WASHINGTON, Nov. 13, 2008 - The wars in Iraq and Afghanistan are fought in deserts and mountains far removed from the oceans\' blue waters. But U.S. Navy sailors are increasingly seeing desert and mountain combat as they augment the units of traditional foot soldiers and medics.
Seeing their numbers of combat wounded increase, Navy leaders launched its Safe Harbor program in 2005 to take care of sailors injured in Operations Iraqi and Enduring Freedom. The program started with three staff working out of the Navy Annex, an office building located just a stone's throw from the Pentagon.
There were 20 wounded sailors in the program at that time, said Navy Capt. Key Watkins, commander of the Safe Harbor program.
In 2006, the number of wounded sailors doubled as they were increasingly assigned to augment units deployed in theater.
By late 2007, there were 120 sailors in the program.
By then Navy leadership, along with the rest of the services, was deep into restructuring its wounded warrior care program in an effort to keep up with the increasing demand placed on its systems by the war on two fronts. Although the Navy had far fewer seriously injured personnel than the Army and Marine Corps, the types of injuries, length of treatment and the extra care required for families began to strain its decades-old system.
The continuum of clinical and nonclinical care was there, Watkins said. But, like the other services, the Navy's wounded care system was complicated and complex.
"The problem is it's such a vast organization. There are so many different disparate entities involved with it, it's very confusing," Watkins said. "And then it's compounded if you're medically incapable of navigating this vast bureaucracy and even worse if you're a family member of a servicemember who's incapacitated ... and you don't understand the system.
"You need an advocate. You need somebody who can help you navigate the bureaucracy."
In January, the Safe Harbor program expanded to include all seriously injured sailors, not just those injured in combat. A month later, the program was expanded again to include the non-clinical oversight of all wounded, ill or injured sailors - more than 6,000 of them - including those in the reserves.
Most of those in the program don't need a lot of support. But their cases are now tracked to ensure no sailor slips through cracks in the health care system, Watkins said.
Leaders 'Kick Down' Doors of Bureaucracy
The primary focus of Safe Harbor remains those who are severely wounded, ill or injured, Watkins said. The Navy has more than 200 sailors in that category. They are assigned case managers who help take care of the sailors' and their families' needs from the time of the injury through the rest of their lives, he said.
"We'll provide case management support as long as they need help," Watkins said. "Unless they put us on the national do-not-call list, we're going to keep in touch with them and follow up with them."
The Navy leans toward a "triad of care" similar to that of provided by the Army and the Marine Corps. The triad approach emphasizes a direct relationship between those providing medical care, medical case management and non-clinical support.
Every seriously injured sailor is assigned a nurse case manager at the military treatment facility, as well as a non-clinical case manager who will manage every other aspect of the sailor's care, from fixing pay problems to finding temporary housing for the family.
"When I first took the job, I swore that I would never say in public 'concierge service,'" Watkins said. "But we really are a five-star concierge service -- with a kick. Because sometimes we have to kick doors down to get things done."
Those doors are sometimes outdated regulations and policies that conflict with today's practices of caring for wounded warriors. Senior Navy officials have vowed to work around any policies that are not in the wounded sailors' best interests until the policies are updated or thrown out.
"If it becomes a question of complying with the rules or doing the right thing, we will do the right thing every time," said Navy Rear Adm. Garry White, who reports directly to the Navy's top officer on wounded warrior care. "And we will either get a waiver or get the policy changed or get the law changed, whatever it is. But we will do the right thing for the individual and for the Navy."
White is the director of total force manpower requirements in the office of the Chief of Naval Operations. As part of a casualty care working group that he started, White has traveled the country with other senior Navy leaders, talking to wounded sailors at their bedsides and asking about their needs. That group now drives policy governing the care of the wounded, ill and injured in the Navy.
"There are no boundaries, there are no rules. There are no limits to what we can and will do. There are no barriers," White said. "If we see a need, we will address that need, no matter where it goes. If it goes outside of Navy, we'll go out there."
Growing and Planning
Safe Harbor has not grown to its fruition, Watkins said. In fact, Safe Harbor is not officially designated as a command - yet, said Watkins, explaining that he is working on that issue.
"We're not just doing this because of the war. We're doing this because we will always have wounded, ill and injured sailors," Watkins said. "It needs to be an enduring organization. I want to get established policy written in place that directs us what to do, how to do it, and then we'll have the right policy, right funding and the right support that we need.
"Right now we're just working on 'Go, and do good things.'"
Ultimately, Safe Harbor will have 15 case managers deployed nationwide at all the fleet concentration areas, major military treatment facilities and the four Veterans Affairs polytrauma centers. It also is to have 12 headquarters staff in Washington, D.C., and a couple at its personnel headquarters in Millington, Tenn. These should be in place by the end of this year, Watkins said.
Currently, five case manager jobs are being filled by reservists on two-year tours. Those will eventually be converted to active duty slots, Watkins said.
The Navy program is similar to the Air Force's in that there are no large units specifically designed to house wounded warriors. Injured sailors receive care at the military hospital closest to their home station. If the sailor is assigned to a ship, the sailor is reassigned to the ship's home port, Watkins said.
The Road to Recovery
Each sailor that enters the Safe Harbor program is screened and, if the service is needed, assigned a non-clinical case manager.
