Transcript Document
“Goldilocks & the 3 Rehabs”
What to look for when choosing a brain injury rehabilitation provider
Lorraine Myro, MSW, LSW Bancroft Brain Injury Services
Our Mission
Bancroft provides opportunities to children and adults with diverse challenges to maximize their potential.
Our Vision
A community where every individual has a voice, a purpose and a rightful place in society.
Our Core Values R
esponsible
E
mpathetic
S
upportive
P
assionate
E
mpowered
C
ommitted
T
rustworthy
R E S P E C T
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 Factors to consider . . .
Access to medical care Research oriented Access to (neuro)psychiatry, neuropsychology, and cognitive rehabilitation therapists Holistic, inter-disciplinary team approach 4
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What protects the brain:
Skull • Sharp bony ridges inside “Meninges” • Dura mater • Arachnoid • Pia mater Cerebrospinal fluid • Surrounds the brain 6
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 7
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: 13 – 15:
moderate brain injury mild brain injury
Common brain injury sequelae
Medical issues Physical changes Cognitive impairment Behavioral challenges Changes in personality 9
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 10
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 11
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Physical changes
Ambulation Coordination Spasticity Balance Contractures Hearing Vision
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*Cognitive Changes
Comprehension Attention, concentration Judgment Communication Memory Processing speed
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*Behavioral/Personality changes
Lability Psychosis Impulsivity Aggression (physical, verbal) Changes in affect Non compliance
*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 15
Who, what is affected
Person
• Physical functioning • Ambulation, Fine and Gross motor skills, Vision, Hearing, Swallowing • Internal Systems • Cognitive functioning • Processing, memory, executive functioning, initiation, communication • Emotional functioning • Frustration tolerance, inhibition, relationships, lability, personality changes 16
Who, what is affected
Family • Significant other, children, siblings, parents, friends • Relationships change • Burden of care now exists • Financial issues Work • Unexpected leave • Undetermined length of absence • Non-guarantee of return, nor guarantee of status if a return Community • Role changes • Financial burden 17
What you will need to know from your provider . . .
Reports and in person meetings • Opportunity to meet with members of the team • Ask questions, receive education, collaborate Estimated length of stay • Financial planning • Discharge planning Treatment plan • Builds awareness of what to expect, what can and cannot be “predicted” • Better understanding can help you plan better 18
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? 19
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
Provider Criteria, why it matters
Accepts your funding Specialty: expert, competent care Credentials: JCAHO, CARF, state approved Reputation Research oriented Location: Accessible
Credentials
TBI Model Systems of Care • 1987 grant from National Institute on Disability and Rehabilitation Research (NIDRR) • Provide exemplary system of care • Conduct uniform data collection related to critical research questions 22
What is specific to a TBI Model System Provider
Provides coordinated system of emergency care Acute neurotrauma management Comprehensive inpatient rehabilitation Long-term inter-disciplinary follow up services *Uniform data collection 23
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 24
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 25
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
Available Family Supports
Communication: clear, thorough, compassionate, patient, accurate Accessibility to clinicians: timely, patient, competent Education: written, verbal, hands-on, repetitive, packets for future reference Support from team, peers, community Referrals and resources
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
Acute Rehab
Provide intensive rehabilitation while “optimizing the person’s medical condition and improving basic functioning” Full inter-disciplinary team 3 hours therapy daily
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 30
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) 31
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 32
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) 33
Outpatient Therapy
Reside at home Go to facility to receive therapies • • • • • Physical Occupational Speech Cognitive rehabilitative therapy Neuropsychological counseling 34
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) 35
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.
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 37
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 38
Examples of how a TBI specific program can make a difference
Post-traumatic amnesia Absence Seizure Bowel program Field cut Fracture TBI induced psychosis 39
4 Factors to consider . . .
Access to medical care Research oriented Access to (neuro)psychiatry, neuropsychology, and cognitive rehabilitation therapists Holistic, inter-disciplinary team approach 40
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?
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? 42
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
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
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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/ 44
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