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Long-Term Outcome > TBI: Three Models. Mary Pepping, Ph.D., ABPP-CN Professor, Dept. of Rehabilitation Medicine University of Washington Medical Center. Severe TBI: What Is It?. Caused by blow to head or severe acceleration-deceleration injury Length of coma > 24 hours

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Long term outcome tbi three models

Long-Term Outcome > TBI: Three Models

Mary Pepping, Ph.D., ABPP-CN

Professor, Dept. of Rehabilitation Medicine

University of Washington Medical Center

Severe tbi what is it
Severe TBI: What Is It?

  • Caused by blow to head or severe acceleration-deceleration injury

  • Length of coma > 24 hours

  • Glasgow Coma Scale < 9

  • Length of Post-Traumatic Amnesia (PTA) > 1 week

  • Time to follow commands > 24 hours

Other indicators of severity
Other indicators of severity

  • Brain contusion

  • Brain hemorrhage

  • Skull fracture

  • Brain swelling

  • Shear injury

  • Infection

What is long term psychosocial outcome
What is long-term psychosocial outcome?

  • Level of function achieved & maintained in a range of real-life roles and settings > 5-10 yrs

    • Activities of daily living (ADLs)

    • School

    • Work

    • Productive activity

    • Family, friends, relationships

    • Leisure

The challenges of objective measurement
The challenges of objective measurement

  • What outcomes should we measure?

  • How do we best define/measure them?

  • How can we be sure the groups of patients are comparable?

  • Why has return to work been used so often as “the gold standard?”

What about indirect measures
What about indirect measures?

  • Level of caregiver burden

  • Degree of social isolation for patients and families

  • Incidence of stress, decreased mental health, and alcohol problems among families of survivors

  • Drug and alcohol abuse in survivors

  • Chronic depression, anxiety, loneliness

  • Economic impact

Long term outcome stats
Long-term outcome stats

  • Thomsen - Scandinavian study

    • 10 years post injury

    • Severe TBI

    • 1/3 obtained and maintained paid employment after inpatient rehabilitation

    • 2/3 not working at 10 years post-injury

    • (Note: what are non-TBI work rates?)

Comprehensive interdisciplinary neuro rehab
Comprehensive Interdisciplinary Neuro-Rehab

  • Early 1980s (Ben-Yishay; Prigatano)

    • 34% back to work after intensive rehab

  • Late 1980s (e.g., Prigatano)

    • Introduction of work trials = 50% RTW

  • Mid 1990s (Klonoff, Pepping & Grant)

    • 60% RTW

  • 2000-2007 (Klonoff, et al)

    • > 80% RTW or productive activity

Disincentives for rtw
Disincentives for RTW

  • Disability income

  • Lack of acceptance of change in skills

  • Current earning power

  • Litigation, depending on patient

  • Worries about maintaining employment

  • Concerns about health insurance

  • Family needs and pressures

Three models
Three Models

  • Rehab Without Walls

    • Home and Community Model

  • Intensive Outpatient Neuro-Rehab

    • Barrow Model; UWMC Model

  • Supported Employment

    • Projects with Industry; Co-worker coaches

Rehab without walls
Rehab Without Walls

  • Strengths

    • Therapies delivered in home: no travel logistics

    • Rapid access to treatment

    • Clinical coordinator for each patient

    • Interdisciplinary team

    • Highly functional therapy focus

    • Strategies developed and taught where they will be used

    • Regular involvement of family

Rehab without walls1
Rehab Without Walls

  • Weaknesses

    • No group treatment opportunities for patients or their families

    • Vocational counselors and other specialty services tend not to be part of the core team and program

    • Cost of program

    • Does not accept Medicare or Medicaid

Intensive outpatient nrp
Intensive Outpatient NRP

  • Strengths

    • Full range of clinic based rehab services, e.g., OT, PT, SP, Neuropsychology, Psychology, Vocational Counselors, Therapeutic Rec, Social Work, Rehab Medicine physicians (physiatrists)

    • Specialties: Job Stations, Assistive Technologies, Certified Driving Evaluators, specialty MD care

    • Treatment groups for patients and families

    • Research opportunities, e.g., exercise study

    • Access to continuing education presentations

    • Most or all insurances accepted

Intensive outpatient nrp1
Intensive Outpatient NRP

  • Weaknesses

    • How well will treatments generalize to home and community?

    • Transportation can be a challenge for patients and families

    • How long does it take to get admitted and seen for treatment or specialty care?

Supported employment model
Supported employment model

  • Strengths

    • Direct treatment and support for work-related goals and needs

    • Use of peer job coaches

    • Capitalizes upon patient’s desire to be back to work = a major motivator for use of strategies and improved behavior

    • Patient is earning money and feels more normal and less isolated

Supported employment model1
Supported employment model

  • Weaknesses

    • Has a more limited treatment focus so that other important personal/family problems > TBI may not get addressed

    • Patient needs to be ready for return to work process, e.g., aware and accepting of new status

    • It is not clear to what extent compensations learned for one job will generalize to other jobs

How are these models doing
How are these models doing?

  • With good “matching” of patient to experienced programs, outcomes are strong in all models, e.g., 60-90%

  • We have learned from our failures, e.g., why don’t people with potential RTW > TBI?

  • The importance of volunteer work

  • Formal and informal follow-up

  • Added help at major transitions

Long term needs we don t yet address well
Long term needs we don’t yet address well

  • Post-program support for families

    • Respite

    • Quality of their work and personal lives

    • Economic advisors

    • Psychotherapeutic support

  • Friendships and intimate relationships for people who survive severe TBI

  • Telephone and internet based supports