“Goldilocks & the 3 Rehabs” What to look for when choosing a brain injury rehabilitation provider

1. “Goldilocks & the 3 Rehabs” What to look for when choosing a brain injury rehabilitation provider Lorraine Myro, MSW, LSW Bancroft Brain Injury Services

2. Our Mission Bancroft provides opportunities to children and adults with diverse challenges to maximize their potential. Our Core Values Responsible Empathetic Supportive Passionate Empowered Committed Trustworthy R E S P E C T Our Vision A community where every individual has a voice, a purpose and a rightful place in society.

3. Learning Objectives • Understand the rehabilitation continuum of care for brain injury recovery • Understand evidenced-based practice • Identify at least 4 factors to consider when searching for the right rehabilitation program • Identify what you specifically need from your provider of choice

4. 4 Factors to consider . . .

6. What protects the brain:

7. Types of brain injury • Traumatic • Sudden jolt or blow to the head • Coup-contracoup: side to side, back and forth • Hypoxic: decreased oxygen to the brain • Anoxic: cessation of oxygen to the brain • Diffuse Axonal Injury: nerve cells stretch and break

8. Course of recovery • Severity • Type • Pre-morbid condition (including age) Glascow Coma Scale: Determined by response to verbal response, eye opening, and motor response. Lowest rating is 1 point per area. 3-8: severe 9-12: moderate brain injury 13 – 15: mild brain injury

9. Common brain injury sequelae • Medical issues • Physical changes • Cognitive impairment • Behavioral challenges • Changes in personality

10. Medical issues can include: • Skin • Lacerations, abrasions • Acne, profuse sweating • Pressure ulcers • Rashes, infections from medications interacting with altered systems • Cardiopulmonary System • Hypertension may occur as a result of TBI • On-going monitoring • Gastrointestinal System • Change in metabolism • Swallowing disorders

11. Medical issues continued. . . • Elimination System • Bowel and bladder dysfunction are common • Neurological System • Seizures • Vision impairments • Hemiparesis (weakness of one side of the body) • Hemiplegia (paralysis of one side of the body) • Musculoskeletal System: common, often undiagnosed in acute setting • Injury to muscle or bones • Peripheral nerve injuries

12. Physical changes

13. *Cognitive Changes

14. *Behavioral/Personality changes

15. *Pharmacological interventions • Consider behavioral, environmental and social interventions first • Weaning of medications is the goal • Effects can impair recovery of other systems • Arousal • Cognition • Heart rate • Mood

16. Who, what is affected

17. Who, what is affected

18. What you will need to know from your provider . . .

19. Progress Updates • What you need to be asking: • What players are on the team? • What are the goals? • What progress has been made? • What are the barriers you are dealing with right now in meeting these goals? • Medical issues, psychosocial issues, behavioral issues? • Any unexpected changes to progress or plan? • What are the patient/client’s concerns? • How does team address his/her concerns? • What does team expect to recommend upon discharge: where, who? • What social supports are in play? Are they communicating with the team?

20. When is it time to transfer from acute hospital to acute rehab? • Maintained medical stability • Able to participate in and benefit from rehab • Exceptions: • Specialty programs, i.e. Responsiveness Program • Patient = minimally conscious • Research • Data collection • Cutting edge intervention • Pharmacological • Therapeutic

21. Provider Criteria, why it matters • Accepts your funding • Specialty: expert, competent care • Credentials: JCAHO, CARF, state approved • Reputation • Research oriented • Location: Accessible

22. Credentials

23. What is specific to a TBI Model System Provider

24. JCAHO and CARF • Joint Commission on the Accreditation of Health-care Organizations (JCAHO) • Commission for the Accreditation of Rehabilitation Facilities (CARF) • Nationwide • Voluntary process • Program meets a comprehensive set of quality and performance standards • Competent delivery of services • Quality of care provided to stakeholders

25. Research Oriented On-going education for staff • Rounds • Lunch-n-Learns • Certificates (e.g. Academy of Certified Brain Injury Specialists) • Conferences, articles, boards, panels Evidence-Based Practice: process of clinical decision making • Research • Practitioner expertise • Client preferences and values

26. Inter-disciplinary Team (IDT) • Discipline expertise • Specialized knowledge of how TBI affects specific system/function • Applied knowledge of how all aspects are related – including psychosocial aspect Symphony of rehab: successful integration of all parts

27. Available Family Supports

28. Discharge Planning • Estimated length of stay = moving target • Brain injury = chronic • Typically most observable changes occur in the first year of rehabilitation • Deficits become more prevalent as environment and circumstances change • “Walkie- talkies”: need for supervision

