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Healing in the Community

July 1, 2007
by THOMAS WATANABE, MD and MADELINE C. DIPASQUALE, PHD
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Details of one provider's path to recovery for patients with traumatic brain injuries

In the United States, 1.4 million people per year sustain a traumatic brain injury (TBI). The number of individuals who sustain TBIs but are not seen by a physician, treated, or correctly diagnosed is unknown.1 The severity of the injuries and the resulting range of problems are quite varied. Therefore, the ideal clinical program provides services that can encompass this wide scope of clinical needs.

State-of-the-art trauma centers and inpatient rehabilitation facilities help minimize the scope of TBIs and maximize recovery from the molecular level to broader levels of function, such as mobility, self-care, and return to community and family activities. However, the majority of this functional recovery typically takes place in an outpatient setting.

About 1.1 million people with a brain injury are seen in an emergency department and released yearly, some with a diagnosis of mild brain injury or concussion, some with no diagnosis at all. Any additional care likely will be done in an outpatient setting. For cases requiring hospitalization, stays are short and the vast majority of their rehabilitative course is accomplished in the outpatient setting. This is driven to some degree by third-party payers' increasingly stringent criteria for inpatient acute and rehabilitation care. Also, the recovery period from a TBI can be quite long, and rehabilitation needs may persist or arise after a period of functional stability. An estimated 5.3 million Americans require long-term assistance with activities of daily living (ADLs) due to TBIs, and ADLs represent only a fraction of this population's overall needs.2

Deficits after a TBI can include:

  • physical problems (difficulty moving or controlling arms and legs);

  • cognitive/language difficulties (poor memory, judgment, insight, communication skills);

  • difficulties with swallowing; and

  • behavioral problems (disinhibition, aggression, poor initiation).

Therefore, a comprehensive outpatient TBI rehabilitation program must be able to accommodate varying degrees and constellations of disability, recovery trajectories, social support, and vocational, recreational, and social goals.

This article outlines the outpatient care continuum at the Jerome M. and Sylvan W. Drucker Brain Injury Center, part of the Moss Rehabilitation Research Institute in Elkins Park, Pennsylvania. Our center has been recognized by the U.S. Department of Education's National Institute on Disability and Rehabilitation Research as a Traumatic Brain Injury Model System program.

The Outpatient Continuum

Based on more than 25 years of experience in working with persons with TBI, we have constructed a continuum of care to meet the needs of survivors, ranging from those with severe deficits to those returning to work or school.

Some of our patients do not have the ability to return directly home after their inpatient care. We have developed a community residence where they are able to relearn the skills to return to community living. This residence is supervised by staff experienced in working with persons with a TBI, who facilitate reacquisition of these skills while ensuring safety. These individuals receive outpatient rehabilitation services and are members of a community-based day program while living in this residential setting.

The outpatient continuum may start with a day hospital program, ideal for patients who still have a number of rehabilitation needs but are medically stable enough to be at home. Day hospital care provides the intensity of an inpatient rehabilitation program but allows patients to go home at night, helping families prepare for the full-time responsibilities of home care.

Our community-based day program called Clubhouse is a member-driven program that challenges survivors, not therapists, to develop individual and group goals around supporting the actual running and maintenance of the Clubhouse. Members select work activities, such as housekeeping, kitchen duty, and communication, and participate in a work-driven day to meet Clubhouse daily tasks, such as cleaning, preparing lunch for members, and arranging transportation. The program provides structure during the day and allows the continued development of self-sufficiency and daily skills. While not every person with a TBI can or wants to work, all people need an activity pattern that is meaningful to them and that provides social contact, social support, and a sense of purpose. Rehabilitation professionals and certified brain injury therapists support this member-driven community in helping them meet their goals.

Our outpatient TBI treatment program, the Community Re-entry Program, starts with a comprehensive functional rehabilitation evaluation that assesses the real-life skills needed to manage daily life: time management, housekeeping, community mobility, return to work/school, and leisure activities. Based on the needs identified, a team of rehabilitation professionals devises a goal-driven treatment plan with the client and teaches the skills and strategies necessary to reach his/her personal goals. The client is assigned a case manager who directs the treatment team in supporting clinical goals.

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