Roles and Responsibilities
The interdisciplinary team or cadre is our team of Warrior Transition Unit (WTU) clinical and non-clinical leaders/supporters that work cohesively to help wounded, ill or injured Soldiers focus on their recovery, rehabilitation, and reintegration. Cadre members provide support and guidance to Soldiers and their Families in developing the Soldier’s Comprehensive Transition Plan (CTP) and play a positive and active role throughout the Soldier’s transition plan. The needs of each Soldier drive the makeup of his/her cadre, which includes, but is not limited to the following:
- Triad of Care
- Squad Leader/Platoon Sergeant
- Primary Care Manager
- Nurse Case Manager
- Company Commander
- Licensed Clinical Social Worker (LCSW)
- Clinical Pharmacist
- Occupational Therapist (OT)/Certified Occupational Therapy Assistant (COTA)
- Physical Therapist (PT)/Physical Therapy Assistant (PTA)
- Army Wounded Warrior (AW2) Advocate
- Transition Coordinator
- Solider Family Assistance Center (SFAC) Representative
The Triad of Care refers to the Primary Care Manager (PCM), Nurse Case Manager (NCM) and Squad Leader (SL)/Platoon Sergeant (PSG) that is assigned to a specific WTU Soldier. The PCM plans, directs, and oversees the care. The NCM coordinates the care. The SL/PSG leads the Soldier, enabling him/her to comply with CTP requirements. The PCM, NCM, and SL/PSG are responsible for ensuring all members of the WTU team operate synergistically and the team’s efforts all work towards the benefit of the Soldier.
The squad leader or platoon sergeant serves as the first line supervisor to the Soldier and the link to Command. The SL/PSG is responsible for facilitating the resolution of administrative issues and helps guide the Soldier through the WTU process, while enforcing military standards. Specific responsibilities include:
- Tracking the completion of the Soldiers’ transition goals established during the CTP Scrimmage.
- Having daily, weekly, monthly and quarterly CTP progress counseling with their Soldiers to determine status of transition progress.
- Tracking a Soldier’s accountability by using standard reporting requirements (automated CTP (aCTP) dashboard, manual CTP data calls, Medical Operational Data System (MODS), etc).
- De-conflicting Soldier’s appointments schedule and ensuring he/she has the information needed to succeed in his/her individual CTP.
- Ensuring that the Soldier completes no less than five hours of adaptive reconditioning activities per week.
- Ensuring Soldiers attend all formations conducted by the company, platoon, or squad (only exceptions are those Soldiers who have “no formation” annotated on their profile DA 3349 or who have approval not to attend from their chain of command prior to formation).
- Ensuring Soldiers are at their assigned place of duty for the week and contacting each work site supervisor monthly to assess the Soldier’s work performance and participation.
- Counsel Soldiers on their performance, review the aCTP Self-Assessment, and discuss Community-Based Warrior Transition Unit (CBWTU) eligibility (if appropriate), documenting the counseling on a development counseling form.
The primary care manager evaluates the Soldier’s holistic medical requirements and plans, directs and oversees all Soldier care during his/her time in the WTU. The PCM’s responsibility to the Soldier continues until the Soldier exits the WTU, and includes ensuring a seamless medical handoff to the Soldier’s VA care provider or other successor primary care provider. Specific responsibilities include:
- Facilitating weekly Triad meetings with the Soldier to effectively direct the Soldier’s medical care to include significant concerns and/or changes to a Soldier’s risk assessment.
- Communicating with specialty and ancillary providers including behavioral health, ensuring that their plans are included in Soldier care-related meetings and discussions.
- Updating the Soldier’s risk assessment and medical care plans and informing the Soldier’s NCM and SL on all aspects of the medical care plan.
The nurse case manager is a registered nurse who works with the Soldier throughout his/her medical treatment, recovery and rehabilitation. NCMs are responsible for helping Soldiers regain health or improved functional capability by facilitating the development and implementation of goals. The NCM ensures that the Soldier and the SL/PSG understands the medical plan of care and the medical team is aware of the Soldier’s non-medical goals. Specific responsibilities include:
- Helping Soldiers maintain and refine their daily schedules and CTP accomplishments, which are inspected by the SL/PSG
- Informing changes to a Soldier’s risk assessment and mitigation plan or the individual Soldier’s CTP to all members of the key interdisciplinary team via email or telephone and entering updates into AHLTA - the Armed Forces Health Longitudinal Technology Application.