When a person sustains a traumatic brain injury (TBI), he and his family are thrust into a health care system that is unfamiliar and difficult to navigate. Too often, patients do not have access to the full continuum of treatment - especially transitional rehabilitation (TR). This article addresses why that is so and ways to change it

Cioe, Nicholas J.

Connors, Susan H.

Seale, Gary S.

English

Digital Commons @ Assumption College

Digital Commons @ Assumption University Human Services and Rehabilitation Studies Department Faculty Works Human Services and Rehabilitation Studies Department 2018 What Families, Clinicians and Payors Need to Know About Transitional Rehabilitation Gary S. Seale Centre for Neuro Skills Nicholas J. Cioe Assumption College, nj.cioe@assumption.edu Susan H. Connors Brain Injury Association of America Follow this and additional works at: https://digitalcommons.assumption.edu/hsrs-faculty  Part of the Medicine and Health Sciences Commons Recommended Citation Seale, G. S.; Cioe, N. J.; and Connors, S. H. (2018). What Families, Clinicians and Payors Need to Know About Transitional Rehabilitation. Brain Injury Professional 15(1): 20-22. https://braininjuryprofessional.com/. This Article is brought to you for free and open access by the Human Services and Rehabilitation Studies Department at Digital Commons @ Assumption University. It has been accepted for inclusion in Human Services and Rehabilitation Studies Department Faculty Works by an authorized administrator of Digital Commons @ Assumption University. For more information, please contact digitalcommons@assumption.edu. What Families, Clinicians and Payors Need to KnowAbout Transitional RehabilitationGary S. Seale, PhD, Nicholas J. Cioe, PhD, Susan H. Connors , Brain Injury ProfessionalWhen a person sustains a traumatic brain injury (TBI), he and his family are thrust into a health care system that isunfamiliar and di cult to navigate. Too often, patients do not have access to the full continuum of treatment – especiallytransitional rehabilitation (TR). This article addresses why that is so and ways to change it.Transitional Rehabilitation De nedTR is a program of comprehensive, residential treatment that includes intensive physical, cognitive, and behavioraltherapies plus counseling, education, and medical care as needed (Chua et al., 2007). TR encompasses remediationtechniques to restore function along with compensatory strategies, assistive technology, and environmental modi cationsto improve function. TR is sometimes called residential rehabilitation or transitional living because patients may reside instructured facilities that mimic real-world settings. TR is appropriate for individuals who have completed acute hospital-based rehabilitation, are medically stable, and able to participate in intensive therapy. TR is also suitable for patients whomay not have received acute rehabilitation or cannot safely transition from hospital to home due to increased risk formedical complications or re-injury. TR patients may have moderate to severe brain injuries and accompanying decrementsin strength, poor balance, or decreased ability to perform basic activities of daily living (ADLs). Individuals whodemonstrate post-traumatic amnesia, behavioral dysregulation, impulsivity, and poor self- and safety awareness areappropriate for TR programs, as are those who experience a change in life circumstances, such as the loss of a familycaregiver or emergence of a secondary health condition. TR may also bene t patients with milder injuries or post-concussive disorders that do not respond to established treatment regimens.TR Di ers from Other TreatmentUnlike acute hospital-based rehabilitation, TR programs are community-based. Skills and strategies taught in the clinic arepracticed in community venues to encourage self-awareness and self-reliance. Therapy, which can last up to eight hoursper day, focuses on resuming former social roles and on mastering advanced ADLs. With proper safety measures in place,patients are allowed to make mistakes based on poor judgement, poor self-awareness, or poor impulse control to gaininsight, re ne goals, and enhance collaboration with the treatment team.TR programs address the individual’s ongoing medical needs,such as seizures, endocrine dysfunction, sleep disorders,pain, or swallowing disorders prior to discharge home. Ideally, the physician providing medical care is a specialist in braininjury medicine, such as a physiatrist. With the assistance of therapists or nurses, patients learn to arrange medicalappointments, manage co-morbidities and medications, and practice the use and care of durable medical equipment. TRprograms also guide families in making home modi cations and learning behavior management techniques prior todischarge.Challenges in Accessing TRAbout 52% of individuals age 15 and older with moderate to severe traumatic brain injury (TBI) are discharged directlyhome from an acute hospital with no further treatment (Cuthbert et al., 2011). Research suggests up to 20% of those with asevere injury return to pre-injury functioning within one year post-injury. Therefore, it is reasonable to believe there areseveral factors beyond spontaneous recovery that explain a premature departure from treatment.Families simply do not know TR exists or how to advocate for admission to a TR program. TR programs may not beavailable in a particular geographic region. Clinicians do not refer patients because they misjudge the patient’s ability tomake further gains or are unaware of the provider expertise, treatment intensity, and outcomes achieved at the