TBI clubhouse funded by alternative resources
Model provides structured work experience
MossRehab in Philadelphia opened its first clubhouse for traumatic brain injury (TBI) patients six years ago as an alternative to outpatient care for patients who were not ready for other TBI services, including the hospital’s community re-entry program.
"The clubhouse program is for people who are perhaps more severely impaired in their disability," says Drew Nagele, PsyD, clinical director of ambulatory programs for the Drucker Brain Injury Center at MossRehab. The hospital has opened another clubhouse program in Woodbury, NJ.
Rehab administrators decided to develop the clubhouse to meet the needs of TBI patients who needed a highly structured work environment with clinical supervision, based on the concept of member empowerment. Due to managed care’s more acute focus and changes in Pennsylvania’s auto insurance laws, which have resulted in less money available to pay for TBI services, the clubhouse was designed to be funded privately. It was started with a grant from The Pew Charitable Trusts in Philadelphia.
"Pennsylvania used to be a no-fault state where all rehabilitation that was medically necessary was covered," Nagele explains. But this changed first in the late 1980s when the state government took over insuring catastrophic loss and placed a million dollar cap on lifetime benefits. Then when this fund went bankrupt, the state returned catastrophic loss coverage to the private sector but made medical benefits above $5,000 optional.
That meant that the majority of TBI patients were covered primarily by their health insurers, and benefits for outpatient rehabilitation were limited. "So we had to design the clubhouse to be a low-cost program because people were mostly going to pay for it privately," Nagele says.
Patients or their family members typically pay $11 to $55 per day, depending on a sliding scale based on family income. The clubhouse also receives income from the sales of a gift packaging and gourmet coffee business operated by the clubhouse program. It receives private donations, such as a recent donation that will fund the purchase of a new clubhouse building. The current site is leased. Less than 20% of the program’s funding comes from workers’ compensation and other insurance coverage, Nagele says.
Here’s how the program works:
• Keeps costs low.
The clubhouse building is in an inexpensive office setting in the community. When the new building is purchased through the private donation, fixed operating costs will be even lower because the program no longer will be paying rent. The staff includes one master’s-level rehab counselor, two bachelor’s-level therapists, all of whom are trained in brain injury but who are not necessarily licensed therapists, plus one student intern. Clubhouse members meet each week and review the operations of each work unit. They give verbal and written reports and vote on items that require action. The clubhouse is run in a democratic way.
• Establishes work programs.
The MossRehab clubhouse serves about 50 people, with up to 25 people on any given day. Members attend the clubhouse two to five days a week. Each clubhouse member is assigned to a particular unit where he or she can develop work skills. Members manage and basically run the clubhouse, handling maintenance, lunches, and other daily operation activities.
Members are listed as volunteers and are not paid for their work, which is considered part of their therapy. Some have developed their work skills to the competitive level and are employed by the clubhouse’s Nifty Gifts business; those workers are paid a competitive hourly rate.
The communications unit has computer workstations, and members staffing those stations are responsible for all correspondence coming into and leaving the clubhouse. They also manage the clubhouse inventory, conduct fundraising activities, and provide public relations. They produce a newsletter about the clubhouse called The Clubhouse News. The newsletter lists member and staff birthdays, Drucker Brain Injury Center resources and training programs, updates on how the other clubhouse units are doing, and various personal items, including recipes, tributes to members who’ve died, vacation news, poems, and essays.
Keeping house
The kitchen unit is responsible for planning a hot meal each day. Members may choose to bring their own lunch or pay a small fee for the daily hot meal. The kitchen unit members plan menus and do the shopping, working within a budget determined by how many people have paid for lunch that day. They do all of the meal preparation work, and they provide catering services for special events. The kitchen unit specializes in desserts and supplies the Nifty Gifts business with baked goods to sell.
Members of the maintenance unit are responsible for keeping the clubhouse in good condition, doing repairs, cleaning, and even some light construction. Members also monitor and maintain compliance with material recycling. One maintenance unit member was talented in woodworking and began to make decorative birdhouses, which clubhouse members decided to sell at Nifty Gifts kiosk shops. "They’re selling like hot cakes," Nagele says.
• Serves as a fundraising venture.
The clubhouse’s Nifty Gifts provides members with ways to bring in money to support the clubhouse while they are learning valuable work skills. Nifty Gifts has a gourmet coffee business, for instance, that operates with kiosks, serving espresso drinks and pastries at the hospital. The business also provides catering services, primarily to Albert Einstein Medical Center and MossRehab hospital departments. Also, the business has a gift-packaging business for corporate customers.
From member to employee
Nifty Gifts hires at least 10 members a year to work as paid employees. They work in the areas of gift package assembly, telephone sales, marketing, advertising, accounting, bookkeeping, purchasing, delivery, housekeeping, customer service, and maintenance. They are paid $5.50 to $6.50 per hour.
"The kitchen unit supports the business by wrapping baked goods and dating them for freshness," Nagele says. "We’re investigating a partnership with a gourmet cookie vendor who will give us an oven to use and will sell dough so members can bake cookies and sell these."
• Trains members to become independent whenever possible.
Members learn through their work in the various units how to handle the organization and stresses of jobs. With trained brain injury counselors to assist them with stumbling blocks, they are able to learn new skills or relearn old ones within a safe environment. As some members progress in their work skills, they might be hired for paid work by the Nifty Gifts enterprise.
Other members move from the clubhouse work to competitively paid work elsewhere, Nagele says. One member refined his computer skills at the clubhouse to the point that he wanted to seek paid work, he recalls. "The vocational rehabilitation agency agreed that he needed more specialized training, so they sent him to a computer school, and he was placed in a business that pays employees on a competitive level."
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