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“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
Responsible Empathetic Supportive Passionate Empowered Committed Trustworthy
RESPECT
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
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What protects the brain:
Skull
“Meninges”
Cerebrospinal
fluid
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• Sharp bony ridges inside
• Dura mater
• Arachnoid
• Pia mater
• Surrounds the brain
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
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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:
9-12:
13 – 15:
severe
moderate brain injury
mild brain injury
Common brain injury sequelae
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Medical issues
Physical changes
Cognitive impairment
Behavioral challenges
Changes in personality
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
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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
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Physical changes
Ambulation
Coordination
Spasticity
Balance
Contractures
Hearing
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Vision
*Cognitive Changes
Comprehension
Judgment
Attention,
concentration
Communication
Memory
Processing
speed
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*Behavioral/Personality
changes
Lability
Psychosis
Impulsivity
Aggression
(physical,
verbal)
Noncompliance
Changes in
affect
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*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
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Who, what is affected
Person
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• 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
Who, what is affected
Family
Work
Community
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• Significant other, children, siblings, parents, friends
• Relationships change
• Burden of care now exists
• Financial issues
• Unexpected leave
• Undetermined length of absence
• Non-guarantee of return, nor guarantee of status if a
return
• Role changes
• Financial burden
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
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• Builds awareness of what to expect,
what can and cannot be “predicted”
• Better understanding can help you
plan better
Progress Updates
 What you need to be asking:
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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?
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
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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
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JCAHO and CARF
 Joint Commission on the Accreditation of
Health-care Organizations (JCAHO)
 Commission for the Accreditation of
Rehabilitation Facilities (CARF)
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Nationwide
Voluntary process
Program meets a comprehensive set of quality and performance
standards
 Competent delivery of services
 Quality of care provided to stakeholders
Research Oriented
On-going education for staff
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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
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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
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Acute Rehab: what you need
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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)
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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
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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)
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Outpatient Therapy
 Reside at home
 Go to facility to receive therapies
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Physical
Occupational
Speech
Cognitive rehabilitative therapy
Neuropsychological counseling
Outpatient Therapy:
What you need
 Therapists experienced with TBI
 Ability to provide TBI specific referrals and resources
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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)
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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
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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
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Examples of how a TBI specific
program can make a difference
Post-traumatic amnesia
Absence Seizure
Bowel program
Field cut
Fracture
TBI induced psychosis
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4 Factors to consider . . .
Access to medical care
Research oriented
Access to (neuro)psychiatry, neuropsychology,
and cognitive rehabilitation therapists
Holistic, inter-disciplinary team approach
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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?
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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.
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-BasedPractice-CE-Providers/
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Questions?
[email protected]
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