post-acutelevel. Sometimes clinicians are pressured to discharge patients to less intensive placements, such as skilled nursingfacilities, or are prohibited from discussing discharge options without prior clearance from payors. Additionally, somereferrals are not made because the TR program is not in network, either a hospital network or payor network of providers.Payors control patient access to TR based on their coverage philosophies and payment policies. Those with long-termresponsibility for the patient – such as workers compensation carriers – tend to invest in rehabilitation that maximizes aperson’s health and independence. Payors with short-term responsibility – such as group health plan insurers – tend tostint on care, thereby shifting costs to families and public programs. Even payors that cover TR may deny admission basedon medical necessity or may discontinue treatment due to lack of measurable progress. This short-sighted strategy maysave money initially but can result in higher long-term costs due to re-hospitalization or the development of medical orpsychosocial complications requiring treatment.Clinicians Fight for PatientsClinicians can stop the harmful ‘delay, deny, discontinue, and discharge to daytime TV’ spiral that patients experience byclearly describing their patient’s on-going medical conditions and the physical and cognitive impairments that prevent asafe transition to home. Clinicians can articulate the bene ts of appropriate treatment intensity and duration to ensuresuccessful reintegration into the community (Tsaousides and Gordon, 2009). They can describe for payors the role ofcognitive rehabilitation therapies in reducing activity limitations and participation restrictions (Malec and Basford, 1996)and the cost e ciencies and improved health outcomes achieved through comprehensive rehabilitation of su cientscope, duration, timing, and intensity (Ashley and Cervelli, 2010).Best Practices for PayorsPayors bene t when they comprehend the di erences in focus and philosophy across the TBI treatment continuum andthe necessary variations in therapy intensity and duration to ensure successful return to the community. Similarly, payorsbene t when they acknowledge that comprehensive-holistic treatment is the standard of care following TBI (Tsaousidesand Gordon, 2009) because it reduces psychosocial problems and promotes community re-integration and return to work(Geurtsen et al., 2010), and can reduce lifetime costs. TR programs are particularly e ective when therapies areimplemented by an interdisciplinary team, using community-based rehearsal, cognitive rehabilitation therapy, and familyinvolvement (Turner-Stokes, 2008).Payors bene t when they appreciate the di erence between progress and outcome measurement at the acute and post-acute levels of care. Most hospital-based programs use the Functional Independence Measure (FIM) as the primaryoutcome measure. The FIM, has ceiling e ects and is not appropriate for patients in TR programs (Hall et al., 2001). TRprograms are focused on the overall functioning of the individual in real-world settings, and a larger range of outcomesare possible, such as return to productive activities, driving, and quality of life.Therefore, most TR programs employ measures of global function, such as the Mayo-Portland Adaptability Inventory, andother measures important at the post-acute level of care, such as life satisfaction, mood, and supervisory need.Finally, payors bene t most when they embrace the substantial lifetime cost savings associated with participation in TRprograms (Ashley et al., 1990 & 1993; Khan et al., 2002). These savings are most salient with regard to attendant care,development of medical and psychosocial complications, and avoidance of re-hospitalization.Selecting a TR ProgramOne of the most important decisions families make is where to obtain treatment for their loved ones. Regrettably, familiesoften make decisions about placement based on marketing brochures rather than outcomes data. Choosing a TR programbased on proximity to the family can be a mistake. Similarly, focusing only on the environment without asking questionsabout the program itself can lead to bad decisions.When selecting a TR program, families should determine how the facility is licensed and if the program uses best practicesand evidenced-based clinical guidelines, or has earned accreditation (e.g., CARF, Joint Commission). They should investigatesta  quali cations, organizational training culture, and sta  to patient ratios. Top TR programs provide coordinated,interdisciplinary treatment by licensed physical, occupational, speech, music, and recreation therapists as wellneuropsychologists, counselors, and case managers. Medical and nursing services are integrated into TR treatment andgenerally involve physiatrists, neurologists, and registered nurses. Residential programs provide up to 24/7 supervision byquali ed sta , such as a certi ed medication assistant, certi ed nursing assistant, or certi ed brain injury specialist. Alsoavailable in top TR programs is around the clock access to a physician and neuropsychologist to avert medical orpsychological crises.TR programs incorporate person-centered principles into treatment plans, and the family is integrated into the treatmentteam (e.g., involved with goal-setting, participate in therapy sessions, regularly visit the patient). Families will want toinquire about the balance between individual and group therapies, the number of therapy hours per day, and how freetime is used. They should ask about the availability of peer support, family training, and