TBI patient care doesn’t end when they leave
NJ facility’s three-pronged approach works
Brain injury rehabilitation continues well after patients are discharged from the rehab hospital and carries into the community at MossRehab of Philadelphia.
The rehab hospital, which in 1999 was named one of the top medical rehabilitation facilities in the nation by U.S. News & World Report, has been expanding its brain injury program over the past 16 years to include a continuum of care extending well beyond the inpatient stay.
By juggling private, entrepreneurial, and traditional funding sources and using volunteers as well as specially trained brain injury therapists, the program has remained financially viable, while giving traumatic brain injury (TBI) patients affordable access to services well after they are discharged from inpatient and outpatient care.
"The main reason we have created these programs is to meet the demand expressed by our consumers," says Drew Nagele, PsyD, clinical director of ambulatory services for the Drucker Brain Injury Center at MossRehab. MossRehab is part of the Albert Einstein Healthcare Network. The network is a founding member of the Jefferson Health System of Philadelphia. "Any excess revenues generated out of these ventures go back into developing new programs," Nagele says. "Brain injury is a lifelong disability, and people have lifelong needs, so a rehab facility needs to design services to meet the needs of TBI patients episodically throughout their lives."
MossRehab has several programs that venture to do exactly that. The facility’s three-pronged approach brings TBI rehab closer to consumers by focusing on their return to community and family life through these programs:
• Community residence program: MossRehab soon will open a home in Woodbury, NJ, in which eight TBI patients can live. The home is within a residential neighborhood and will be completely wheelchair accessible. This program serves people who need an opportunity to develop self-sufficient living skills and who are coming out of the acute phase of their injury and are not yet able to live on their own.
"It also may serve people who have been living in the community with certain support from their families and are no longer able to receive that support," Nagele says. For example, a TBI patient’s parents, who have been caring for him for 20 years, may suddenly be disabled or have died, and now there is no one to provide support for the patient. (A story on MossRehab’s community residence program will appear in the July issue of Rehab Continuum Report.)
• Clubhouse program: This is a program for people who are severely impaired by their disability and need a much more highly structured work environment in order to resume a productive role in their everyday lives. While the community re-entry program provides support and training for a patient to become a volunteer or to seek competitive paid work, the clubhouse program offers structured work within an environment where the members themselves run the program with the support of rehabilitation therapists. (See story on MossRehab’s club house program, p. 74.)
• Community re-entry program: This program is designed to help patients integrate the skills they have learned in their inpatient rehabilitation care and in their discipline-specific outpatient care. "This is the next level of taking rehab and making it useful in a person’s life, by taking it out of the clinic setting and putting it into an everyday life situation," Nagele says.
MossRehab recently started a new community re-entry program in an office setting on the main street of Woodbury, NJ. The new program will serve southern and central New Jersey and Delaware. MossRehab’s Philadelphia community re-entry program was started in 1984.
The rehab facility’s supported employment approach through the community re-entry program has been successful in assisting hundreds to return to competitive employment. MossRehab studied how well patients were doing in staying employed after leaving the program and found that 64% of the people were still working at 18 months post-placement. They decided to extend the job follow-up program and were able to raise that rate to 84% still employed at 18 months post-placement, Nagele says.
"That’s pretty good compared to the literature showing that, in general, less than half of TBI patients are still working six months later," he adds.
MossRehab’s community re-entry program has a transdisciplinary staff of 30, including occupational therapists, physical therapists, speech therapists, physiatrists, educational psychologists, neurobehavioral specialists, brain injury therapists, rehab social workers, therapeutic recreation specialists, special educators, vocational specialists, rehab counselors, brain injury job coaches, and neuropsychologists.
Everyone on the team is trained additionally as a brain injury specialist capable of evaluating and treating patients in functional contexts as they attempt tasks in their homes, communities, and on their jobs.
The Philadelphia program serves a five-county area and has a census of 250 clients per year, with about 80 people in treatment at any given time. The program in Woodbury, NJ, began this year.
The program begins with a comprehensive outpatient rehabilitation evaluation, which is a neurofunctional evaluation using a combination of neuropsychological testing, academic testing, vocational testing, and situational assessments. The team of therapists meets after all the assessments are complete and determines the patient’s strengths and weaknesses, making recommendations for the community-re-entry or other rehabilitation programs.
Therapists assess how patients handle day-to-day activities within a community setting. For example, therapists take patients to a grocery store and ask them to plan a meal for making a hot lunch that will be prepared in the rehab facility’s kitchen the next day.
"We’re doing this to look at their planning and organizational skills," Nagele says. "Then we look at their efficiency, such as did they use their list and did they utilize the overhead aisle markers?"
For example, therapists observe whether the patient has mentally grouped the list of food items according to category, so that when the patient picks up mustard, he also picks up salad dressing in the same aisle. "It’s what most of us do automatically, but it’s a frontal lobe function that may be impaired for people with brain injury," Nagele says.
Driving is evaluated by first observing how patients handle themselves on a walking route in the community and on public transportation. If they are safe in those tasks, they are referred to MossRehab’s Disabled Driving School for testing using dual-controlled vehicles.
The team also arranges community skills training that relates to the patient’s particular goals and desires. If a patient’s return to school is seen as a viable projected outcome, the team may develop a program of skills training in the area of academic strategies. The team might assign an academic coach to go with the patient to high school or college, where the coach will develop strategies with the student and the student’s teachers.
If a patient needs to improve skills in the home setting, the therapist will accompany the patient home and help set up routines and learning tasks such as bill paying or home maintenance.
When patients are ready to look for work, the team will have the patient prepare through different volunteer trials as part of a vocational directions program to determine potential for a par- ticular type of work. Then they’ll do job development and coaching and send the therapist out as a job coach to work beside the patient until a coach is no longer needed.
MossRehab includes the payer as an integral part of the team in developing a program for what the patient needs. This approach has helped ease reimbursement difficulties and has resulted in the program’s acceptance by a variety of payers, including health insurers, auto insurers, workers’ compensation companies, state vocational rehabilitation, and state Medicaid programs.
"Payers are involved from day one in understanding their insured’s needs and our approach to meeting these needs," Nagele says. "By including them from day one, we usually are able to arrange for the resources the patient needs, by demonstrating realistic outcomes at each step of the way."
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