Transcript Brain Injury Rehabilitation Trust (BIRT)

The Brain Injury Needs Indicator
Dr Sue Copstick – Clinical Director
Erin Rodgers – Policy and Campaigns Manager
Brain Injury Rehabilitation Trust
(BIRT)
• Leading brain injury rehabilitation charity
• Specialist assessment and rehabilitation
• Referrals
• UK Wide
www.birt.co.uk
The year of change - Care Act 2014
• Most significant reform of care and support in more
than sixty years
• Single, modern law makes clear what kind of care
people should expect and receive
• Councils will now have a duty to consider the
physical, mental, and emotional wellbeing of the
individual needing care
• Legislation is largely positive
• Funding & Eligibility
Care Act 2014: Implementation
Part 1 – April 2015
• New assessment process
• Assessments for carers
• National eligibility criteria
• Advice and information
• Legal responsibility of transition to adult services
Part 2 - April 2016
• New rights to personal budget and direct payments
• Cap on care costs for all (72k for elderly)
More Info - http://www.local.gov.uk
The year of change
• Care Act 2014
• Social Care reform
• Implementation Processes
What could BIRT add to the mix?
• Advocate positive change for our service users
• Research
• Department of Health backing
• Care Act Guidance
• Would social workers agree?
Will social workers take the BINI
onboard?
• You already have the knowledge and
emotional intelligence
• BIRT want to add to this using their
knowledge and tools
• BINI should give you confidence in trusting
your gut feeling by evidencing the Brain
Injury
Brain Injury Needs Indicator
• A tool to be used in conjunction with a social care
needs assessment
• Indicates deficits of brain injury
• Uses clinically evidenced questions to elicit true
care and support needs
• Simple traffic light and next step system
• Free to use
• BINI is highlighted in Care Act and Practice
Guidance
A study carried out by BIRT showed that
timely rehab could achieve lifetime
savings in direct care costs between
£0.57 and £1.13 million per person.
Savings between £0.19 – £0.86 million per
person were apparent even for individuals
who received rehabilitation more than a
year after injury.
Brain injury rehabilitation works
Hence there have been numerous attempts
internationally to try and establish a reliable
way of assessing the need for rehabilitation
following brain injury.
The assessment of need is mentioned in the
recent NICE guidelines, as being a necessary
part of discharge from hospital.
The Brain Injury Needs Indicator
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“Don’t reinvent the wheel”
Quick and easy to use
Robust and reliable
Scientifically and clinically credible
Meaningful, usable results for social workers
and others.
The BINI, in development,
1. Uses the ability and expertise of social
workers
2. Uses previous research on brain injury
outcomes
3. Uses well accepted clinical diagnostic
questions to identify brain injury, and the
need for treatment
Existing work in needs assessment
• Not much of this at all.
• There was an assessment of disability
following brain injury, the GODS, to be used
in inpatient settings.
• No assessment of need, nothing to indicate
when a referral on for more assessment and
treatment was needed.
• Not everyone needs rehab.
The GODS
The Glasgow Outcome at Discharge Scale:
An Inpatient Assessment of Disability after
Brain Injury
Thomas M. McMillan, Christopher J. Weir, Alaister
Ireland, and Elaine Stewart
JOURNAL OF NEUROTRAUMA 30:970–974 (June 1,
2013)
Use of the GODS
• ‘Designed to assess disability after discharge
in an in-patient setting’
• Uses the Glasgow Outcome Scale to assess
disability
• There is a 20 minute video available to help
guide people through use of the tool.
GODS: assessing disability on the
ward
• 1a: Is the brain injured person conscious eg: able to obey simple
commands, write, say any words or communicate by other means?
• Could the absence of response be due to sedation? [Yes / No]*
• ·Has the person been diagnosed as being in a vegetative state [Yes
/ No ] *Note: Corroborate with nursing staff.
• 1 – No
• 2 - Yes
More ‘behavioural’ questions
2e Does the person’s behaviour cause severe disruption or difficulties with ward staff, visitors, other
patients or carers
Independence outside the unit/ward
3a Are they able to shop without assistance?
· For example at the hospital shop could they plan what to buy, handle money appropriately and purchase
a list of items successfully without assistance
1 – No (Upper SD)
2 – Yes
3b Were they able to shop without assistance before the injury? 1 – No 2 – Yes
4a Are they able to travel outside the unit/ward safely without assistance?
· They may walk, self propel a wheelchair, drive or use public transport to get around. Examples include
visiting the hospital shop independently and safely or travelling home and returning on pass successfully
and safely. Use of a taxi is sufficient if the person can phone for it themselves and instruct the driver.
