The National Intrepid Center of Excellence (NICoE) was conceived to be the hub of the Defense Centers of Excellence for Psychological Health and TBI, the place that physically and programmatically bridges all the centers together, according to James P. Kelly, MD, director of the NICoE. Dr. Kelly, who is currently on a leave of absence from his position as professor of neurosurgery and physical medicine and rehabilitation at the University of Colorado School of Medicine, had previously served as director of the Brain Injury Program at the Rehabilitation Institute of Chicago.
Neurology Today spoke with Dr. Kelly about how the NICoE aims to advance the treatment of TBI and psychological issues, while at the same time improve the quality of care available to our nation's service members.
HOW DID YOU BECOME THE DIRECTOR OF THE NICOE?
I had been the chair of the TBI External Advisory Subcommittee of the Defense Health Board (previously called the Armed Forces Epidemiology Board), which created several new subcommittees it didn't previously have under its former structure. After the Department of Defense created the DCoE, Gen. Sutton asked me in 2008 if I would consider assuming the position of Director of the NICoE.
ARE YOU SEEING MORE TBI DUE TO INVOLVEMENT IN AFGHANISTAN?
TBI had occurred during previous conflicts and in training. However, improvised explosive devices and other explosives have produced proportionately more TBI and limb injuries in Iraq and Afghanistan since body armor improvements now offer better protection to the chest and abdomen. While penetrating head injuries still occur, helmets now afford improved protection against penetration. Blast exposures, vehicle crashes, and rollovers account for most of the TBI in the current conflicts.
HOW WILL THE NICOE ADDRESS THE STIGMA ASSOCIATED WITH SEEKING HELP?
The concept of a special place, such as this one, that offers the opportunity for detailed diagnosis and treatment planning will help break down this stigma. The NICoE will be a place where patients and their families can come and be actively engaged for two weeks, get the care they need, and return to their referring location, where care will continue to be provided. This whole process should help everyone understand the importance and need for quality care for our service members who have these conditions.
The NICoE's efforts will also coincide with the DCoE's anti-stigma campaign — especially the Real Warriors — that has been an effective educational campaign against the stigma associated with seeking treatment for mental health disorders. Many senior military leaders have come forward to stress the importance of destigmatizing the issue and even emphasizing the strength in the individual who seeks help.
HOW WILL THE NICOE'S TREATMENT OPTIONS DIFFER FROM THAT CURRENTLY AVAILABLE TO SERVICE MEMBERS?
We largely anticipate individuals who will already have been through treatment that's available at other locations throughout the military health system. If service members have persistent lingering symptoms, or problems of a magnitude that are out of the range clinicians think they can properly address, they will be sent here for the two-week intensive diagnostic and treatment planning.
When someone is referred to the NICoE, there will be a thorough review of medical records and test results to determine the nature of the problem and the fit for the NICoE. We anticipate that most individuals referred will be experiencing symptoms due to a combination of TBI and psychological health conditions that require specialty evaluation. At the NICoE, an experienced interdisciplinary team of specialists will meet with the service member and family in one room to begin the process of assessment and treatment.
The NICoE includes subspecialty experts in different fields gathered in one location who have extensive experience in TBI and psychological conditions such as stress, anxiety, and depression, including neurologists, psychiatrists, psychologists, neuropsychologists, and allied health professionals. You may have pieces of that in certain locations around the country, but the concept behind a Center of Excellence is to pull everything together into one location and one health system so information can be exported throughout the system. It's really not much different than a tertiary care model at an academic center compared to a community-hospital setting.
WHAT LONG-TERM TREATMENT OPTIONS ARE AVAILABLE TO SERVICE MEMBERS?
There are already cognitive rehabilitation and psychological treatment opportunities at various locations around the military health system, and we have been working with those locations with referrals back and forth. Also, some patients will leave with treatment plans that can be conducted by primary care physicians with just check-ins by a specialist from remote locations.
In addition, patients will also leave with the opportunity to tele-connect with us. Right now it's arranged by the bases they return to, but it can also be done by the VAs, especially the polytrauma centers around the country, which are very sophisticated in providing this type of care. Ultimately, it could be done from home — we don't have that worked out just yet, but using their personal computers and/or a Skype-type mechanism patients could connect with us.
There will also be connections to academic and civilian partners around the country. Individuals will use their military insurance for certain locations where there aren't available specialty treatment programs. I've begun engaging with those organizations around the country in order to expand the treatment options available and create a NICoE network across the nation.
HOW DOES THE DESIGN OF THE BUILDING FOSTER HEALING AND ENHANCE TREATMENT?
The building itself emanates calm: It's very quiet, the lights are not intense or bright, the wood paneling is very warm, and the features are round and curved as opposed to angular and sharp. There's an almost immediate sense when you come into the building that there's something more to it – that it's not just a clinic.
It also features a healing garden we call “Central Park” that's an internal part of the second floor, which has a skylight for a year-round outdoor feel. It's a large circular room that has natural sounds piped in by speakers and areas that are very quiet and contemplative, intended for meditation and other peaceful inward looking experiences. This room was intentionally designed for the purpose of providing a calming, healing getaway.
A lot of thought has gone into how you keep patients from being bombarded with stimulation, and we've managed to establish a calm setting in the NICoE, where tests are also performed to determine patients' underlying conditions.
WILL RESEARCH ON TBI BE CONDUCTED AT THE NICOE?
Everyone who comes to the NICoE for treatment planning will be encouraged to engage in research. There will be multiple projects, with the biggest emphasis placed on the state-of-the-art neuroimaging equipment — functional MRI scanning, PET scanning, and magnetoencephalography. These three imaging techniques will actually allow us to view the brain in the same locations anatomically in the same individual.
WHAT'S THE OVERALL GOAL OF THE CENTER REGARDING PATIENT HEALTH?
The NICoE should be the rising tide that lifts all boats — it should help the entire military health system further improve its level of sophistication, knowledge, and care it provides our deserving service members. This will not only occur within the confines of the physical building, but also remotely and broadly throughout the entire military health system as we collaboratively work together.