help with transition planning,including vocational options and day programs. Above all else, families will want to know how patients with brain injuriesof similar type and severity performed in the TR program.ConclusionWhile hospital-based surgical and medical treatment saves a person’s life, transitional rehabilitation often places animportant role in making that life worth living. The evidence for TR’s e ciency and long-term cost savings is substantial(Ashley & Cervelli, 2010), but too often payors dictate access to care, length of stay, and clinical services provided. We urgefamilies and clinicians to advocate for improved insurance coverage of TR because it maximizes health outcomes andpersonal independence.Authors Note: We use the term “patient” throughout this article to re ect our opinion that transitional rehabilitation is a type ofmedically necessary treatment that should be paid by health insurance carriers.ReferencesAshley MJ and Cervelli L. Maximizing rehabilitation outcomes and cost e ciency following acquired brain injury. BrainInjury Source. 7: 10-21, 2010.Ashley MJ, Krych DK, Lehr RP. Cost-bene t analysis for post-acute rehabilitation of the traumatically brain injured patient.Journal of Insurance Medicine. 22: 156-161, 1990.Ashley MJ, Persel CS, Krych DK. Changes in reimbursement climate: Relationship among outcome, cost, and payor type inthe post-acute rehabilitation environment. Journal of Head Trauma Rehabilitation. 8: 30-47, 1993.Chua KSG, Ng YS, Yap SGM, et al. A brief review of traumatic brain injury rehabilitation. Annals Academy of Medicine. 36:31-42, 2007.Cuthbert JP, Corrigan JD, Harrison-Felix C, et al. Factors that predict acute hospitalization discharge disposition for adultswith moderate to severe traumatic brain injury. Archives of Physical Medicine and Rehabilitation. 92:721-730, 2011.Geurtsen GJ, van Heugten CM, Martina JD, et al. Comprehensive rehabilitation programmes in the chronic phase aftersevere brain injury: A systematic review. Journal of Rehabilitation Medicine. 42: 97-110, 2010.Hall KM, Bushnik T, Lakisic-Kazazic B, et al. Assessing traumatic brain injury outcome measures for long-term follow-up ofcommunity-based individuals. Archives of Physical Medicine and Rehabilitation. 82: 367-74, 2001.Katz DI, Polyak M, Coughlan D, et al. Natural history of recovery from brain injury after prolonged disorders ofconsciousness: outcome of patients admitted to inpatient rehabilitation with 1-4 year follow-up. Prog Brain Res. 177:73–88,2009.Khan S, Khan A, Feyz, M. Decreased length of stay, cost savings and descriptive  ndings of enhanced patient care resultingfrom an integrated brain injury programme. Brain Injury. 16: 537-554, 2002.Malec JF, and Basford JS. Postacute brain injury rehabilitation. Archives of Physical Medicine and Rehabilitation. 77: 198-207, 1996.Nakase-Richardson R, Whyte J, Giacino JT, et al. Longitudinal outcome of patients with disordered consciousness in theNIDRR TBI Model Systems Programs. J Neurotrauma. 29: 59–65, 2012.Tsaousides T, and Gordon WA. Cognitive rehabilitation following traumatic brain injury: Assessment to treatment. MountSinai Journal of Medicine. 76: 173-181, 2009.Turner-Stokes L. Evidence for the e ectiveness of multidisciplinary rehabilitation following acquired brain injury: asynthesis of two approaches. Journal of Rehabilitation Medicine. 40: 691-701, 2008.About the Authors, PhD, is Regional Director of Clinical Services for the Centre for Neuro Skills. He received his doctoral degreein Rehabilitation Science from the University of Texas Medical Branch (UTMB) in Galveston. He is licensed in Texas as aPsychological Associate and Chemical Dependency Counselor and holds a clinical appointment at UTMB in the School ofHealth Professions – Department of Rehabilitation Science. He has worked exclusively in post-acute brain injuryrehabilitation for over 27 years and has conducted research and published peer-reviewed articles on rehabilitationoutcomes, the relationship between positive emotion and recovery of functional status following stroke, and emergencypreparedness for disabled populations.Gary S. Seale, PhD, is the Director of Rehabilitation Counseling at Assumption College in Worcester, MA. He is agraduate from the College of the Holy Cross and received his Masters and Doctoral degrees from Southern IllinoisUniversity – Carbondale. He is a Certi ed Rehabilitation Counselor and Certi ed Brain Injury Specialist Trainer. Dr. Cioe hasworked at all levels in TR programs and continues to provide sta  training and individual rehabilitation plan developmentin the post-acute sector. His research and publications focus on response to disability following brain injury, impaired self-awareness, rehabilitation issues, and brain injury outcomes.Nicholas J. Cioe is president and chief executive o cer of the Brain Injury Association of America (BIAA). She wasexecutive director of the National Association of State Head Injury Administrators from 2001 to 2005 and BIAA’s nationaldirector of state a airs from 1995 to 2001. She has served in advisory capacities and on expert panels for several federalagencies, universities, and nonpro t organizations and has authored numerous publications, position statements andarticles. She has a bachelor’s degree in public communication from George Mason University.Susan H. Connors

What Families, Clinicians and Payors Need to Know About Transitional Rehabilitation

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What Families, Clinicians and Payors Need to Know About Transitional Rehabilitation

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