1 – No (Upper SD)
2 - Yes
GODS Ratings of disability
1. Dead
2. Not conscious
3. Lower Severe Disability (Lower SD)
4. Upper Severe Disability (Upper SD)
5. Lower Moderate Disability (Lower MD)
6. Upper Moderate Disability (Upper MD)
7. Lower Good Recovery (Lower GR)
8. Upper Good Recovery (Upper GR)
The Disabilities Trust
• How can we use reliable assessment of
outcome of brain injury and use it as a basis
for a needs assessment?
• McMillan et al. and scores of others agreed
that the Glasgow Outcome Scale was a good
indicator of outcome after brain injury. We
had to use this peer promoted scale.
BP: BINI Principles
1. The outcome of brain injury will define the
level of rehabilitation need for that person
(the worse the outcome, the higher the need)
2. Lack of insight is a feature which significantly
increases risk, and that increased risk leads
to increased need for treatment.
The Second Principle
• Oddy et al. (1985): 7 years after brain injury 53% of patients reported
memory problems in comparison with 79% of family members.
• 40% of the families reported their BI loved one was more childish in
comparison to 0% of the person with the brain injury.
• 40% of those with a brain injury denied any problems at all
• The lack of insight and self-awareness is thought to be a function of the
brain injury (i. e. organic) rather than ‘denial’ or other psychological
effect. Rehabilitation treatments address this deficit (e.g. see review by
Fleming & Ownsworth, 2006).
The needs assessment
• All other assessments had suggested
speaking to nursing staff or a relative.
• No other assessment had formally
incorporated the relative or advocate
responses into outcomes, and given it equal
weighting to subject responses in this
context.
The BINI
Who is the BINI for?
• Use of the BINI is not limited to those who
you know to have suffered a brain injury
• It can and should also be used with someone
you suspect may have suffered a brain injury
(e. g. someone who may appear to have
more difficulties than what is known about
health or medical history would suggest)
Assessment of need for rehabilitation
via the BINI
• All assessments require interpretation: anyone can ask
the questions but you will have the expertise to interpret the data.
• The interpretation will provide details for reliable
reporting: when you say there are risks and urgent treatment is required,
you can provide evidence to say why
• The interpretation will allow accurate prescription
for next step treatment, dependent on need.
The Triple Lock System
Advocate
BINI
Clinician
A ‘treating clinician’ can be a number
of different professionals…
• NHS rehabilitation services
• Community brain injury teams
• Specialist clinical charities (Disabilities Trust and many
other providers)
• Clinical Neuropsychologist
• Neuro-Occupational Therapists
• Neuro-Physiotherapist
• Speech and Language Therapist
• Neurologist or Neurosurgeon
• GP with a special interest in brain injury
Brain Injury Needs Indicator
• The questionnaire is given to THREE different sources.
• Where answers are the same you have good, reliable
clinical data for evidence of a brain injury, and need for
rehabilitation.
• Inconsistencies between sources indicate increased risk and
the urgency of intervention increases.
Part 1: Identifying a Brain Injury
• Have they been knocked unconscious and
required help afterwards?
• Have they had minor or several bangs to the head
where they felt ill or dizzy?
• Have they had an illness affecting their brain?
• What medical attention did they required for their
brain injury or illness?
Identifying TBI
• Establishing accuracy will save time and
trouble.
• Some people think they have a TBI when
they have not, and some people think they
have no risk of brain injury (the concussed,
those with alcohol and drug problems).
• Your skill in obtaining personal information is
crucial here – establishing empathy and trust.
If people have no evidence of BI
• Discontinue assessment.
Part 2: Outcome of Brain Injury
Assesses outcome in the following areas:
• Daily tasks
• Shopping and travel
• Work
• Family and friendships
• Other issues
Questions here
• Based on the Glasgow Outcome Scale
• Has been reliably shown to assess the outcome or ability of
the person after brain injury.
• The degree of disability or outcome of the brain injury will
indicate the level of need for
a) current help
b) rehabilitation treatment to help the person learn to
compensate and manage their deficits.
Part 3: Behaviour difficulties
• Do they need regular reminders or prompts?
• Does their behaviour/mood/memory affect their
daily life?
• Would knowing more about their injury help them?
• Do they have any other health problems?
• Do friends and family think they are aware of their
problems?
The ‘behaviour’ section aims to
capture more subtle aspects of brain
injury
Tries to capture information about:
• Mood
• Insight
• Motivation
We need clinical data now to evaluate whether
this sort of tool and assessment is useful for
social workers and others.
How does the BINI assess need?
• Normally, there is consistency between the
three sections of the BINI
• And there is consistency between the BINI
and what the relative/advocate says, and the
medical case notes.
• Lack of consistency is a ‘red flag’.
Why do inconsistencies increase risk?