The non-clinical case manager then meets with the sailor, and his or her family, and completes a needs assessment. An assigned nurse case manager completes a similar assessment from a medical perspective. The two assessments are combined and later matched with the goals of the sailor and his or her family.
Less seriously injured sailors who are expected to return to duty will be put in a limited duty program. Once they recover, they go back into the assignment pool and are eventually reassigned, Watkins said.
The more seriously injured, if they are not expected to return to active duty, may move from the military hospital, to a VA polytrauma center closer to their home, and eventually to their hometown for recovery.
"They try to get them as quickly as they can to where they're going to be for their long-term rehabilitation," Watkins said.
Once the needs assessment is matched with the patient's goals, a recovery plan is created outlining the steps that will take the sailor from recovering in the hospital to meeting his or her goals.
"He may be a welder in the Navy today, but he may want to become an astrophysicist," Watkins said. "So we're going to help him get enrolled in college and take college courses and get prepared to transition while he's rehabilitating medically."
The recovery plan includes milestones and Safe Harbor watches to ensure that the care providers and the sailors meet those milestones.
When it is time to transition to Veterans Administration care, the non-clinical case manager works closely with VA officials to ensure the sailor's care transitions smoothly between the two government agencies. In fact, Safe Harbor has on-site case managers at each of the four VA polytrauma centers across the United States. Many of their offices are steps away from VA case managers and social workers.
Retaining Wounded Sailors
Not all seriously injured sailors choose to separate from the Navy, though. And the Navy has joined the other services in the recent trend to allow seriously injured servicemembers to return to active duty. Advances in treatment and technology, as well as rewritten policies and the determination of the troops has put many, including amputees, back in boots and sometimes even back into combat.
"We bend over backwards," Watkins said. "If a sailor has the desire to remain on active duty and has something to contribute to the mission, whatever it may be ... we're going to do what we can to retain them on active duty."
One sailor was blinded by a homemade bomb in Iraq. As a senior chief petty officer, he was about three years shy of his 20-year retirement goal.
Safe Harbor retained him on active duty to help develop the Navy's wounded care program. His unique perspective helped determine how and where case managers are needed and how they should deal with severely injured sailors. The senior chief petty officer also went into military hospitals and talked to those freshly injured, filling them in on what to expect during their recoveries.
"It was a no-brainer for us to retain him on active duty," Watkins said. "Even though he was not qualified by the regulations -- by the medical standards -- to serve, we were able to get that waived, keep him on active duty, because he still had a lot to contribute to our mission."
The sailor retired this year.
Watkins now spends his time developing the program and traveling around the country giving his "stump" speech about Safe Harbor and its efforts to commanders and senior enlisted, medical officials and physical evaluation board liaisons. One of the challenges is that many of those deep within the Navy's ranks and who have already separated do not know about its services.
"Anybody who wants to hear about what Safe Harbor does, I'll go talk to them," Watkins said.
Even if the sailor is completely out of the Navy, he or she still is eligible for Safe Harbor help, he said.
"If it is service connected, we can get them enrolled with the VA and get them treated," Watkins said. "Rather than them having to figure it out on their own, we're going to put them right in touch with whomever they need to be working with."
Bringing Sailors Back for Treatment
There are even ways for the Navy to bring a sailor back on active duty to ensure he or she gets needed treatment, Watkins said.
For example, Navy Petty Officer Zachary Crites deployed to Iraq as a medic in a Marine combat unit in July 2006. It was an assignment he loved, Crites said, despite the fact that he was rocked so many times by bomb blasts while traveling in convoys that he eventually had to be pulled from duty outside the wire and treated in country for symptoms of a traumatic brain injury.
Crites suffered from migraines and tremors, and when he returned stateside, doctors here began a battery of neurological and other tests and prescribed medications.
In June 2007, Crites was ordered into the naval reserves as part of a program that places sailors on active duty for 15 months and then transfers them into the reserves for the remainder of their enlistment. It wasn't long before Crites found himself in another battle - one for his health.
His active-duty command gave Crites as much medication as they could legally for the transition, and told him Veterans Affairs would continue the care. Crites filed a claim with VA that summer. But soon he ran out of medicine and was told by VA officials that they were still processing his forms.
Crites could have seen doctors using the healthcare plan provided by his civilian employer, a hospital where he worked as an emergency medical technician. But he was worried about his job stability if his employer found out that he had a brain injury.
"I didn't know what they would do if they knew that I had a traumatic brain injury," he said.
Crites didn't even tell his then-fiancAfA, now his wife. He didn't want to worry her, and hoped the problem would fix itself.
By December 2007, Crites knew he needed help. With nowhere else to turn, he went to his command at his reserve unit.
Crites' command contacted the Safe Harbor program and within a month, he was receiving the treatment and medication he needed.
"Crites is lucky that his leadership noticed something was not right ... and knew what to do about it," said Watkins said.
In April, Crites was brought back onto active duty for his treatment. He plans to stay in the Navy and wants to return to the "green side," or back with the Marines.
Recovery isn't easy and Crites knows it won't happen over night. But he's glad to be back on duty.
For Crites, Safe Harbor was the turnaround.
"There are days when it sucks. And it really isn't that much fun," he said. "But when I wake up 20 years down the road, I definitely will be glad that I decided to come back.
"Safe Harbor's been great. They have done everything that they said they were going to do."