29. Acute Rehab • Provide intensive rehabilitation while “optimizing the person’s medical condition and improving basic functioning” • Full inter-disciplinary team • 3 hours therapy daily

30. The Team • Doctors, nurses, CNAs: medical component • Neuropsychologists: context*, mood, behavior, psychosocial • Speech: language/communication and eating • Cognitive rehabilitation therapists: cognition, communication, behavior • Occupational therapists: ADL’s, IADL’s • Physical therapists: mobility impairments • Social worker/case manager: psychosocial issues, discharge planning, communication • Psychiatrist: management of psychotropic medication • Family education: entire team

31. Acute Rehab: what you need • Access to 24/7 medical care • On-site testing • Collaboration with neuropsychiatry • Experience with wound care • Inter-disciplinary team approach • Neuropsychologist, social worker part of communication with patient, family and you • Educate and train caregiver(s)

32. Sub-Acute/Skilled Nursing Facility • Continued medical needs • Complex nursing needs • Ability to participate in and benefit from therapy (1- 3 hours day) • Discharge: decreased medical risk • ELOS: depends on rate of progress, funding

33. Sub-Acute: What you need • Nearby access to reputable hospital with emergency department • Medical doctor on staff (TBI experience) • Therapists experienced with TBI • Collaboration with neuropsychiatry • Experience with wound care • Inter-disciplinary team approach • Neuropsychologist, social worker part of communication with patient, family and you • Educate and train caregiver(s)

34. Outpatient Therapy • Reside at home • Go to facility to receive therapies • Physical • Occupational • Speech • Cognitive rehabilitative therapy • Neuropsychological counseling

35. Outpatient Therapy: What you need • Therapists experienced with TBI • Ability to provide TBI specific referrals and resources • Psychiatry • Psychology • Support Groups • Inter-disciplinary team approach that can determine what needs to happen next based on client’s progress/*newly exhibited deficits • Social worker to communicate with patient, family and you • Educate and train caregiver(s)

36. Post-Acute Brain Injury Rehabilitation Program (PABIR) • Live in group homes, supervised apartments with support from staff • Comprehensive therapeutic focus on functional skills, reintegration into home, community • Structured activities daily, including PT, OT, SP therapy, neuropsychological services*, and cognitive rehabilitation therapy.

37. Post-acute brain injury rehabilitation: What you need • Nearby access to reputable hospital with emergency department • Link to medical doctor with TBI experience • Therapists experienced with TBI • Collaboration with neuropsychiatry • Inter-disciplinary team approach • Emphasis on community reintegration

38. Post-acute brain injury rehabilitation: What you need • Neuropsychologist, case manager part of communication with client, family and you • Education and training for caregiver(s) • On-going education for staff/therapists • Participates in research

39. Examples of how a TBI specific program can make a difference

40. 4 Factors to consider . . .

41. Qualities of the Program Itself • Population served: age • Specialty: right service for the identified stage of rehab • Program design: • Part of the TBI Model System? • What is the program’s mission and vision? • Therapists on staff? What does the patient/client do during his time in program? If it’s residential, what is the staff ratio? Do they get out into the community? • Expertise among staff: is there a structure in place for staff to receive on-going education about TBI rehab and research?

42. Qualities of the Program Itself • Communication/outreach: how is this done? Is it even a part of the program? Meetings, reports? How accessible and responsive are members of the program? • Does staff include key players – doctor, psychiatrist, neuropsychologist, cognitive rehabilitative therapist? • Teaching center? Volunteers encouraged?

43. Communication with funders Quality of information provided: • Give you a clear picture of what therapists/treatment team are doing • How interventions are helping patient/client progress, and in what areas patient/client is progressing • What the barriers are, what strategies will be used • What challenges are expected to be long lasting • What role will family/caregivers play • Identify what the team expects to recommend next and why Limitation: because of the incredible amount of variables that affect TBI rehabilitation, no prediction is completely accurate

44. References • Brain Injury Association of America. (2009). The Essential Brain Injury Guide, Edition 4 • Memories, photographs, and the Human Brain. Retrieved January 20, 2014 from www.easybranches.us. • Mullen, R. Director, National Center for Evidence-Based Practice in Communication • Disorders, ASHA Evidence-Based Practice: Opportunities and Challenges for Continuing Education • Providers. Retrieved January 20, 2014 from http://www.asha.org/CE/forproviders/Evidence-Based- • Practice-CE-Providers/

45. Questions? Lorraine.myro@bancroft.org