• Capacity to consent depends on reasoning
and understanding; there might be capacity
issues to consider with family.
• Care maybe inappropriate or insufficient for
enablement.
• Relatives and carers may be struggling to
cope (parenting, finances)
When is a referral urgent other than
when there are inconsistencies?
A referral will be urgent if there is a very poor
outcome from the brain injury:
• Cannot cope with daily activities independently
• Relationships are affected
• Ability to work is affected
• Lack of insight into their problems and the
associated risk
BINI and the Triple Lock System
Look for:
Red answers + inconsistencies between
sections of the BINI within the triple lock
assessment process:
HIGH RISK and HIGH NEED
Are you at least obliged to try and improve
deficits and risks, not accept them as ‘given’?
Case Studies
Case Study 1
• You visit a 46 year old man in his home
• The client has an odd walking pattern and is
unsteady on his feet. His lifestyle is chaotic –
his house is very full, untidy, unclean
• Triple lock says you should:
– Speak with an advocate (in this case, his partner)
– Complete the BINI with the client
– Speak with a clinician (in this case, his GP)
BINI Interview
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He was knocked unconscious for 20 minutes
He has had 4 falls and mild head injuries
He has alcohol problems and Diabetes Type I
He lives with his partner and their two teenage
children
• His partner also has alcohol problems
• They live on benefits
• They live in a chaotic home
Brain Injury Needs Indicator (BINI)
Go through the three main parts of the BINI:
1. Identifying the brain injury – Has the person had
a brain injury? When was it? What was the cause?
2. Assessing outcome – How much help does the
person need in areas such as daily tasks,
shopping, or travel
3. Assessing behaviour: How does their
behaviour/mood/cognition affect their life? Would
they like to learn more about this?
This man…
1. Identifying a Brain Injury
He scores RED on this section – he has had a
number of brain injuries
2. Outcome
He scores AMBER and GREEN in this section
– he needs help to go shopping
3. Behaviour
He scores AMBER and GREEN in this section
His wife thinks.....
1. Identifying a Brain Injury
He scores RED on this section
2. Outcome
He scores mostly RED in this section – he
needs prompting and a lot of help
3. Behaviour
Several REDS– he is moody, dizzy,
symptomatic, his relationships are poor
His GP reports…..
1. Identifying a Brain Injury
He scores RED on this section
2. Outcome
Cannot answer
3. Behaviour
Cannot answer
However, the GP does confirm he has poor diabetic
control and the need for Vitamin B and Thiamine for
his alcohol abuse
Case 1: BINI data
Person
Advocate
GP
ID Brain injury Red
Red
Red
BI outcome
Amber
Red
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Awareness
Amber
Red
-
Case 1: BINI Outcome
• There are inconsistencies in perceived
outcomes, risks and problems after the brain
injury.
• Refer on for more assessment and
rehabilitation, if possible.
• Definite injury with at least moderate
disability.
Using all the information
• The BINI is a framework for meaningful
reporting of evidence-based concerns about
your client
Positive history of brain injury
+ Definite psychological/physical disability
+ Triple lock inconsistency (lack of insight)
= URGENT need for further assessment due to
high level of risk
The BINI
• Has allowed meaningful questioning and
data gathering about significant clinical facts
• Has allowed a risk assessment and
assessment of need for rehabilitation
• The problem now is finding the services to
rehabilitate this man
Case Study 2
• A young 23 year old unemployed man with
reports of offending and violence, living with
his Mum
• On the BINI, he scores AMBER for a mild
head injury in section 1
Clinician…..
• Not much information was provided by the GP,
so you decide to go to the police
• The police have two records of ‘breach of the
peace’
• The police also report that he is currently
awaiting trial for minor drug offences
(possession)
• No head injury was mentioned by the police or
by the GP
How can we interpret need?
• In this case, the client reports a mild brain
injury
• It is generally agreed that the symptoms of
concussion and mild head injury should have
recovered within 3-6 months (SIGN 130)
• If this is not the case, a psychological
intervention may be needed (rather than
rehabilitation)
BINI Training
• We are currently looking for local authorities
willing to trial the BINI
• We are also offering free, expert training
which covers:
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Overview of the Care Act
The context of the BINI in social care
Brain Injury awareness training
The BINI
Clinical case studies
BINI Training
Feedback from a recent training session with
SWs from a Local Authority in England
• 72% found that the session was useful to
learn about ABI
• 75% said they would recommend the training
to colleagues
• 100% said they were likely to use the BINI
• We are determined to get it right, and adapt
the training after each session
Next Steps
• Recruit more local authorities to trial the BINI
• Work with stakeholders to highlight the BINI
• Evidence and evaluate our work
• Publish BINI in April 2015
Thank you