Background Communication between levels of care can be complex for any patient. For the Servicemember or Veteran with complex medical issues, who needs transitioning between multiple levels of care, this communication involves detailed, individualized information pivotal to quality clinical outcomes and patient/family satisfaction. These complex cases also typically include communication between multiple family members. Purpose The purpose was to summarize the evidence and present recommendations for facilitating effective transitions of patient care within the complex Veterans Affairs (VA) Polytrauma System of Care. Design Evidence Based Review. Methods Selected members of the VA Office of Nursing Service Polytrauma Field Advisory Committee conducted an evidence-based review, and queried a clinical panel of polytrauma nursing experts and direct care rehabilitation nurses. Findings Search results, key practice recommendations, a plan of care template, and future plans for dissemination and implementation are presented. Conclusions Communication is a key to success when managing many details and requires both focus and knowledge of larger systems. Clinical Relevance Direct communication, using a standardized approach, is recommended for successful patient transitions.

The complex care needs of these returning service members require astute case management in addition to clinical care. This collaboration ensures the best life-long outcomes and will be discussed in detail in this article.