research and Materiel Command U.S. Army Research Laboratory Walter Reed Army Institute of Research The Institute for Rehabilitation and Research (TIRR) Memorial Hermann Intrepid Fallen Heroes Fund Kessler Foundation Drexel University Harvard University Northwestern University University of Michigan University of North Carolina University of Pittsburgh University of Utah May 2016

Intrepid Spirit Centers The generosity of the IFHF has funded nine additional facilities, called Intrepid Spirit centers, which are located on major military bases throughout the country. They operate using a NICoE-influenced clinical care model with a focus on diagnosis and treatment. Command and control of the Intrepid Spirit centers belongs to their respective Military Treatment Facility. Open Broken Ground Future Site Open for Patient Care: Fort Belvoir, VA (September 2013) Camp Lejeune, NC (October 2013) Fort Campbell, KY (September 2014) Fort Bragg, NC (January 2016) Fort Hood, TX (March 2016) Broken Ground: Joint Base Lewis-McChord, WA (October 2015) Future Sites: Fort Bliss, TX (TBD) Fort Carson, CO (TBD) Camp Pendleton, CA (TBD) May 2016