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

injury rehabilitation provider

Lorraine Myro, MSW, LSWBancroft Brain Injury Services

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

A community where every individual has a voice, a purpose and a rightful place in society.

Our Vision

Our Mission

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 . . .

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What protects the brain:

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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: severe9-12: moderate brain injury13 – 15: mild brain injury

Common brain injury sequelae

Medical issues Physical changes Cognitive impairment Behavioral challenges Changes in personality

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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

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*Cognitive Changes

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*Behavioral/Personality changes

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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

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Who, what is affected

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

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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?

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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

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What is specific to a TBI Model System Provider

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JCAHO and CARF

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Research OrientedOn-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 values25

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

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 componentNeuropsychologists: context*, mood, behavior, psychosocialSpeech: language/communication and eating Cognitive rehabilitation therapists: cognition,

communication, behaviorOccupational therapists: ADL’s, IADL’s Physical therapists: mobility impairmentsSocial worker/case manager: psychosocial issues,

discharge planning, communication Psychiatrist: management of psychotropic medicationFamily education: entire team

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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,

funding32

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

• Physical• Occupational• Speech • Cognitive rehabilitative therapy• Neuropsychological counseling

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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

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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 38

Examples of how a TBI specific program can make a difference

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4 Factors to consider . . .

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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 fundersQuality 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

ReferencesBrain 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/

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Questions?

Lorraine.myro@bancroft.org

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